Keywords: Digital rectal examination/ This special focus on bowel care Nursing Practice Bowel assessment/Bowel function/ was produced in partnership Bowel dysfunction/Continence Practice educator with the Association for ●This article has been double-blind Continence Advice Bowel assessment peer reviewed Why digital rectal examinations are an important part of bowel assessments Digital rectal examination

In this article... Box 1. equipment Performing a digital rectal examination ● Incontinence sheet Equipment needed for the procedure ● Non-latex disposable gloves Which patients and conditions require special care ● Gauze swabs ● Lubricating jelly Box 2. ssessing patients with bowel Need for consent contraindications dysfunction presents many DRE is an intimate and invasive procedure, challenges. Health profes- so valid consent must be obtained before it ● Lack of consent or if a patient refuses sionals not only have to over- is performed. Consent is the legal means (Department of Health, 2009) A ● come communication barriers associated by which a patient gives valid authorisa- If the patient’s doctor has given with bowel habits as well as the embarrass- tion for any treatment or care. Obtaining specific instructions not to undertake the ment that is associated with an intimate consent is a necessary part of good profes- procedure rectal examination, but must also be aware sional practice, ensuring trust between ● If the patient has recently undergone that bowel dysfunction may not result nurse and patient (Department of Health, rectal or anal surgery or trauma from a single, straightforward cause. 2009). ● If the nurse does not feel competent In the past, the intimate nature of DRE, (Nursing and Midwifery Council, 2008) Considering causes together with fears of litigation and accu- Assessment is based on considering all the sation of abuse, has led to confusion possible causes of bowel dysfunction, among nurses about their professional and checking in particular that it is not because legal responsibilities. Perhaps more alarm- of an underlying undiagnosed medical ingly, some nurses believe they are not condition. allowed to perform a DRE, thinking it part Evidence-based guidelines (National of a medical examination. These fears and Institute for Health and Clinical Excel- anxieties are further compounded if a lence, 2007) suggest a structured approach patient lacks the capacity to make a deci- is needed when assessing patients with sion about this intimate procedure. How- bowel dysfunction. All symptoms should ever, the Mental Capacity Act 2007 gives be considered in the context of relevant nurses a statutory framework to empower medical history. The aim of assessment is and protect patients who are unable to to establish a symptom profile to plan make their own decisions. individualised bowel care. NICE (2007) identified the procedure of Training digital rectal examination (DRE) as an Chronic constipation is one of the most essential component of bowel assessment. common lower gastrointestinal disorders However, recent results of the National affecting people in the western world Audit of Continence Care highlighted a (Müller-Lissner et al, 2005) and it is esti- lack of DRE being carried out in bowel mated that 1-10% of adults are affected assessment (Wagg et al, 2010). It was per- with faecal incontinence (NICE, 2007). formed on less than a third of the patients These facts highlight the importance of in primary care (29%), falling to 15% of res- nurses possessing the skills and know- idents in care homes. Only in acute care ledge to assess bowel dysfunction compe- were more than half the patients examined tently to make a clear nursing diagnosis. rectally (53%). These rates are clearly unsat- Fitness to practise means having the isfactory. required skills, knowledge and competency

