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
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.