Rectal medicines are medications prepared specifically for insertion into the rectum. They are compounded in many forms. Liquid rectal medicine solutions are given by enema. Creams, lotions and ointments are applied externally or inserted internally using an applicator. Suppositories are prepared by mixing medicine with a wax-like substance to form a semi-solid, bullet-shaped form that will melt after insertion into the rectum.
Purpose
Rectal medications are administered for a localized effect on the rectum or for a systemic effect when a patient is vomiting, unable to swallow, or unconscious. Rectal medicine is most commonly used as a localized treatment for constipation or as a topical treatment for rectal inflammation or infection. Rectal suppositories may be used for the treatment of fever, nausea, and pain; they may also be prescribed to induce sedation or bronchodilation, or to reduce the nausea and vomiting that can accompany chemotherapy. Medicated enemas may be used to cleanse the bowel, to combat bacteria, or to kill parasites.
Precautions
Rectal medications must be used with caution in the cardiac patient who has arrhythmias or has recently had a myocardial infarction (i.e., heart attack). Insertion of a rectal medicine can cause vagus nerve stimulation and may trigger an arrhythmia—such as bradycardia. Rectal medicines should not be given to the patient with undiagnosed abdominal pain because peristalsis of the bowel can cause an inflamed appendix to rupture. Rectal medicines should be used cautiously in patients who have undergone recent surgery on the rectum, bowel, or prostate gland. If the patient has rectal bleeding or a prolapse of rectal tissue from the rectal opening, the medicine should be withheld and the physician consulted before administration. Rectal medicines should not be taken orally, and only medications labeled as rectal preparations should be placed in the rectum.
Description
Administration of rectal medication should be done after the patient is positioned correctly. Lifting the upper buttocks will enable visualization of his or her rectal opening. External lotions, ointments or creams can be applied directly, using a gloved finger or a 4×4 gauze pad. Prior to administering internal rectal medicine, the tip of the suppository, enema catheter, or applicator should be lubricated with a water-soluble lubricant. To insert a rectal suppository, the lubricated, tapered end of the suppository should be placed at the rectal opening and gently pushed into the rectum. The suppository should be pushed continually toward the umbilicus until the full length of the nurse's gloved index finger has been inserted into the rectal opening (i.e., about 3 inches, or7.5 cm, for an adult patient). When inserting suppositories into children, the suppository should be pushed about 1 inch (2.5 cm) beyond the rectal opening, or up to the first knuckle of the nurses's index finger. When inserting suppositories into infants, the little finger should be inserted one-half inch (1.25 cm) beyond the rectal opening. The buttocks should be released and the finger removed.
Administration of internal rectal medicated cream or ointment requires placement of the applicator's lubricated tip at the rectal opening, gently pushing the applicator into the rectal opening about 3 inches (7.5 cm) for an adult (or as indicated on the applicator's directions). The correct dosage of medicine should then be squeezed into the rectum. After withdrawal of the applicator tip, the buttocks should be released.
To administer rectal medicine using an enema solution, the lubricated tip of the enema catheter must also be placed at the rectal opening. The tip of the catheter should then be gently advanced into the rectum, about 3 inches (7.5 cm) for an adult (or as indicated on the enema tubing). After the patient is alerted, the enema tubing should be opened, allowing the enema solution to flow into the rectum. A prepared enema should also be administered in this manner. When all of the solution has been administered, the enema catheter should be removed. Then, the buttocks should be released.
Preparation
Before administering rectal medicine, the door to the room should be closed to assure patient privacy. The patient should be encouraged to empty his or her bladder and bowels before the procedure. After removing lower garments and underwear, the patient should be positioned in bed on his or her left side, with the top knee bent and pulled slightly upward. A waterproof pad should be placed under the patient's hips to protect the bedding, and a sheet should be draped over the patient to cover all of his or her body except the buttocks.
