Skill 13-1

Administering a Large-Volume Cleansing Enema

Cleansing (evacuant) enemas are given to remove feces from the colon. Some of the reasons for administering a cleansing enema include relieving constipation or fecal impaction , evacuating the bowel before surgery to prevent involuntary escape of fecal material during surgical procedures, and promoting visualization of the intestinal tract by radiographic or endoscopic examination. Cleansing enemas are classified as either large or small volume. This skill addresses administering a large-volume enema. (Small-volume enemas are addressed in Skill 13-2.)

Large-volume enemas are known as hypotonic or isotonic, depending on the solution used. Hypotonic (tap water) and isotonic (normal saline solution) enemas are large-volume enemas that result in rapid colonic emptying. However, using large volumes of solution (adults: 500 to 1,000 mL; infants: less than 250 mL [Kyle & Carman, 2021]) may be dangerous for patients with weakened intestinal walls, such as those with bowel inflammation or bowel infection. The enema solution should be at or just above body temperature and warmed, if necessary, by placing the container with the enema solution in a container of warm water (Dougherty & Lister, 2015, as cited in Mitchell, 2019b, p. 155). See Table 13-1 (on page 794) for a list of commonly used enema solutions.

Delegation Considerations

The administration of some types of enemas may be delegated to assistive personnel (AP) who have received appropriate training. The administration of a large-volume cleansing enema may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Enema solution as prescribed at or just above body temperature (Dougherty & Lister, 2015, as cited in Mitchell, 2019b, p. 155) in the prescribed amount (amount will vary depending on the type of solution, patient's age, and patient's ability to retain the solution; average cleansing enema for an adult may range from 500 to 1,000 mL)
Disposable enema set, which includes a solution container and tubing
Water-soluble lubricant
IV pole
Necessary additives, as prescribed
Waterproof pad
Bath thermometer (if available)
Bath blanket
Bedpan or commode and toilet tissue
Disposable gloves
Additional PPE, as indicated
Paper towel
Washcloth, skin cleanser, and towel

Assessment

Ask the patient when they had their last bowel movement. Assess the patient's abdomen, including auscultating for bowel sounds and palpating for tenderness and/or firmness. Because the goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds, assess the abdomen before and after the enema. Assess the rectal area for any fissures , hemorrhoids , sores, or rectal tears. If any of these are present, take added care while inserting the tube. Assess the results of the patient's laboratory work, specifically the platelet count and white blood cell (WBC) count. Rectal agents should be avoided in patients at risk of thrombocytopenia, leukopenia, and/or mucositis and manipulation of the rectum and anus, including administration of enemas, should be avoided in immunocompromised patients and/or patients at risk for myelosuppression and mucositis (NCI, 2020). Enemas are also contraindicated for patients with bowel obstruction or paralytic ileus (Mitchell, 2019b) and in situations in which administration could cause circulatory overload, mucosal damage, necrosis, perforation, or hemorrhage or following any GI or gynecologic surgery in which sutures may be ruptured (Dougherty & Lister, 2015, as cited in Mitchell, 2019b, p. 154). Assess for dizziness, lightheadedness, diaphoresis, and clammy skin. The enema may stimulate a vagal response or stimulus , which increases parasympathetic stimulation, causing a decrease in heart rate.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Acute pain
Constipation
Constipation risk

Outcome Identification and Planning

The expected outcome to achieve when administering a cleansing enema is that the patient expels feces. Other appropriate outcomes may include that the patient verbalizes decreased discomfort, abdominal distention is absent, and the patient remains free of any evidence of trauma to the rectal mucosa or other adverse effects.

