An enema is the administration of a substance in liquid form into the rectum.

This may be performed to aid bowel evacuation or to administer medicines.

The administration of an enema not only requires skill and competence on

behalf of the practitioner but also requires compliance with the NMC (2004)
guidelines on the administration of medicines and local drug administration
policy.

Enemas for bowel evacuation

There are two different types of enema for bowel evacuation, although they
are very similar. Some enemas are given to produce an immediate effect,
which is to lubricate, thus facilitating the passage of faeces. The
administration of a fluid into the rectum may also induce peristaltic contraction
of the rectal walls.

Retention enemas, while producing the same effects, are intended to remain
in the rectum for a longer period of time penetrating and thus lubricating the
faeces further. Retention enemas tend to be oil based.

Enemas as a method of drug administration

Medicines can be administered rectally in enema form. This may be carried
out for local effect, such as steroids and agents that reduce inflammation in
the colonic mucosa. In addition, drugs may be absorbed for systemic effect by
the vascular network surrounding the rectum.

Contraindications/risks of administering enemas

The administration of enemas should be avoided in patients following colonic
surgery or patients with injury or obstruction, as the risk of perforation may be
increased. This risk may also be raised in patients who have undergone
gynaecological surgery or radiotherapy.

Enemas should also be avoided in cases of paralytic ileus as the peristaltic

movement of the colon is lost. Absorption of enema fluid/solutes may occur
and this must be considered in all patients.
Small-volume concentrated enemas may be contraindicated in cases of
ulcerative and inflammatory conditions.

The risks associated with enema administration are considered to be low but
can be detrimental and in some cases may be fatal. Expert advice should be
sought from specialist practitioners in any of the circumstances stated above.

The procedure
Warming the enema solution to body temperature may be beneficial as heat
stimulates the rectal mucosa. Dougherty and Lister (2004) recommend a
solution temperature of 40.5-43.3 degsC for non-oil-based enemas. Cold
solutions should be avoided as they may cause cramping.

Advising the patient to empty her or his bladder before the procedure may
reduce the feeling of discomfort (Dougherty and Lister, 2004).

The equipment required to perform an enema is as follows:

 Gloves and disposable apron;

 Incontinence pads;

 Lubricating solution;

 Jug with water, warmed to the desired temperature;

 Water thermometer;

 Bedpan/commode;

 Prepared solution.

The procedure is as follows:

 Obtain informed consent, identifying allergies and any contraindications.

 Provide the patient with reassurance.

 Assess patient privacy and dignity and take steps to maximise both.
  Ascertain prescription details if required.

 Wash hands and don plastic apron.

 Check the enema for expiry and intactness. Warm the solution to desired
temperature (Fig 1).

 Position the patient on left side, lying with the knees drawn to the abdomen
(Fig 2). This eases the passage and flow of fluid into the rectum. Gravity and
the anatomical structure of the sigmoid colon also suggest that this will aid
enema distribution and retention.

 Position an ‘incontinence’ sheet underneath the patient.

 Assess the area and perform a digital rectal examination if this has not already
been carried out.

 Break the enema seal. Lubricate the nozzle. Air should be expelled.

 Gently separate the buttocks, identifying the anus. Insert the lubricated nozzle
into the rectum slowly to a depth of approximately 10cm (in adults) (Fig 3).

 Gently expel the contents into the rectum, rolling the container from the bottom
up to reduce backflow.

 Keeping the container rolled/compressed withdraw the container (Fig 4).

Attend to peri-anal hygiene.

 Ask the patient to retain the enema for as long as required or suggested in the
manufacturer’s recommendations, providing a commode or nurse-call system
as indicated (Fig 5).

 Dispose of any waste, remove apron, wash hands.

 Document the procedure accurately, completing drug record if required (Fig

6).

 Ensure effect is noted and documented accurately.

