A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?
A.
Insert the tubing about 15 cm (6 in) into the anus.
B.
Hang the enema container 61 cm (24 in) above the anus.
C.
Assist the client to the left Sims’ position.
D.
Put on sterile gloves.
The correct answer and Explanation is :
The correct answer is C. Assist the client to the left Sims’ position.
Explanation:
When administering a soapsuds enema to an adult client, positioning the client correctly is crucial for the procedure’s effectiveness and comfort. The left Sims’ position is preferred because it facilitates the proper flow of the enema solution into the rectum and sigmoid colon. Here’s a detailed breakdown:
- Positioning (Left Sims’ Position):
- Why Left Sims’? This position involves the client lying on their left side with their right knee flexed and the left leg extended. This positioning helps to optimize the introduction of the enema solution into the sigmoid colon and helps in retaining the solution longer in the bowel. The left-side positioning allows the enema solution to flow more readily into the colon due to the anatomical positioning of the rectum and the descending colon.
- Benefits: It reduces the risk of injury or discomfort and enhances the effectiveness of the enema. It also facilitates better access for the nurse and helps the client in maintaining the position for the duration needed.
- Other Actions (Explanation of Incorrect Options):
- A. Inserting the tubing 15 cm (6 in) into the anus: While inserting the tubing, a general guideline is to insert it 7.5 to 10 cm (3 to 4 inches) for adults. Inserting it too deeply (15 cm) could cause discomfort or potential injury.
- B. Hanging the enema container 61 cm (24 in) above the anus: The ideal height for hanging the enema container is typically 30 to 45 cm (12 to 18 inches) above the anus. Hanging it too high can cause discomfort due to rapid infusion or increased pressure.
- D. Putting on sterile gloves: Sterile gloves are not necessary for this procedure. Clean, non-sterile gloves are typically sufficient since the enema is a non-invasive procedure and does not require sterile technique.
In summary, positioning the client in the left Sims’ position is essential for administering a soapsuds enema effectively and comfortably.