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Digital Rectal Examination & Manual Removal of Faeces

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1 Digital Rectal Examination & Manual Removal of Faeces
Cath Stansfield. Advanced Practitioner - Gastroenterology

2 Before you begin… Review your A&P of the GI tract, in particular:-
The function of the colon The anatomy and physiology of the rectum Review the principles of constipation management

3 Objectives Anal & perianal observations Principles of DRE
Principles of constipation management and manual evacuation Prescribing rectal medication Legal and ethic considerations of DRE and manual evacuation

4 Anatomy of the lower gi tract

5 colon The main function of the colon is the propulsion of faecal matter and absorption of fluid.

6 Why is the colon important in considering constipation?
Transit time Length of time that food is in the colon. The longer the transit time the more water is absorbed The harder and more solid the evacuated stool will be Total water content of the gut per 24 hours Salivary glands 1500mls Stomach 2500mls Bile 500mls Pancreas 1500mls L & S bowel 1000mls Only 200mls is expelled in faeces

7 The rectum and anal canal
The rectum is the last 15-17cm of the large colon. It is situated at the level of the pelvic floor, the last 2-3cm becomes the anal canal.

8 Key characteristics of the rectum
Capable of distension Usually empty Gastro colic reflex is necessary for its function Affected by emotion Able to distinguish wind from solid

9 Pelvic floor The pelvic floor, in particular the pubo-rectalis muscle is important to maintain faecal continence and successful defecation

10 mechanism The junction of the sigmoid colon & the rectum is angled sharply 60° ° Continence is maintained by the acute angle 2 Anal sphincters

11 Anal Sphincters The Internal Anal Sphincter.
Surrounds the anal canal Not under voluntary control The External Anal Sphincter. surrounds the bottom of the internal anal sphincter. is under voluntary control.


13 And finally.. faeces Product of elimination, consists of
75 % water 20 % Dead bacteria 5 % Fat Nitrogen Bile pigments & undigested food Colour usually brown influenced by food Dark = protein Black = Blood or iron Clay = Fat

14 Assessing bowel function

15 Assessing bowel function – medical/ surgical history
Illness Bowel disorders Neurological illness Chronic pain Terminal illness Injury Child birth Spinal injury Surgery Spinal surgery Bowel surgery

16 Assessing bowel function - medication
Diarrhoea Antacids ( Magnesium) Antibiotics Antidepressants Beta Blockers Diuretics Iron preparations Hypoglycaemic preparations Sorbitol Constipation Antacids (Aluminium) Analgesics Anti-inflammatory drugs Antidepressants Anti hypertensives Diuretics Iron preparations Sedatives Motility drugs

17 Bristol stool chart

18 Constipation

19 THE FACTS 10% of the population are affected
25% of the elderly are affected More common in females 13 out of 1000 GP consultations are for constipation

20 Impact of constipation
Loss of well being Pain Depression Loss of mobility Loss of appetite

21 Defining Constipation
Going less often passing hard faeces difficulty in passing a stool Straining at stool Going less than 3 times per week Pain on defaecation

22 3 Categories of Constipation
Primary diet Lifestyle Secondary Disease associated Iatrogenic 50% of medication can have constipatory affects on the bowel

23 Causes of constipation
Pregnancy and childbirth Ignoring the call to stool Diabetes Depression Lifestyle Immobility – walking 0.5km per day will reduce constipation Poor diet Irregular meals

24 The Goal The feeling you want to go is definite but not irresistible
Once you sit on the toilet there is no delay No conscious effort or straining The faeces glides out smoothly & comfortably Followed by a pleasant feeling of relief

25 Digital Rectal Examination

26 DRE and MEF Any concerns about scope of practice the RCN Guidance for DRE should be followed.

27 Before you do… Understanding of A&P of the lower gastro-intestinal tract Identification of possible causes of constipation Planning stepped approach to nursing care to prevent & treat constipation

28 Think about…. Invasive and should only be performed when necessary.
Awareness of cultural & religious beliefs. There can be conflict over Manual Removal of Faeces between patient/carers/nurses. Wide range of alternatives available, but not suitable for all. Keep discomfort to a minimum

29 Why? To establish the need and outcome of digital stimulation to trigger defecation by stimulating the recto anal reflex (RCN, Bowel Care, Guidance for Nurses, March 2008) To establish the presence, amount & consistency of faecal matter in the rectum To establish anal tone, the ability to initiate a voluntary contraction and to what degree Anal/rectal sensation (

30 Preparing the patient DO: Complete a full bowel assessment
Consider ALL other treatment options with your team Inform the patient of treatment options and risks Gain valid consent

31 Preparing the patient Don’t
Proceed if YOU do not feel competent (NMC 2002) Proceed if there is a lack of consent Proceed if the doctor has given specific instructions NOT to undertake the procedure Proceed if the patient has recently undergone rectal, anal surgery or trauma.

32 Preparing the patient Don’t proceed if
Active inflammatory bowel disease Rectal pain Obvious rectal bleeding Spinal Injury at T6 or above- consult local guidance and spinal injury team as allowing constipation to occur leads to a greater risk of autonomic dysreflexia (Getliffe et al 2007)

33 DRE Introduction Explain WHY you are doing the procedure
Introduce yourself, check you have the right patient, explain procedure; “will involve examining back passage with a finger” Explain WHY you are doing the procedure Get verbal consent Alcohol gel hands! Get a chaperone if opposite sex and advised still if same sex.

34 DRE Get patient to roll onto left hand side with knees up to chest. (Always examine from right hand side!) Collect equipment: Clean tray Gel (lubricant) Gloves Gauze (for wiping)

35 observation Look at perianal area what can you see??

