1. Practical lesson № 14
Theme: «Enemas»

2. Practical lesson № 14
Theme: «Enemas»
CONTROL QUESTION
Enema, definition.
Classification enemas.
Cleansing enema. Purpose. Mechanism of action. Indication. Type. Used solution.
Methods used in given a large-volume cleansing enema.
Retention enema. Purpose. Mechanism of action. Indication. Type. Used solution.
Carminative enema. Return flow enema. Purpose. Mechanism of action.
The contraindications for cleansing enema.
General instruction for Giving Enema.
PRACTICAL SKILLS
Cleansing enema.
Retention (oil) enema.
Application of colonic tube (flatus tube).

3. Learning objectives
On completion of this practical lesson the learner will be able to do the following:
Define key terms used.
Explain constipation, its etiology, management and nursing care.
Enumerate diarrhoea, its causes and nursing care.
Describe the various treatments of the colon.
Perform practical skill: Cleansing enema.
Perform practical skill: Retention (oil) enema.
Perform practical skill: Application of colonic tube (flatus tube).

4. Enema - a medical manipulation, the essence of which is the introduction of the liquid into a direct or colon through the anus.
Enema is a procedure of administration different fluids in lower section of colon for therapeutic and diagnostic purpose.

5. For therapeutic purposes enemas are used for a very long time
For therapeutic purposes enemas are used for a very long time. In ancient Indian manuscripts are described prominately enema.
There are records of such treatment and in the Egyptian sources. Hippocrates developed the method of cleansing enemas from harmful juices by gastric lavage, laxatives and cleansing enemas.
Especially the widespread use of enemas in the treatment received in centuries, when patients put sometimes up to 10 enemas in a row.
С лечебной целью клизмы применяются очень давно. В древнеиндийских рукописях описываются промывательные клизмы.
Имеются упоминания о таком лечении и в Египетских источниках. Гиппократ разрабатывал метод очищения клизмами от вредных соков путем промывания желудка, слабительными средствами и очистительными клизмами.
особенно широкое применение клизм в лечении получило в вв., когда больным ставили иногда до 10 клизм подряд.

6. Enemas are classified into four groups according to their action:
cleansing,
carminative,
retention,
return-flow enemas.

7. A cleansing enema is probably the most common
CLEANSING ENEMAS
A cleansing enema is probably the most common
type of enema.
Purpose. Cleansing enemas are intended to remove feces.
Mechanism of action. This type of enema stimulates peristalsis via irritation of the colon/rectum and by causing intestinal distention with fluid.
They are given chiefly to (indication):
Remove feces in instances of constipation.
Prepare the intestine for certain diagnostic tests such as x-ray or visualization tests (e.g., colonoscopy)
Prepare the patient for surgery (prevent the escape of feces during surgery).

8. There are two general types of cleansing enemas: the large-volume enema the small volume enema.
A large-volume enema is designed to clean the colon of as much feces as possible. In a large-volume enema between 500 and 1000 ml of fluid is instilled into the rectum/colon and the patient is asked to retain the fluid as long as possible. This allows the fluid to soften and loosen the feces.
The large volume of fluid also distends the bowel, stimulating peristalsis.
Большая клизма для очистки кишечника как можно больше фекалий. В больших по объему клизмы между 500 и 1000 мл жидкость вводят в прямую кишку/толстую кишку и пациента просят как можно дольше удерживать жидкость. Это позволяет жидкости для размягчать и разрыхлять каловые массы. Большой объем жидкости также раздражает кишечник, стимулируя перистальтику.

