Enema Administration Order Form

Enema Number __________                Session Date:__________

Device:                                                                      Position

_____bag                                                                   _____on back

_____squeeze bulb                                                   _____on left side

_____JBL Cascade                                                  _____on tummy

                                                                                     _____over lap

                                                                                     _____on hands and knees

Location                                                                    Nozzle

_____on table                                                            _____regular enema

_____bathroom floor                                                 _____curved douche

_____over lap                                                            _____special enema

_____in restraints                                                      _____dual Inflatable nozzle

_____other________________                             _____other ________________

Atmosphere:                                                             Offer comfort:

_____loving caregiver                                               _____back rub

_____erotic                                                                 _____tummy rub

_____clinical                                                               _____other ________________

_____punishment

First enema only                                                       Subsequent enemas

_____Ivory soap                                                             _____tsp. Salt

_____Peppermint soap                                                  _____tsp. Baking soda

_____other_________________                                 _____other_________________

Amount

_____mls or ccs

_____ounces

Timing of enema

_____pause _____ seconds ____times per minute

_____pause when requested

_____raise bag for maximum _____ seconds if necessary

_____jiggle bag when almost finished (causes interesting feelings inside patient)

Other instructions:

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Ordered by:_______________________          Time Administered:_____________