 Professional responsibilities
All nurses who carry out clinical procedures must have received approved
training, undertaken supervised practice and demonstrated competence in the
clinical area. The onus is also on the individual to ensure that knowledge and
skills are maintained from both a theoretical and a practical perspective.
Nurses should also undertake this role in accordance with an organisation’s
protocols, policies and guidelines.

How it is done
 Wash your hands before and after using this product.
 Remove the protective shield from the enema.
 Let the patient lie on the left side with knee bent. Or if the patient finds it
more comfortable, he/she may kneel, with the head lowered and chest
forward until the left side of the face is resting on a flat surface with the left
arm folded comfortably.
 With steady pressure, gently insert enema tip into the rectum with a slight
side-to-side movement, pointing the tip toward the navel
 Do not force the enema tip into the rectum because you could hurt the
patient.
 Squeeze the bottle until the recommended amount of the drug is inside the
rectum. You do not need to empty the bottle completely because it has
more liquid than needed.
 Remove the bottle tip from the rectum. Let the patient stay in position for 1
to 5 minutes until he/she feels a strong urge to have a bowel movement.
 The use of this product is ordered by the doctor(either before surgery or a
bowel procedure), he or she should tell you how long before the
surgery/procedure you should use this product.
 Follow your doctor’s directions closely. After using the medication, the
patient may be asked to drink plenty of clear liquids as directed by the
doctor. Doing so will help prevent serious side effects (such as kidney
problems, dehydration).
 The dosage is based on the patient’s age, medical condition, and response
to treatment. This medication is not to be used more than directed, use this
medication more often than once in 24 hours, or use this medication for
more than 3 days unless directed by the doctor.
 Also, other laxative products shouldn’t be used while using this product
unless directed by the doctor since doing so may increase the risk for
serious side effects.
 This medication may cause a condition known as laxative dependence,
especially if used regularly for a long time. In such cases, the bowel may
stop working normally and the patient may have ongoing constipation. For
most people with occasional constipation, a bulk-forming laxative (such as
psyllium) or a stool softener (such as docusate) is a better and safer
product.
  Tell the patient to inform you or the doctor right away if the enema tip
causes rectal bleeding/pain, if he/she does not have a bowel movement
within 30 minutes of using the product, or if the patient has symptoms of
dehydration, or if the patients thinks he/she may have a serious medical
problem.

About Your Jackson-Pratt Drain

Figure 1. Jackson-Pratt drain

Your Jackson-Pratt drain has a soft plastic bulb with a stopper and a flexible tube
attached to it (see Figure 1). The drainage end of the tubing (flat white part) is placed
into your surgical site through a small opening near your incision. This area is called the
insertion site. A suture (stitch) will hold it in place. The rest of the tube will extend
outside your body and will be attached to the bulb.

When the bulb is compressed (squeezed) with the stopper in place, a constant gentle
suction is created. The bulb should be compressed at all times, except when you’re
emptying the drainage.

How long you’ll have your Jackson-Pratt drain depends on your surgery and the amount
of drainage you’re having. Everyone’s drainage is different. Some people drain a lot,
some only a little. The Jackson-Pratt drain is usually removed when the drainage is 30
mL or less over 24 hours. You’ll write down the amount of drainage you have in the
drainage log at the end of this resource. It’s important to bring your log to your follow-up
appointments.
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Caring for Your Jackson-Pratt Drain
When you leave the hospital, you’ll care for your Jackson-Pratt drain by:
 Milking your tubing to help move clots.
 Emptying your drain 2 times a day and writing down the amount of drainage on your
Jackson-Pratt drainage log at the end of this resource.
o If you have more than 1 drain, make sure to measure and write down the
drainage of each one separately. Don’t add them together.
 Caring for your insertion site.
 Checking for problems.

Milking your tubing

These steps will help you move clots through your tubing and keep the drainage
flowing.

