Enema
From NursingWiki
Enema is the introduction of a fluid into the human intestine by way of the anus. Enemas (or enemata) are performed to relieve constipation, to introduce pharmatic medications, and to prepare patients for physiological or intestinal analysis such as x-ray surveys or colonoscopy. Advocated by naturopathist authorities and practicioners, a common use of enemas in home care and personal hygiene is practised outside of medical, paramedical, and nursing control or supervision. This use of enema is an essential part of colon cleansing, and it is largely home- and even self-administered. It is controversial but tolerated legally. In societies or nations with inadequate health care and access to medication, and in religions that limit the use of medication, the enema is a more easily available form of health care. In some countries, enemas with specific medication are remedies against intestinal parasites (e. g. Oxyuridae).
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enema types
Enemas vary by medical purpose, by volume, by added medication, by equipment used, and by nursing help applied. Present and traditional variations of enema types are expressed in the terminology. A common type of enema is the Fleet Enema. Binding regulations for nursing helpers and staff carefully define a number of enema types, not discussed in the present article.
Based on incidental or anecdotal evidence, specific enema types and ingredients are occasionally declared as dangerous or adverse to healing. Both the digital and the printed literature abound with cookbook-like or even absurd recipes for enemas and their recommended prescription. An example is "Natursekt" in German, "natural champaign" translated, meaning human urine. Beyond the four stated purposes, however, the therapeutic classification of enemas is limited. This reflects the long pre-scientific history of enemas.
The goal of the enema varies. Low-volume implants of medication are instilled into the colon and not intended to trigger peristalsis. The goal of most high-volume enemas is to evacuate the colon, that is, to achieve or restore the normal or increased peristalsis. Peristalsis is the involuntary but orderly and wave-like contraction of the colon, that is, an essential part of healthy digestion. For home use against constipation and other digestive discomfort, advocates of alternative medicine typically recommend enemas of 1 to 2 liter, about 5 degrees F warmer than body temperature, as diluted aqueous solutions of small amounts of commercially traded liquid castil soap (typically one teaspoon per 2 liter), or as water with other mild stimulants of peristalsis (e. g. Kamillosan), or as clear water, or as physiological solutions of sodium chloride and/or sodium carbonate, all to be retained for a few minutes before the onset of peristalsis is sensed and expulsion is appropriate.
Loss of intestinal flora and ions of trace elements, such as potassium, is being discussed as undesirable side effects of enema. The daily need of K+ ions is obtained in the descending colon by the normal extraction of water from the stool. Replacing this water by enema may dilute the body's ion concentration through osmosis, if the enema is not expelled. The addition of potassium to the enema water is not recommended because the tolerable range of K+ is not well known but certainly very low. The habitat of the intestinal flora is located in the caecal and ascending area of the colon. Therefore, large-volume enemas should assure expulsion but should avoid the flushing of the ascending colon. This protection can be achieved by taking the enema in the knee-elbow position.
enema equipment
All enema equipment consists of a recipient for the enema fluid, a conduit or tube into the patient's anus, and a setup to maintain the flow or hydrostatic pressure. A flexible enema bag or a rigid and pitcher-like irrigator, commonly with capacities of 1 to 2 liters, are the most convenient enema devices. Fluid pressure is maintained by uplifting the recipient above the patient. The tubing must be connected to a nozzle or colon tube lubricated for rectal insertion. Squeeze bulbs with capacities of 0.2 to 0.5 liters directly incorporate nozzles, but for large enemas they must be withdrawn, refilled, re-lubricated, and re-inserted. The Higginson syringe or, in French, clysopompe, incorporates a squeeze bulb inserted between two lengthes of enema tubing and two one-way flow valves. The front end of the tubing is connected to a rectal nozzle. The proper use of a Higginson syringe requires a separate fluid recipient and three hands: one for submerging the tubing in the recipient, one for squeezing the bulb, and one for inserting and holding the rectal nozzle. Despite these complications of handling, Higginsons are often recommended for self-administered enemas.
Klistiere (in German), that is, Fleet-type or microclyst ready-made enemas are helpful to the nursing staff because they are disposable, because they require little time and attention, and because they can be recommended for self-administration. Physiologically, however, they are not recommended. They derive their colonic fluid fill by osmotic extraction of water from the body fluid, thereby arguably disrupting the body chemistry more than a water enema does.
enema nozzles and colon tubes
Nozzles and colon tubes are devices used for administering enemas. Modern colon tubes are made from silicon and are disposable as needed in the normal hospital environment with high risk of infection and low spare time for disinfecting re-usable equipment. Colon tubes and enema nozzles are attached, by medium of a spigot or a connector, at the distal end of the irrigator tubing, and they are inserted rectally. Enema nozzles and colon tubes vary in material, diameter, length, and depth of insertion. All enema nozzles and colon tubes must be carefully lubricated for insertion and use, and all of them must be manually held in place during the enema.
