Enema

Enema

Enema is the introduction of plain or medicated fluid into the rectum. Enema means introduction of solution into the large intestine for removing faces and cleaning the bowel.

An enema administration is a technique used to stimulate stool evacuation. It is instillation of a solution into the rectum and sigmoid colon. There are many types of enema given for many purposes. The primary reason for an enema is to promote defecation by stimulating peristalsis. The volume of fluid instilled breaks up the fecal mass stretches the rectal wall and initiates the defecation reflex. It is also a vehicle for medications that exert a local effect on rectal mucosa.

Purposes

• To relieve constipation, flatulence or distension.
• To prevent involuntary escape of fecal matter during surgical procedure and delivery.
• To promote visualization of the intestinal tract during a radiographic or instrumental examination like protoscopy.
• To stimulate peristalsis.
• Pre-operative preparation for bowel surgeries.
• To sooth or treat irritated mucosa of the colon.
• To supply fluids, nutrients or medications like sedatives.
• To induce labour, qa sides sno) sails hisc
• To relieve the retention of urine by reflex stimulation of bladder.
• To diagnose disease conditions of the colon such as ulcer, tumours or new growth.
• To establish regular bowel functions during bowel training program.

Principles

• The appropriate size of rectal catheter or rectal tube of cleansing enema is 22 fr. for adults, 12 fr. for infants and 14 to 18 fr. for children (school age child).
• Be sure that the equipment is in a good working condition.
• Check the doctor's order, maintain the patient's privacy.
• The rectal tube needs to be smooth and flexible.
• Use lubricant water soluble or Vaseline to facilitate insertion and to decrease irritation of the rectal mucosa.
• Prevent air from entering the rectum by expelling the air and clamping the tube before inserting it into the rectum.
• Maintain the temperature of fluid about 105°f.
• Do not let the fluid run completely out of the container.
• Tell the patient to take a deep breath while the rectal tube is inserted and to hold the fluid inside the rectum until the procedure is finished.
• The patient usually placed in left lateral position, when an enema is administered. In this position sigmoid colon is below the rectum, thus facilitating instillation of the fluid.
• 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 2.5 to 3.75 cm (1 to 11/2 inches).
• The height of the enema should not be above 18 inches (45 cm) from the anus.

Contraindications

• Acute renal failure.
• Acute myocardial infractions and cardiac problems.
• Appendicitis.
• Obstetrical contraindications like antepartum hemorrhage, leaking membranes.
• Recent surgical procedures involving lower intestinal tract.
• Intestinal obstruction.
• Inflammation and infection of abdomen.

Commonly Used Enema Solutions

Hypertonic: e.g. Sodium phosphate, fleet enema; 70- 130 ml.

Action: Draws water into the colon, distends intestine, irritates intestine mucosa. Effective in 5 to 10 minutes.

Adverse effects: Retention of sodium.

Hypotonic/Tape Water: 500 to 1,000 mL of tap water.

Action: Distends colon, stimulate peristalsis, and softens feces. Effective in 15 to 20 minutes.

Adverse effects: Fluid and electrolyte imbalance; water intoxication.

Isotonic: 500 to 1,000 mL of NS or Physiological saline (one table spoon of table salt in 500 ml of tap water.).

Action: Distends colon; Stimulates peristalsis, and softens feces. Effective in 15 to 20 minutes.

Adverse effects: Possible sodium retention. 

Soapsuds: 3-5 mL soap to 1,000 ml water. Effective in 10 to 15 minutes.

Action: Irritates mucosa, distends colon.

Adverse effects: Irritates and may damage mucosa.

Oil: mineral, olive oil or cottonseed oil; 150 to 200 ml; lubricates stool and intestinal mucosa; effective in 10 to 15 minutes.

Types of Enema

Non-Retention Enema

Purposes

• Evacuating faeces and gas from the bowel for surgical or any other diagnostic purposes.
• Stimulating the colon by heat and chemicals used in the solution.
• Softening fecal matter and relieving constipation.
• Withdrawing fluid from tissue to reduce edema.

Purgative/Cleansing Enema

Cleansing enema promotes the complete evacuation of faeces from the colon. They act by stimulating peristalsis through the infusion of a large volume of solution or through local irritation of the mucosa of the colon. It is given to cleanse the bowel before x-ray studies, surgery and retention enema. There is high and low cleansing enema. The term high and low refers to the height from and hence the pressure with which, the fluid is delivered. High enemas cleanse the entire colon. After the enema is infused ask the patient to turn from the left lateral to the dorsal recumbent, over to the right lateral position. The position change ensures that fluid reaches the large intestine. A low enema cleanses only the rectum and sigmoid colon.

