Skill 23 An enema is the instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis. Cleansing enemas promote complete evacuation of feces from the colon. They act by stimulating peristalsis through infusion of large volumes of solution. Oil-retention enemas act by lubricating the rectum and colon,
allowing feces to absorb oil and become softer and easier to pass. Medicated enemas contain pharmacological therapeutic agents. Some are prescribed to reduce dangerously high serum potassium levels (e.g., sodium polystyrene sulfonate [Kayexalate] enema) or to reduce bacteria in the colon before bowel surgery (e.g., neomycin enema). The skill of enema administration can be delegated to nursing assistive
personnel (NAP) unless medication is instilled via an enema. The nurse directs the NAP about: Feb 19, 2017 | Posted by admin in NURSING | Comments Off on 23 Enemas Premium Wordpress Themes by UFO Themes WordPress theme by UFO themes 16 May, 2006 An enema is the administration of a substance in liquid form into the rectum. This may be performed to aid bowel evacuation or to administer medicines. To continue reading this clinical article please log in or subscribe. Subscribe for unlimited access
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Already have an account, click here to sign in Continuing Education ActivitySodium polystyrene sulfonate is a medication used in the management and treatment of hyperkalemia. This activity outlines and reviews the indications, mechanism of action, and contraindications for sodium polystyrene sulfonate in the treatment of hyperkalemia. Furthermore, this activity will highlight adverse event profile, dosing, pharmacodynamics, pharmacokinetics, and relevant interactions related to hyperkalemia management. Objectives:
Access free multiple choice questions on this topic. IndicationsSodium polystyrene sulfonate (SPS) is approved by the Food and Drug Administration (FDA) for the treatment of hyperkalemia though it is not typically the first-line treatment.[1] A potassium level greater than 5 mEq/L qualifies as hyperkalemia. Hyperkalemia is often asymptomatic; however, it may cause fatigue, muscle cramps, muscle weakness, rarely paralysis. A high potassium level is associated with an increase in morbidity and mortality, especially K > 6.5 mEq/L can be fatal. Hence, prompt management is essential to avoid serious consequences. Sodium polystyrene sulfonate helps by removing extra potassium from the body. Due to its slow onset of action, it is a second-line agent in emergent situations. Data on the non-FDA-approved use of this drug is limited. This drug can also help to remove excess calcium, sodium from solutions in technical applications.[2][3][4][5][6][7] Mechanism of ActionSodium polystyrene sulfonate (SPS) is an insoluble polymer cation-exchange resin. After ingestion of the oral formulation or application through the rectal route, this resin exchanges sodium with potassium ions from the intestinal cells. Then the potassium binds with SPS, continues to move through the gastrointestinal tract, and is finally eliminated in the feces.[8][9] But sodium polystyrene sulfonate is not selective for potassium; it may bind with calcium and magnesium.[10] This drug begins its action within 2 to 24 hrs of its administration and continues its work up to 4 to 6 hours before it gets eliminated from the body through feces.[11] The exchange capacity of SPS is approximately 33% or 1 mEq of potassium per 1 gram of resin, and this number is not constant. It may be as low as 0.4 to 0.8 mEq/gram of SPS resin. Competition from other cations, especially sodium, calcium, and magnesium, contributes to this reduction of this exchange capacity. AdministrationSodium polystyrene sulfonate can be administered either orally or rectally. It is available in oral suspension, oral powder formulation, and rectal enema formulation. Appropriate dosing of sodium polystyrene sulfonate is varying on the route of administration. Usually, the dose of sodium polystyrene sulfonate is between 15 g (60 mL) to 60 g (240 mL), and each 15 g of sodium polystyrene sulfonate can bind 15 mEq of potassium.