A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?
A. Hold the container of solution 30 cm (12 in) above the anus.
B. Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.
C. Hold the container of solution level with the client’s upper hip.
D. Keep the container of solution at a level to maintain client comfort.
The correct answer and Explanation is :
The correct answer is C. Hold the container of solution level with the client’s upper hip.
Explanation:
Administering a cleansing enema requires careful consideration of several factors, including the height of the solution container, the type of solution used, and the client’s comfort. The primary purpose of a cleansing enema is to promote bowel evacuation by introducing a solution into the rectum and colon.
When the nurse holds the container at hip level, it allows for optimal gravity flow, which helps to control the rate of solution infusion and prevents rapid influx that could cause discomfort or cramping. If the container is held too high (like in option A), the solution may flow in too quickly, leading to potential complications such as pain, discomfort, or even perforation of the rectal tissue. Holding it lower than hip level (like in option B) may reduce the gravitational force needed for effective solution delivery, making it difficult for the enema to achieve its intended effect.
Moreover, maintaining the container at hip level promotes client comfort. When administering an enema, the nurse should also ensure the client is in a comfortable position—typically lying on their left side with knees drawn up to the chest. This position can help the solution flow more easily into the colon and may enhance the effectiveness of the procedure.
In summary, option C strikes a balance between effective solution delivery and client comfort. It allows gravity to assist in the administration of the enema while minimizing the risk of complications. Proper positioning, careful attention to the height of the solution container, and monitoring the client’s response throughout the procedure are crucial components in delivering safe and effective care during enemas.