Most enema nozzles are made of rigid materials, such as hard rubber, plastic, or glass. They are 4 to 15 cm long, and they measure 0.3 to 1.5 cm in diameter. Some enema nozzles are pointed and, during careless use, present a modest danger of rectal perforation, and often they are perceived as being inconvenient, leaky, or painful. To avoid the danger of perforation by an enema tip, some writers suggest to use the somewhat larger and blunt-ended commerial vaginal tip for enema. However, these vaginal tips are also short and painful for use in enema. Other enema nozzles have fancy bulbous shapes and appear to be made for erotic rather than medical use. All enema nozzles enter only the relatively inflexible human rectum, thereby tending to make the enema a painful experience.
Colon tubes and rectal tubes differ only in length, and both tube types avoid some of the shortcomings or enema nozzles. The conventional, re-usable colon- or rectal tubes are made of flexible red rubber or latex or silicon. Their closed and rounded front ends make them much safer against perforation, and they drain through one or two offset lateral eye openings. Their thickness is measured in cm diameter or in mm circumference, also called "French Scale". As generally used in Europe, standard flexible-rubber colon tubes are 30 or 40 cm long and 0.9 to 1.2 cm thick, or French 28 to 38. Most patients do not notice differences in the thickness of inserted colon tubes, but the flexibility of colon tubes varies with the diameter. The correct flexibility allows the tube to be inserted deeply enough to follow the colonic curvature and to pass the sigmoidal flexure. This deep insertion avoids the painful expansion of the rectum. After withdrawal, a deeply inserted colon tube may preserve for a few minutes the curvature of the sigmoidal bend, due to its anelastic component. In one carefully recorded case, a 30 cm long Ruesch 12 mm colon tube showed a strong bend between 16 and 25 cm of insertion depth. However, an excessively soft (thin) tube may painfully kink or double up just before it reaches the flexure. Much longer and not too flexible colon tubes reportedly can be inserted as far as the hepatic bend and into the ascending colon, but the need for such deep insertion is commonly doubted.
For all tube insertions intended to pass the rectal/sigmoidal flexure, and before the clamp is released, experts recommend that the patient abdominally press against the insertion, simulating the opening of a colonic fold or valve during defecation. Without this applied abdominal pressure, the tube is likely to get stuck within the flexure, increasing the risk of perforation. Objections against deep insertion are also based on the possibility that the colon tube may penetrate the fecal content of the lowermost colon and will clog undesirably.
enema positions
For receiving an enema, the patient should assume a body position in which he or she is comfortable and can retain the enema, and in which the helping person can access the patient's anus and can administer the enema. In all enema positions, the patient lies down and is placed on a soft substratum.
Common enema positions include the prone (belly-up) position with a slightly or steeply elevated pelvis. A pillow below the small of the patient's back is used to elevate the pelvis and to extend the abdomen. This position is suitable for self-administration, but it is inconvenient for the helper because the anus is not easily accessible.
sideways
Lying sideways, with a straight leg below and a flexed leg above, is known as the Simm's position. The left-sided Simm's position accommodates the curvature of the colonic sigmoid and therefore is preferred for small-volume enemas. The right-sided Simm's position permits fluid to enter the transverse colon (through a colon tube inserted into the sigmoid) and therefore is used for large-volume enemas. In both Simm's positions, the anus must be exposed by manually spreading one of the buttocks.
knee-chest position
In the knee-chest position, the patient kneels and bends over forward to rest on his or her arms and head. The anus is well accessible. The patient can receive large quantities of fluid with ease and comfort. If she is comfortable supporting herself one-sidedly, the helper should ask her to use her free hand to hold in place the inserted colon tube. Her cooperation will enable the helper to pay attention to the flow rate and status of the enema. Given enough enema volume and time, the fluid can enter nearly all segments of the colon by gravity, excepting most of the ascending colon. However, many patients consider the knee-chest position as embarassing or humiliating.
knee-elbow position
The knee-elbow position (KEP) is recommended for large-volume enemas (2 liter or more), because the fluid can reach the transverse colon by gravity, because the normal or pathological sag of the transverse colon is straightened out, and because the rectal tube can be inserted easily in the direction of the abdomen. The KEP is also recommended because the enema does not fully flush the caecal and ascending colon segment. A lubricated soft-rubber colon tube of FR-30 to FR-36 can safely reach and pass the distal sigmoidal flexure near 15 to 18 cm. The deeply inserted colon tube places the enema directly into the expandable colon, thus largely avoiding the painful ballooning of the less expandable rectum.
