Assessment of the anus & rectum

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assessment of the anus and rectum including the prostate.

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Assessment of the anus & rectum

  1. 1. Assessment of Anus and RectumMaria Carmela L. Domocmat, RN, MSNInstructor, Nursing Health AssessmentSchool of NursingNorthern Luzon Adventist College
  2. 2. Objectives:At the end of the lecture the student will be able to: Specify the important anatomy and physiology of the anus, rectum, and prostate. Enumerate at least three interview topics/questions. Identify normal assessment findings in the anus, rectum, and prostate. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 2
  3. 3. ANUS AND RECTUMAnatomy and PhysiologyTechniques of ExaminationRelated Abnormalities
  4. 4. Anatomy andPhysiology6/26/2011 Maria Carmela L. Domocmat, RN, MSN 4
  5. 5. Female Male6/26/2011 Maria Carmela L. Domocmat, RN, MSN 5
  6. 6. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 6
  7. 7. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 7
  8. 8. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 8
  9. 9. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 9
  10. 10. CollectingSubjective DataHistory of present health concernPast Health HistoryFamily HistoryLifestyle and Health Practices
  11. 11. Collecting Subjective Data Provide clues to client’s overall health and whether he is at risk for diseases and disorders of the anus, rectum, or prostate. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 11
  12. 12. Collecting Subjective Data A good time to teach client about the risk factors related to diseases, such as colorectal or prostate cancer, and about ways to decrease those risks. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 12
  13. 13. Collecting Subjective Data Note: Can be embarrassing to both the examiner and the client. It is important to ease the client’s anxiety as much as possible Ask questions in straightforward manner, and let the client voice any concerns throughout assessment. RN, MSN 6/26/2011 Maria Carmela L. Domocmat, 13
  14. 14. Collecting Subjective Data Note: In some cultural groups, only nurses of the same gender will be considered acceptable assessors of intimate bodies. Client’s comfort and privacy 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 14
  15. 15. History of present healthconcern COLDSPA Bowel patterns: What is your usual bowel pattern? Have you noticed any recent change in the pattern? Any pain while passing a bowel movement? Do you experience Domocmat, RN, MSN 6/26/2011 Maria Carmela L. constipation? 15
  16. 16. History of present healthconcern Do you experience constipation? Do you experience diarrhea? Is the diarrhea associated with any nausea and vomiting? Do you have trouble controlling your bowels? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 16
  17. 17. History of present healthconcern Stool What is the color of your stool? Hard or soft? Have you noticed any blood on or in your stool? If so, how much? Have you noticed any mucus in your stool? Itching and Pain Do you experience any itching or pain in the rectal area? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 17
  18. 18. History of present healthconcern Pattern of urination Do you have any difficulty starting the urine stream? Or holding back urine? Is the flow weak? What about frequent urination, especially at night? Or pain or burning as you pass out urine? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 18
  19. 19. History of present healthconcern Pattern of urination Do you notice blood in your urine or semen or pain with ejaculation? Is there frequent pain or stiffness in the lower back, hips, or upper thighs? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 19
  20. 20. Past Health History Have you ever had anal or rectal trauma or surgery? Were you born with any congenital deformities of the anus or rectum? Have you had prostate surgery? Have you had hemorrhoids or surgery for hemorrhoids? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 20
  21. 21. Past Health History When was the last time you had a stool test to detect blood? Have you ever had proctosigmoidoscopy? When was the last time you had DRE by a physician? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 21
