Practice comment

Why are nurses failing to undertake digital rectal examinations?

3 December, 2010

Patients with bowel dysfunction should be rectally assessed, but many nurses are either wary of undertaking this procedure or unaware of its importance, says Gaye Kyle

A structured approach is required when assessing a patient with bowel dysfunction according to evidence based guidelines (NICE, 2007). All symptoms should be considered in the context of relevant medical history. The aim of assessment is to establish a symptom profile in order to plan individualised bowel care.

Assessing a patient with bowel dysfunction presents certain challenges to the health care professional. The communication barriers associated with bowel habits are often difficult to overcome, as is the embarrassment associated with an intimate digital rectal examination (DRE).

Despite the role of DRE being part of the national guidelines, the results of the recent National Audit of Continence Care (Royal College of Physicians, 2010) showed that this essential assessment examination was performed on less than half of patients in primary care (29%), falling to 15% of patients in care homes. Only in the acute sector were more than half the patients examined rectally (53%). Clearly these results are unsatisfactory.

DRE should always be used as part of the assessment process and never as a stand alone investigation to evaluate treatment. A DRE involves first observing the peri-anal area for any abnormalities. These include: rectal prolapse, haemorrhoids, anal skin tags, anal lesions, scarring from episiotomy or tears, gaping anus, bleeding, faecal soiling, infestation or foreign bodies and general skin condition. Excoriation around the anus may indicate leakage from the bowel. Observation of any perineal movement and anal sphincter squeeze is very useful, as poor muscle co-ordination may indicate obstructive defaecation.

Further examination requires the insertion of a lubricated gloved finger into a patient’s rectum to assess the presence of faecal matter in the bowel, the amount and consistency of faecal matter, the need for rectal medication or the need for a digital removal of faeces in extreme cases of faecal impaction, and anal sphincter function and tone.

Initially, nurses should check for rectal prolapse. A low resting tone is associated with passive soiling. There is often a gaping of a “funnel shaped” anal introitus if gentle traction is applied away from the anal verge. Many patients with post defaecation soiling have trapped soft faeces in this funnel. Reduced strength and duration of contraction of the external sphincter (voluntary) has been found to correlate with the symptom of urgency.

The strength and endurance of puborectalis muscle, anal sphincter tone and evidence of propreception should also be checked. (This is a post-graduate assessment for physiotherapists and is only undertaken by those who have had appropriate training). Nurses should also check the patient’s rectal sensation.

The intimate nature of this procedure together with fears of litigation and accusations of abuse have, in the past, led to confusion among nurses concerning their professional and legal responsibilities with regards to DRE. These fears are compounded if a patient lacks the capacity to make a decision about this intimate act. However, the Mental Capacity Act (2007) provides nurses with a statutory framework to empower and protect those patients who are unable to make their own decisions.

If nurses lack sufficient knowledge and expertise to perform a DRE competently they will be reluctant to include it in bowel assessment. Certainly nurses must acknowledge the limits of their professional competence and only undertake practice and accept responsibilities for those activities in which they are competent. DRE courses organised by continence services are now widely available throughout the UK to support the profession. Many DRE courses are free to attend. Some trusts, acknowledge the importance of this training by making attendance part of their mandatory training.

More alarmingly, some nurses believe they are not allowed to perform a DRE, thinking it part of a medical examination. However, fitness to practice means having the required skills, knowledge and competency to provide a high standard of practice and care at all times.

Nurses need to possess the skills and knowledge to assess bowel dysfunction competently in order to make a clear nursing diagnosis. Effective assessment, including a DRE, provides nurses with the relevant information upon which advice and interventions can be planned, outcomes measured and evaluation of care made.

GAYE KYLE, RGN, BA, Dip Ed, MA, is an independent lecturer and recognised teacher, University of Ulster

References:

National Institute of Clinical Excellence (2007) Faecal incontinence. London: NICE.

Royal College of Physicians(2010)National Audit of Continence Care. London: Royal College of Physicians.

Readers' comments (25)

halfanurse1987 | 6-Jan-2011 1:34 am
I have not been trained how to do it...something to request on next placement then.
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Anonymous | 6-Jan-2011 12:38 pm
What has happened to full nursing case histories and initial assessment for the planning and provision holistic patient care?
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Anonymous | 6-Jan-2011 11:46 pm
Why are nurses failing to undertake digital rectal examinations?

Because they fail to understand the needs of some of their patients or choose to ignore them
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halfanurse1987 | 12-Jan-2011 5:53 pm
DRE is not something that seems to be taught at the moment. I could very well give it a go but realistically I would have no idea what I was feeling for.

Taking histories and assessments (in other areas) are taught.
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Anonymous | 12-Jan-2011 6:27 pm
'Taking histories and assessments (in other areas) are taught.'

A full history and assessment cannot be taken if some assessments are not taught and there is little point in doing incomplete assessments as this only results in an incomplete history
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Anonymous | 13-Jan-2011 11:50 am
Qualified nurses who don't know how to do a PR
how is faecal impaction or impaction with incontinence diagnosed and treated in patients such as the elderly or paraplegics?
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halfanurse1987 | 13-Jan-2011 5:31 pm
I am not arguing with you but in my case highlighting a gap in knowlege. As I have previously posted when I am on placement in the next few weeks, asking to be taught about this skill is something I will do.