During an enema in the KEP, it is neither comfortable nor necessary for the patient to spread her legs. In the KEP and with closed legs, the anus is easily accessible with or without manual cheek-spreading by the helping person. The pelvic sexual dimorphism helps the female patient: she can expose her anus by flexing the femural joints far more easily than the male patient can. The KEP for enema is not advised for patients on high hospital beds, because it would require the helper to elevate the enema bag or irrigator can to more than shoulder height.
Done in the KEP on an athletic floor mat, a large-volume enema is convenient for the helper and comfortable for the patient, if the bag or irrigator can be suspended about 1 metre or a lttle higher above the floor. With necessary care and slowly, the colon tube can be inserted to a depth of 25 to 30 cm, that is, into the descending colon. If the patient is capable of supporting herself one-handedly, she should be asked to hold the inserted colon tube in place. Her cooperation will help to set her mind at ease. The Ruesch soft-rubber colon tubes of 40 cm length are excellent devices for this procedure.
flow rates for enema
In general, the slower the enema, the more comfortable and efficient it is experienced. An enema of two liters should take about three minutes of instilling time to reach and fill the transverse colon. A colon affected by chronic constipation may require much more time to fill. This type of colon is better evacuated in smaller steps, that is, with a series of smaller enemas, say one liter or less, as is described for therapeutic forms of colon cleansing. Some enema experts recommend small pauses in the flow of any enema, to be achieved by temporarily squeezing the tubing. Adversely, however, the work load of the professional helping person may set time limits. The disposable ready-to-use enemas of the Fleets or Microclyst types ( Fertig-Klistiere in German) were developed and marketed for their fast administration.
retention time for enema
Colonic evacuation after enema takes place by peristalsis and is triggered by a slow command through the vagus neural system. It is difficult to regulate the onset of peristalsis, but most authorities suggest to retain an enema for 5 to 10 minutes, in the same body position as assumed during the enema. One acquainted (unpublished?) authority in Europe suggests to delay expulsion until three peristaltic contractions have been clearly sensed. Abdominal massage during the retention of a large enema is recommended or performed by commercial healing help. This massage is thought to induce peristalsis, and it focuses on the belly area underlain by the transverse and descending colon segments. The patient should learn or try to distinguish his or her sensation of abdominal fullness from the sensation of active peristalsis. To impose retention of an enema during active peristalsis is counterproductive. It causes pain or discomfort for the patient, and neural confusion for the peristaltic mechanism.
Contrary to many comments, an enema cannot clearly undo the clotting and hardening of the colon content (achieved by water extraction during a much longer transit time), regardless of the time span of enema retention. Based on the state of expelled colon contents from single or seriated enemas, the enema mainly breaks up a blockage, suspends the hard lumps in water, mobilizes the lumps and clots, and opens access to less dewatered content in higher colonic reaches.
After a high-volume enema, the first splash of expulsion evacuates about one half of the total instilled fluid plus any mobilized colon content. Subsequent pulses of evacuation follow in intervals of one half to several minutes and are obviously governed by peristalsis. A small or large portion of the enema sometimes stays behind and replenishes the body's fluid requirement. Diuresis later will regulate the fine points of fluid concentration. During the last stages of enema expulsion, patients commonly report a feeling of pleasant relief and abdominal comfort, and this sensation probably reflects the peristalsis decreasing to total quiescence.
Enema: psychological aspects
As is emphasized elsewhere in this article or in its companion (see the German version Einlauf in Pflegewiki), the enema is an intrusive procedure affecting a patient's private mind and private body regions, and it requires careful manners and polite understanding from the nurse or medical helper. However, the patients' expressions of relief during and after the enema do need attention and professional study, not yet available at present.
Of rarely recorded (and never systematically studied) comments made by patients about their feelings during the enema, some clearly suggest an adult experience of helpful and healthy unity between body and mind. Other comments refer to childhood experience of anxiety and pain, or, on the contrary, to pleasant remembrance of special motherly care and love. Clearly sexual connections are made rarely, if ever, although the use of enema topics in pornographic settings is common and very damaging. An acquainted psychotherapist privately reports that she prescribes (and occasionally administers personally) enemas to her female patients, as a help to disclose and overcome fears to communicate, or as a gentle pretext to discuss their marital problems, or perhaps only to shelter the psychiatric part of the private consultation.
Is there something like "healing by enema?" - Maybe not, and clearly, the allopathic or main-trend medicine has other goals and concerns, but the alternative medicine should seriously study the psychological aspects of the enema.
