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 B. Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.
Explanation:
When administering a cleansing enema, it is essential to control the flow of the solution to ensure the procedure is effective and comfortable for the client. The height at which the enema solution container is held affects the flow rate and pressure of the solution entering the rectum.
- Optimal Height for Solution Container:
- Holding the container 15 cm (6 inches) above the anus allows for the proper flow rate of the solution into the rectum. This height creates a sufficient gravitational pull to instill the solution without causing excessive pressure, which can lead to discomfort or complications.
- Lowering the container 15 cm below the anus during the procedure helps to decrease the flow rate, allowing the client to tolerate the solution better. This method also aids in reducing the risk of cramping and ensures that the solution is absorbed appropriately.
- Understanding Flow Rates:
- If the container is held too high (such as 30 cm above the anus), the solution may flow too rapidly, potentially causing discomfort, pain, or cramping. It can also lead to an incomplete evacuation if the client cannot tolerate the speed of the infusion.
- Holding the container level with the client’s upper hip (option C) or at a level to maintain client comfort (option D) is less precise and does not guarantee the appropriate flow rate or pressure for effective cleansing. While comfort is important, it must be balanced with ensuring the solution flows at an optimal rate for the procedure.
- Procedure and Client Comfort:
- Proper height management ensures that the enema solution is administered effectively while maintaining client comfort. Holding the container initially at the recommended height and then lowering it is a standard practice that aligns with the guidelines for administering enemas safely.
By adhering to this procedure, the nurse can provide an effective cleansing enema while minimizing discomfort and potential complications for the client.