Suppositories and Enemas NCLEX Notes

Premedication assessment and Tylenol contraindications

• Premedication assessment is required before administering medications via rectal routes (suppositories) or enema solutions.
• If giving Tylenol (acetaminophen) suppositories, assess the patient’s temperature prior to administration.
• Know contraindications for Tylenol: Tylenol is hepatotoxic; avoid in patients with liver disease such as cirrhosis.
• Assess vital signs before and after medication administration; monitor for adverse effects, including potential vagal responses during rectal procedures.
• Vagal responses can occur if the patient strains or pushes; monitor heart rate and blood pressure in these moments.
• Importance of documenting the premedication assessment and monitoring parameters after administration.
• Ethical/practical implication: ensure patient understanding, obtain consent, maintain privacy, and provide education about what to expect after administration.

Suppositories: indications, contraindications, technique, and patient education

• Indications for rectal medications via suppository: antimicrobial or analgesic agents (e.g., Tylenol), laxatives, or other medications that can be delivered rectally.
• Contraindications for suppositories:
  • Recent prostatic surgery or rectal surgery
  • Rectal trauma
• Not all rectal routes are appropriate for every patient; assess history for rectal procedures or trauma before choosing a suppository.
• Technique and positioning:
  • Provide privacy and ensure comfort; wear gloves; perform hand hygiene (seven rights of medication administration).
  • Position the patient on the left side in the Left Sims position for suppositories and enemas.
  • Use a water-soluble lubricant on the suppository.
  • For insertion depth: insert the suppository about 1\text{ inch} beyond the internal anal sphincter.
  • Do not insert the suppository into stool; place it to the side so it can be absorbed through the mucosa.
  • After insertion, the patient should remain on their side for 5\text{ to }10\text{ minutes} to reduce expulsion.
  • If the suppository is refrigerated, warm it in your hands before insertion to minimize discomfort.
  • For adults, expect insertion to be about 4\text{ inches}; for children, about 2\text{ inches}.
  • In adults insert toward the umbilicus to direct toward the rectal mucosa; ensure not to rupture or damage tissue.
• Post-administration care and education:
  • Remove gloves and wash hands after administration.
  • Educate the patient to retain the suppository for as long as possible, especially if it is a laxative; for other medications (e.g., Tylenol), explain what symptom relief to expect (fever reduction, pain relief).
  • Instruct the patient on when to use the call light and report new symptoms (dizziness, persistent pain, fever, etc.).
• Special pediatric considerations:
  • For infants: left side is maintained; infant positioning remains left-side with sidelying; insert with the pinky finger.
• Common questions on exams:
  • Is suppository administration sterile? No — this is a clean procedure because stool and the rectal canal are not sterile; the urinary system is considered sterile when in the bladder, which has implications for urinary catheterization.
• Optional clinical tip shared in lecture:
  • Do not cut a suppository unless it is scored; if refrigerated, warm before insertion to reduce discomfort.

Enema administration: types, technique, and safety considerations

• Enema types:
  • Cleansing enemas: tap water, saline, or soap suds; used for cleansing procedures or to relieve constipation.
  • Retention enemas: oil retention or medicated; used to soften stool or deliver medications.
• Positioning and setup:
  • Position the patient on the Left Sims position to utilize gravity for rectal flow into the sigmoid colon.
  • Keep a bedpan or a commode nearby for immediate defecation after the enema.
  • Lubricate the rectal tube prior to insertion.
• Insertion and instillation details:
  • Insert the lubricated rectal tube to a depth of 3\text{ to }4\text{ inches} in an adult; insert about 2\text{ inches} in a child.
  • Hold the enema bag or container at a height of 12\text{ to }18\text{ inches} above the rectum to control flow.
  • Infuse the solution slowly over 5\text{ to }10\text{ minutes} to minimize cramping.
• Aftercare and retention:
  • Instruct the patient to retain the solution for 5\text{ to }15\text{ minutes} if possible; provide easy access to a toilet or bedpan afterward.
• Safety and contraindications:
  • Stop the enema if the patient reports severe pain, dizziness, or rectal bleeding.
  • Large-volume enemas are contraindicated in patients with increased intracranial pressure (ICP), recent bowel or rectal surgery, or severe heart failure.
• NCLEX tips for enemas:
  • Use the left Sinus/Sims position consistently.
  • Keep the bag height within 12\text{ to }18\text{ inches} to avoid cramping or rupture.
  • Increase vigilance for vagal responses; monitor pulse and blood pressure during administration.
• Additional notes on technique:
  • After enema administration, the patient should be encouraged to retain the fluid for a short period, then defecate.
• Practical tips during assessment:
  • Stop the enema if patient experiences severe pain or dizziness; monitor for signs of vagal response (bradycardia, hypotension).

