Before administering a cleansing enema to an 80-year-old patient, the patient says "I don't think I will be able to hold the enema." Which is the next priority nursing action?
a. Rolling the patient into right-lying Sims' position
b. Positioning the patient in the dorsal recumbent position on a bedpan
c. Inserting a rectal plug to contain the enema solution after administering
d. Assisting the patient to the bedside commode and administering the enema
ANS: B
If you suspect the patient of having poor sphincter control, position on bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control are unable to retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because it is impossible to safely guide the tubing into the rectum, and it will be difficult for the patient to retain the fluid as he or she is in the position used for emptying the bowel. Rolling the patient into right-lying Sims' position will not help the patient retain the enema. Use of a rectal plug to contain the solution is inappropriate and unsafe.
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