9. Methods used in given a large-volume cleansing enema:
enema set (the rectal tip, enema bag, tubing)
enema bag

10. Skill 1. CLEANSING ENEMA
Purpose: Emptying of the lower part of the colon from feces and gases.
 Indications:
Remove feces in instances of constipation.
Prepare the intestine for certain diagnostic tests such as x-ray or visualization tests (e.g., colonoscopy)
Prepare the patient for surgery (prevent the escape of feces during surgery).
Counter-indications:
GI bleeding
Acute inflammatory and ulcerous processes in a colon or anus
Anal fissure
Rectal cancer
Bleeding hemorrhoids
The first days after operation on organs of the digestive system
Equipment. Sterile: enema bag, tubing, rectal tube (or enema set), gauze napkins, spatula, Vaseline, tray.
Unsterile: stand, oilcloth and diaper (or absorbent pad), container with water (volume 1 liters), basin (or bedpan), screen, oilcloth apron, disposable latex gloves, container with disinfectant solution.
Algorithm of action:
Explain to the patient the purpose and procedure course. Obtain patient’s consent.
Conduct hygienic washing hand and processing hand. Put the gloves on.
Prepare the equipment.
Isolate the patient with a screen.
Place the absorbent pad (oilcloth and diaper ) on bed under patient. Place the patient in left lateral position with flexed legs.
Wear an apron.
Prepare the enema set: Attach a rectal tube to the tubing. Close the clamp of enema bag. Prepare the solution at the required temperature. Enemas administered to adults are usually given at 105°–110°F (40.5°–43°C). Hang the enema bag with the solution on the stand. The solution should be 30–45 cm above the rectum for an adult. Fill the enema bag with a solution. Loosen the clamp and let a small amount of fluid to run into the kidney tray. Close the clamp.
Take the Vaseline with spatula. Lubricate rectal tube with Vaseline.
Spread patient buttocks with thumb and forefinger of the left hand.
Insert the rectal tube 7 to 10 cm slowly into the rectum, directing it toward the umbilicus.
Open the clamp of enema bag.
Slowly enter the about 500 to 1000 ml of fluid in the rectum.
Control for patients condition. Ask the patient to breath by abdomen.
Clamp the tubing.
Gently remove the rectal tube by pulling it through 3 to 4 layers of rag pieces.
Offer to the patient to take the water in the intestine during minutes.
Empty the intestine in bedpan or toilet pan.
Conduct disinfection used material. Take the gloves off and put them in the container for disinfection.
Wash hands.
Record the type of enema. The result.

11. Small-volume enemas are designed to clear the rectum and the sigmoid colon of fecal matter. Small volume enemas can be delivered with the traditional enema kit using 50 to 200 ml of solution.
But most frequently small-volume enemas are administered using a prepackaged disposable enema. Prepackaged enemas (Fleet enema) are easily administered and available over the counter in most drug stores.

12. Cleansing enemas. Solution used:
large-volume enema:
Hypotonic (Tap water)
Isotonic solution (Norman saline)
Soapsuds (3-5 ml soap and 1000 ml water
Small-volume enemas:
Hypertonic solution

13. Retention enema.
Retention enema introduces oil or medication into the rectum and sigmoid colon. The liquid is retained for a relatively long period of time, usually 1 to 3 hours. It acts to soften the feces and to lubricate the rectum and anal canal, thus facilitating the passage of feces. The effect in 3-6 hours.
Solution used: oil (olive, cottonseed, castor, mineral), medication. Temperature of the solution – 37,7°C.

14. Skill 2. RETENTION (OIL) ENEMA
Purpose: emptying of lower section of colon from fecal matter and gases (these are given to soften faecal matter)
Indications:
1. inefficiency the cleansing enema
2. the first days after operation on organs of abdominal cavity
3. after childbirth
Counter-indications:
Bleeding of intestine
ulcerous processes in a colon or anus
rectal prolapse
rectal growth
prolapse of the rectum
Rectal cancer
Equipment. Sterile: colonic tube, Janet's syringe with oil solution in a volume of 50–200 milliliters, Vaseline oil, gauze napkins, tray. Unsterile: gloves, oilcloth and diaper (or absorbent pad), apron, screen, container with disinfectant solution.
Algorithm of action:
Explain to the patient the purpose and procedure course. Obtain patient’s consent.
Conduct hygienic washing hand and processing hand. Put the gloves on.
Prepare the equipment.
Isolate the patient with a screen.
Place the absorbent pad (oilcloth and diaper ) on bed under patient. Place the patient in left lateral position with flexed legs.
Wear an apron.
Moisten the end of the colonic tube on the distance of cm by Vaseline.
The rounded end colonic tube to take as a pen.
Spread patient buttocks with thumb and forefinger of the left hand.
Insert the colonic tube 20 to 30 cm slowly into the rectum, directing it toward the umbilicus.
Attach the Janet's syringe to colonic tube and enter the oil solution.
Disconnect the Janet's syringe from the tube.
Fill the Janet's syringe with air, attach to colonic tube and carefully intake the air.
Gently remove the colonic tube by pulling it through 3 to 4 layers of rag pieces.
Wipe the anus with napkin.
Remove the diaper and oilcloth. Take off an apron, gloves and put into container with disinfectant solution.
Help patient to take a comfortable position. Give him recommendation - to lie during hours. Therefore this procedure should be done for the night.
Wash hands.
Record the type of enema. The result.