Implementation

Action	Rationale
1. Review the patient's health record for any limitations in physical activity. Verify the prescribed intervention for the enema. Gather equipment.	Physical limitations may require adaptations in performing the skill. Verifying the prescribed intervention ensures that the correct intervention is administered to the right patient. Assembling equipment provides for an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Explain the procedure to the patient and provide the rationale as to why the enema is needed. Discuss the associated discomforts that may be experienced and possible interventions that may allay this discomfort. Answer any questions, as needed.	Explanation facilitates patient engagement and reduces anxiety.
5. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
6. Close the curtains around the bed and close the door to the room, if possible. Discuss where the patient will defecate. Have a bedpan, commode, or nearby bathroom ready for use.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates patient engagement. The patient is better able to relax and participate if they are familiar with the procedure and know everything is in readiness when the urge to defecate is felt. Defecation usually occurs within 5 to 15 minutes.
7. Warm the enema solution to at or just above body temperature by placing the container with the enema solution in the amount prescribed in a container of warm water, and check the temperature with a thermometer, if available. If a thermometer is not available, warm and test on your inner wrist. If tap water is used, adjust the temperature as it flows from the faucet.	Enema solution should be at or just above body temperature and warmed, if necessary, by placing the container with the enema solution in a container of warm water (Dougherty & Lister, 2015, as cited in Mitchell, 2019b, p. 155). Warming the solution prevents chilling the patient, adding to the discomfort of the procedure. A cold solution could cause cramping; a too-warm solution could cause trauma to intestinal mucosa.
8. Add the enema solution to the enema set solution container. Release the clamp and allow fluid to progress through the tube before reclamping.	This causes any air to be expelled from the tubing. Although allowing air to enter the intestine is not harmful, it may further distend the intestine.
9. Adjust the bed to a comfortable working height (VHACEOSH, 2016). Position the patient on their left side (Sims position), with the upper thigh pulled toward the abdomen, if possible, or the knee-chest position, as dictated by patient comfort and condition. Fold the top linen back just enough to allow access to the patient's rectal area. Drape the patient with the bath blanket, as necessary, to maintain privacy and warmth. Place a waterproof pad under the patient's hip.	Having the bed at the proper height prevents back and muscle strain. The Sims or knee-chest position facilitates flow of solution via gravity into the rectum and colon, optimizing solution retention. Folding back the linen in this manner minimizes unnecessary exposure and promotes the patient's comfort and warmth. The waterproof pad will protect the bed.
10. Put on gloves.	Gloves prevent contact with contaminants and body fluids.
11. Elevate the solution so that it is no higher than 18 inches (45 cm) above the level of the anus (Figure 1). Plan to give the solution slowly over a period of 5 to 10 minutes. Hang the container on an IV pole or hold it at the proper height.	Gravity forces the solution to enter the intestine. The amount of pressure determines the rate of flow and pressure exerted on the intestinal wall. Giving the solution too quickly causes rapid distention and pressure, poor defecation, or damage to the mucous membrane.
12. Generously lubricate the end of the rectal tube 2 to 3 inches (5 to 7 cm). A disposable enema set may have a prelubricated rectal tube.	Lubrication facilitates passage of the rectal tube through the anal sphincter and prevents injury to the mucosa.