[12] While using as an oral suspension, it should not be heated or should not be used along with heated foods or liquids because this may cause a decrease in the effectiveness of this drug. This drug should not be mixed with banana or orange juice (potassium-rich). SPS may impair the absorption of other orally administered medications and may lead to reduced efficacy, so other oral drugs should be administered at least 3 hours before or 3 hours after SPS therapy. Patients with gastroparesis may require a longer period between SPS and other oral medications. When using an enema, the administration of a cleansing enema should be before administering sodium polystyrene sulfonate. It should be as warm as body temperature for rectal formulation. After administration, SPS should be retained in the colon for at least 30 to 60 min. After completing retention, irrigation should be done with a non-sodium colonic irrigant to remove the remaining resin. In the past, SPS used to be coadministered with sorbitol to reduce the chance of constipation, but in 2009, the FDA issued a warning against the concomitant use of SPS and sorbitol due to the occurrence of colonic necrosis and other serious GI side effects. Nowadays, the concurrent use of sorbitol is not recommended.[13] Storage Resin powder should be stored at 25 degrees C (77 F); excursions permitted to 15 to 30 degrees C (59 to 86 F). After the preparation of suspension, it should be used within 24 hours. Adverse EffectsSodium polystyrene sulfonate has several side effects.[14][15] Some are mild and should eventually resolve spontaneously; others are serious and need urgent care. Mild Adverse Effect
Serious Side Effects
ContraindicationsSPS is contraindicated in the following conditions:
Cautions SPS can contribute to sodium overload and lead to fluid retention. Hence, SPS use requires caution in certain conditions such as congestive heart failure, severe hypertension, and marked edema. Clinicians should not use SPS in patients with abnormal bowel functions, such as bowel obstruction, Ileus, and postoperative patients. Using SPS in these patients may increase the risk of bowel ischemia, necrosis, and serious constipation. Pregnancy and Lactation SPS does not get absorbed systemically; thus, maternal use of SPS is not expected to cause harm to the fetus. Similarly, as it is not secreted through breast milk, breastfeeding is not expected to result in any particular risk to the newborn. MonitoringSince SPS is not selective for potassium ions, other electrolyte imbalances may occur while using SPS in hyperkalemic patients. Patients should be monitored carefully for the signs and symptoms of other electrolyte abnormalities such as hypokalemia, hypomagnesemia, and hypocalcemia. Hypokalemia may be associated with cardiac arrhythmias and severe muscle weakness. Hypokalemia may be evident as prolongation of the QT interval, T-wave inversions, prominent U waves (an extra upward wave after the T-wave) in Electrocardiogram (ECG). Some patients may present with significant symptoms of rebound hyperkalemia, which may be evident in ECG as a tall peaked T wave. Hypomagnesemia can present with muscle weakness and potentiate hypokalemia. Hypocalcemia presents with tremors, muscle weakness, tetany, and rarely, seizures. ToxicityProlong use of Sodium polystyrene sulfonate can be attributed to several toxicities, including hypomagnesemia, hypocalcemia, sodium load, and colonic necrosis. Toxicity may occur to a greater extent with the concomitant administration of aluminum hydroxide, which may cause intestinal obstruction. Hypokalemia associated with SPS use may also increase the adverse effects of digitalis.[14][9] Excessive SPS use may also cause sodium load, potentially precipitating worsening hypertension and congestive heart failure symptoms. Enhancing Healthcare Team OutcomesSPS is usually prescribed by clinicians, including primary care providers, PAs or NPs, or internists. Since the drug can cause several side effects and is related to several toxicities, all interprofessional healthcare team members should be familiar with its pharmacology. They must be aware of its side effects and toxicities. A proper history and physical examination should take place before the initiation of SPS in any patient. Interprofessional discussion with nephrology, pharmacists, and nursing staff is prudent when considering using SPS as the primary line of therapy for hyperkalemia. The team should monitor the signs-symptoms of toxicity regularly and be ready to initiate any necessary measures if any complications occur. Upon successful management, this interprofessional team should educate the patients about dosing, side effects, and warning signs which may arise in the future. This approach will result in better patient outcomes with fewer adverse events. [Level 5] Review QuestionsReferences1.Lehnhardt A, Kemper MJ. Pathogenesis, diagnosis and management of hyperkalemia. Pediatr Nephrol. 