Keywords: Administration/Drug/ Nursing Practice Enema/Rectum/Suppository Practice educator ●This article has been double-blind Drug administration peer reviewed Health professionals are not always clear on the procedure for administering medication rectally, the benefits of this route or its indications Rectal drug administration in adults: how, when, why

Learning points... 5 practice The relevant anatomy of the gastrointestinal tract points Practitioners How drugs are absorbed when administered rectally 1must ensure their The principles of safe administration of drugs per rectum knowledge and practices about drug administration Author Michael Lowry is lecturer in nursing effective route for delivering medication, per rectum are at the University of Bradford. rectal administration also reduces side- based on a solid Abstract Lowry M (2016) Rectal drug effects of some drugs, such as gastric irri- evidence base administration in adults: how, when, why. tation, nausea and vomiting (Tortora and Nurses must Nursing Times; 112: 8, 12-14. Derrickson, 2008). 2 understand all Administering medication per rectum There are occasions when the adminis- the advantages, can be the most appropriate route for tration of medication PR is contraindi- contraindications some patients may not always be consid- cated, for example: and safety aspects ered by health professionals. Cultural » Lack of consent (verbal, written of rectal drug sensitivities, as well as misinformation or implied); administration regarding insertion methods, may be » Recent rectal or anal surgery – this Clinical staff barriers to the practice. This article can include tissue changes caused by 3 should explain explains how the rectal route functions in pelvic radiation; to patients the drug absorption, clarifies when this route » Abnormalities or trauma involving the benefits of is appropriate to use and outlines the steps perineal or perianal areas; administering drugs nurses should follow to prepare patients » When a prescriber has specifically via this route adequately and safely to carry out the instructed that it not take place; Patients must procedure. » Suspected paralytic ileus or colonic 4 be informed obstruction – this should be discussed about, and consent edications administered per first with relevant medical or other to, receiving drugs rectum (PR) are ideal for local prescribing staff. per rectum or systemic treatment, as the Cultural Mrectal mucosa has a blood and Suppositories and enemas 5 diversity lymph supply that is capable of effective Medication intended for rectal administra- and individual systemic absorption. The rectum is rela- tion often comes in the form of a supposi- sensitivities must tively underused in some societies as a tory or an enema. Suppositories (Fig 1a) are be considered route for safe administration of medicines, small, torpedo-shaped pellets that melt at when preparing arguably due to the intimacy of the site body temperature, whereas enemas (Fig patients to receive compared with more socially accepted and 1b) are substances in liquid form designed drugs per rectum visible routes, such as oral or topical for rectal administration. administration, or injection. Suppositories and enemas are adminis- tered for a number of reasons including: FIG 1. rectal medicines Benefits and contraindications » To evacuate the bowel before surgical Drugs administered PR have a faster action intervention and other investigations than via the oral route and a higher bio- – enemas and suppositories may be availability – that is, the amount of effec- combined for this type of preparatory tive drug that is available is greater as it has treatment and the patient may have to not been influenced by upper gastrointes- self-administer; tinal tract digestive processes. Rectal » To help relieve constipation – a simple absorption results in more of the drug suppository formulation, such as reaching the systemic circulation with less glycerine, can soften stools and aid the 1a. Suppository 1b. Enema

Alamy alteration on route. As well as being a more passage of faeces. An enema may also

