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Administering an Enema |
灌腸法 |
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Assessment |
評(píng)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. 確定上次排便、腸鳴音或腹痛。 2. 評(píng)估病人外括約機(jī)控制情況。 3. 確定有無痔瘡。 4. 評(píng)估腹痛。 5. 評(píng)估病人是否了解操作程序。 6. 評(píng)估病人移動(dòng)狀況。 |
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Implementation |
實(shí)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. 采用標(biāo)準(zhǔn)儀式。 2. 灌腸包： A. 將750至1000ml溫水倒入灌腸包。 B. 檢查水溫。 C. 在膠管內(nèi)倒入溶液，排出空氣，夾好。 3. 安醫(yī)囑加入肥皂。 4. 協(xié)助病人到側(cè)臥（Sims’)位，屈右腿。 5. 臀下放置防水墊。 6. 替病人蓋上小毯，露出肛門。 7. 備好衛(wèi)生紙、床邊盆或馬桶。 |
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8. Use prepackaged container: A. Remove plastic cap from rectal tip, applying more lubricant to tip if needed. 醫(yī)學(xué)全在線www.med126.com 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. 使用事先包裝好的容器： A. 取下肛管頭塑料帽，需要時(shí)可在頭上涂潤滑劑。 B. 輕輕分開臀部露出肛門。囑病人張口深呼吸。 C. 將潤滑后管頭插入直腸3－4吋（成人)。 D. 連續(xù)捏擠瓶子，將溶液完全排出。 |
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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. 使用灌腸包： A. 潤滑肛管前端3－4吋。 B. 輕輕分開臀部露出肛門。 C. 將管頭朝臍方向慢慢插入3－4吋（成人)。 D. 握住肛管直至液體全部注入。 E. 容器置于臀部水平位置，打開夾子開始灌腸。 F. 抬高灌腸筒至離肛門12－18吋處，掛于輸液架上。 G. 如病人出現(xiàn)腹痛，降低灌腸筒高度。 H. 溶液注入后夾住肛管，告訴病人將取出肛管。 |
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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. 向病人說明會(huì)有腹脹感。囑病人保留溶液（5－10分鐘)。 11. 處理灌腸筒及肛管。要重復(fù)使用者行沖洗。 12. 協(xié)助病人使用浴室、便盆或馬桶。 13. 囑有心臟病史病人排便時(shí)呼氣（瓦爾薩爾瓦操作會(huì)導(dǎo)致心臟停博)。 14. 教導(dǎo)病人在排便前呼叫護(hù)士檢查灌腸結(jié)果。 15. 必要時(shí)協(xié)助病人進(jìn)行會(huì)陰護(hù)理。 16. 應(yīng)用完成儀式。 |
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Evaluation |
評(píng)價(jià) |
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1. Evaluate results of enema (decreased abdominal discomfort; palpate abdomen). 2. Observe characteristics of stool. 3. Identify Unexpected Outcomes and Intervene as Necessary |
1. 評(píng)價(jià)灌腸結(jié)果（腹部不適減輕，觸摸腹部)。 2. 觀察大使質(zhì)量。 3. 確認(rèn)意外結(jié)果并加以必要處理。 |
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Report and Record |
報(bào)告記錄 |
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l Type of enema given l Results (color, amount, and appearance of stool) l Subjective response |
l 灌腸種類 l 結(jié)果（糞便顏色、數(shù)量、形狀) l 病人反應(yīng) |