NCLEX strategies, safety, and math/dosage considerations

• When faced with multiple choices, select the safest option if more than one seems reasonable.
• Recalculate calculations twice before answering to catch simple math mistakes (HESI style questions test arithmetic rigor).
• Be mindful of unit differences:
  • Distinguish micrograms vs milligrams; ensure correct units in dosing questions.
• Watch for decimal-related distractors:
  • Answers off by a decimal place can be 10x too high or too low; verify decimal placement matches the problem.
• Pediatric dosing awareness:
  • If a patient dose requires five tablets, that is almost always incorrect for pediatrics; expect smaller, weight-based or age-appropriate dosing.
• General exam clinical reasoning:
  • Read the entire question, verify all given numbers, and avoid overthinking; use structured logic to determine the safest, most appropriate choice.

Diverticulosis vs diverticulitis: enemas and laxatives in context

• Diverticulosis:
  • Enemas and laxatives are not strictly contraindicated but are used with caution; typically not the first choice unless absolutely necessary.
  • Management focuses on bowel regularity without excessive pressure: high-fiber diet, adequate fluids, stool softeners instead of stimulant laxatives or enemas when possible.
• Diverticulitis:
  • Enemas and laxatives are contraindicated due to the risk of increasing inflammation, perforation, or bleeding.
  • Management includes bowel rest (clear liquids), antibiotics, IV fluids, and sometimes hospitalization; enemas and laxatives should be avoided until inflammation resolves.
• Practical implications for healthcare providers:
  • Tailor bowel regimens to the patient’s condition and inflammatory status; avoid enemas when diverticulitis is suspected or confirmed.

Quick references and practical pearls drawn from the session

• Anatomical and procedural notes:
  • Suppositories: left-side position (Left Sims) and insertion beyond the internal anal sphincter; avoid placing in stool to avoid expulsion.
  • Enemas: left Sims position, correct depth, and bag height critical to prevent cramping or rupture; monitor for symptoms.
• Safety monitoring and emergency signs:
  • Watch for vagal symptoms (bradycardia, hypotension, dizziness) during rectal administration and respond promptly.
  • Stop treatment for severe pain, dizziness, or rectal bleeding.
• Patient education focuses:
  • Privacy, comfort, and dignity during administration; educate about what to expect after the procedure (fever/pain relief, need to notify if symptoms worsen).
  • Encourage retention of enemas, but be mindful of patient tolerance and comfort.
• Miscellaneous notes:
  • The urinary system is described as sterile; this informs why urinary catheterization requires sterile technique to prevent introducing bacteria into the bladder.
  • Some clinical scenarios discussed (e.g., the “survival urine” anecdote) are included for context and test familiarity, but should be interpreted within evidence-based guidelines.
• Final reminder for exam readiness:
  • Expect questions focusing on large vs small doses, correct calculation methods, and safe practice strategies; prioritize safety and accuracy when selecting answers.

Quick recap of key numeric/tactical values to memorize

• Suppository insertion depth (adult): 4\text{ inches}; (child): 2\text{ inches}
• Insertion depth beyond internal sphincter: 1\text{ inch}
• Patient side-lying duration after insertion to prevent expulsion: 5\text{ to }10\text{ minutes}
• Enema insertion depth (adult): 3\text{ to }4\text{ inches}; (child): 2\text{ inches}
• Enema bag height for infusion: 12\text{ to }18\text{ inches} above the rectum
• Infusion duration: 5\text{ to }10\text{ minutes}
• Retention time after enema: 5\text{ to }15\text{ minutes}
• Large-volume enema contraindications: increased ICP, recent bowel/rectal surgery, severe heart failure
• Pediatric dosing caution: avoid assuming that 5 tablets equals pediatric dose; verify weights and age-based dosing