12 Nursing Times 24.02.16 / Vol 112 No 8 / www.nursingtimes.net be needed for cases that do not respond manufacturer’s legal terms of use, and adequately to a suppository. This must FIG 2. The rectum nurses should reflect on how they might be addressed with caution and the defend criticism of their chosen method. patient’s overall health will need to be Logic, alongside manufacturers’ rec- considered before administration; ommendations and those of other authors, » To introduce medications, such as such as Macqueen et al (2012), determines sedation, respiratory treatments, that suppositories should be inserted analgesia, antibiotics – as long as the pointed-end first. patient does not object to medicines via this route. For those who require Nursing observations multiple medications, PR administra- Rectum It is essential to obtain the patient’s con- Anal columns tion may be inappropriate due to Pectinate line sent to carry out an assessment before the overloading the rectum at any one time; Anal canal External anal rectal administration of medication. With sphincter » To relieve and treat haemorrhoids or Internal anal consent, the perineal and perianal area anal pruritus (itching) – many prepara- sphincter should be examined for signs of: Anus tions soothe the mucosa and relieve » Soreness or redness in the anal area or symptoms of common anal disorders. inner buttocks; Guidelines for the administration of » Excoriation of skin, especially where medicines should be followed and medi- whereas the area above (proximal) is only there are signs of infected tissue; cines should be prescribed according to sensitive to stretch. Therefore, once care- » Pruritus: although this is not neces- local policy. fully inserted into the rectum, medication sarily a contraindication for PR Nurses should familiarise themselves should not cause pain. administration, it will need to be with the indications and contraindications Within the anal canal are two areas to monitored and reported if persistent; of all drugs including enemas and supposi- control the opening of the anus – the » Skin tags: these are unlikely to cause tories for treatment of constipation. internal and external sphincters (Fig 2). problems during administration but The internal sphincter functions involun- care should be taken to avoid damage Spinal cord injury tarily, whereas the external sphincter is that might lead to bleeding; There are particular precautions for under the control of the individual. This is » Infestations; patients who have a spinal-cord injury important and underlines the need to » Haemorrhoids: these may be a problem (SCI), especially above the level of T6, when ensure a patient receiving drugs via the if they are large and friable, as insertion using the rectal route. Such individuals are rectal administration route is sufficiently of PR drugs may cause pain or bleeding; at risk of autonomic dysreflexia, which relaxed and cooperative, to enable both » Foreign bodies: these are uncommon occurs in response to a noxious stimulus insertion and retention of the drug. but their presence should be reported below the level of injury, such as bowel to senior staff; distension or insertion of a suppository. Inserting suppositories » Bleeding: this requires further This can trigger an episode of extreme There have been a number of conflicting investigation and should reported hypertension that can lead to stroke, reports about which end of a suppository to senior staff; haemorrhage, seizures and death (Cowan, should be inserted first. Most of the confu- » Wounds and discharge from dressings. 2015). sion stems from an article published in The If any of the above are present, advice Many people with SCI are dependent on Lancet (Abd-el-Maeboud et al, 1991), which should be sought before proceeding. bowel management regimes and health- suggested that suppositories should be care staff must be taught how to perform inserted blunt-end first. The procedures the procedure correctly (Ness et al, 2012). Bradshaw and Price (2007) identified a Equipment According to Coggrave (2012), autonomic lack of evidence for the claims made by » Appropriate personal protective dysreflexia is worsened as a consequence of Abd-el-Maeboud et al. Unfortunately sub- equipment that is compliant with faecal loading and impaction. This raises sequent adoption of their advice is uncriti- local policies; special considerations for nurses, as failure cally applied, to the extent that their “find- » Prescription chart noting the to support the elimination needs of people ings” have entered common clinical legal requirements for the with SCI increases the likelihood of this practice, as evidenced by Kyle (2009) and correct prescription; complication. Dougherty et al (2015). The Royal Marsden » Medication as prescribed – after first Manual (Dougherty et al, 2015) continues to checking the patient’s allergy status; Related anatomy and physiology refer to Abd-el-Maeboud et al’s (1991) study, » Lubricant may be required for either a The rectum constitutes the final 20cm or but there is now a caveat to say that a suppository or enema insertion tube; so of the terminal gastrointestinal tract; common-sense approach should be » Small clinical waste bag; approximately 2-3cms of this is the anal adopted when deciding which end of a sup- » Absorbent pad in case of discharge; canal. Absorption from within the anal pository should be inserted first. » Gauze swabs or tissues; canal is via its highly vascular mucous However, other authors, for example » Bedpan, commode and toilet paper, or membrane that is divided into folds or pil- Peate and Gault (2013), agree that evidence ready access to a toilet if required. lars, known as anal columns (Tortora and to support instructions on which end of a Derrickson, 2008). The anal canal is divided suppository is to be inserted first may be Preparing the patient into areas above and below the pectinate obtained from the manufacturers, who rec- Once equipment has been prepared: line (Fig 2); the area below (distal) is sensi- ommend inserting the pointed end first. 1. Explain the procedure in terms the tive to pain, touch and temperature, This is important when considering a patient will understand. Ask the patient