  22. 22. Past Health History Have you ever had blood taken for a prostate screening, which measures the level of prostate-specific antigen (PSA) in prostate- your blood? When was the test and what was the result? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 22
  23. 23. Family History Is there a history of polyps, colon, or rectal cancer, or prostate cancer in your family? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 23
  24. 24. Lifestyle and HealthPractices Do you use any laxatives, stool softeners, enemas, or other bowel movement- movement-enhancing medications? Do you engage in anal sex? Do you take any medications for your prostate? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 24
  25. 25. Lifestyle and HealthPractices How much high-fiber food and roughage high- do you consume everyday? Do you eat foods high in saturated fat? Do you engage in regular exercise? Do you use calcium supplements? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 25
  26. 26. Lifestyle and HealthPractices For postmenopausal women: do you use hormone replacement therapy? Has any anal or rectal problem affected your normal activities of daily living (working and engaging in recreation)? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 26
  27. 27. Important topics for healthpromotion and counseling Screening for prostate cancer Screening for polyps and colorectal cancer 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 27
  28. 28. Collecting ObjectiveData: Techniques ofExamination
  29. 29. Preparing the client Client positioning Standing Knee- Knee-chest Squatting Left lateral Lithotomy 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 29
  30. 30. Techniques ofExaminationInspection of Perineum andSacrococcygeal Area
  31. 31. Positions for Rectal Examination6/26/2011 Maria Carmela L. Domocmat, RN, MSN 31
  32. 32. Equipments needed Gloves Lubricant Guaiac Testing Equipment Tissue 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 32
  33. 33. Inspection of Perineum andSacrococcygeal Area Inspect the buttocks and sacral region for lesions, swelling, inflammation, and tenderness. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 33
  34. 34. Male Female6/26/2011 Maria Carmela L. Domocmat, RN, MSN 34
  35. 35. Normal Findings Area should be smooth and free of lesions, swelling, inflammation, and tenderness. There should be no evidence of feces or mucus on the perianal skin. No additional opening 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 35
  36. 36. Palpation of CoccygealArea Palpate the coccygeal areaNormal Finding No tenderness 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 36
  37. 37. Pilonidal Sinus 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 37
  38. 38. Inspection of Anal MucosaSpread the buttocks apartwith both hands, exposingthe anus.Examine the anus forcolor, appearance,lesions, inflammation,rash, and masses.Instruct the client to bear down as thoughmoving the bowels (Valsalva maneuver) (Valsalva 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 38 Watch video
  39. 39. Normal FindingsDeeply pigmented,coarse, moist, andhairless.Free of lesions,inflammation, rash,masses and additionalopenings. The analopening should beclosed. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 39
  40. 40. Normal FindingsThere should not beany tissue protrusionNo leakage of fecesor mucus from theanus while strainingNo tissue perfusion 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 40
  41. 41. Let’s Watch:Examining the Anusand Anal Sphincter
  42. 42. Abnormal FindingsImperforate Anus HemorrhoidSkin Tag Venereal WartsAnorectal Fistula HerpesAnal Fissure Gonococcal ProctitisRectal Prolapse Carcinoma
  43. 43. Imperforate Skin Tag anus6/26/2011 Maria Carmela L. Domocmat, RN, MSN 43
  44. 44. Fistula-in-Fistula-in- Anorectalano fistulaFistula-In-Ano: External opening of fistulus tractis apparent in photo above. Proximal opening This patient presented with "just a little blood when I wipe."would be at level of crypts, within the anal canal. When anoscopy revealed no anal pathology, closer inspection Maria Carmela L. Domocmat, RN, MSNidentify this papular area. The woodenFistulas are frequently associated with perirectal 6/26/2011 allowed the physician to 44abscesses, though none are present in this case. end of a cotton-tipped applicator was inserted 3 cm confirming a fistula, and the patient was referred for surgery.