But the question is, how many others do the same?
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Anonymous | 13-Jan-2011 8:02 pm
halfanurse1987 | 13-Jan-2011 5:31 pm

from Anonymous | 13-Jan-2011 11:50 am

You are taking a good initiative and it will be interesting to see what response you get, which will hopefully be positive. However, nurses shouldn't need to ask for what should be considered an integral part of general training like many other essential skills which seem to be omitted in recent times.
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Anonymous | 17-Jan-2011 4:48 pm
we shyed away from DRE for years with the debate over abuse. Bowel management has become a bit of a hit or miss subject and we do not train our trained staff in some trusts so how can we supervise students doing this procedure

As nurse we need to be ensuring there is a policy and training so that we can say with hand on heart we are doing the best for our patients.

We also have changed the way we learn when i trained it was see 1 do 1 teach 1

the time has come to train our nurses in a way that ensures we ca actually care for our patients. DRE should be trained in every trust and organisation to ensure patients comfort.
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halfanurse1987 | 18-Jan-2011 6:14 pm
Its an OSCE station for med students but not for us.
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Anonymous | 18-Jan-2011 7:40 pm
that's fine if med students do the routine diagnostic tests but they are not going to treat patients for and clean out impacted faeces. just imagine how uncomfortable and damaging that must be and some pts such as the elderly, those with neuro disorders and paraplegics may need this regularly - what then? somebody needs to do it and it is not the patients themselves or their families or other visitors.
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halfanurse1987 | 15-Feb-2011 10:37 pm
Have now started my next placement. I asked about DRE and have firmly been told that the docs do that not us. So that solves the question of "why nurses are not doing DREs"
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Anonymous | 15-Feb-2011 10:42 pm
Above, this still not solve the problem of who undertakes manual evacuation for impacted faeces which do not respond to other treatments. This is nursing care and not a medical examination and there is no way round it for patients with paralysis, neurological conditions such as MS, the comatose or the elderly who are debilitated.
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halfanurse1987 | 17-Feb-2011 6:33 pm
Again, was told not the nurses job. Manual evacuation is not something that is done in my current clinical area apparently and if it is required the job would go to the medics.

I can only pass on what I am being instructed. I am not willing to do a procedure I have not been trained in and have been told is outwith my remit.
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Anonymous | 17-Feb-2011 6:44 pm
poor patients is this yet another example of negligent care or is this really a treatment that is obsolete. I cannot imagine what happens when medication is insufficent.
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Anonymous | 29-Jun-2011 0:10 am
I remember in the 80"s bowel care was a very important part of looking after the elderly. If patients had not had their bowels opened after 3 days they were given a mild enema with fantastic results. i even had the dubious nick name of the bowel queen! Unfortunatley now pr examinations seem to be regarded as abuse even with patients consent and now nurses are reluctant to perform it. I've seen student nurses looking repulsed while watching a pr examination so they are obviously not taught anything about it. I feel embarassed now to do it even though sometimes you know your patient is bunged up and the cause of their diarrohea is constipation. We get loads of patients coming from nursing homes with overflow caused by constipation taking up siderooms because they are querie "infectious." I think we all need re-educating and get rid of the stigma attached to bowel care.
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Anonymous | 29-Jun-2011 1:12 am
Anonymous | 29-Jun-2011 0:10 am

i have already written a few comments here and still fail to see how this procedure can be omitted and feel that if the patient is suffering as a result it is a case of negligence. I cannot understand why it is no longer taught and what is being proposed as an alternative treatment.
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halfanurse1987 | 30-Jun-2011 3:52 pm
In my trust I have found that the nursing staff are very quick to have have medical staff perform DRE and have a bowel regime written up if required. The doctors tend to be very good at listening to nurses concerns about a patients bowel function.

Usually observation and questioning of the patient is enough to estabolish if the person is constipated/impacted. So far I have not seen anyone suffering a lack of nurse led DRE. But then again I may be in a very good area where junior docs are quick to act on such things.
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halfanurse1987 | 30-Jun-2011 3:58 pm
As for students looking repulsed at DRE I would wonder what they are like with inserting sups or enemas? Or simply cleaning a soiled patient. It would smack of immaturity to me. I have been in with drs as a chaperone quite a few times for this procedure.

I would also like to make it clear that in the event I was actually cleared to perform this procedure in my trust, I would willingly do it. Patients are often admitted with consitpation and impaction and I have seen the amount of pain, distress and "challenging behaviour" it can cause. It is not something I take lightly.

As an aside, hearsay on my part has also told me of carehomes over using enemas on patients who dont require them - simply to make "toileting" of residents easier. Cases like this can make people scared of bowel care and potential acusations of abuse.
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µ | 30-Jun-2011 4:04 pm
halfanurse1987 | 30-Jun-2011 3:52 pm

don't nurses act on their own initiative any more? why does it need a doctor to confirm that a patient has impacted faeces? is the doctors that carry out all patient obs nowadays?

how can somebody who is not capable of giving full care to a patient call themselves a registered nurse or even get on the register in the first place?
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