Chapter 20: Assessing the Anus and Rectum

Chapter 20: Assessing the Anus and Rectum

Introduction

  • Source: Essential Health Assessment, Second Edition, F.A. Davis Company, 2022.
  • Objective: To understand the comprehensive assessment of the anus and rectum, which requires professionalism and sensitivity.

Considerations During Assessment

  • The rectum and anus are intimate and sensitive areas; therefore, a professional approach is necessary.
  • Sensitivity to the patient's feelings is crucial during this assessment.
  • The assessment techniques apply to both male and female patients similarly.

Anatomy and Physiology

Rectum
  • Function:   - Primary function is to store and process fecal material.   - Located at the end of the large intestine, it opens into the rectum and has sensory nerves and transverse folds.
Anus
  • Location: Located in the perineum and serves as the endpoint of the gastrointestinal tract.
  • Sphincters:   - Comprises internal and external sphincters, which the nurse evaluates during a rectal assessment.

Health History

  • Bowel Movement Patterns: Document changes in size and diameter of stools.
  • Constipation and Diarrhea:   - Use the ROME-III diagnostic criteria for diagnosing constipation; reference Box 20-1.
  • Hematochezia:   - Bright red blood in stool indicates possible bleeding; the color helps determine the bleeding source.
Sources of Rectal Bleeding
  • Conditions:   - Anal fissures   - Hemorrhoids   - Polyps   - Anal fistulas
  • Other Symptoms: Itching or pain in the anal area and abnormal drainage.
  • Anal Cancers: Potential sources for concern.

Clicker Check - Case Scenario

  • Scenario: Patient reports bright red blood in stool.   - Expected bleeding location:     - A) Duodenum     - B) Small bowel     - C) Transverse colon     - D) Lower colon or rectum [Correct answer: D]

Managing Patient Anxiety

  • Scenario: A female patient expresses anxiety about rectal pain and examination.   - Recommended response should reassure the patient about the painlessness of most rectal assessments.   
Suggested Responses:
  • Option A: "I know that it is embarrassing, but you need to be examined."
  • Option B: "Most rectal assessments are painless; I will be here during the assessment." [Correct answer: B]
  • Option C: "Don't be so nervous, it is better to find out now what is causing the pain."
  • Option D: "Why are you so anxious?"

Preparation for Assessment

  • Timing: The anus and rectum are assessed at different times for male and female patients.   - Females should be assessed after the pelvic assessment.   - Males should be contemplated after assessing the male genital area, including the prostate gland.
  • Sequence of Assessment Techniques:   1. Inspection   2. Digital rectal examination   3. Stool for occult blood

Technique 20-1: Inspecting the Anus

Purpose
  • To assess for abnormalities of the anus.
Equipment
  • Gloves, tangential lighting.
Procedure
  1. Explain the technique to the patient.
  2. Wear gloves.
  3. Position the patient on their left side with the right knee slightly bent.
  4. Gently spread the buttocks to expose the anus and perianal area.
Findings
  • Assessment Points:   - Redness   - Inflammation   - Lesions or lumps   - Wounds or excoriation   - Presence of hemorrhoids, fissures.
  • Post-assessment: Assist the patient to a sitting position.
Normal Findings
  • Anus is tightly closed.
  • Skin is moist and darkly pigmented.
  • Hair may be present.
  • Absence of redness, inflammation, lesions, lumps, wounds, hemorrhoids, or fissures.
Abnormal Findings
  • Patulous Anus: Open and distended.
  • Presence of redness, inflammation, lesions, wounds, hemorrhoids, or rectal prolapse.

Clicker Check - Scenario Assessment

  • Scenario: Observing protruding, swollen, dilated veins during anus inspection.   - Options:     - A) Anal fistula     - B) Prolapsed rectum     - C) Hemorrhoids [Correct answer: C]     - D) Polyps
Understanding Hemorrhoids
  • Swollen, dilated veins in the lower rectum or anus that may cause bleeding, irritation, or itching.

Preparation for Internal Rectal Assessment

  • This assessment is more invasive and should be performed with caution.
  • Indications: Assess for fecal impaction, rectal abnormalities, or prior to administering rectal medications.
  • Acknowledgment of potential discomfort for the patient; reassurance is critical.
  • Suggest that patients take deep, calming breaths during the assessment.

Technique 20-2: Digital Rectal Examination

Purpose
  • Assess for abnormalities of the rectum and prostate in males.
Equipment
  • Gloves, water-soluble lubricant.
Positioning Options
  • Lateral decubitus (side-lying) position.
  • Lithotomy position.
  • Patient standing, bending over, and holding onto an examination table.
Procedure
  1. Assist the patient to the chosen position.
  2. Put on gloves.
  3. Apply a generous amount of water-soluble lubricant to the index finger.
  4. Gently touch the anus with your finger and encourage the patient to bear down during insertion into the lower rectum.
  5. Assess rectal sphincter muscle tone.
For Male Patients
  • Position the index finger anteriorly toward the umbilicus.
  • Palpate the posterior surface of the prostate gland for:   - Size   - Shape   - Smoothness   - Tenderness
Inside Rectum Assessment
  • Use the pad of the finger to palpate the interior length of the entire rectum, assessing for:   - Tenderness   - Lumps   - Masses
  • If necessary, perform a stool smear for occult blood.
  • Properly remove finger, discard gloves, and assist the patient to a sitting position.
Abnormal Findings
  • A rectum without tenderness, masses, or hemorrhoids signifies normal health.
  • Male Patients: Normal prostate gland identified as two smooth lobes of a standard size, no hard nodules, and nontender.
Normal Findings
  • Lump, mass, or nodule presence suggests abnormalities in rectal health.
  • Prostate gland may be enlarged or have hard/nodular textures.

Technique 20-3: Assessing Stool for Fecal Occult Blood

Purpose
  • Identify hidden blood in stool samples.
Equipment
  • Gloves, agency-specific Fecal Occult Blood Test (FOBT).
Procedure
  1. Open the FOBT kit, ensuring the expiration date of the developing solution is valid.
  2. Collect a stool sample and apply to both windows of the FOBT slide.
  3. Follow the kit directions to apply developing solution drops and observe color changes at the specimen site.
Findings
  • Abnormal: Window turns bluish hue; indicates positive for occult blood.
  • Normal: Window remains brown; indicates negative for occult blood.

Clicker Check - Fecal Incontinence Scenario

  • Scenario: A middle-aged patient complains of fecal incontinence. What assessment technique should be performed initially?   - Options:     - A) Digital rectal exam     - B) Assessing stool for occult blood     - C) Palpating the rectal area     - D) Inspecting the anus [Correct answer: D]
  • Rationale: Inspection can indicate whether the anus is tightly closed or exhibits a patulous state (open and distended).