MOD 14- Chapter 20: Assessing the Anus and Rectum (Chapter 20)

Considerations During Assessment

• The rectum and anus are intimate parts of the body; the nurse needs to be professional and sensitive to the patient’s feelings during this assessment.
• This assessment is the same for both the male and female patient.

Anatomy and Physiology

• Rectum
  • Primary function is to store processed fecal material.
  • Large intestine opens into the rectum.
  • Sensory nerves and transverse folds (rectal folds).
• Anus
  • Located in the perineum.
  • Endpoint of the gastrointestinal tract.
  • Internal and external sphincters.
  • Rectal assessment involves feeling both sphincters.

Health History

• Bowel movement pattern; changes in size and diameter of stools.
• Constipation and/or diarrhea; $ ext{ROME-III}$ diagnostic criteria for constipation (see Box 20-1).
• Hematochezia: color of blood provides clues to where bleeding is occurring.
• Sources of rectal bleeding:
  • Anal fissures
  • Hemorrhoids
  • Polyps
  • Anal fistula
• Itching or pain in the anal area.
• Abnormal drainage from the anus.
• Anal cancers.

ClickerCheck: Health History Question

• Question: During the health history, the patient reports bright red blood in his stool. What part of the colon is the blood likely coming from?
  • Duodenum
  • Small bowel
  • Transverse colon
  • Lower colon or rectum
• Correct answer: D Bright red blood usually indicates bleeding low in the colon or rectum.

ClickerCheck: Empathy/Communication Strategy

• Question: A female patient c/o rectal pain and is anxious to be examined. What should the nurse say?
  • “I know that it is embarrassing, but you need to be examined.”
  • “Most rectal assessments are painless; I will be here during the assessment.”
  • “Don't be so nervous, it is better to find out now what is causing the pain.”
  • “Why are you so anxious?”
• Correct answer: B A rectal assessment may be embarrassing and cause anxiety; talking through the process helps; reassure that rectal assessments are often painless.

Preparation for Assessment

• The anus and rectum are assessed at different times for the female and male assessment:
  • Female patients are assessed after a pelvic assessment.
  • Male patients are assessed after the male genital area assessment; prostate gland is also assessed.
• Sequence of assessment:
  • Inspection
  • Digital rectal examination
  • Stool for occult blood

Technique 20-1: Inspecting the Anus

• Purpose: To assess for abnormalities of the anus.
• Equipment: Gloves, tangential lighting.
• Explain the technique.
• Procedure:
  • Put on gloves.
  • Have the patient lie on their left side with the right knee slightly bent (left lateral decubitus).
  • Gently spread the buttocks to expose the anus and perianal area.

Inspecting the Anus: Findings

• Assess the anus and the perianal area for:
  • Redness
  • Inflammation
  • Lesions or lumps
  • Wounds or excoriation
  • Hemorrhoids, fissures
• Always assist patient to a sitting position after the assessment.

Normal vs Abnormal Findings (Anus)

• Normal:
  • Anus is tightly closed.
  • Skin is moist and darkly pigmented.
  • Hair may be present.
  • No redness, inflammation, lesions, lumps, wounds, hemorrhoids, or fissures.
• Abnormal:
  • Patulous anus: open and distended.
  • Redness, inflammation, lesions, wounds, or hemorrhoids.
  • Rectal prolapse.

ClickerCheck: Anus Inspection

• Question: You are inspecting the anus and note protruding, swollen, dilated veins. What do you see?
  • Anal fistula
  • Prolapsed rectum
  • Hemorrhoids
  • Polyps
• Correct answer: Hemorrhoids are swollen, dilated veins that protrude from the lower rectum or anus; may bleed, irritate, or itch.

Preparation for Internal Rectal Assessment

• This is an advanced assessment and should be performed with caution.
• Performed to assess for fecal impaction, rectal abnormalities, and prior to administering rectal medications.
• May be uncomfortable for the patient.
• Encourage the patient to report any discomfort or pain.
• Encourage deep, relaxing breaths.

