Skill List > Administration of an Enema
Clinical Alert
Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Nicol: Essential Nursing Skills 4E
Adapted by: Doreen Molloy BA MSc(MedSci) PGCTLHE RGN
Updated by: Patricia Cronin BSc(Hons) MSc PhD DipN(Lond) RGN
Last updated: August 2017
Learning Objective
After reading the skill overview, watching the video, following up some of the references/websites, and completing the Self Test quiz you should be ready to be assessed in practice in the skill of administering an enema.

Introduction

An enema is a liquid preparation that is administered into the body via the rectum to aid bowel evacuation or to administer medication (Peate & Gault 2013). Enemas are used when other methods of administration are not appropriate or not available, or when a local effect on the lower intestine is required.

The most common type of enema is the evacuant enema, which is generally used to relieve constipation, to cleanse the bowel prior to surgery or to promote visualisation of the intestinal tract during radiological or other bowel examination. Evacuant enemas work by stimulating peristalsis. The insertion of fluid into the intestinal tract causes rapid expansion, which stimulates peristalsis resulting in the expulsion of faecal matter along with the enema itself.

The most common types of evacuant enema are the phosphate enema and the Dioctyl sodium sulphosuccinate 0.1% and sorbitol 25% enema. The phosphate enema tends to be used to cleanse the bowel prior to surgery or radiological or endoscopic examination. The Dioctyl sodium sulphosuccinate 0.1% and sorbitol 25% enemas, which have a smaller volume, are commonly used to soften faecal matter (Peate & Gault 2013).  

Retention enemas are used with the purpose of fluid being retained for a period of time. They can be used to soften impacted stool or administer medication (Lowry 2016, Peate & Gault 2013).  Arachis oil enemas lubricate and soften impacted faeces and can thus promote bowel movement. In cases where the patient is impacted with very hard faeces, it may be necessary to give an arachis oil retention enema first, followed the next day by an evacuant enema. Their performance is improved if warmed to body temperature and the patient retains the enema for as long as they can (Peate & Gault 2013). Arachis oil enemas contain refined peanut oil but such refined peanut oils do not contain allergic peanut proteins and there is no evidence of reaction in allergic individuals (National Institute for Clinical Evidence (NICE) 2012).

The most common medications administered in enema form are steroid and aminosalicylate preparations, which are used in the management of inflammatory bowel disease. Retention medication enemas are given for a number of reasons and include respiratory treatments, sedation (e.g. diazepam for patients in a state of acute agitation or status epilepticus), analgesia, antibiotics and lowering serum potassium in patients with severe hyperkalaemia  (calcium resonium enemas) (Joint Formulary Committee 2016, Lowry 2016).

Potential complications of enema administration can occur as a result of the method of administration and the chemical properties of the solution administered. Insertion of an enema into the rectum can cause damage to the rectal mucosa and the fluid inserted can cause bloating, cramp, and a feeling of urgency. Serious water and electrolyte imbalances have been associated with the administration of sodium phosphate enemas as a result of phosphate absorption. Risks appear to be greatest in patients of extreme age (i.e., over 65 years or below 5 years of age) and patients with significant comorbidity such as chronic renal failure (Chapman 2014). However, for most patients the risk associated with the administration of phosphate enemas is low. 

Enema administration may be contraindicated in some circumstances such as:

  • Paralytic ileus (disruption of the normal propulsion of the gastrointestinal tract)
  • Intestinal obstruction or where there is risk of perforation of the colon
  • Patients with low platelet counts (thrombocytopenia)
  • Increased colonic absorption
  • Ascites (accumulation of fluid in the peritoneal cavity)
  • Uncontrolled hypertension
  • Recent abdominal or gynaecological surgery
  • Cancer of the peri-anal region
  • Proctitis (inflammation of the lining of the rectum)
  • Peri-anal disease
  • Patients who are frail
  • Patients with inflammatory or ulcerative conditions of the large bowel
  • Recent radiotherapy to the lower pelvis
  • Patients with spinal cord injury (SCI) (patients with SCI particularly above the level of T6 are at risk of autonomic dysreflexia which is a response to noxious stimuli (e.g. bowel distension/insertion of a suppository) below the level of the injury and can trigger extreme hypertension that can lead to stroke, haemorrhage, seizures and death).

(Chapman 2014, Cowan 2015, Joint Formulary Committee 2016, Lowry 2016, Peate & Gault 2013, Randle et al. 2010).


The insertion of an enema is potentially embarrassing for the patient and therefore it is important the procedure is performed in a skilled manner while preserving the patient’s dignity. Patient education is essential to ensure consent and agreement with the procedure. Before administration of the enema it is important that the perineal and peri-anal area are examined. The nurse should look for signs of soreness or redness/excoriation of the skin and/or pruritis on the buttocks and anal area. The presence of skin tags, haemorrhoids, foreign bodies (rare) or infestations should be noted and if necessary further clinical advice should be sought. The procedure of enema insertion can cause pain and bleeding in those with large haemorrhoids. Evidence of bleeding from the anus should be investigated prior to insertion of an enema.  

Nurses who administer enemas should have an understanding of the anatomy of the large bowel. They should also have knowledge of the indications for enema administration, modes of action, and potential complications associated with their use. In addition, it is important that before the administration of any rectal medication that a bowel risk assessment is undertaken (Lowry 2016) including, if necessary, a digital rectal examination and the nurse should have undertaken the appropriate education and training. 

This skill section focuses on routine enema administration in adults. Administration of an enema in emergency situations, for example, in status epilepticus, is not described here.