36 Common perianal observations
Rectal prolapse Haemorrhoids Skin tags Wounds/dressing/ discharge Anal lesions fistula Abscesses Fissure excoriation

37 Abscesses Discharge Blood Mucus Faecal matter

38 Anal fissure Document as clock:- Common in Crohn’s and constipation
6 o’clock 12 o’clock Common in Crohn’s and constipation

39 haemorrhoids 1st degree- remain in rectum, 2nd degree- prolapse through but spontaneously reduce, 3rd degree- as for 2nd but require digital reduction, 4th degree- remain prolapsed persistently

40 Haemorrhoids Haemorrhoids are abnormalities of these cushions which may slip due to : Straining at stool Pregnancy


42 Rectal Prolapse Common in elderly females There may be Faecal incontinence due to stretching of the anal sphincter Mucus discharge from the prolapsed bowel Treatment of a complete rectal prolapse requires an operation (rectopexy) to fix the rectum within the pelvis

43 Fistula in Ano Common causes:-
Constipation Repeated enemas Childbirth Exploration and laying open of the fistula under general anaesthesia may be necessary

44 Anal Carcinoma Present with Treatment with surgery pruritus ani,
fissures, perianal warts bleeding mass Treatment with surgery

45 Anal Warts Commonest STD Results from HPV
Associated genital warts in the sexual partner are common

46 Perianal Crohn's Multiple signs Anal strictures Skin tags Erythema
Fistula Abscesses scarring Anal strictures

47 Skin tags Not significant May become:- Can lead to:- Can be removed
Chronic straining Childbirth Constipation May become:- Thrombosed Oedematous Can lead to:- Pruritus Haemorrhoids Can be removed

48 Examination Inform patient you are going to examine with your finger now Put blob of lubricant on finger With your left hand, raise up the patient’s right buttock.

49 Assessing Sphincter function
Insert finger, assessing sphincter tone Is it hypertonic – difficult to insert finger Remember patient may be anxious and can ask patient to take a deep breath Indicative of Crohn’s disease, Fissure, stricture, nerves Is it hypotonic - no resistance Indicative of old age, nerve damage (spinal injury), muscle damage (multigravida)

50 Advance finger If resistance noted - ask the patient to take a deep breath, or to push, as if they are going to the toilet. If patient is unable to tolerate at any point STOP

What is in rectum/anal canal; is it empty? full of compact material? Rotate posteriorly, feeling each side systematically Are there any:- polyps – these will feel soft and mobile cancers; fixed, hard, irregular, lumpy. Describe according to site, size, shape, smoothness, surface, surroundings.

52 And twist finger round. Prostate; walnut sized, 2 lobes, separated by sulcus. In prostatic cancer you lose the sulcus. In a woman, you are likely to feel in the region of the cervix when you feel anteriorly.

53 And finally… At the end, take out finger, and look at it; check if any blood, faeces, mucus Can take swab if necessary. Wipe the patients or ask them to wipe themselves (use your discretion). Take off glove, thank patient THANK PATIENT! And WASH HANDS!

54 Manual removal of faeces

55 Indications for manual removal of faeces
Faecal impaction/loading Incomplete defecation Inability to defecate Other bowel emptying techniques have failed Neurogenic bowel function – although alternatives should be considered In patients with spinal injury

56 Exclusions for Manual Removal of Faeces
Lack of consent A doctor has given specific instructions that these procedures are not to take place The patient has recently undergone rectal/anal surgery or trauma. The patient gains sexual satisfaction and the nurse performing them finds this embarrassing. The presence of abnormalities on the perianal area Rectal pain

57 Consent and Manual Removal of Faeces
Consent should be given by someone with the mental ability to do so. Sufficient information should be given to the patient to make an informed decision. Consent must be given freely. (RCN, 2006)

58 Undertaking Manual Removal of Faeces
Explain the procedure and its necessity to the patient, to gain co-operation and consent. Document consent has been given. Ask patient if they wish to use the toilet prior to undertaking the procedure.

59 Manual Removal of Faeces
Position patient: left lateral with knees flexed, ensuring privacy at all times. Take the patient’s pulse rate prior to commencing the procedure Wash hands with soap and water put on disposable gloves. Observe and examine anal/perianal area

60 Manual Removal of Faeces
In spinal injuries as an acute intervention blood pressure should be monitored at rest, during and at the end of the procedure For patients who have a manual evacuation performed on a regular basis Place some lubricating jelly on index finger For patients who have not had a manual evacuation of faeces before. Lubricate index finger and anus with anaesthetic gel, following manufacturer’s guidelines for gel to take effect.

61 Manual Removal of Faeces
Inform patient of imminent examination when finger is to be inserted. Insert gloved finger slowly and encourage patient to relax when it is in situ – Use one finger only.

62 Manual Removal of Faeces
In scybala type stool (type 1,2), remove one lump at a time . In a solid mass (type 3) gently, push finger into middle of the mass, split it and remove small pieces at a time. Soft stool, remove small amounts at a time

63 Manual Removal of Faeces
A period of rest may allow further faecal matter to descend into the rectum. If mass too hard or large to divide STOP procedure and refer to GP Extra lubrication may be required Place faecal matter into receptacle as it is removed.

64 Manual Removal of Faeces
Check patient’s pulse rate during the procedure. Stop the procedure if the heart rate drops or rhythm changes. When the procedure is complete, wash and dry patient’s buttocks and anal area. Remove and dispose of equipment. Wash hands Make patient comfortable and ensure patient has access to commode or toilet if needed.

65 Manual Removal of Faeces
Record outcome, documenting:- Consent Stool type Communicate findings to patient/carer and doctor if appropriate. Referral to doctor (where indicated)

66 Any questions?

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