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to provide a high standard of practice and 5 key care at all times. A failure to undertake a Box 3. cautions points DRE during a bowel assessment may result Take special care when ● Has had recent rectal or anal Digital rectal in a patient receiving inappropriate or ill- undertaking a digital rectal surgery 1examinations timed bowel intervention. examination if the patient: ● Has spinal cord injury to (DREs) are an Bowel Care, including Digital Rectal ● Has active inflammatory T6 or above because of essential part of Examination and Manual Removal of Faeces bowel disease, such as Crohn’s autonomic dysreflexia bowel assessments (Royal College of Nursing, 2008) addressed disease, ulcerative colitis and ● Has a history of abuse Consent must many of the issues pertaining to the pro- diverticulitis ● Gains sexual pleasure from 2be obtained fessional and legal aspects of DRE. The ● Has had recent radiotherapy the procedure before performing document identified Skills for Health to the pelvic area Any concerns should be a DRE bowel care competencies (SfH, 2008) and ● Has rectal or anal pain addressed with the patient’s Failure to carry emphasised the importance of appropriate ● Has obvious rectal bleeding doctor 3out DREs training in order to undertake this proce- during bowel dure competently. Most continence assessments may services organise DRE training, which is Box 4. assessment using digital result in patients available throughout the UK. The courses rectal examination receiving aim to improve knowledge and increase Consult local policies and documented and reported to inappropriate or skills in the management of bowel dys- procedures before the healthcare team. ill-timed bowel function. undertaking a DRE Observation of any perineal interventions Rectal examination should always be Stage 1 movement and anal sphincter DREs should performed as part of the bowel assessment Observe the perineal perianal squeeze is useful, as poor 4always be used process and never as a standalone investi- area (SfH, 2008) for any muscle coordination may as part of the gation to evaluate treatment (SfH, 2008). abnormalities or signs of: indicate problems with bowel assessment Nurses who lack the necessary knowledge ● Rectal prolapse: (protrusion obstructive defaecation process and never and expertise to perform a DRE compe- of rectal tissue through the as a standalone tently must acknowledge the limits of anus to the exterior of the Stage 2 investigation their professional competence (Nursing body occurs when the internal Following local procedures for Training in DRE and Midwifery Council, 2008). anal sphincter is incompetent DRE, insert a lubricated, 5is essential. It is important that all nurses access and/or pelvic floor muscles are gloved finger into the patient’s Most continence their local DRE courses so they are able to weak) observe the degree of rectum to: services organise perform this important procedure. Effec- protrusion, colour, swelling and ● Establish the presence of DRE courses; these tive bowel assessment, including a DRE, signs of any ulceration faecal matter in the bowel are available gives nurses the information they need in ● Haemorrhoids: note number, (SfH, 2008) throughout the UK order to plan advice and interventions, size and check for signs of ● Assess the amount and measure outcomes and evaluate care. NT bleeding consistency of faecal matter ● Anal skin tags: note number, (SfH, 2008) Examination should Gaye Kyle is an independent lecturer and position and condition ● Assess the need for rectal include observing recognised teacher, University of Ulster ● Anal lesions or swelling: medication or the need for the perianal area could indicate anal/rectal digital removal of faeces in and recording References malignancy extreme cases of faecal abnormalities or Department of Health (2009) Reference Guide to ● Gaping anus: may indicate impaction (SfH, 2008) conditions such as Consent for Examination or Treatment. London: poor sphincter tone; if faecal ● Assess anal sphincter haemorrhoids and DH. tinyurl.com/DH-consent matter is observed this can function and tone (SfH, 2008) Müller-Lissner SA et al (2005) Myths and ● anal warts misconceptions about chronic constipation. indicate faecal impaction Assess rectal sensation American Journal of Gastroenterology; 100: ● Skin condition, broken (SfH, 2008) 232-242. areas, pressure ulcers: ● Assess size, consistency of National Institute for Health and Clinical excoriation or pruritus the prostate gland (usually Excellence (2007) Faecal Incontinence: The Management of Faecal Incontinence in Adults. indicates possible signs of part of specialist nurse London: NICE. www.nice.org.uk/CG49 faecal incontinence practitioner’s role). Nursing and Midwifery Council (2008) The Code: ● Soiling: may indicate faecal The rectum is normally empty Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC. tinyurl.com/ incontinence or inability to so a lack of faecal matter on NMC-thecode maintain personal hygiene DRE does not necessarily Royal College of Nursing (2008) Bowel Care, ● Bleeding or mucus signify the absence of including Digital Rectal Examination and Manual may indicate constipation. Constipation of Removal of Faeces. London: RCN. tinyurl.com/ discharge: digital-rectal-examination inflammatory bowel disease or the sigmoid colon has been Skills for Health (2008) Continence Care malignancy found in 30% of patients with Competencies. London: SfH. ● Infestations: including anal an empty rectum (Smith and Smith RG, Lewis S (1990) The relationship between digital rectal examination and abdominal warts caused by a virus, or Lewis, 1990) radiographs in elderly patients. Age and Ageing; 19: threadworms 142-143. ● Foreign bodies: any of these Wagg A et al (2010) National Audit of Continence Care. London: Royal College of Physicians. tinyurl. abnormalities should be

com/audit-continence-care SPL

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