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Types of enemas

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tap-water enema saline enema soapsud enema small-volume enema oil-retention enema

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Safety and comfort measures for giving enemas

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-void first -measure solution temp - position patient into left sims position -lubricate tio -usually insert 2-4 inches in adults

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Safety and comfort measures contd...

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-stop insertion if feel resistance -raise bag 12 inches above anus -give solution slowly -hold enema tube in place -determine how long person should retain solution

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After enema is administered

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-make sure the bathroom is vacant or that a BSC is readily available at bedside -observe enema rsults and document in the patients chart

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What is an enema

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an installation of a solution into the rectum and sigmoid colon.

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Primary reason for giving an enema

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promote defecation by stimulating peristalsis

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What happens during an enema

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the volume of fluid instilled breaks up the fecal mass, stretches the rectal wall, and initiates the defecation reflex

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most common use for an enema

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temporary relief of constipation, but other indications include removing impacted feces, emptying the bowel before diagnostic tests or surgery, and beginning a program of bowel training

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enemas are also a vehicle for

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medications that exert a local effect on rectal mucosa

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is sterile technique necessary when administering an enema

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no because the colon normally contains bacteria...however wear gloves to prevent the transmission of fecal organisms

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What is to be done before administration

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explain the procedure, including the position to assume, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation. If enema is prescribed at home, explain the procedure to a family member

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What does it mean to give an enema until clear

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the enema is repeated until the patient passes fluid that is clear and contains no fecal material. Often have to give as many as three enemas, but caution against using more than three because it can deplete fluids and electrolytes.

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If the enema fails to return clear solution after 3 times, or if the patient seems to not be tolerating the rigors of repeated enemas

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notify the health care provider

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The skill of administering an enema can be delegated to NAP HOWEVER...

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The nurse must first assess the patient for specific considerations such as need for alternative positioning, comfort, and stable vital signs before the procedure

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Instruct NAP about

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-proper way to position patients who have mobility restrictions such as patients with arthritis or severe fatigue -how to position patients who also have therapeutic equipment present such as drains; intravenous catheters or traction -specific signs and symptoms of patient's intolerance to the procedure and when to stop it such as abdominal pain more than pressure sensation, abdominla cramping, abdominal distention, or rectal bleeding

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Startings of administering an enema

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-assess patient: last bowel movement, norma bowel patterns, hemorrhoids, mobility, sphincter control, and abdominal pain -assess for intracranial pressure, glaucoma, or recent rectal or prostate surgery which is a contraindication -check med rec for rationale -review the order for the enema -identify patient with 2 identifiers (name and dob) -inspect for ab distention and ausculate bowel sounds -explain purpose of enema and ensure PT understands -collect appropriate equipment and position it at bedside -assemble bag and tube -hand hygien and gloves -privacy with curtains -raise bed -raise side rail on PTs left -position in left SIMS -place waterproof pad under hips and butt -cover patient w/ bath blanket, exposing only anus -place bedpan or commode in an easily accessible postion

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administering the actual enema bag

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-add warmed solution to enema bag - check temp -raise container, release clamp, and allow solution to flow long enough to fill tubing -lubricate 2.5 to 3 inches of tip of rectal tube with water soluble lubricating jelly -seperate butt and locate anus -instruct patient to relax by breathing out slowly -insert tubing in the anus by pointing it towards the umbilicus (adult 3-4 inches, adolescent 3-4 inches, child 2-3 inches, infant 1-1.5) -hold tubing in rectum until fluid is in -open clamp and allow fluid to flow -raise height of enema (12-18 inches for high enema, 12 inches for regular enema, 3 inches for low enema) -lower to decrease flow or clamp tubing if patient experiences cramping -clamp tubing after all solution is instilled

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administering a prepackaged disposable container

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this process is very similar to the enema bag, except you squeeze it until all of the solution has entered. instruct patient to retain solution until urge to defecate occurs, usually 2-5 minutes

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endings of the enema process

