Protouch

Protouch

350Ambidextrous

Powder-free non-sterileNitrile examination gloves

100PCS

Ref:Size Large

350Ambidextrous

Powder-free non-sterileNitrile examination gloves Ref:

Size Large

100PCS

PHOSPHATE ENEMA READY TO USE DISPOSABLE SINGLE DOSE ENEMA PHOSPHATE ENEMA BP FORMULA 128ml

Procedure pad

Disposable gloves

Gauze swabs

Lubricating jellyTissues

Jug

Enemawater soluble for general lubricating needs

lubricating jelly

An enema is a liquid preparation given via the rectum for the purpose of producing a bowel action or instilling medication. Administration of an enema may be required for:

• Acute disimpaction of the bowel; • Prevention of recurrent impaction in people with hypotonic bowel or rectum;• Bowel clearance before bowel investigations or surgery;• Those with chronic inflammatory bowel disease such as ulcerative colitis and Crohn’s disease, to soothe and treat the bowel mucosa.

Administering medication per rectum can be the most appropriate route for some patients but may not always be considered by healthcare professionals. Cultural sensitivities, as well as misinformation regarding insertion methods, may be barriers to the practice (Lowry, 2016). Also, the use of enemas for bowel evacuation in clinical practice is on the decline due to a range of oral alternatives. These are less invasive, less embarrassing and more comfortable for patients, and they enable many patients to take responsibility for their own bowel medication. When giving enemas (especially phosphate enemas), be aware of the contraindications and risks of rectal administration. For some individuals, however, rectal medication will form a regular part of their lower bowel care as part of a bowel management programme (RCN, 2019).

There are two main types of enemas—evacuant and retention.

Evacuant enemas are introduced into the rectum with the intention of prompting a bowel action of faecal matter and flatus, including expulsion of the contents of the enema. Phosphate enemas and sodium citrate enemas (Microlette) are the most commonly used.

Davies (2004) identified risks associated with the use of phosphate enemas and concluded that there was insufficient evidence to support their use in practice. In a systematic review, Mendoza (2007) noted an absence of randomised controlled trials, meta-analyses and systematic reviews regarding the adverse effects of phosphate enemas. Mendoza concluded, however, that patients under 5 years old and those over 65 years old are at higher risk; and that older people with chronic renal failure and/or diseases altering intestinal mobility (neurological and gastrointestinal) are at highest risk. It is important to assess the patient’s need for treatment with a phosphate enema, as use of these enemas is not without risk, although the incidence of side-effects is low. Use of a sodium citrate enema (Microlette) may worsen oedema in patients with heart failure, because of its high salt content.

Retention enemas are introduced into the rectum with the intention of being retained. If the enema is for local effect, it must be prescribed on an appropriate treatment chart. A healthcare professional who administers an enema must understand how this treatment works, what its effects are, the dose and any possible side-effects.

The following are the most common types of retention enema:

• Steroid and aminosalicylate preparations. • Arachis oil. This type of enema softens and lubricates impacted faeces, but is rarely used now, due to the availability of more effective oral preparations for the treatment of faecal impaction. Arachis oil enemas contain groundnut and peanut oil and should therefore be avoided in all patients with a nut allergy.

Patients with spinal injuries should not be given volume retention enemas.

Page 1 of 4

Bowel CareAdults

Administration of an enemaEdited by Wendy Ness, Colorectal Nurse Specialist, Croydon University Hospital

©2021 Clinical Skills Limited. All rights reserved

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Risk assessment is essential before carrying out an invasive procedure such as administering an enema (RCN, 2019). Assess the patient’s suitability for the treatment, taking into account the cautions and contraindications:

• Risk awareness—understand the complications that could occur when administering an enema.

• Risk assessment—consider risks before administering an enema; for example, has the patient had recent anal surgery?

• Risk importance and priority—is the clinical need an emergency, and have all other appropriate options been tried? Does the likely benefit of giving the enema outweigh the possible risks?

• Risk identification—a phosphate enema may have more complications in certain patients, such as frail elderly patients.

• Risk likelihood and factors—does the patient have dementia? Are they able to give consent?

• Risk severity—administering a phosphate enema in an elderly patient with poor renal function may induce hyperphosphataemia.

• Risk prevention—staff competency.• Risk avoidance—to avoid the risk completely the enema is not

administered, but this must be weighed against the risks of not giving the enema.

• Risk reduction—use other rectal medication, such as suppositories.

Carry out a risk assessment

Equipment

PHOSPHATE ENEMA

READY TO USE

DISPOSABLE

SINGLE DOSE

ENEMA PHOSPHATE ENEMA BP FORMULA

128ml

Anus Rectum Sigmoidcolon

ONCE ONLY AND PREMEDICATION MEDICINES

Date Drug Dose Route Instructions TimeOrdered

Signature TimeGiven

Signature

AS REQUIRED PRESCRIPTIONS OR DOSES ADMINISTERED UNDER 'STANDING OR

Drug Dose Route

Instructions Minimum Interval

Signature Start Date Pharmacy

Date

Time

Dose

Given

Drug Dose Route

Instructions Minimum Interval

Signature Start Date Pharmacy

Date

Time

Dose

Given

/3/21 ENEMA ONE PR 10.00AM 10.00AMPHOSPHATE9

Bowel CareAdults

Administration of an enema Page 2

Preparation Explain the procedure

Ensure privacy Patient position

Warm the enema Decontaminate your hands and put on gloves

Decontaminate your hands. Check the patient’s identity and any reasons for taking extra precautions. Explain the procedure including the potential risks. Gain and document the patient’s consent. Explain to the patient that they can withdraw their consent at any time by asking you to stop. Ask if they want a chaperone present and organise if needed.

