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Definition

An enema is a procedure wherein liquid is infused into the rectum via a tube either for treatment or to diagnose a condition.

Purpose

Enemas may be given for the following purposes:

• To remove feces when an individual is constipated or impacted.
• To infuse oil into the rectum to help soften feces when the person is constipated or impacted.
• To remove feces and cleanse the rectum in preparation for an examination.
• To remove feces prior to a surgical procedure to prevent contamination of the surgical area.
• To administer drugs such as corticosteroids dissolved in water to stop inflammation and bleeding caused by ulcerative colitis.
• To introduce barium sulfate, a metallic chemical substance that outlines the intestines for diagnostic purposes.
• To act as a carminative, or remove flatus, or gas, from the intestines.
• To irrigate the colon or large intestine, thus stimulating peristalsis (sometimes called a colonic irrigation).

Precautions

The rectal tube used for infusion of the enema solution should be smooth and flexible to decrease the possibility of damage to the mucous membrane that lines the rectum. Tap water is commonly used for adults but should not be used for infants because of the danger of electrolyte imbalance. (Electrolytes are substances that conduct electric current in the body fluids. Proper balance is essential for sustaining life.) The colon absorbs water, and repeated tap water enemas can cause cardiovascular overload and electrolyte imbalance. Similarly, repeated saline enemas can cause increased absorption of fluid and electrolytes into the bloodstream, resulting in overload. Individuals receiving frequent enemas should be observed for overload symptoms that include dizziness, sweating, or vomiting.

Soap suds and saline used for cleansing enemas can cause irritation of the lining of the bowel, with repeated use or a solution that is too strong. Only white soap should be used; the bar should not have been previously used, to prevent infusing undesirable organisms into the individual receiving the enema. Common household detergents are considered too strong for the rectum and bowel. The commercially prepared castile soap is preferred, and should be used in concentration no greater than 5 cc soap to 1,000 cc of water. Enemas should not be administered to individuals who have recently had colon or rectal surgery, a heart attack, or who complain of undiagnosed abdominal pain (which can be a ruptured appendix), or suffer from an irregular heartbeat.

Description

Traditionally, soap suds enemas (SSEs) have been used, as the soap caused some irritation of the bowel wall. This irritation, paired with distention caused by the volume of fluid instilled, causes bowel contractions and stimulation that usually will lead to expelling feces from the rectum. When the enema is administered, the individual is usually on the left side-lying position, which places the sigmoid colon (lower portion of bowel) below the rectum and facilitates infusion of fluid. The length of time it takes to administer an enema depends on the amount of fluid to be infused. The amount of fluid administered will vary depending on the age and size of the person receiving the enema; however, general guidelines would be:

• Infant: 250 cc (approximately one cup) or less.
• Toddler and preschooler: 500 ml (two cups) or less.
• School-aged child: 500 to 1,000 cc (between a pint and a quart).
• Adult: 750 to 1,000 cc (three-quarters to a full quart).
• Colonic irrigations or carminative enemas are normally administered only to adults and usually less than 200 cc (three-quarters of a cup) of fluid is used. This is instilled and allowed to flow back out five to six times.

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KEY TERMS

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Carminative—An agent that will remove gases from the gastrointestinal tract.

Electrolyte—A substance that conducts electric current within the body and is essential for sustaining life.

Intestine—Also called the bowels. Divided into large and small intestine, they extend from the stomach to the anus, where waste products exit the body. The small intestine is about 20 ft (6 m) long and the large intestine, about 5 ft (1.5 m) long.

Rectum—The portion of bowel just before the anus. The prefix recto is used with a variety of words in relation to conditions that affect the rectum.

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Some health care workers differentiate between high and low enemas. A high enema, given to cleanse as much of the large bowel as possible, is usually administered at higher pressure and with larger volume (1,000 cc), and the individual changes position several times in order for the fluid to flow up into the bowel. A low enema, intended to cleanse only the lower bowel, is administered at lower pressure, using about 500 cc of fluid.

Oil retention enemas serve to lubricate the rectum and lower bowel, and soften the stool. For adults, about 150 to 200 cc (approximately two-thirds, to three-quarters of a cup) of oil is instilled, while in small children, 75 to 150 cc (one-third to two-thirds of a cup) of oil is considered adequate. Salad oil or liquid petrolatum are commonly used at a temperature of 91°F (32.8°C). There are also commercially prepared oil retention enemas. The oil is usually retained for one to three hours before it is expelled.

The rectal tube used for infusion of the solution, usually made of rubber or plastic, has two or more openings at the end through which the solution can flow into the bowel. The distance to which the tube must be inserted is dependent upon the age and size of the patient. For adults, insertion is usually 3–4 in (7.5–10 cm); for children, approximately 2–3 in (5–7.5 cm); and for infants, only 1–1.5 in (2.5–3.75 cm). The rectal tube is lubricated before insertion with a water-soluble lubricant to ease insertion and decrease irritation to the rectal tissues.

The higher the container of solution is placed, the greater the force with which the fluid flows into the patient. Routinely, the container should be no higher than 12 in (30 cm) above the level of the bed; for a high cleansing enema, the container may be 12–18 in (30–45 cm) above the bed level, because the fluid is to be instilled higher into the bowel.

Preparation

The solution used in the procedure is measured, mixed, and warmed before administration of the enema.

Aftercare

If necessary, a stool specimen will be collected for diagnostic evaluation. If the enema was given to alleviate constipation, good nutritional education is necessary to prevent the recurrence of constipation in the future. The recommendation is normally with a high fiber diet (between five and six servings per day of whole grain foods) and adequate fluid intake (between seven and eight glasses of water per day). A study reported in the Canadian Nurse sought to evaluate whether the use of laxatives, enemas, and suppositories could be reduced by using more bran in the diet. It was found that the subjects given bran with their breakfasts each day reduced use of laxatives, enemas, and suppositories by nearly 50%. Regular exercise and going to the bathroom when necessary will also help. If constipation is a chronic problem, medical help should be consulted to determine if there is an underlying disorder.

Complications

Habitual use of enemas as a means to combat constipation can make the problem even more severe when their use is discontinued. Enemas should be used only as a last resort for treatment of constipation and with a doctor's recommendation. The use of enemas can cause an irregular heartbeat in some patients.

Results

Optimum results are thorough and appropriate cleansing of the lower bowel when necessary, and the introduction of proper diet and exercise to prevent chronic constipation.

Health care team roles

Healthcare providers will typically become involved in the treatment of constipation or fecal impaction as a side effect of other, debilitating illnesses.

• Primary care physicians (PCPs) will commonly order enemas for the relief of constipation, or for patients at risk for fecal impaction, to prevent more serious complications such as intestinal obstruction, or as a means of cleansing the bowel prior to tests or surgery.
• Registered nurses (RNs) or licensed practical nurses (LPNs) will often be responsible for either administering the enema or assuring that the patient knows how to administer it to themselves. Nurses will monitor the results of the enema to see if it has been effective in cleansing the lower bowel. Nursing staff involved in the administration of enemas need to be aware that this is an intrusive procedure that can be upsetting to patients. Professionalism and understanding are essential. Nurses should educate the patient about the procedure and should also be involved in teaching patients about the importance of diet and exercise in the prevention of chronic constipation.

Joan M. Schonbeck