St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur
DEPARTMENT OF NURSING
PERFORMANCE CHECKLIST
“ADMINISTERING ENEMAS”
Name: Jemina R. Racadio Subject:______________________Score_________________
Section: BSN-III Instructor Mr. Melanio Rojas Date:_________________
Direction: Rate the procedure based on the rating scale below by putting a check mark on the column
provided beside the steps as follows:
5- The skill was performed very comprehensively
4- The skill was performed comprehensively
3- The skill was performed with some minors
2- The skill was performed with major errors
1- The skill was performed with none of the required features at all

NA- Not applicable

PROCEDURE RATIONALE
ASSESSMENT
1. Check the physician’s order. To prevent errors.
2. Assess the patient’s capabilities. It serves as a baseline before administering
an enema.
3. Assess the condition of the patient Establishes a baseline assessment for
such as sphincter control, last bowel determining the efficacy of the enema.
movement, amount, color,
consistency, abdominal distenstion
and can use a toilet or commode or
must remain in bed and use a
bedpan.
4. Determine availability of equipment. To prevent any error before administering an
enema.
PLANNING
5. Wash your hands. To prevent transmission of microorganisms.
6. Gather equipment. To save time.
7. Plan for any assistance. To prevent any error during the procedure.
8. Inform the patient about the To reduce the anxiety of the patient.
procedure.
IMPLEMENTATION
9. Check the doctor’s order. To determine the proper volume of the
solution and size of the tube that patient
needed.
10. Provide privacy. Promotes cooperation and decreases
anxiety.
11. Promote relaxation To ensure the patient is not bothered during
the procedure.
12. Position the client:
 1 Adult- left lateral position Provides easy passage of the solution by
following the natural curve of the sigmoid
colon and rectum.
 12. 2 Dorsal recumbent- Infant/small Provides easy passage of the solution by
 children following the natural curve of the sigmoid
colon and rectum.
13. Prepare the sizes of the tube: Adult Double check the sizes to prevent errors.
( French 22-32) Children ( French 14-
18) Infant ( French 12)
14. Lubricate 5 cm ( 2 inches) of the Facilitates insertion and promotes comfort.
rectal tube.
15. Allow solution to flow through the Promotes continuous slow installation of the
connecting tubing and rectal tube to solution, with minimization of complications.
expel air before insertion of rectal
tube.
16. Insert 7 to 10 cm ( 3-4 inches) of Too rapid administration can cause painful
rectal tube gently in rotating motion. distention of the colon.
17. Introduce solution slowly. Promotes continuous slow installation of the
solution, with minimization of complications.
18. Change the position to distribute To ensure that the solution distributes to the
solution well in the colon; if low colon.
enema, remain in left lateral position.
19. If the order is cleansing enema. Give To prevent any complications to the patient.
the enema 3 x alternate hypotonic
solution to prevent water intoxication
or hypoosmolar fluid imbalance.
20. If abdominal cramps occur during To prevent irritation during the introduction of
introduction of solution, temporarily the solution.
stop the flow of solution by clamping
the tube until peristalsis relaxes.
21. After introduction of the solution, High pressure could defecate urgently the
press the buttocks together to inhibit patient.
the urge to defecate.
22. Ask the client who is using the toilet To determine the characteristic and
not to flush it. The nurse must consistency of the stool. For documentation
observe the return flow. purposes.
23. Do perianal care. Promotes comfort to the patient.
24. Makes the patient comfortable. To ensure the patient is comfortable and safe
after the procedure.
25. After care of the unit and materials Aftercare of the unit and used material
used. prevent transmission of microorganisms.
EVALUATION
26. Evaluate using the following criteria
a. Perform detailed follow-up based on To determine the effectiveness of the
the findings that deviated from procedure.
expected or normal for the client.
b. Report significant deviations from To ensure the procedure is effective to the
normal to the primary care provider. patient.
DOCUMENTATION
27. Document the type and volume, if For charting purposes.
appropriate of enema given.
Described the results.
28. Client’s reaction to the procedure. For charting purposes.
29. Client’s experience with ostomy and To determine the tolerance of the patient
 skills learned by the client. during the procedure.
30. Add information to the nursing care To easily determine the next nurse what is
plan relative to care needed. the care needed by the patient.