2011 Mar;26(3):377-84. [PMC free article: PMC3061004] [PubMed: 21181208] 2.Acker CG, Johnson JP, Palevsky PM, Greenberg A. Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med. 1998 Apr 27;158(8):917-24. [PubMed: 9570179] 3.Moore ML, Bailey RR. Hyperkalaemia in patients in hospital. N Z Med J. 1989 Oct 25;102(878):557-8. [PubMed: 2812582] 4.Shapiro S, Slone D, Lewis GP, Jick H. Fatal drug reactions among medical inpatients. JAMA. 1971 Apr 19;216(3):467-72. [PubMed: 5107928] 5.Paice B, Gray JM, McBride D, Donnelly T, Lawson DH. Hyperkalaemia in patients in hospital. Br Med J (Clin Res Ed). 1983 Apr 09;286(6372):1189-92. [PMC free article: PMC1547392] [PubMed: 6404388] 6.Kraft MD, Btaiche IF, Sacks GS, Kudsk KA. Treatment of electrolyte disorders in adult patients in the intensive care unit. Am J Health Syst Pharm. 2005 Aug 15;62(16):1663-82. [PubMed: 16085929] 7.Nakamura T, Fujisaki T, Miyazono M, Yoshihara M, Jinnouchi H, Fukunari K, Awanami Y, Ikeda Y, Hashimoto K, Yamasaki M, Nonaka Y, Fukuda M, Kishi T, Ikeda Y. Risks and Benefits of Sodium Polystyrene Sulfonate for Hyperkalemia in Patients on Maintenance Hemodialysis. Drugs R D. 2018 Sep;18(3):231-235. [PMC free article: PMC6131120] [PubMed: 30097847] 8.Gruy-Kapral C, Emmett M, Santa Ana CA, Porter JL, Fordtran JS, Fine KD. Effect of single dose resin-cathartic therapy on serum potassium concentration in patients with end-stage renal disease. J Am Soc Nephrol. 1998 Oct;9(10):1924-30. [PubMed: 9773794] 9.Sterns RH, Rojas M, Bernstein P, Chennupati S. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective? J Am Soc Nephrol. 2010 May;21(5):733-5. [PubMed: 20167700] 10.KLINGENSMITH WC, ELKINTON JR. Cation exchange resin in the treatment of congestive heart failure. II. Clinical effectiveness and chemical complications during prolonged periods of use. Circulation. 1952 Jun;5(6):842-50. [PubMed: 14936180] 11.Kessler C, Ng J, Valdez K, Xie H, Geiger B. The use of sodium polystyrene sulfonate in the inpatient management of hyperkalemia. J Hosp Med. 2011 Mar;6(3):136-40. [PubMed: 21387549] 12.Chaitman M, Dixit D, Bridgeman MB. Potassium-Binding Agents for the Clinical Management of Hyperkalemia. P T. 2016 Jan;41(1):43-50. [PMC free article: PMC4699486] [PubMed: 26765867] 13.Nguyen T, Ondrik D, Zhufyak O, To W, He S. Hyperkalemia and potential pitfalls of sodium polystyrene sulfonate. JAAPA. 2015 Mar;28(3):41-5. [PubMed: 25710403] 14.Harel Z, Harel S, Shah PS, Wald R, Perl J, Bell CM. Gastrointestinal adverse events with sodium polystyrene sulfonate (Kayexalate) use: a systematic review. Am J Med. 2013 Mar;126(3):264.e9-24. [PubMed: 23321430] 15.Lepage L, Dufour AC, Doiron J, Handfield K, Desforges K, Bell R, Vallée M, Savoie M, Perreault S, Laurin LP, Pichette V, Lafrance JP. Randomized Clinical Trial of Sodium Polystyrene Sulfonate for the Treatment of Mild Hyperkalemia in CKD. Clin J Am Soc Nephrol. 2015 Dec 07;10(12):2136-42. [PMC free article: PMC4670766] [PubMed: 26576619] Which of the following actions should the nurse take when administering the enema solution?Which of the following actions should the nurse plan to take? Position the client on his left side. Positioning is an important aspect of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon.
Which is an appropriate intervention when giving an enema quizlet?Which of the following is the appropriate intervention? Lower the enema fluid container.
What position should the nurse assist the client to before administering an enema?The left lateral position is the most appropriate position for giving an enema because of the anatomical characteristics of the colon.
Which action should be performed when a patient reports abdominal cramping while receiving an enema quizlet?Some abdominal cramping is to be expected during enema administration. To ease the client's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container.
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