15. Medications can be administered by enema as well
Medications can be administered by enema as well. A small-volume enema can deliver a medicated solution directly to the rectal mucosa. This method of medication administration is useful when the rectum is the area to be medicated if the client is unable to take oral medications or if rapid absorption of the medication is required.

16. Carminative enema
Carminative enema. This is given primarily to expel flatus. The solution instilled into the rectum releases gas, which in turn distends the rectum and the colon, thus causing peristalsis ml of fluid is introduced.
An alternative method for flatulence - application of colonic tube (flatus tube).

17. APPLICATION OF COLONIC TUBE (flatus tube)
Purpouse: evacuation gases of intestine
Indications:
1. Meteorism (bloat) - accumulation of gases in intestine.
2. Using for staging of medicinal and oil enemas
Counter-indications:
Gastric and intestinal bleeding
Acute inflammatory and ulcerous processes in a colon or anus
Anal fissure
Rectal cancer
Bleeding hemorrhoids
Equipment. Sterile: colonic tube, vaseline, tray, gauze napkins.
Unsterile: gloves, screen, oilcloth, diaper, apron, bedpan, container with disinfectant solution.
Algorithm of action:
Explain to the patient the purpose and procedure course. Obtain patient’s consent.
Conduct hygienic washing hand and processing hand. Wear gloves.
Prepare the equipment.
Isolate the patient with a screen.
Place the absorbent pad (oilcloth and diaper ) on bed under patient. Place the patient in left lateral position with flexed legs.
Wear an apron.
lubricate the end of the colonic tube on the distance of cm by Vaseline.
The rounded end colonic tube to take as a pen.
Spread patient buttocks with thumb and forefinger of the left hand.
With a gentle rotatory movement, Insert the colonic tube 4 to 6 cm slowly into the rectum, directing it toward the umbilicus.
The free end of the tube being kept into the water in the kidney tray (or bedpan).
Leave the colonic tube on 20 minutes.
Wear gloves. Remove the colonic tube from the rectum using a napkin.
Put the colonic tube in container with disinfectant solution. Wipe the anus with napkin. Remove the bedpan, the diaper and the oilcloth. Take off an apron, gloves and put into container with disinfectant solution.
Wash hands.
Record the type of enema. The result.
NOTE: The tube can be re-inserted every 3 to 4 hour, if necessary.

18. Return flow enema. Return flow enema is used Referred also as colonic irrigation, this is used to expel flatus. This involves the alternating flow of fluid into and out of the large intestine to stimulate peristalsis and the expulsion of feces.

19. The contraindications for cleansing enema
Gastric and intestinal bleeding
Acute inflammatory and ulcerous processes in a colon or anus
Rectal cancer
Cracks in the anus or rectal prolapse
The first days after operation on organs of the digestive system
Bleeding hemorrhoids

20. General instruction for Giving Enema
1. Use the appropriate size catheter or rectal tube. 2. The rectal tube needs to be atraumatic. 3. Use lubricant. 4. Follow the temperature of solution. 5. Follow the amount of the solution. 6. Keep the correct patient position. 7. Keep the height of the enema bag. 8. Follow the depth introduction of rectal tube. 9. Follow the time of retention of solution in intestines. 10. Good condition equipment. 11. Follow the flow speed of fluid. 12. Prevent air from entering into the rectum Observe the patient's condition during the procedure.

21. General instruction for Giving Enema
1. The appropriate size catheter or rectal tube need to be used. For giving a cleansing enema use no. 22 French for adults, no. 12 French for an infant and no. 14 to 18 French for the school age child.
2. The rectal tube needs to be smooth and flexible. Any tube with a sharp or ragged edge should not be used because of the possibility of damaging the mucus membrane of the rectum.
3. The rectal tube is lubricated with a water soluble lubricant or with vaseline to facilitate insertion and to decrease irritation of the rectal mucosa. Use only a small amount to prevent blockage of the tube.
4. The temperature of the solutions needs to be adjusted according to the purpose of the enema. To give an evacuant enema, the temperature should be between 105 and 110°F (40.5° to 43° C) for adults and 100°F (37.7°C) for children. A retained enema should be given at the body temperature.

22. 5. The amount of the solution to be administered depends upon the type of the enema and the age and size of the person. For giving evacuant enema u 500 to 1000 ml for adults, 250 to 500 ml for a child and 250 ml or less for an infant.
For giving retained enema, the quantity given at a time should not be more than 100 ml to 150 ml so that the rectum will not be distended to cause peristaltic movement.