St. Paul College of Ilocos Sur

 (Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING

Name: Jemina R. Racadio Subject: NCM-112 Score:_________________

Section: BSN – III Instructor: Mr. Melanio Rojas Date: _________________

PROCEDURE RATIONALIZATION
Assessment
1. Check the physician’s order. To prevent errors.
2. Assess the patient’s capabilities. It serves as a baseline before
administering an enema.
3. Assess the condition of the skin surrounding the Establishes a baseline
stoma. assessment for determining the
efficacy of the stoma.
4. Determine availability of equipment. To prevent any error before
administering an enema.
Planning
5. Wash your hands. To prevent transmission of
microorganisms.
6. Gather equipment. To save time during the
procedure.
7. Plan for any assistance. To prevent any error during the
procedure.
8. Inform the patient about the procedure. To reduce the anxiety of the
patient.
Implementation
9. Identify the patient. To prevent errors.
10. Explain the procedure to the patient. To reduce the anxiety of the
patient.
11. Wear gloves To prevent transmission of
microorganism.
12. Remove current ostomy appliance after empty the Gentle removal helps prevent skin
pouch. tears.
13. Dispose the appliance appropriately. To prevent the spread of
microorganisms.
14. Wash hands. To prevent the spread of
 microorganisms.
15. Wear gloves. It serves as a protection to a
health care provider.
16. Cleanse the stoma and skin with warm tap water Aggressive cleaning can cause
and pat dry. bleeding.
17. Measure stoma at base. To ensure the ostomy bag is fit to
stoma.
18. Place the gauze pad over the stoma and prepare To ensure the stoma is dry before
the new wafer pouch. administer the ostomy bag.
Preparing the new wafer pouch
saves time to the health care
provider.
19. Trace the pattern on paper backing of wafer. To ensure the ostomy wafer is fit
to prevent shrinking.
20. Cut wafer as traced Always follow the measurement
guide to prevent errors.
21. Attain clean pouch to wafer. Be sure that the port if To prevent the spread of
closed. microorganisms.
22. Gently remove the gauze pad from orifice of the Gently removing the gauze
stoma. ensures patient comfort and
prevent trauma or irritation to the
stoma.
23. Gently remove the paper backing from wafer and Ensure the wafer is fit to prevent
place it on skin with stoma wafer, and place it on leaking.
skin with stoma centered in cutout opening of
water.
24. Using hypo-allergenic tape, secure the edges of To prevent leaking.
the water.
25. Dispose the soiled materials properly and wash Disposing the soiled material
hands. helps decrease odor. Wash
hands prevents transmission of
microorganisms.
Evaluation
26. Evaluate using the following criteria
a. Encourage and support self-care as soon as To determine the effectiveness of
possible as clients should be perform self-care the procedure.
by discharge.
b. Perform detailed follow-up based on the To ensure the procedure is
findings that deviated from expected or normal
 for the client. effective to the patient.
c. Report significant deviations from normal to For charting purposes.
the primary care provider.
Documentation
27. Increase size of the stoma and change in color. It serves as a baseline to the
health care provider.
28. Amount and type of drainage. It serves as a baseline to the
health care provider.
29. Client’s reaction to the procedure. To ensure the tolerance of the
patient during the procedure.
30. Client’s experience with ostomy and skills learned To determine the tolerance and
by the client. response of the patient during the
procedure.
31. Add information to the nursing care plan relative to To easily determine the next
care needed. nurse what is the care needed by
the patient.

St. Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING

PERFORMANCE CHECKLIST
 “ADMINISTERING ENEMAS”

Name: Jemina R. Racadio Subject: NCM-112 Score:_________________

Section: BSN – III Instructor: Mr. Melanio Rojas Date: _________________

Calculate the gtts/min manual flow rates for the following infusions. Round rates to the
nearest whole number

1. An IV of 2000 ml is to infuse over 12 hour using a 10 gtt/ml set. 2,000 x 10 ÷ 12 x 60

= 20,000 ÷ 720
= 27.77 or 28
gtts/min
2. 3500 ml are ordered to infuse in 24 hour using a set a calibrated at 3,500 x 20 ÷ 60 x 24
20 gtt/ml
= 70,000 ÷ 1,440
= 48.61 or 49
gtts/min
3. Infuse 500 ml in 3 hour using a 15 gtt/ml set 500 x 15 ÷ 3 x 60
= 7,500 ÷ 60
= 41.66 or 42
gtts/min
4. A volume of 1500 ml is to infuse in 5 hour a 15 gtt/ml 1,500 x 15 ÷ 3 x 60
= 22,500 ÷ 300
= 75 gtts/min
5. 1750 ml are ordered to infuse in 9 hour using a 20 gtt/ml 1,750 x 20 ÷ 9 x 60
= 35,000 ÷ 540
= 68.81 or 69
gtts/min
6. An IV of 2500 ml is to infuse in 18 hour on a set calibrated at 10 2,500 x 10 ÷ 60 x 5
gtt/ml
= 25,000 ÷ 1,080
= 23.15 or 23
gtts/min
7. A 3000 ml volume is to infuse in 24 hour 3,000 x 15 ÷ 24 x 60
= 45,000 ÷ 1,440
= 31.25 or 31
gtts/min
8. A volume of 2750 is to infuse in 22 hour on a 15 gtt/ml set 2,750 x 15 ÷ 22 x 60
41,250 ÷ 1,320
31.25 or 31 gtts/min
9. An IV if 750 ml is ordered to infuse in 8 hour on a 10 gtt/ml 750 x 10 ÷ 8 x 60
= 7,500 ÷ 480
= 15.62 or 16
gtts/min
10. A volume of 1250 ml is to infuse in 12 hour using a 15 gtt/ml 1,250 x 15 ÷ 12 x 60
= 18,750 ÷ 720
= 26.04 or 26
gtts/min
11. The doctor orders ferrous sulfate 5 grains. Ferrous sulfate is 5 grains to mg
available to the nurse in 150 mg tablets. How many tablets should
= 323.9mg
the nurse administer?
= 323.9 ÷ 150
= 2.16 or 2 tablets
12. The doctors orders rocephin 1 gram in 10 ml of D5W give 250 mg 1 gram to mg
IV every 12. How many ml should the nurse administer for each
= 1,000mg
dose?
= 1,000 ÷ 250 x 10 ÷
12
= 3.33 ml
13. The doctor orders rocephin 1 g in 10 ml of D5W give 250 mg I.V. 1 gram to mg
every 12 hour. How many ml should the nurse administer for each
= 1,000mg
dose?
= 1,000 ÷ 250 x 10 ÷
12
= 3.33 ml
14. The doctor’s order Demerol 60 mg I.M. stat. The drug is available 60 ÷ 100 x 1
in a prefilled, 1 ml syringe containing 100 mg/ml. How many ml
= 0.6ml
should the nurse waste before administering ordered dose?
15. A 150 lb patient is to receive gentamicin 3 mg/kg daily in 3 divided 150lb to kg
doses. Gentamicin is available to the nurse in 80 mg/2 ml. How
=68.3 x 3 ÷ 80 x 2
many ml should the nurse administer every 8 hours
=204.09 ÷ 160
=1.27 x 2
=2.55 ÷ 3
= 0.85ml