The cleansing enemas include tap water, normal saline, soapsuds solution and low volume hypertonic saline. Each solution has a different osmotic effect, influencing the movement of fluids between the colon and interstitial spaces beyond the intestinal wall. Infant and children receive only normal saline because they are risk for fluid imbalance.

Administering a Cleansing Enema

Articles needed

A tray containing:

• Rubber tubing with connection
• Rectal catheter and clamp
• Oil or water soluble lubricate such as vaseline for rectal tube
• Kidney tray or emesis basis
• Bowl of water
• Forceps
• Paper bag
• A pair of gloves
• Bath thermometer

Enema can, Solution required for enema.

Enema stand or any other stand to hang the enema can. 

Screen

Mackintosh/water proof under pad.

Bedpan (for helpless patient)

Appropriate size of rectal tube

• Adult size- 22-30 fr.
• Child size- 12-18 fr.

Temperature of solution

• Adult: 105-110° f. (40-43°C)
• Child: 100° f (37.1°C)

Amount of solution for different age groups

• Adult: 750-1000 ml
• Adolescent: 500 - 750 ml.
• School age: 300 - 500 ml
• Toddler: 250-300 ml
• Infant: 150-250 ml.

Procedure

Special Consideration

• Patients with hemorrhoids may experience discomfort/bleeding when enema 18 administered. Warm sitz bath can be given to relieve discomfort after the procedure. Be observant for persistent rectal bleeding.
• Assess the status of the patient, last bowel movement, normal bowel pattern, hemorrhoids, mobility, external sphincter control, abdominal pain and perineal lesions.
• Determine the level of consciousness and understanding of the patient.
• Check the medical record and clarify the rationale for enema and review the physician's order.
• Improper administration of an enema may cause electrolyte imbalance (with repeated enemas).
• Ruptures to the bowel or rectal tissues resulting in internal bleeding.
• The enema tube and solution may stimulate the vagus nerve, which may trigger an arrhythmia such as bradycardia. Enemas should not be used if there is an undiagnosed abdominal pain since the peristalsis of the bowel can cause an inflamed appendix to rupture.

Normal Saline Enema

Physiologically normal is an isotonic solution. So it is the safest solution to use because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel. The volume of infused saline stimulates peristalsis. It considered as the safe enema because it does not create the danger of excess fluid absorption.

Tap Water Enema

It is use of plain tap water as the enema solution. It is hypotonic and exerts an osmotic pressure lower than fluid in interstitial spaces. Due to its less concentration than the body fluids, it may be drawn into the body and may cause electrolyte imbalance or circulatory overload.

Hypertonic Solutions

Hyper tonic solutions infused into the bowel exert osmotic pressure that pulls fluids out of the interstitial spaces. The colon fills with fluid, and the resultant distention promotes defecation. Patients unable to tolerate large volumes of fluid benefit most from this type of enema, which is by design low volume. This type of enema is contraindicated for patients who are dehydrated and young infants. A hypertonic solution of 120 to 180 ml is usually effective. The commercially prepared fleet enema is the most common.

Soap Water Enema/ Soapsuds

A soap enema is when a mild soap is added to an enema for a more thorough colon cleansing. Soap enemas expand the colon and clean the walls to remove anything caked on its sides. An enema is a safe, effective, and natural way to cleanse the bowel. It more closely approximates a natural movement than laxatives or suppositories and is much more gentle on the system.

Retention Enema

Retention enemas are to be retained for a shorter or longer period. These enemas are given slowly with a small rectal catheter and a funnel. It introduces oil or medication into the rectum. Types:

• Antibiotic
• Anthelmintic
• Nutritive

Retention enema is further classified as:

Short Retaining Enemas

Short retaining enema allows fluid and remains inside for 10-30 minutes for absorption. Sometimes these are called small enema.

Oil-retention

An oil-retention enema is administered to lubricate the rectum and the colon. The oil is absorbed by the feces, making them softer and easier to pass. The enema must be retained ½ or 1 hour to soften the faeces. The solutions used are olive oil, gingerly oil, castor oil etc. For adults, the usual amount of solution instilled is 150 to 200 mL; for children, it is 75 to 100 ml and the temperature of the solution is 100°F.

