The administration of some types of enemas may be delegated to assistive personnel (AP) who have received appropriate training. The administration of a small-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.

• Commercially prepared enema with rectal tip
• Water-soluble lubricant
• Waterproof pad
• Bath blanket
• Bedpan or commode and toilet tissue
• Disposable gloves
• Additional PPE, as indicated
• Paper towel
• Washcloth, skin cleanser, and towel

Ask the patient when they had their last bowel movement. Assess the patient's abdomen, including auscultating for bowel sounds and palpating the abdomen. Because the goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds, assess the abdomen before and after the enema. Inspect the rectal area for any fissures, hemorrhoids, sores, or rectal tears. If any of these are noted, take added care while administering the enema. Check 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 (Doughery & 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.

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 for why the tube 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.	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). 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. 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 provide 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 retention of solution. 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.
9. Put on gloves.	Gloves prevent contact with contaminants and body fluids.
10. Remove the cap (Figure 1) and generously lubricate the end of the rectal tube 2 to 3 inches (5 to 7 cm). Purge the air from the enema nozzle, based on the manufacturer's guidance (Mitchell, 2019b).	Lubrication facilitates passage of the rectal tube through the anal sphincter and prevents injury to the mucosa. Introduction of air into the colon causes distention of the walls and unnecessary discomfort for the patient (Mitchell, 2019b).
11. Lift a buttock to expose the anus. Ask the patient to take several deep breaths. Slowly and gently insert the enema rectal tube 4 to 5 inches (10 to 12.5 cm) for an adult. Direct it at an angle pointing toward the umbilicus, not bladder (Figure 2). Do not force entry of the tube.	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, helping prevent perforation of the bowel. Slow insertion of the tube minimizes spasms of the intestinal wall and sphincters. Forcing a tube may injure the intestinal mucosa wall.
12. Compress the container with your hands (Figure 3). Roll the end of the enema container up on itself, from the bottom, toward the rectal tip. Administer all the solution in the container. 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.	Rolling the container aids administration of all its contents. 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.
13. After the solution has been given, remove the tube, keeping the container compressed. Have a paper towel ready to receive the tube as it is withdrawn.	If the container is released, a vacuum will form, allowing some of the enema solution to reenter the container.
14. 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 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 prevents the spread of microorganisms.
15. Raise the side rail. Lower the bed height and adjust the head of the bed to a comfortable position.	Positioning promotes patient safety.
16. 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.
17. 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 the bathroom. 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.
18. Remind the patient not to flush the toilet or empty 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” on the following page.
19. Put on gloves and assist the patient, if necessary, with cleaning of 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. Hand hygiene prevents the spread of microorganisms.
20. 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.
21. Perform hand hygiene.	Hand hygiene deters the spread of microorganisms.