23. How can we strengthen the mechanical action of an enema?
The mechanical action of the enema, the more significant the greater the amount of liquid.
With the introduction of water into the rectum it increases the pressure. A large amount of water is an irritant to the intestinal wall. The increasing pressure and irritating effects of water leads to increased peristalsis. Intensive reduction of the walls of the intestine lead to washing of their inner surface and cleaned of residue content.

24. 6. When an enema is administered, the patient usually assumes a left lateral position. In this position, the position of the sigmoid colon is below the rectum, thus facilitating instillation of the fluid. For a high cleansing enema, the patient changes position during the administration of the enema from left lateral to dorsal recumbent and then to right lateral. In this way the entire colon will be reached by fluid. For an evacuant enema the bed should be made flat and for a retained enema the foot end should be raised.

25. If the patient is contraindicated movement, an enema can be put in the position of the patient on his back, placing it on the ship.

26. The height of the enema bag should be adjusted to regulate the flow of the solution according to the type of the enema administered.
For cleansing enemas, the height of the can should not be above 18 inches (45 cm) from the anus and for retention enemas, it should not be above 8 inches (20 cm) the from the anus.
The higher the container, the greater is the force with which the solution flows into the rectum. There inches an increase of 0,5 lb of pressure for every 12 inches of elevation.

27. What should be done if the water does not go into the intestine?
8. The distance to which the tube is inserted depends upon the age and the size of the patient. For an adult it is normally inserted 7.5 to 10 cm (3 to 4 inches), for children it is inserted only 2.5 to 3.75 cm (1 to 1.5 inches). If any obstruction is encountered, it should be withdrawn and reported.
What should be done if the water does not go into the intestine?

28. If the water does not go into the intestine can raise a mug Esmarch above or change the position of the tip, pulling it back to 1-2 cm;
If water still does not enter the intestine, remove the tip and replace it ( as it can be hammered feces).
If the rectum is impacted, attempt to remove the faecal matter with a gloved finger. The bowels should be cleaned out by a simple enema before giving retention enema.

29. 9. The length of time that the enema solution is retained will depend upon the purpose of enema and the ability of the patient to contract the external sphincter to retain the solution. Oil retention enemas are usually retained for 2 to 3 hours. Other cleansing enemas are normally retained 5 to 10 minutes. To assist a baby to retain the solution, the nurse can press the baby's buttocks together, thus providing pressure over the anal area. 10. Make sure the whole apparatus used for the administration of enemas is in a good working condition.

30. 11. Regulate the flow of fluid according to the type of the enema: give retention enemas very slowly, usually by Murphy drip. Before giving cleaning enemas, regulate the flow of fluid and pinch the tube before the tube is inserted into the rectum.
12. Prevent air from entering into the rectum:
By removing the froth from the solution
By expelling air from the tube
By not letting the fluid run in completely from tube.

31. Tell us what you will do if the patient felt pain?
13. Listen to the complaints of the client and should not ignore any discomfort however small they are.
Tell us what you will do if the patient felt pain?
If the patient appeared abdominal pain, you should immediately stop the procedure and wait until the pain goes.
If the pain does not subside remove the tip and report to the doctor.
With the introduction of the tip should not be in pain. In this case, you should remove the tip and try to enter it in the right direction.
With the introduction of water should not experience sharp pain, sharp or cutting. There should be no pain in the abdominal wall and ligaments, navel, perineum and scrotum. When such sensations procedure should be stopped immediately.

32. 14. Prepacked enemas will have their own instruction which need to be followed unless there are other instructions from the physician.

33. Dictionary Umbilicus – пупок Intestine - кишечник
Colon – толстая кишка
Rectum – прямая кишка
Sigmoid colon – сигмовидная кишка
Feces – кал
Stool – стул
Constipation - запор
Enema - клизма
Cleansing enema – очистительная клизма
Return-flow enemas – сифонная клизма
Oil enema – масляная клизма
Tubing – трубка
Rectal tube – ректальный наконечник
Colonic tube - газоотводная трубка
Bedpan - подкладное судно
Indication - показания
Counter-indications - противопоказания
Fluid – жидкость
Large volume of Fluid – большой объем жидкости
Small volume of Fluid – маленький объем жидкости
Explain to the patient – объяснить пациенту
Obtain patient’s consent – получить согласие пациента
Lubricate rectal tube – смазать трубку
Slowly enter – медленно ввести
Gently remove - аккуратно удалить

34. Homework for next practical lesson:
Lecture: Peculiarities of care for patients with diseases of the urinary system.
Practical lesson № 15.