Antispasmodic or Carminative

Carminative enemas provide relief from gaseous distention. They improve the ability to pass flatus. It is given to relieve gaseous distension of abdomen by increasing peristalsis and expulsion of flatus. An example of a carminative enema is MGW solution, which contain 30 ml of magnesium, 60 ml of glycerin and 90 ml of water.

Anti-helminthic Enema

It is given to destroy and expel worms from the intestines. Cleaning enema must be given prior to anti helminthic enema, so that the drug comes in direct contact with worms and the lining of intestine. Hypertonic 60ml with saline 600 ml of water is mainly used. The amount should be 250ml.

Astringent Enema

Astringent enema contracts the tissues and blood vessels, checks bleeding and inflammation, lesions the amount of mucus discharge and temporary relief in the inflamed area. It is given to relieve spasms of inflamed intestine e.g. in colitis and dysentery. The solutions used are tannic acid 25 gm. to 600 ml water, Alum 30 gm to 600 ml of water and Silver nitrate 2% (silver nitrate is dissolved in the distilled water.)

Diagnostic Enema

Introduce barium for x-ray to find the outline of the intestine.

Varipague Enema

This contains a substance which activates the colon. It could be given in combination with barium enema or before the barium enema. It includes One phial of varipague dissolved in 2 liters of water at 38°c and is given by a funnel and catheter.

Long Retaining Enemas

Long retaining enemas allow fluid to remain inside for 30-60 minutes for absorption.

Sedative Enema

Sedative enema contains an anesthetic drug to produce anethesia in the patient. The commonly used drugs are paraldehyde, chloralhydrate and potassium bromide. The dose is according to the patient's condition and physicians'.

Purposes

• For sedative action
• To relieve pain
• To relief diarrhoea and dysentery.

Nutrition Enema

It is given to supply food and fluids to the body. Selection of the fuids depends upon the ability of the colon to absorb it. Nutrient enema is particularly useful in conditions like hemophilia. Normal saline, glucose saline, 5%, 10% glucose, peptonised milk (120ml) are used for nutrient enema. The amount of solution is taken about 180-200 ml every 4 hourly. The temperature of the solution should be 100°f.

Cold Water or Ice Water Enema 

It is given to reduce temperature by drip method in hyperpyrexia and heat stroke. The temperature of the solution should be 65 to 75°f.

Medicated Enema

Medicated enema may be given for the local effect they exert on the rectal mucosa. A common example is one containing the antibiotic neomycin, which is used to reduce bacteria in the colon before bowel surgery. Medicated enema can also be given to produce a systemic effect. An example is one containing sodium polystyrene sulfonate (Kayexalate), which is administered to treat patients who have dangerously high serum potassium levels. 

Ezevac Enema (Commercially Prepared Enema)

It is the commercially prepared solution for enema.

Procedure

Rectal Suppositories

Rectal suppositories are solid forms of medication that are inserted into the rectum. They come in different shapes and sizes, but they are usually narrowed at one end. Rectal suppositories can deliver many types of medication. For instance, they may contain glycerin to treat constipation or acetaminophen to treat a fever. Medication from a rectal suppository tends to work quickly. This is because the suppository melts inside the body and is absorbed directly into the bloodstream.

Procedure

• Gently squeeze the suppository to check if it is firm enough to insert.
• Wash hands with soap and water.
• Remove clothing to expose your buttocks.
• Remove any wrapping from the suppository. If you need to cut the suppository, carefully cut it lengthwise with a clean, single-edge razor blade.
• To moisten the tip of the suppository, apply a lubricating jelly.
• Position the patient. Lie down on side with top leg slightly bent toward stomach and bottom leg straight. Relax your buttocks to make it easier to insert the suppository.
• Insert the suppository into the rectum, narrow end first. Gently but firmly, push the suppository past the sphincter. For adults, push it in one inch. For children, depending on their size, push it in a half inch to one inch. And for infants, push it in about a half inch.

• Sit or lie with legs closed for 15 minutes. If giving the suppository to a child, may need to gently hold their buttocks closed during this time.
• Throw away all used material in a trash can.
• Wash your hands right away with soap and warm water.