  45. 45. Anal Fissure Rectal Prolapse 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 45
  46. 46. External hemorrhoid6/26/2011 Maria Carmela L. Domocmat, RN, MSN 46
  47. 47. Prolapsed Internal Thrombosed Hemorrhoid External Hemorrhoid 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 47
  48. 48. Condylomata Perianalacuminatum herpes(Venereal warts) Rectal HSV infection with perianal ulcers 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 48
  49. 49. Gonococcal proctitis 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 49
  50. 50. Anal Carcinoma6/26/2011 Maria Carmela L. Domocmat, RN, MSN 50
  51. 51. Palpation of Anus andRectum
  52. 52. Palpation of Anus andRectumReassure the clientthat sensations ofurination anddefecation arecommon during therectal assessment. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 52
  53. 53. Palpation of Anus andRectum 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 53
  54. 54. Palpation of Anus andRectum While the client strains, place gloved and lubricated finger at anal opening as sphincter relaxes Slowly insert the flexed tip of your finger into the anal sphincter pointing toward client’s umbilicus 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 54
  55. 55. Digital Pressure is applied against anal verge until the external sphincter is felt to yield6/26/2011 Maria Carmela L. Domocmat, RN, MSN 55
  56. 56. The gloved, lubricated finger is slowly flexed and introduced in the direction of the umbilicus6/26/2011 Maria Carmela L. Domocmat, RN, MSN 56
  57. 57. Avoid this incorrect approach at a right angle to the sphincterIt causes discomfort for the clientDoes not promote relaxation 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 57
  58. 58. If the client tightens the sphincter, remove your finger, reassure the client, and try again, using a relaxation technique such as deep breathing Feel the sphincter relax. Insert as far as it will go. Note anal sphincter tone.6/26/2011 Maria Carmela L. Domocmat, RN, MSN 58
  59. 59. Subcutaneuos portion of the externalsphincter is palpated between thumband index finger 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 59
  60. 60. Digital exploration of the deepexternal sphincter6/26/2011 Maria Carmela L. Domocmat, RN, MSN 60
  61. 61. Palpation of the levator animuscle 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 61
  62. 62. Palpate the lateral,posterior, andanterior walls of therectum in asequenced manner.The lateral walls feltby rotating thefinger along thesides of the rectum 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 62
  63. 63. Palpate fornodules,irregularity,masses, andtenderness.Ask the client tobear down again(which may help topalpate masses.) 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 63
  64. 64. Normal FindingsSmoothNo mass, nodules,tendernessEven pressure on fingerContinuous, smoothsurface with minimaldiscomfort to client 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 64
  65. 65. Normal FindingsRectum should accommodatethe index finger.Sphincter tightens evenlyaround finger with minimaldiscomfort to clientGood sphincter tone at restand with bearing down. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 65
  66. 66. Normal FindingsNo excessive pain,tenderness, induration,irregularities, or nodulesin the rectum or rectalwall.Anal canal isapproximately 2.5 cmlong. It is bordered bythe external and internalsphincters, which arenormally firm andsmooth 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 66
  67. 67. Let’s Watch:Palpating Posteriorand Lateral RectalWalls
  68. 68. Anoscopy 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 68
  69. 69. Abnormal Findings Rectal polyps Pedunculated Sessile
  70. 70. Pedunculated polyps6/26/2011 Maria Carmela L. Domocmat, RN, MSN 70
  71. 71. Sessile, multilobulated polyp 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 71On biopsy, turned out to be a benign tubularadenoma.
  72. 72. Prostatic andCowper’s GlandPalpation
  73. 73. Palpation of Prostate 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 73
  74. 74. Palpate the posteriorsurface of the prostategland.Note the size, shape,consistency, sensitivityand mobility of theprostate.Note whether themedian sulcus ispalpable.6/26/2011 Maria Carmela L. Domocmat, RN, MSN 74
  75. 75. Normal Findings Approximately 4 cm (1 ½ inches) in diameter; projecting less than 1 cm into rectum. About the size of a walnut. Rubbery consistency (like a pencil eraser). Smooth, firm and nontender. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 75
  76. 76. If prostate protrudes into the rectal lumen, probably enlarged. Classified as grades 1 to 4: protruding less than 3/8 inch or 1 cm into the rectal lumen to 1 ¼ inch or 3 cm into the rectal lumen6/26/2011 Maria Carmela L. Domocmat, RN, MSN 76
  77. 77. Let’s Watch:Palpating theAnterior Rectal Walland Prostate
  78. 78. AbnormalitiesBenign Prostatic HypertrophyProstate Cancer
  79. 79. Benign Prostatic Hypertrophy 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 79
  80. 80. Prostrate Cancer: Single nodule 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 80