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-place layers of tissue aorund tubing and withdraw from the rectum -explain to patient the feeling of distention is normal -ask patient to retain solution as long as possible -discard of enema container -assist patient to bathroom or bedpan -assist patient with washing anal area -remove glove and do hand hygiene

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evaluation

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-evaluate color and consistency, amount and odor -observe abdomen for distention - ask patient about crmaping or discomfort

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unexpected outcomes and related interventions

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-abdomen becomes distended and rigid (stop enema) -ab pain or cramping (decrease height/slow, slow deep breaths) -Bleeding occurs (stop enema, vital signs, and rectum)

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***READ OVER THE TYPED OF ENEMAS IN THE BOOK ON PG 1107

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...

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When would you do a specimen collection

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a provider may order tests on urine or stool to help with a patient's diagnosis or to determine effectiveness of therapy/treatment

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2 common specimen collections

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mid-stream urine collection guaiac for occult blood in stool

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Mid-stream urine collection

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-use 2 patient identifiers -assess voiding status of patient and when they last voided -assess for signs and symptoms of UTI -Provide fluids 1/2 hour before if patient doesn't feel the urge to void -explain procedure to patient and reason for sampling -perform hand hygiene -provide privacy -provide cleaning towelette or soap and washcloth to clean perineal area -use surgical asepsis, open sterile urine sampling kit or prepare sterile supplies -wearing gloves, open sterile specimen cup, placing cap with sterile inside surface up; do not touch inside of container or cap -instruct patient on how to collect (30-60mL) or assist a dependent patient

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How to collect the urine

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women- clean the perineal area, hold the labia apart, and place cup underneath urethra and begin urinating men- clean penis tip in circular motion and hold cup underneath penis and begin urinating

question

after urine has been collected

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-replace cap -clean urine form exterior of cntainer -remove and empty bedpan -attach lab requisition to bag -remove gloves do hand hygiene -transport to lab within 15-30 mins or refrigerate immediately

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unexpected outcomes

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urine is contaminated with feces or toilet paper (obtain new one) specimen is accidentally discarded (new one)

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Observation of stool

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color, amount, consistency, presence of blood or mucus, odor, shape, freqency of defecation, complaints of pain or discomfort

question

Guaiac stool for occult blood

answer

-stool is collected in a clean bedpan or white hat placed under commode lid -open the front of the hemocult slide using the wooden stick, take a smal sample of stool and smear in window A. And take another sample from a differet location in the stool and then smear in window B. -close the front flap. Turn slide over to the back of kit. Open the flap on the reverse side and place two drops of hemocult solution on each box and one drop on the control strip at the bottom -Observe any change in color. blue color indicates presence of blood in stool (positive)

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specimen labeling

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• If the patient has pre-printed labels in his/her medical chart, you can use one of those labels to place on the collected specimen. • If the patients has no label, then you need to obtain a blank label

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what goes on a specimen label

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o Patient name o DOB o Name of test requested o Specimen type (stool, urine, throat, culture, wound culture, ect.) o Date and time collected o Your initials -Room # -MRN o Place specimen in a biohazard plastic bag along with a requisition sheet (if needed) and send down to the lab for processing

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Intake and output

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-Measuring and recording intake and output during a 24 hour pd is a part of the assessment database for fluid and electrolyte balance -You are responsible for accurate recording of all intake (liquids taken orally, by enteral feeding, and parentally) and output (urine, diarrhea, vomitus, gastric suction, and drainage from surgical tubes)

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Monitor I&O for patients with

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a fever or edema, receiving intravenous (IV) or diuretic therapy, or on restricted fluids. This monitoring is also important when a patient has electrolyte losses associated with vomiting, diarrhea, GI drainage, or extensive open wounds such as burns

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Because fluid imbalance can occur at any time

answer

be aware of I&O for all patients, even when documentation is not required

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I&O the nitty gritty

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o Part of assessment database for fluid and electrolyte balance o Accuracy critical; requires patient and family cooperation o Used to monitor patients with fever, edema, IV fluids, diuretic therapy, and restricted fluids