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to repeat what to expect from the Box 1. “Six rights” of mucous membranes. An example of a procedure to ensure comprehension. drug administration retention enema is prednisolone for When you are satisfied the patient patients who have ulcerative colitis or understands, gain declared spoken con- Each time you administer a medication, Crohn’s disease. Ask the patient to remain sent, as appropriate. you need to check you have the: in the left lateral position for at least 30 2. Ensure privacy by drawing curtains ● Right individual minutes to aid retention. Raising the foot around the bed space. Retain the ● Right medication of the bed may also help. patient’s dignity by minimising ● Right dose exposure and checking their comfort ● Right time Conclusion – for example, absence of ● Right route Clinical nurses need to think about when it pain, agreeable temperature. ● Right documentation may be preferable to administer drugs to a 3. If the suppository or enema is for drug patient PR. If they think it may be appro- administration rather than aperient, priate, they should discuss this with the where possible the bowels should be 9. The patient should be asked to retain patient and then, if the patient is in agree- opened before administration. the suppository for 20 minutes or ment, liaise with prescribers. 4. Help the patient to lie on their left side longer, providing this is comfortable, Efforts should also be made to ensure with the right knee raised towards the in order for the drug to be absorbed. clinical staff are aware of the correct inser- chest, if possible. This enables eventual 10. Leave the patient in a comfortable tion method for suppositories and check gravity-assisted flow into the rectum position, preferably still lying on the that the information on which they base and ideally towards the sigmoid colon, left side, with a call bell so staff can be their practice has a solid evidence base. NT which deviates to the patient’s left- called for assistance if necessary. hand side. The right knee may be 11. Document the administration References Abd-el-Maeboud KH et al (1991) Rectal supported by a pillow. A rectal exami- procedure. suppository: commonsense and mode of insertion. nation to assess whether faecal matter 12. Document the effectiveness of the The Lancet; 338: 8,770, 798-800. is present may be performed before suppository, as appropriate. Bradshaw A, Price L (2007) Rectal suppository insertion: the reliability of the evidence as a basis administering suppositories or enemas 13. Observe the patient for any for nursing practice. Journal of Clinical Nursing; that are designed to relieve constipa- adverse reactions. 16: 1, 98-103. tion. Staff should have appropriate Coggrave M (2012) Guidelines for management training prior to carrying out a rectal Enemas of neurogenic bowel dysfunction in individuals with central neurological conditions. examination (Ness et al 2012). 1. Follow preparation instructions Bit.ly/MASCIPNeurogenicGuide 5. Place an absorbent pad under the and steps 1-4 above for suppository Cowan H (2015) Autonomic dysreflexia in spinal patient’s hips and buttocks. insertion; cord injury. Nursing Times; 111: 44, 22-23. Davies C (2004) The use of phosphate enemas in 6. Ensure the patient remains comfort- 2. Remove the cover from the nozzle the treatment of constipation, Nursing Times; able and ready for the procedure. and lubricate the tip of the nozzle, 100: 18, 32-35. 7. Wash your hands thoroughly to remove and along its length; Department of Health (2001) Medicines and Older any potential bacteria that could 3. Part the buttocks and, holding People: Implementing Medicines-related Aspects of the NSF for Older People. London: DH. contaminate the patient. the nozzle, gently insert it into the Dougherty L et al (2015) The Royal Marsden 8. Wear non-sterile gloves and apron anal canal; Manual of Clinical Nursing Procedures. London: while at the bedside. 4. Slowly squeeze the bag or pack until all Wiley-Blackwell. Galbraith A et al (2007) Fundamentals of the contents have been deposited; Pharmacology: An applied Approach for Nursing Suppositories 5. While still squeezing – which helps to and Health. Harlow: Pearson Education. 1. Check the “six rights” for administra- avoid any re-entry of contents due to Kyle G (2009) Should a suppository be inserted with the blunt end or the pointed end first, or does tion of medicines (Box 1). vacuum effect in the enema – gently it not matter? Nursing Times; 105: 2, 16. 2. Remove all packaging from the withdraw the nozzle. Macqueen S et al (2012) The Great Ormond Street suppository and place the equipment Be aware, this procedure can sometimes Hospital Manual of Children’s Nursing Practices. onto a clean dressing trolley or similar. make the patient feel faint or nauseated. Oxford: Wiley-Blackwell. National Patient Safety Agency (2004) Improving 3. Squeeze sufficient lubrication onto a the Safety of Patients With Established Spinal piece of gauze and lubricate the apex Evacuant enema Injuries in Hospital: Spinal Cord Lesion and (pointed end) of the suppository. Ask the patient to retain the enema for as Bowel Care. London: NPSA. Ness W et al (2012) Management of Lower Bowel 4. Ask the patient to relax, perhaps by long as possible before discharging faecal Dysfunction, Including DRE and DRF: RCN concentrating on their breathing or material. The effect is likely to be rapid, as Guidance for Nurses. Bit.ly/RCNBowels controlling their breaths. the presence of the enema itself may stim- Peate I, Gault C (2013) Clinical skills series/2: 5. Part the buttocks and gently insert the ulate a response. enemas and suppositories. British Journal of Healthcare Assistants; 7: 2, 76-81. suppository into the anal canal to Where feasible, elevate the foot of the Pegram A et al (2008) Safe use of rectal around 2-4cm using a gloved index bed to aid enema retention. When the suppositories and enemas with adult patients. finger. patient is ready to evacuate, help them to a Nursing Standard; 22: 38, 39-41. Tortora GJ, Derrickson BH (2008) Principles of 6. Repeat the process if more than one commode or onto the bedpan, as appro- Anatomy and Physiology. Hoboken, NJ: Wiley. suppository has been prescribed; priate. 7. Wipe away excess traces of lubrication For more on this topic go online... from the anal area; Retention enema Administration of drugs 2: 8. Place all used equipment, gloves Unlike evacuant enemas, retention enemas non-oral and apron in clinical waste and wash are designed to be kept in the rectum to Bit.ly/NTNonOralDrugAdmin your hands. enable absorption of the drug via the

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