Digital Removal of Stool

Digital evacuation is the use of fingers to aid in the removal of stool from the rectum. In cases where one has hardened and large impaction, manual bowel impaction removal is often employed where the masses are broken down using gloved fingers. It is often recommended patients who suffer from serious neurological problems including spinal injuries. To do the procedure, a health provider will insert one or two fingers into your rectum and slowly break the masses down to smaller pieces which can then come out. Care must be taken to avoid rectum injury i.e. it should be with small steps. During the process, it is possible for treatments laxative suppositories to be inserted to rectum to help in clearing feces i.e. in removal of the impacted fecal matter.

Diarrhoea

Diarrhoea is defined as an increase in the number of bowel elimination that occurs more than 3 times a day. Diarrhea can be acute or chronic. Acute diarrhea occurs when the condition lasts for one to two days. It's usually the result of a viral or bacterial infection and due to food poisoning. Chronic diarrhoea refers to diarrhoea that lasts for at least two weeks. It's usually the result of an intestinal disease or disorder, such as celiac disease or Crohn's disease.

Causes

• Infection (with a virus, bacteria or parasite)
• Food intolerance
• Inflammatory bowel disease (ulcerative colitis or Crohn's disease)
• Mal-absorption
• Emotional stress
• Food allergic
• Medications such as antibiotics
• Laxatives.
• Surgery (e.g. when part of the bowel has been removed)

Sign and Symptoms

In addition to frequent, watery bowel movements, the stool may also contain mucus, pus, blood or excessive amounts of fat. Diarrhoea can be accompanied by: 

• Painful abdominal cramps
• Nausea
• Fever Bloating
• Generalised weakness.

Diarrhoea can cause dehydration, especially in young children and older people. Symptoms of dehydration can include:

• Thirst, dry mouth;
• Irritability;
• Lack of energy;
• Passing less urine than normal;
• Dizziness or light-headedness; and
• The skin on the back of your hand being slow to return to position after being pinched upwards.
• Sunken eyes.

Principles of Diarrhoea Management

• Assessment of the children's condition.
• Assessment of the fluid and electrolyte imbalance.
• Identify the level of prevention.
• Correction of rehydration.
• Maintenance fluid therapy.
• Proper nutritional care.
• Treatment of underlying causes and associated problems.
• Treatment of complications.
• Prevention of diarrhea.

Management of Diarrhoea

• Restrict food intake if the patient has gastroenteritis with vomiting. However, do not limit fluid intake.
• When the patient starts eating, feed small frequent feedings of food and only bland, avoiding grains and uncooked fruit and vegetables.
• Restrict consumption of fatty, sweet or spicy foods.
• Watch for signs of dehydration, especially in children and the elderly.
• Replacement of fluid and electrolytes.
• Skin around the rectum should be clean and dry.
• The patient must have adequate sleep & rest, because it will reduce bowel activity.
• Antimicrobial drugs can be given only when the patient has specific infective disease like dysentery or cholera.
• The patient needs emotional support in this situation and needs to know that the nurse is there to help him/her. 

Components of a Diarrhoeal Disease Control Programs

The intervention measures recommended by WHO may be classified as below:

Appropriate clinical management

• Oral rehydration therapy
• Appropriate feeding
• Drug therapy

Better MCH care practices

• Maternal nutrition
• Child nutrition

Preventing strategies

• Sanitation
• Health education
• Immunization
• Fly control

Oral Rehydration Therapy

Oral rehydration therapy means drinking of solution of clean water, sugar and mineral salts to replace the water and salt lost from the body during diarrhea, especially when accompanied by vomiting, i.e. gastroenteritis. The introduction of oral rehydration, by WHO in 1971, has greatly simplified the treatment of diarrhea diseases. The aim of the oral fluid therapy is to prevent dehydration and reduce mortality. ORT is beneficial in three stages of diarrheal disease, i.e. (a). Prevention of dehydration (b) rehydration of the dehydrated child and ( maintenance of hydration after severely dehydrated patient has been rehydrated with IV fluid therapy. Oral fluid therapy is based on the observation that glucose given orally enhances the intestinal absorption of salt and water, and is capable of correcting the electrolyte and water deficit.

Method of Making Oral Rehydration Solution

Packets of "oral rehydration mixture" are now freely available at all primary health centers, sub centers and hospitals. The contents of the packet are to be dissolved in one liter of drinking water. The solution should be made fresh daily and used within 24 hours. It should not be boiled.