After placing a bedpan within quick access, the nurse should explain the procedure to the patient. This explanation should include the importance of breathing slowly through the mouth to enhance relaxation of the rectal sphincter and to avoid oppositional pressure. The patient should be made aware that there may be an urge to push the medicine out, but that he or she should try to hold it for at least 10–15 minutes after instillation (30 minutes for suppositories), as most rectal medications need time to be absorbed. It is advisable for the professional to check the medication label each time the medicine is given, to avoid medication errors. It must be the right medicine and the right dose (strength), the right time, the right patient, and the right method. The expiration date on the label should be inspected. If the medicine is outdated, it should not be used.
The nurse should wash his or her hands and put on gloves. The foil wrap should be removed from the rectal preparation or suppository. To prepare internal rectal creams, lotions or ointments, the applicator should be examined so that the nurse can estimate the proper amount to instill after insertion. In preparation for rectal enema instillations, the directions on the package of premixed disposable enemas should be read. Most premixed disposable enemas come with the tip already lubricated. The cap from the tip should be removed, and air should be expelled from the apparatus before use. If liquid medicine solutions are given using a standard enema bag and tubing, the procedure for enema instillation should be followed.
KEY TERMS
Arrhythmia—An irregularity of the heartbeat.
Bradycardia—An abnormal slowing of the heart rate to fewer than 60 beats per minute.
Myocardial infarction—A cardiac condition caused by decreased blood flow and oxygen to the heart muscle; may cause tissue death and heart damage. Commonly known as a heart attack.
Peristalsis—The wave-like muscular contractions of the intestinal walls that move food and refuse through the gastrointestinal system.
Prostate gland—A gland found in males, located below the bladder and around the urethra, that secretes the fluid for semen and controls the release of urine from the bladder.
Rectum—The last portion of the large intestine located just above the anal canal, where stool collects prior to evacuation from the body.
Vagus nerve—One of the paired cranial nerves that supplies motor and sensory enervation to the abdominal and thoracic organs.
Aftercare
After administering rectal medicines, the nurse should remain near the patient in case there is a need for assistance with the bedpan, or to walk to the bathroom. If a suppository is expelled within the first few minutes of insertion, the tip should be relubricated and reinserted. Medicated enemas that are expelled immediately may need to be repeated, using fresh solution. Directions provided with a prepared enema should be followed, but the physician may need to be consulted. To assist the patient with retaining the medicine, the nurse can apply gentle pressure to the rectal opening, using a 4×4 gauze pad or by squeezing the buttocks together after rectal medicine instillation. A 4×4 gauze pad should also tucked between the buttocks to collect seepage; this may help the patient feel more secure. After the procedure is completed, the patient should be covered and instructed to remain still for 10–15 minutes (30 minutes if a suppository was inserted). This period will allow time for medication absorption. Items that can be reused, such as enema pouches, tubing, and applicator tips, should be cleaned with warm running water and allowed to air-dry. Ointments and creams need to be recapped and returned to the medicine boxes. Disposable items and gloves should be placed in an appropriate trash bag that can be sealed and discarded.
Complications
Rectal medicines can cause tissue irritation or allergic reactions. If irritation, swelling, redness, bleeding or prolapse of the rectal tissue is apparent, or if the patient complains of pain or burning, the medication should be stopped and the physician notified.
Results
When given correctly, rectal medications work within 30–60 minutes to relieve pain, nausea, constipation, or fever. Rectal ointments for swelling and irritation of hemorrhoids may reverse the condition within several days. Because of their liquid state, rectal enemas are absorbed quickly and work rapidly. Retention enemas are meant to be held for 30 minutes to achieve full therapeutic effect.
Health care team roles
Rectal medicines are administered by a licensed nurse (R.N. or L.P.N.) in the health care setting. An alert and cooperative patient may be allowed to apply external and internal rectal ointments and suppositories under the direction of the nurse. The nurse, however, should assess the site and the effectiveness of the medicine. The patient or members of the patient's family can be taught to administer rectal medicines in the home setting.