13. Lift a buttock to expose the anus. Ask the patient to take several deep breaths. Slowly and gently insert the enema tube 4 to 5 inches (10 to 12.5 cm) for an adult. Direct it at an angle pointing toward the umbilicus, not the bladder (Figure 2).	Good visualization of the anus helps prevent injury to tissues. Deep breathing helps relax the anal sphincters. The anal canal is about 1 to 2 inches (2.5 to 5 cm) long. Insertion 4 to 5 inches (10 to 12.5 cm) ensures the tube is inserted past the external and internal anal sphincters (Dougherty & Lister, 2015, as cited in Mitchell, 2019b, p. 155); further insertion may damage the intestinal mucous membrane. The suggested angle follows the normal intestinal contour and thus will help to prevent perforation of the bowel. Slow insertion of the tube minimizes spasms of the intestinal wall and sphincters.
14. If resistance is met while inserting the tube, permit a small amount of solution to enter, withdraw the tube slightly, and then continue to insert it. Do not force entry of the tube. Ask the patient to take several deep breaths.	Resistance may be due to spasms of the intestine or failure of the internal sphincter to open. The solution may help to reduce spasms and relax the sphincter, thus making continued insertion of the tube safe. Forcing a tube may injure the intestinal mucosa wall. Taking deep breaths helps relax the anal sphincter.
15. Introduce the solution slowly over a period of 5 to 10 minutes. Hold the tubing all the time that solution is being instilled. Assess for dizziness, lightheadedness, nausea, diaphoresis, and clammy skin during administration. If the patient experiences any of these symptoms, stop the procedure immediately, monitor the patient's heart rate and blood pressure, and notify the health care team.	Introducing the solution slowly helps prevent rapid distention of the intestine and a desire to defecate. Assessment allows for detection of a vagal response. The enema may stimulate a vagal response, which increases parasympathetic stimulation, causing a decrease in heart rate.
16. Clamp the tubing or lower the container if the patient has the urge to defecate or cramping occurs (Figure 3). Instruct the patient to take small, fast breaths or to pant.	These techniques help relax muscles and prevent premature expulsion of the solution.
17. After the solution has been given, clamp the tubing (Figure 4) and remove the tube. Have a paper towel ready to receive the tube as it is withdrawn.	Wrapping the tube in a paper towel prevents dripping of the solution.
18. Return the patient to a comfortable position. Encourage the patient to hold the solution until the urge to defecate is strong, usually in about 10 to 15 minutes. Make sure the linens under the patient are dry. Remove your gloves and ensure that the patient is covered. Perform hand hygiene.	This amount of time usually allows muscle contractions to become sufficient to produce good results. Dry linens promote patient comfort. Removing contaminated gloves and performing hand hygiene prevent the spread of microorganisms.
19. Raise the side rail. Lower the bed height and adjust the head of the bed to a comfortable position.	Positioning promotes comfort and safety.
20. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
21. When the patient has a strong urge to defecate, place them in a sitting position on a bedpan or assist them to a commode or a nearby bathroom. Offer toilet tissues, if not in the patient's reach (Figure 5). Stay with the patient or have the call bell readily accessible.	The sitting position is most natural and facilitates defecation. Fall prevention is a high priority due to the urgency of reaching the commode.
22. Remind the patient not to flush the commode before you inspect the results of the enema.	The results need to be observed and recorded. Additional enemas may be necessary if the health care provider has prescribed enemas “until clear.” Refer to “Special Considerations” below.
23. Put on gloves and assist the patient, if necessary, with cleaning the anal area. Offer washcloths, skin cleanser, and water for handwashing. Remove gloves. Perform hand hygiene.	Cleaning the anal area and proper hygiene deter the spread of microorganisms. Gloves prevent contact with contaminants and body fluids. Hand hygiene deters the spread of microorganisms.
24. Leave the patient clean and comfortable. Care for equipment properly.	Bacteria that grow in the intestine can be spread to others if equipment is not properly cleaned.
25. Perform hand hygiene.	Hand hygiene deters the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient has expelled feces, the patient has verbalized decreased discomfort, abdominal distention has not occurred, and the patient has remained free of any evidence of trauma to the rectal mucosa or other adverse effect.

