Digital Rectal Examination & Manual Removal of Faeces Cath Stansfield. Advanced Practitioner Gastroenterology 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 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 ANATOMY OF THE LOWER GI TRACT colon • The main function of the colon is the propulsion of faecal matter and absorption of fluid. 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 Stomach Bile Pancreas L & S bowel 1500mls 2500mls 500mls 1500mls 1000mls • Only 200mls is expelled in faeces The rectum and anal canal • The rectum is the last 1517cm of the large colon. • It is situated at the level of the pelvic floor, • the last 2-3cm becomes the anal canal. 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 Pelvic floor • The pelvic floor, in particular the puborectalis muscle is important to maintain faecal continence and successful defecation mechanism • The junction of the sigmoid colon & the rectum is angled sharply 60° - 105 ° • Continence is maintained by – the acute angle – 2 Anal sphincters 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. 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 Assessing bowel function 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 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 Bristol stool chart Constipation 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 Impact of constipation • • • • • Loss of well being Pain Depression Loss of mobility Loss of appetite 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 3 Categories of Constipation • Primary – diet – Lifestyle • Secondary – Disease associated • Iatrogenic – 50% of medication can have constipatory affects on the bowel 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 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 Digital Rectal Examination DRE and MEF • Any concerns about scope of practice the RCN Guidance for DRE should be followed. Before you do… • Understanding of A&P of the lower gastrointestinal tract • Identification of possible causes of constipation • Planning stepped approach to nursing care to prevent & treat constipation 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 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 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 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. 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) DRE • Introduction – 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. 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) observation • Look at perianal area what can you see?? Common perianal observations • • • • Rectal prolapse Haemorrhoids Skin tags Wounds/dressing/ discharge • Anal lesions • fistula • Abscesses • Fissure • excoriation Abscesses • Discharge – Blood – Mucus – Faecal matter Anal fissure • Document as clock:– 6 o’clock – 12 o’clock • Common in Crohn’s and constipation haemorrhoids • 1st degree- remain in rectum, 2nd degreeprolapse through but spontaneously reduce, • 3rd degree- as for 2nd but require digital reduction, • 4th degree- remain prolapsed persistently Haemorrhoids • Haemorrhoids are abnormalities of these cushions which may slip due to : – Straining at stool – Pregnancy 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 Fistula in Ano • Common causes:– Constipation – Repeated enemas – Childbirth • Exploration and laying open of the fistula under general anaesthesia may be necessary Anal Carcinoma • Present with • pruritus ani, • fissures, • perianal warts • bleeding mass • Treatment with surgery Anal Warts • Commonest STD • Results from HPV • Associated genital warts in the sexual partner are common Perianal Crohn's • Multiple signs – – – – – Skin tags Erythema Fistula Abscesses scarring • Anal strictures Skin tags • Not significant – Chronic straining – Childbirth – Constipation • May become:– Thrombosed – Oedematous • Can lead to:– Pruritus – Haemorrhoids • Can be removed 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. 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) • 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 ARE YOU FEELING FOR:• 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. 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. 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! MANUAL REMOVAL OF FAECES 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 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 Consent and Manual Removal of Faeces 1. Consent should be given by someone with the mental ability to do so. 2. Sufficient information should be given to the patient to make an informed decision. 3. Consent must be given freely. (RCN, 2006) 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. 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 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. 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. 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 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. 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. Manual Removal of Faeces • Record outcome, documenting:– Consent – Stool type – Communicate findings to patient/carer and doctor if appropriate. – Referral to doctor (where indicated) ANY QUESTIONS?