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Parts of this task cannot be delegated to an NA; some parts can be delegated...The nurse directs NAP to:

answer

Measure and record input and output Report changes in patients condition such as alteration in intake or changes in color, amount, or odor of output

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Most fluids that patient takes will be measured in

answer

ml

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Most units will have special forms or white boards where ongoing I&O cann be calculated...these can be written down by

answer

NA or RN depending on who is measuring the I&O

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urinals have hash marks on them that

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measure the urine before being discarded

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for more accurate urine measurement

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clear, plastic, triangular graduated cylinders are used

question

How is a liquid stool measured

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bedpan or BSC bucket, or a white hat or collection container is placed under the commode lid

question

Bowl of soup

answer

6oz

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coffee cup

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8oz

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bedside pitcher

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900ml

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soda can

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8oz

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milk carton

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240ml

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jello container

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4oz

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juice container

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4oz

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ice is calculated as

answer

half its volume to take into account its volume after it melts

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characteristics of urine

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color, odor, clarity

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intake and output- each kilogram of weight lost or gained is equal to

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1L of fluid retained or lost

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In the fluid assessment of I&O compare patients

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24 hour intake with their output. they should be approximately the same if the patient has normal fluid balance

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if intake is greater than output

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2 possibilities: the patient may be gaining excessive fluid or may be returning to normal fluid status by replacing fluid lost previously from the body

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if intake is smaller than output

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the patient may be losing needed fluid from the body and developing ECV deficit and/or hypernatremia or may be returning to normal fluid status by excreting excessive fluid gained previously

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fluid intake includes

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all liquids that a person eats, drinks, or receives through nasogastric or J feeding tubes

question

fluid output includes

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urine, diarrhea, vomitus, gastric suction, and drainage from post-surg wounds

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a change in urine volume is a significant indicator of

answer

fluid alterations or kidney disease

question

report any extreme increase or decrease in

answer

urine volume

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daily output generally ranges from

answer

1200-1500 ml

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an hourly output of less than __ml for more than 2 consectutive hours is a cause for concern

answer

30

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Also need to report high volumes which range from

answer

2000-2500

question

colostomy

answer

large intestine

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ileostomy

answer

small intestine

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when should you empty an ostomy bag?

answer

when it is 1/3 to 1/2 full

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When are pouches changed and why?

answer

every 3-7 days or when leaks occur, because it prevents odor

question

changing an ostomy appliance

answer

-position patient in a semireclining or reclining position -perform hand hygiene and place chux on top of patients abdomen -remove pouch and skin barrier gently -empty pouch and measure for I&O -Dispose of pouch and skinbarrier -clean peristomal skin with water no soap

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Pouching a new ostomy cannot be delegated to NAP, but

answer

pouching an existing ostomy can

question

NAP needs to be informed about

answer

-appropriate pouch and skin barrier -signs of stoma and peristomal skin changes to report to a registered professional nurse -monitoring and reporting characteristics and volume of ostomy output -special equipment needed for the procedure

question

how to pouch an ostomy

answer

-hand hygiene -ausculate bowel sounds -observe skin barrier -observe stoma for color, swelling, trauma, and healing; it is normally moist and reddish pink -observe effluent from stoma and record it

question

READ HOW TO POUCH A OSTOMY ON PAGE 1121 and look over types of colostomies on pg 1093

answer

...

question

Nutrition when using an ostomy

answer

low fiber foods so that a blockage doesnt occur from hard stools Avoid foods that cause gas and odor like broccoli, cauliflower, dried beans, and brussel sprouts

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Bowel diversions

answer

certain diseases cause conditions that prevent normal passag of feces through the rectum, and treatment results in the need for a temporary or permanent artificial opening (stoma) in the abdomnal wall

question

what determines the consistency of the stool?

answer

the location of the ostomy (ileostomy=frequent wet stools, colostomy= solid formed stool)

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