  81. 81. Prostrate Cancer: Multiplenodules 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 81
  82. 82. Bidigital Examination ofthe Bulbourethral Gland Reassure the client that sensations of urination and defecation are common during the prostatic assessment. Use a well-lubricated, gloved index well- finger. Insert the gloved index finger and follow the steps 3 to 6 above 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 82
  83. 83. Bidigital Examination ofthe Bulbourethral Gland Press your gloved thumb into the perianal tissue while pressing your gloved index finger toward it. Assess for tenderness, masses, or swelling Release pressure of the thumb and index finger. Remove thumb from the perianal tissue and advance your index finger.6/26/2011 Maria Carmela L. Domocmat, RN, MSN 83
  84. 84. Bidigital Examination ofthe Bulbourethral Gland Photo 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 84
  85. 85. Normal Finding Bulbourethral Gland Nontender 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 85
  86. 86. Seminal Vesicles Palpation Attempt to palpate the seminal vesicles by extending your index finger above the prostate gland. Assess for tenderness and masses. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 86
  87. 87. Normal Findings Normally, too soft to be palpated. Proximal portions can sometimes be palpated as corrugated structures above the lateral to the midpoint of the gland. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 87
  88. 88. Let’s Watch:Palpating the AnteriorRectal Wall SeminalVesicle & Cowper’sGland
  89. 89. Slowly withdraw the finger; inspect any fecal matter on your glove and test it for occult blood. (if not previously performed). Offer the client tissues to wipe off any remaining lubricant.6/26/2011 Maria Carmela L. Domocmat, RN, MSN 89
  90. 90. Normal Findings Stool Brown Soft No mucus 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 90
  91. 91. Fecal Occult Blood Test Stool Guaiac Test
  92. 92. Stool Guaiac Test Other names: Guaiac smear test Fecal occult blood test - guaiac smear Stool occult blood test - guaiac smear 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 92
  93. 93. Guaiac Testing Equipment 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 93
  94. 94. Stool Guaiac Test Purpose Finds hidden (occult) blood in the stool. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 94
  95. 95. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 95
  96. 96. stool guaiac test a small sample of stool is placed on a paper card and a drop or two of testing solution is added. A color change is a sign of blood in the stool. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 96
  97. 97. How to Prepare for theTest Do not eat red meat, any blood-containing food, blood- cantaloupe, uncooked broccoli, turnip, radish, or horseradish for 3 days before the test. These foods can sometimes interfere with the test. test. You may need to stop taking medicines that can interfere with the test. These include vitamin C and nonsteroidal anti-inflammatory medicines (NSAIDs) anti- such as ibuprofen and aspirin. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 97
  98. 98. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 98
  99. 99. Positive guaiac test shown on right, as would be seen for this patient.Negative result (on left) included for comparison. http://meded.ucsd.edu/isp/2002/desai/images/LGB46.jpg6/26/2011 Maria Carmela L. Domocmat, RN, MSN 99
  100. 100. Normal Finding Negative. No blood in the stool 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 100
  101. 101. Documentation samples“No perirectal lesions or fissures. Externalsphincter tone intact. Rectal vault withoutmasses. Prostate smooth and nontenderwith palpable median sulcus. (Or in female,uterine cervix nontender.) Stool brown andhemoccult negative.” 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 101
  102. 102. Documentation samples “Perirectal area inflamed; no ulcerations, warts, or discharge. Cannot examine external sphincter, rectal vault, or prostate because of spasm or external sphincter and marked inflammation and tenderness of anal canal.” 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 102
  103. 103. Documentation samples“No perirectal lesions or fissures. Externalsphincter tone intact. Rectal vault withoutmasses. Left lateral prostate lobe with 1 x 1cm firm hard nodule; right lateral lobesmooth; medial sulcus is obscured. Stoolbrown and hemoccult negative.” 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 103
  104. 104. Sources:Weber, Janet & Kelley, Jane. (2007). Health assessment in nursing (3rd ed). Philadephia, ed). Philadephia, PA : Lippincott Williams & Wilkins.Bickley,Bickley, Lynn S . (2004). Bates’ Pocket guide to physical examination and history taking (4th ed). New York: Lippincott Williams and ed). Wilkins. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 104
  105. 105. Have a blessed Day!6/26/2011 Maria Carmela L. Domocmat, RN, MSN 105
  106. 106. Have a blessed Day!6/26/2011 Maria Carmela L. Domocmat, RN, MSN 106

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