| Administering an Enema | 灌肠法 |
| Assessment | 评估 |
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1. Determine last bowel movement and presence of bowel sounds or abdominal pain. 2. Assess ability to control external sphincter. 3. Determine presence of hemorrhoids. 4. Assess abdominal pain. 5. Assess client's understanding of procedure. 6. Assess client's mobility status. |
1. 确定上次排便、肠鸣音或腹痛。 2. 评估病人外括约机控制情况。 3. 确定有无痔疮。 4. 评估腹痛。 5. 评估病人是否了解操作程序。 6. 评估病人移动状况。 |
| Implementation | 实施 |
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1. Use Standard Protocol. 2. Enema bag:A. Fill enema bag with 750 to 1000 ml warm tap water. B. Check temperature of water. C. Fill tubing with solution, removing air, and clamp. 3. Add soap to water if ordered. 4. Assist client to side-lying （Sims'） position with right knee flexed. 5. Place waterproof pad under hips and buttocks. 6. Cover client with bath blanket, exposing only rectal area. 7. Ensure that toilet, bedpan, or commode is available. |
1. 采用标准仪式。 2. 灌肠包：A. 将750至1000ml温水倒入灌肠包。 B. 检查水温。 C. 在胶管内倒入溶液，排出空气，夹好。 3. 安医嘱加入肥皂。 4. 协助病人到侧卧（Sims’）位，屈右腿。 5. 臀下放置防水垫。 6. 替病人盖上小毯，露出肛门。 7. 备好卫生纸、床边盆或马桶。 |
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8. Use prepackaged container: A. Remove plastic cap from rectal tip, applying more lubricant to tip if needed. B. Gently separate buttocks and locate anus. Instruct client to take deep breaths through mouth. C. Insert lubricated tip into rectum 3 to 4 inches （adult）. D. Squeeze bottle continuously until all fluid is expelled. |
8. 使用事先包装好的容器： A. 取下肛管头塑料帽，需要时可在头上涂润滑剂。 B. 轻轻分开臀部露出肛门。嘱病人张口深呼吸。 C. 将润滑后管头插入直肠3－4吋（成人）。 D. 连续捏挤瓶子，将溶液完全排出。 |
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9. Use an enema bag: A. Lubricate 3 to 4 inches of tip of tubing. B. Gently separate buttocks and locate anus. C. Insert tip of tube slowly, pointing tip toward umbilicus, for 3 to 4 inches （adult）. D. Hold tubing until fluid is instilled. E. With container at hip level, open clamp and begin instillation. F. Raise height of container to 12 to 18 inches above anus and hang on IV pole. G. Lower height of container if client experiences cramping. H. Clamp tubing after solution instilled and inform client that tubing will be removed. |
9. 使用灌肠包：A. 润滑肛管前端3－4吋。 B. 轻轻分开臀部露出肛门。 C. 将管头朝脐方向慢慢插入3－4吋（成人）。 D. 握住肛管直至液体全部注入。 E. 容器置于臀部水平位置，打开夹子开始灌肠。 F. 抬高灌肠筒至离肛门12－18吋处，挂于输液架上。 G. 如病人出现腹痛，降低灌肠筒高度。 H. 溶液注入后夹住肛管，告诉病人将取出肛管。 |
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10. Explain to client that a feeling of distention is expected. Ask client to retain solution as long as possible （5 to 10 minutes）. 11. Discard enema container and tubing, or rinse if to be reused. 12. Assist client to use bathroom, bedpan, or commode. 13. Instruct clients with history of cardiovascular disease to exhale during defecation （Valsalva maneuver can cause cardiac arrest）. 14. Instruct client to call for nurse to inspect results before discarding. 15. Assist client with perineal care as necessary. 16. Use Completion Protocol. |
10. 向病人说明会有腹胀感。嘱病人保留溶液（5－10分钟）。 11. 处理灌肠筒及肛管。要重复使用者行冲洗。 12. 协助病人使用浴室、便盆或马桶。 13. 嘱有心脏病史病人排便时呼气（瓦尔萨尔瓦操作会导致心脏停博）。 14. 教导病人在排便前呼叫护士检查灌肠结果。 15. 必要时协助病人进行会阴护理。 16. 应用完成仪式。 |
| Evaluation | 评价 |
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1. Evaluate results of enema （decreased abdominal discomfort; palpate abdomen）. 2. Observe characteristics of stool. Identify Unexpected Outcomes and Intervene as Necessary |
1. 评价灌肠结果（腹部不适减轻，触摸腹部）。 2. 观察大使质量。 识别意外结果并加以必要处理。 |
| Report and Record | 报告记录 |
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l Type of enema given l Results （color, amount, and appearance of stool） l Subjective response |
l 灌肠种类 l 结果（粪便颜色、数量、形状） l 病人反应 |