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Practice comment

Why are nurses failing to undertake digital rectal examinations?


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


Readers' comments (25)

  • I have not been trained how to do it...something to request on next placement then.

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  • What has happened to full nursing case histories and initial assessment for the planning and provision holistic patient care?

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  • 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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  • 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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  • '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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  • 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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  • 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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  • 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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  • 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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  • Its an OSCE station for med students but not for us.

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