Documentation

Guidelines

Document the amount and type of enema solution used; amount, consistency, and color of stool; pain assessment rating; assessment of the perineal area for any irritation, tears, or bleeding; and the patient's reaction to the procedure.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Solution does not flow into rectum: Reposition the rectal tube. If solution will still not flow, remove the tube, and check for any fecal contents clogging the tube.
Patient cannot retain enema solution for adequate amount of time: The patient may need to be placed on a bedpan in the supine position while receiving the enema. The head of the bed may be elevated 30 degrees for the patient's comfort.
Patient cannot tolerate large amount of enema solution: Amount and length of administration may have to be modified if the patient begins to report pain.
Patient reports severe cramping with introduction of enema solution: Lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur.

Special Considerations

General Considerations

Rectal agents should be avoided in patients at risk of thrombocytopenia, leukopenia, and/or mucositis, and manipulation of the rectum and anus, including administration of enemas, should be avoided in immunocompromised patients and/or patients at risk for myelosuppression and mucositis (NCI, 2020). These actions can lead to development of anal fissures or abscesses, which are portals for infection (NCI, 2020).
If the patient experiences fullness or pain, or if fluid escapes around the tube, stop administration. Wait 30 seconds to a minute and then restart the flow at a slower rate. If symptoms persist, stop administration, and contact the health care team.
If the order states the enema is to be given “until clear,” check with the health care team before administering more than three enemas. Severe fluid and electrolyte imbalances may occur if the patient receives more than three cleansing enemas. Results are considered clear whenever there are no more pieces of stool in the enema return. The solution may be colored but still considered a clear return.

Infant and Child Considerations

When administering an enema to a child, use isotonic solutions. Plain water is not used because it is hypotonic and can cause rapid fluid shift and fluid overload (Silbert-Flagg & Pillitteri, 2018).
Appropriate fluid volume for an enema (Silbert-Flagg & Pillitteri, 2018):
- Infant: 250 mL or less
- Toddler or preschooler: 250 to 350 mL
- School-aged child: 300 to 500 mL
- Adolescent: 500 mL
Position the infant or toddler on their abdomen with knees bent. Position the child or adolescent on their left side with the right leg flexed toward the chest (Cincinnati Children's, 2018).
Insert the tubing into the rectum 2 to 3 inches (5 to 7.5 cm) for children (ages 2 to 10 years); 1 to 1.5 inches (2.5 to 4 cm) for infants (Cincinnati Children's, 2018).

Older Adult Considerations

If the older adult cannot retain the enema solution, administer the enema with the patient on the bedpan in the supine position. For comfort, elevate the head of the bed 30 degrees, if necessary, and use pillows appropriately.

EVIDENCE FOR PRACTICE

Milk and Molasses Enemas

Constipation is a common condition (Wangui-Verry et al., 2019). Enemas may be used as part of interventions to relieve constipation. There are several types of enema solutions; milk and molasses enemas has traditionally been used by nurses and other health care providers for severe constipation that has not resolved with standard interventions. However, there has been little research examining the safety and efficacy of this type of enema (Wangui-Verry et al., 2019).

Related Research

Wangui-Verry, J., Farrington, M., Matthews, G., & Tucker, S. J. (2019). CE: Original Research: Are milk and molasses enemas safe for hospitalized adults? A retrospective electronic health record review. American Journal of Nursing, 119(9), 24-28. https://doi.org/10.1097/01.NAJ.0000580148.43193.76

The purpose of this study was to evaluate the safety of milk and molasses enemas for hospitalized adults with constipation that persisted after use of standard treatment interventions. Data were obtained retrospectively from the electronic health records (EHRs) of patients at an academic medical center over a period of 4 years. The final sample (n = 196) was chosen by random selection from the EHRs of 615 adult patients who had received a milk and molasses enema during this time frame. Data collected included patient demographics and presenting medical characteristics as well as three safety outcomes associated with milk and molasses enemas. Safety outcomes of interest included bloating, flatus, and bleeding; serious complications including allergic reactions, bacteremia, bowel perforation, electrolyte abnormalities, abdominal compartment syndrome, cardiac arrhythmia, dehydration, death, and sodium and potassium changes. Findings indicated no milk and molasses enema-associated allergic reactions, bacteremia, bowel perforation, electrolyte abnormalities, abdominal compartment syndrome, cardiac arrhythmia, dehydration, or death. Sodium and potassium levels remained within normal limits during hospitalization, with no significant changes noted before or after milk and molasses enema administration. The authors concluded that the use of milk and molasses enemas for relief of constipation did not result in safety concerns in hospitalized adults. The authors suggested the findings indicated that this treatment is safe, and further study examining its efficacy in adults was warranted.

Relevance to Nursing Practice

There are still many health care practices that are based on tradition. Nurses are in an excellent position to consider existing evidence and to investigate practices for which there is little to no evidence related to use. The use of milk and molasses enemas to relieve constipation has been an intervention grounded in tradition but appears to have support for use as a treatment option for adults when other treatments have been ineffective.

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Skill 13-1

EVIDENCE FOR PRACTICE