Presentation on theme: "Digital Rectal Examination & Manual Removal of Faeces"— Presentation transcript:
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 colonThe anatomy and physiology of the rectumReview the principles of constipation management
3 Objectives Anal & perianal observations Principles of DRE Principles of constipation management and manual evacuationPrescribing rectal medicationLegal and ethic considerations of DRE and manual evacuation
5 colonThe 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 timeLength of time that food is in the colon.The longer the transit time the more water is absorbedThe harder and more solid the evacuated stool will beTotal water content of the gut per 24 hoursSalivary glands 1500mlsStomach 2500mlsBile 500mlsPancreas 1500mlsL & S bowel 1000mlsOnly 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 distensionUsually emptyGastro colic reflex is necessary for its functionAffected by emotionAble to distinguish wind from solid
9 Pelvic floorThe pelvic floor, in particular the pubo-rectalis muscle is important to maintain faecal continence and successful defecation
10 mechanismThe junction of the sigmoid colon & the rectum is angled sharply60° °Continence is maintained bythe acute angle2 Anal sphincters
11 Anal Sphincters The Internal Anal Sphincter. Surrounds the anal canalNot under voluntary controlThe 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 % water20 % Dead bacteria5 % FatNitrogenBile pigments & undigested foodColour usually brown influenced by foodDark = proteinBlack = Blood or ironClay = Fat
19 THE FACTS 10% of the population are affected 25% of the elderly are affectedMore common in females13 out of 1000 GP consultations are for constipation
20 Impact of constipation Loss of well beingPainDepressionLoss of mobilityLoss of appetite
21 Defining Constipation Going less oftenpassing hard faecesdifficulty in passing a stoolStraining at stoolGoing less than 3 times per weekPain on defaecation
22 3 Categories of Constipation PrimarydietLifestyleSecondaryDisease associatedIatrogenic50% of medication can have constipatory affects on the bowel
23 Causes of constipation Pregnancy and childbirthIgnoring the call to stoolDiabetesDepressionLifestyleImmobility – walking 0.5km per day will reduce constipationPoor dietIrregular meals
24 The Goal The feeling you want to go is definite but not irresistible Once you sit on the toilet there is no delayNo conscious effort or strainingThe faeces glides out smoothly & comfortablyFollowed by a pleasant feeling of relief
26 DRE and MEFAny 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 tractIdentification of possible causes of constipationPlanning 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 rectumTo establish anal tone, the ability to initiate a voluntary contraction and to what degreeAnal/rectal sensation(
30 Preparing the patient DO: Complete a full bowel assessment Consider ALL other treatment options with your teamInform the patient of treatment options and risksGain valid consent
31 Preparing the patient Don’t Proceed if YOU do not feel competent (NMC 2002)Proceed if there is a lack of consentProceed if the doctor has given specific instructions NOT to undertake the procedureProceed if the patient has recently undergone rectal, anal surgery or trauma.
32 Preparing the patient Don’t proceed if Active inflammatory bowel diseaseRectal painObvious rectal bleedingSpinal 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 procedureGet verbal consentAlcohol gel hands!Get a chaperone if opposite sex and advised still if same sex.
34 DREGet patient to roll onto left hand side with knees up to chest. (Always examine from right hand side!)Collect equipment:Clean trayGel (lubricant)GlovesGauze (for wiping)
35 observationLook at perianal area what can you see??
36 Common perianal observations Rectal prolapseHaemorrhoidsSkin tagsWounds/dressing/ dischargeAnal lesionsfistulaAbscessesFissureexcoriation
42 Rectal ProlapseCommon in elderly femalesThere may beFaecal incontinence due to stretching of the anal sphincterMucus discharge from the prolapsed bowelTreatment of a complete rectal prolapse requires an operation (rectopexy) to fix the rectum within the pelvis
43 Fistula in Ano Common causes:- ConstipationRepeated enemasChildbirthExploration and laying open of the fistula under general anaesthesia may be necessary
44 Anal Carcinoma Present with Treatment with surgery pruritus ani, fissures,perianal wartsbleeding massTreatment with surgery
45 Anal Warts Commonest STD Results from HPV Associated genital warts in the sexual partner are common
47 Skin tags Not significant May become:- Can lead to:- Can be removed Chronic strainingChildbirthConstipationMay become:-ThrombosedOedematousCan lead to:-PruritusHaemorrhoidsCan be removed
48 ExaminationInform patient you are going to examine with your finger nowPut blob of lubricant on fingerWith your left hand, raise up the patient’s right buttock.
49 Assessing Sphincter function Insert finger,assessing sphincter toneIs it hypertonic – difficult to insert fingerRemember patient may be anxious and can ask patient to take a deep breathIndicative of Crohn’s disease, Fissure, stricture, nervesIs it hypotonic - no resistanceIndicative of old age, nerve damage (spinal injury), muscle damage (multigravida)
50 Advance fingerIf 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
51 WHAT ARE YOU FEELING FOR:- What is in rectum/anal canal;is it empty?full of compact material?Rotate posteriorly, feeling each side systematicallyAre there any:-polyps – these will feel soft and mobilecancers; 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, mucusCan take swab if necessary.Wipe the patients or ask them to wipe themselves (use your discretion).Take off glove, thank patientTHANK PATIENT! And WASH HANDS!
55 Indications for manual removal of faeces Faecal impaction/loadingIncomplete defecationInability to defecateOther bowel emptying techniques have failedNeurogenic bowel function – although alternatives should be consideredIn patients with spinal injury
56 Exclusions for Manual Removal of Faeces Lack of consentA doctor has given specific instructions that these procedures are not to take placeThe 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 areaRectal 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 procedureWash 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 interventionblood pressure should be monitored at rest, during and at the end of the procedureFor patients who have a manual evacuation performed on a regular basisPlace some lubricating jelly on index fingerFor 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 GPExtra lubrication may be requiredPlace 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 handsMake patient comfortable and ensure patient has access to commode or toilet if needed.
65 Manual Removal of Faeces Record outcome, documenting:-ConsentStool typeCommunicate findings to patient/carer and doctor if appropriate.Referral to doctor (where indicated)