Technique 20-2: Performing Digital Rectal Examination

• Purpose: To assess for abnormalities of the rectum and prostate (in males).
• Equipment: Gloves, water-soluble lubricant.
• Rectal assessment can be performed in three positions:
  • Lateral decubitus (side-lying)
  • Lithotomy
  • Standing and bent over, holding the examination table

Performing Digital Rectal Examination

• Steps:
  • Assist patient to the preferred position.
  • Put on gloves.
  • Apply a moderate to large amount of water-soluble lubricant to the index finger of the dominant hand.
  • Gently touch the anus with the index finger and ask the patient to bear down on the finger as you gently insert the finger into the lower rectum.
  • Assess the rectal sphincter muscle tone.

Male-Specific Prostate Palpation

• If male:
  • Move the index finger anteriorly toward the umbilicus.
  • Palpate the posterior surface of the prostate gland and assess:
  • Size and shape
  • Smoothness
  • Lumps
  • Tenderness

Palpation of the Rectum

• Using the pad of the index finger, gently palpate the inside of the entire rectum assessing for tenderness, lumps, or masses.
• If needed, a stool smear for occult blood may be taken to assess for hidden blood.
• Gently remove the finger.
• Discard gloves.
• Assist patient to a sitting position.

Abnormal vs Normal Findings (DRE)

• Abnormal Findings:
  • Rectum is without tenderness, masses, or hemorrhoids.
  • Male: Prostate gland has two smooth lobes within normal size; No hard nodules; Nontender.
• Normal Findings:
  • Rectum has lump, mass, or nodule.
  • Rectum is tender to touch.
  • Internal hemorrhoids, mass, or fissure.
  • Prostate gland is enlarged, hard, or with nodules.
• Note: The source text lists these findings in a way that appears to invert normal/abnormal labels; use with clinical judgment and be aware of a potential typographical error in the source.

Technique 20-3: Assessing Stool for Fecal Occult Blood

• Purpose: To identify hidden blood in stool.
• Equipment: Gloves, agency-specific FOBT (Fecal Occult Blood Test).
• Always read the directions of the FOBT testing kit; check the expiration date of the FOBT developing solution.

Procedure

• Set up FOBT by opening the side for sample application.
• Put on gloves.
• Apply a sample specimen to both FOBT windows.
• Close the specimen side of the FOBT slide.
• Open the opposite side of the FOBT slide and follow directions for dropping one or two drops on each window.
• Observe the specimen site’s color.

Abnormal vs Normal Findings (FOBT)

• Abnormal Findings: Window turns a bluish hue; Positive for occult blood.
• Normal Findings: Window remains brown in color; Negative for occult blood.

ClickerCheck: FOBT and Incontinence Question

• Question: A middle-aged patient complains of fecal incontinence. What assessment technique would you expect the nurse to perform first?
  • A digital rectal exam
  • Assessing the stool for occult blood
  • Palpating the rectal area
  • Inspecting the anus
• Correct answer: D There are many causes of fecal incontinence (see Box 20-2); the nurse would first inspect the anus to see if it is tightly closed or patulous (open and distended).

Practical considerations and implications

• Ethical and practical considerations include maintaining privacy, obtaining consent, and ensuring patient comfort during intimate assessments.
• Recognize and address anxiety or embarrassment; use clear explanations and reassurance to promote cooperation and accurate findings.
• Document findings clearly, including both normal and abnormal observations, and note any potential confounding factors (e.g., patient position, tolerated depth of examination).

Connections to Foundation and Real-World Relevance

• These assessments reinforce fundamental principles of patient-centered care, anatomical knowledge of lower GI tract, and principles of nonverbal communication and empathy.
• Understanding the sources and presentations of rectal bleeding helps in differentiating likely etiologies (fissures, hemorrhoids, polyps, fistula) from less common causes.
• Occult blood testing is an important screening tool with implications for early detection of colorectal pathology.

Formulas, Numbers, and Key References

• $ ext{ROME-III}$ diagnostic criteria referenced for constipation.
• Three positions for rectal assessment: lateral decubitus, lithotomy, standing.
• Note: When converting page references or box numbers to study notes, Box 20-1, Box 20-2, and Box 20-3 correspond to constipation criteria, fecal incontinence etiologies, and occult blood testing guidance, respectively.