Check that the enema has been prescribed, its expiry date and the manufacturer’s instructions to ascertain the recommended method of insertion. Assess the need for an evacuant enema.

Gather the equipment needed. Before beginning the procedure, encourage the patient to empty their bladder as fluid entering the rectum may cause discomfort. Administering an enema is an invasive and embarrassing procedure, so ensure that the patient has privacy. Make sure that a commode or toilet is nearby, as the procedure may cause an urgent need to defecate.

Help the patient to remove any clothing below the waist and, to avoid embarrassment, cover them with a blanket or disposable drape. Assist the patient to adopt, if possible, the left lateral position with knees flexed (RCN, 2019). This position exposes the anus and allows easy insertion of the enema; the left side is preferred due to the position of the rectum but it is not essential (the right side may be better if the patient has left-sided weakness).

Warm the enema to just above body temperature in a jug of water at hand-hot temperature. A cold enema is unpleasant and uncomfortable for the patient; it may also cause spasm in the rectum. Warming the enema ensures comfort for the patient and maximum effectiveness of the enema (this may not apply to some retention enemas; check the manufacturer’s guidelines).

To minimise cross infection, decontaminate your hands again and put on a disposable apron and non-latex gloves. Place a procedure pad under the patient to protect bedding from faecal matter.

Page 2 of 4

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

PHOSPHATE

R

EADY TO

DISPOSABLE

SINGLE D

OSE

ENEM

A

PHOSPHATE ENEMA

BP

128

ml

PHOSPHATE

R

EADY TO

DISPOSA

BLE

S

INGLE D O SE

ENEM A

P

HOSPHATE ENEMA BP

128ml

Are you ok for me to continue?

Before administering an enema, carry out a digital rectal examination (DRE) to assess the rectum. Lubricate a gloved index finger, part the buttocks and gently insert it into the anus to avoid trauma to the anal mucosa, noting tone (slight resistance indicates good internal sphincter control) and spasm or pain on insertion. Calmly talk to the patient to reassure them during the procedure.

Bowel Care

Adults

Administration of an enema Page 3

Observe the patient Carrying out a digital rectal examination: (a)

(b) Lubricate the nozzle and expel excess air

Insert the enema into the anal canal Check that the patient agrees to continue

Inform the patient that you are going to look at and examine the outer and internal areas. Observe the perineal and perianal areas and anus, checking for rectal prolapse, anal skin tags, haemorrhoids, wounds, discharge, anal lesions, gaping anus, bleeding, infestation, foreign bodies and broken skin. Document and report abnormalities at the end of the procedure (RCN, 2019).

If the patient feels pain, check they want to continue. Ask them to talk/exhale to prevent spasm/difficulty on insertion. Work with the anal reflex: put your finger on the anus gently and wait a few seconds to allow the anus to contract and then relax. After the DRE, remove gloves, decontaminate hands and put on clean gloves. Document and report abnormalities at the end of the procedure.

Remove the enema from the warm water ensuring that the enema fluid is not too warm. Remove the cap from the enema. To make insertion easier and prevent trauma to the anus and anal canal, lubricate the end of the nozzle with some lubricating jelly on a swab. Expel excess air (inset): if this passes into the patient, it may distend the colon wall, causing abdominal discomfort.

Part the patient’s buttocks and gently insert the enema into the anus and on into the anal canal. The anal canal is approximately 5 cm in length, so insert the nozzle of the enema by its full length, to ensure that the contents will reach the rectum.

If the patient is experiencing any discomfort on inserting the nozzle, withdraw and check that patient is happy for you to continue. The procedure may be uncomfortable but should never be painful. If the patient asks you to stop and withdraws consent, you must adhere to this, and seek medical advice as soon as possible.

Page 3 of 4

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Patient Notes ? X

OK Cancel

General Notes

Digital rectal examination carried out with patient’s consent. Verbal informed consent gained to administer enema. Enema given to patient with good result. Type 2 (Bristol Stool Chart) stool passed. No adverse effects experienced by patient. Patient made comfortable following the procedure. To continue with laxatives as prescribed, and have encouraged eating a well-balanced diet.

Allergy Notes

Slowly withdraw the nozzle of the enema, to avoid a reflex emptying of the bowel. Wipe the perianal area with a clean swab, to leave the patient comfortable and clean, and to prevent excoriation of the anal area. Inform the patient that the procedure is complete and cover them with a blanket or disposable drape.

PHOSPHATE

R

EADY TO

DISPOSA

BLE

S

INGLE D O SE

Bowel Care

Adults

Administration of an enema Page 4

Slowly introduce the enema Withdraw the nozzle

Retain the enema Ensure access to a commode/toilet

Dispose of equipment Documentation

Slowly introduce the contents of the enema. It is important to give the enema slowly, to avoid unnecessary discomfort caused by sudden pressure to the rectal walls. Patients may complain of light-headedness during insertion or during evacuation of their bowels: this is due to vagal nerve stimulation which can slow the heart rate and alter its rhythm. Stop administering if there is bleeding or if the patient complains of pain, feels faint or withdraws consent.

To enhance the effects of the enema, ask the patient to retain it for 10 to 15 minutes before using the commode/toilet. Patients often find this easier if they remain lying down as this position avoids the pressure of rectal contents on the external anal sphincter.

To minimise embarrassment, ensure that the patient has access to a call bell (if in hospital), or a commode and/or toilet with a supply of toilet paper or tissues.

Remove and dispose of equipment. Remove your gloves and apron, and decontaminate your hands to minimise cross infection. Inform the patient of the outcome as appropriate.

Document the procedure with clear evidence of care delivered, decisions made and care planned. Document the outcome with reference to the Bristol Stool Chart (see procedure: “Constipation: causes and assessment”). Monitor the patient for any adverse effects and assist them with redressing if required.

Page 4 of 4

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.