Preparation and safety

  • Check the six ‘rights’ of drug administration. Identify the correct patient and check the drug prescription chart. Check the expiry date, drug, dose, route, and time. Check the patient’s allergy status. Only registered nurses can administer medications. 
  • Check the patient's medical notes to ensure there are no contraindications to enema administration.
  • Explain the procedure to the patient to gain consent and cooperation.
  • Encourage the patient to pass urine before the procedure to reduce discomfort to the bladder when the enema is administered.
  • Ensure the patient has easy access to the toilet or that the commode or bedpan is placed nearby in case of urgency following administration.
  • Gather the equipment beforehand: apron, close-fitting non-sterile gloves, prescribed enema, lubricant, non-sterile gauze, disposable absorbent pad, toilet paper, and receptacle for carrying equipment (e.g., non-sterile tray/receiver). Large-volume enemas should be warmed to body temperature prior to administration by placing them in a jug of hot water (refer to manufacturer's instructions).
  • Check the prescribed enema against the prescription chart.
  • Perform hand hygiene and put on an apron.
  • Draw screens to ensure privacy.
  • Ask or assist the patient to remove clothing below the waist and lie in the left lateral position. Keep the patient covered as much as possible to ensure warmth, comfort, and dignity.

Procedure

  1. Check the patient’s identity against the prescription chart.
    Rationale – To avoid drug error by ensuring the correct patient is receiving the correct enema.
  2.  Raise the bed to a safe working height and ask the patient to lie on their left side with the knees drawn up to the chest. 
    Rationale – To prevent stooping and facilitate the insertion of the enema using the contour of the bowel. It is necessary for the patient to be in the left lateral position because of the position of the rectum.
  3. Put on the gloves, expose the buttocks, and examine the peri-anal area for any abnormalities such as soreness/redness, skin excoriation, pruritis, haemorrhoids, skin tags, infestations, bleeding or foreign bodies. If present, seek advice before proceeding.
    Rationale – To ensure enema can be given safely and no contraindications to administration are present.
  4. If administering an evacuant enema, it may be necessary to gently insert a lubricated, gloved finger into the rectum. (Appropriate training must be undertaken before carrying out a rectal examination.) 
    Rationale To assess if the rectum is empty or full (Peate 2015).
  5. Place the equipment within easy reach and place the absorbent pad under the buttocks.
    Rationale – Some leakage of fluid may occur during or after administration and so it is necessary to protect the bedding.
  6. Squeeze some lubricant onto a gauze swab. Remove the cover from the nozzle and lubricate the tip thoroughly.
    Rationale – To ease insertion into the anus and prevent trauma to the mucosa.
  7. Reassure the patient and encourage them to relax. Part the buttocks with the left hand. With the right hand, hold the nozzle of the enema and gently insert it through the anus and into the rectum (usually about 5 cm).
    Rationale – Enema administration can be unpleasant and therefore it is necessary to communicate appropriately throughout the procedure, to insert the enema carefully and slowly, and to ensure the contents are deposited in the rectum. As the patient needs to be in the left lateral position even left-handed nurses will need to use their right hand for this.
  8. If the patient experiences pain on insertion of the nozzle, the procedure should be stopped.
     Rationale  If the patient experiences pain or discomfort on insertion of the nozzle or if bleeding occurs advice needs to be sought to ascertain if there is trauma to the rectal mucosa or an obstruction preventing administration.
  9. Administer the enema contents slowly by squeezing the bag or pack until all the contents have been deposited.
    Rationale – Slow administration reduces the likelihood of spasm and discomfort.
  10. Continue squeezing while withdrawing slowly and place the used enema in a receptacle.
    Rationale – To avoid fluid running back into the bag and reflex emptying of the bowel.
  11. Use gauze to wipe away any residual lubricant, cover the patient and assist them into a comfortable position. Ensure the call bell is within easy reach. Advise the patient to retain the enema for the appropriate length of time in accordance with the type of enema administered. It may help to elevate the foot of the bed.
    Rationale – Different types of enema require different periods of retention. Evacuant enemas may require retention for 15–30 min for optimal effect whereas stool-softening enemas and calcium resonium enemas require retention for several hours.
  12. Replace the bedclothes and lower the bed. Remove all equipment then remove gloves and apron and perform hand hygiene. Rationale The bed should be left at the lowest height so the patient is able to safely get out of bed. To prevent contamination and ensure safe disposal of contaminated equipment.   
  13. If administering an evacuant enema, assist the patient to use the toilet, commode, or bedpan as necessary and to attend to hand hygiene following use of the toilet.
     Rationale – To promote patient comfort and maintain dignity.
  14. Document the enema according to local policy.
    Rationale – To ensure the procedure is correctly documented and to promote consistency of patient care.

Ongoing care, monitoring and support

  • Observe the patient for any adverse reactions such as feeling faint, nausea, pain, or cramp. Report any adverse reactions to medical staff.
  • If it is an evacuant enema, ask the patient to hold the enema for as long as possible; however, the effect is likely to be rapid. Assist the patient to use the toilet, commode, or bedpan as necessary and to attend to hand hygiene.
  • If it is a retention enema (drug administration), the patient should be instructed to stay in the left lateral position for at least 30 min to aid retention and absorption of the fluid.

Documentation and reporting

  • Document the result of the enema. If an evacuant enema has been used, document the colour, consistency, and volume of stool passed, preferably using a tool such as the Bristol Stool Chart.
  • Report any adverse reactions or complications to medical staff.
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