A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client’s discomfort?
A.
Lower the height of the solution container.
B.
Stop the enema and document that the client did not tolerate the procedure.
C.
Encourage the client to bear down
D.
Allow the client to expel some fluid before continuing
The correct answer and Explanation is :
The correct answer is A. Lower the height of the solution container.
Explanation:
A tap-water enema is often used to relieve constipation by stimulating bowel movement and softening the stool through the introduction of water into the rectum and lower bowel. The process involves instilling a certain volume of water using gravity, where the height of the solution container affects the rate at which the fluid flows into the client’s rectum.
When a client reports cramping during the instillation of the enema, it often indicates that the solution is being delivered too quickly, causing discomfort. Cramping can occur due to rapid distention of the colon or irritation of the bowel walls.
Lowering the height of the solution container (Option A) will decrease the flow rate of the enema solution. This action helps slow down the instillation process, allowing the colon to adjust to the fluid and reducing the risk of further discomfort or cramping. Lowering the container reduces the gravitational force that drives the fluid into the rectum, which can ease the symptoms without stopping the procedure.
Option B suggests stopping the enema altogether, which is unnecessary at this stage. Mild discomfort like cramping can often be alleviated by adjusting the flow rate, making it possible to continue with the procedure.
Option C, encouraging the client to bear down, could increase abdominal pressure and might not help with the discomfort caused by rapid fluid flow.
Option D, allowing the client to expel some fluid, could provide some relief but is unnecessary if simply lowering the solution container can resolve the issue more effectively.
Thus, lowering the height of the solution container is the most appropriate action to alleviate discomfort while safely continuing the procedure.