Milk your tubing before you open the stopper to empty and measure your drainage. You
should also do this if you see fluid leaking around the insertion site.
1. Clean your hands.
o To wash your hands with soap and water, wet your hands, apply soap, rub them
together for at least 20 seconds, then rinse. Dry your hands with a towel and use
that same towel to turn off the faucet.
o If you’re using an alcohol-based hand sanitizer, cover your hands with it, rubbing
them together until they’re dry.
2. Look in the mirror at the tubing. This will help you see where your hands need to be.
3. Pinch the tubing close to where it goes into your skin between the thumb and forefinger
of your hand. Keep this hand in place while you milk your tubing. This will help make
sure that you aren’t tugging on your skin, which can be painful.
4. With the thumb and forefinger of your other hand, pinch the tubing right below your other
fingers. Keeping your fingers pinched, slide them down the tubing, pushing any clots
down toward the bulb. You may want to use alcohol wipes to help you slide your fingers
down the tubing.
5. Repeat steps 3 and 4 as many times as you need to push clots from the tubing into the
bulb. If you can’t move a clot into the bulb and there’s little or no drainage in the bulb,
call your healthcare provider.

Emptying your drain

You’ll need to empty your Jackson-Pratt drain 2 times a day, in the morning and in the
evening. Follow these instructions when emptying your Jackson-Pratt drain.
1. Prepare a clean area to work on. This can be done in your bathroom or in an area with a
dry, uncluttered surface.
2. Gather your supplies. You’ll need:
o The measuring container your nurse gave you
 o Your Jackson-Pratt drainage log
o A pen or pencil
3. Clean your hands.
o To wash your hands with soap and water, wet your hands, apply soap, rub them
together for at least 20 seconds, then rinse. Dry your hands with a towel and use
that same towel to turn off the faucet.
o If you’re using an alcohol-based hand sanitizer, cover your hands with it, rubbing
them together until they’re dry.
4. If the drainage bulb is attached to your surgical bra or wrap, first remove it from there.
5. Unplug the stopper on top of the bulb. This will make the bulb expand. Don’t touch the
inside of the stopper or the inner area of the opening on the bulb.

6.
Figure 2. Emptying the bulb
Turn the bulb upside down and gently squeeze it. Pour the drainage into the measuring
container (see Figure 2).
7. Turn your bulb right side up.
8. Squeeze the bulb until your fingers feel the palm of your hand.
9. Continue to squeeze the bulb while you replug the stopper.
10. Check to see that the bulb stays fully compressed to ensure a constant gentle suction.
11. Don’t let the drain dangle.
o If you’re wearing a surgical bra, there will be either a plastic loop or
Velcro® straps attached at the bottom. Attach the drainage bulb to the bra.
o If you’re wearing a wrap, attach the drainage bulb to the wrap.
o It may be helpful to hold your drain in a fanny pack or belt bag.
12. Check the amount and color of drainage in the measuring container. The first couple of
days after surgery, the fluid may be a dark red color. This is normal. As you continue to
heal, it may look pink or pale yellow.
13. Write down the amount and color of your drainage on your Jackson-Pratt drainage log.
 14. Flush the drainage down the toilet and rinse the measuring container with water.
15. At the end of each day, add up the total amount of drainage you had for the day and
write it in the last column of the drainage log. If you have more than 1 drain, measure
and record each one separately.
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Caring for Your Insertion Site

Check for signs of infection
Once you empty your drainage, clean your hands again and check the area around your
insertion site for:
 Tenderness
 Swelling
 Pus
 Warmth
 More redness than usual. Sometimes the drain causes redness about the size of a dime
at your insertion site. This is normal.

If you have any of these signs or symptoms, or if you have a fever of 101° F (38.3° C) or
higher, call your healthcare provider. You may have an infection.

Your healthcare provider will tell you if you should place a bandage over your insertion
site.

Keep your insertion site clean

Keep your insertion site clean and dry by washing it with soap and water and then
gently patting it dry.