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How to do Digital Rectal Examination:Nursing Case Study

Wednesday, 5 March 2014

rectal exam

Digital rectal examination is defined as a routine [screening] exam in which a physician inserts a lubricated gloved finger into the rectum and feels for abnormal areas to detect rectal cancer—in general—and, in a man, inflammation, enlargement, or cancer of the prostate. As is true for all types of cancers, the sooner prostate cancer is detected, the greater the options available to the patient and his physician for treating the disease and the greater the chances of achieving a cure.
Although it has dual function in principles, for detecting colorectal and prostate cancers, in this presentation, the discussion will be focused on the screening for prostate cancer.

Purposes, Indications, and Contraindications

Purpose:
The reasons for performing DRE can be classified into two categories: Colorectal cancer screening procedure for both males and females, and Prostate cancer screening procedure (only in males). The purpose of any cancer screening test is to find a malignancy before the patient begins to show symptoms, before the cancer has spread, and to treat it in hopes of reducing the mortality (death) rate from it; thus, it was hoped that prostate cancer screening would increase life expectancy for men with the disease. It’s useful in detecting gland’s posterior-lateral aspects.

To make it clear, other reasons of performing DRE (Dougherty and Lister, 2004:296) are:
  • To establish whether fecal matter is present in the rectum and if so, to assess the amount and consistency.
  • To assess the need for rectal medication and to evaluate its efficacy in certain circumstances, e.g. in patient who have diminished anal/rectal sensation (and to assess anal/rectal sensation).
  • For digital stimulation of the recto-anal reflex to trigger defecation.
  • To assess anal sphincter function and tone.
  • Not for primary investigation for constipation unless a full assessment is done already.

Indications:

Men at high risk for prostate cancer should begin screening before age 50 (as early as 40). Two groups of men fall into this category are #1 and #2 below.

1. Race, ethnicity, and nationality. Afro-Americans—60% and having incidence to die two times higher than white men. Worldwide, men living in North America and North-western Europe have highest prevalence.

2. Family history (Genetics and Heredity). Having *two or more first-degree relatives (father, brother, son, etc.) with prostate cancer increases the risk.

3. Ages (Growth). Men ages 20 and above, especially upon reaching 50 and having a life expectancy of at least 10 years. The older the person, the higher the chance.

4. Obesity, Physical inactive people, and Diet. High-fat and free-radical molecule-contained foods and sedentary lifestyle support the development of prostate cancer.

5. Physical conditions (especiallyurinary tracts), such as inflammations or infections (GUT: STD’s, UTI’s) either presently or recently, or with colorectal cancer history.

6. High levels of serum testosterone.

7. High frequency of s-e-x-ual experience or multiple s-e-x-u-al partners.

8. Exposure to chemical carcinogens, such as working in chemical product industry.

This screening test gives the doctor an indication of the size of the prostate gland and whether there are any irregular or abnormally firm areas. By itself, the DRE does not determine whether the patient has prostate cancer; only suggest the need for more tests.

Contraindications: 

Strict contraindication is not boldly underlined but there are many conditions that need precautions. Special care should be used in performing DRE in clients when disease processes or treatments in particular affect the anus or the bowel mucosa. The conditions include (Dougherty and Lister, 2004:296, 297):

1. Active inflammation of the bowel, e.g. ulcerative colitis.

2. Recent radiotherapy to the pelvic area.

3. Rectal/anal pain.

4. Rectal surgery or trauma to the anal/rectal area.

5. Obvious rectal bleeding.

6. Spinal injury patients with autonomic dysreflexia.

7. Patients with known allergies, e.g. latex.

8. Patients with a history of abuse (especially s-e-x-ual, e.g. anal intercourse).

Normal Values & Normal Findings

The normal prostate is palpable as a rounded, heart-shaped structure measuring approximately 1 to 1.5 inches (2.5 to 3.8 cm) in diameter length and project less than 0.5 inch (1 cm) into the rectum, with a palpable vertical groove in the center (median sulcus) between the contour of two symmetric lateral lobes (bilobed). Normally somewhat rubbery and non-tender, the prostate should feel firm, smooth, and slightly mobile (Held-Warmkessel, 2006:85; Wilson and Giddens, 2005:538).

Assessment

It is important to do assessment initially prior to DRE for several reasons:
· Purposes, type of exam, frequency (head-to-toe, checkup, postoperative care, etc.).
· Age (personal treatment, position, and vital signs).
· History: past medical/surgical, family health, family background and personal demographic data (s-e-x-u-al/child abuse, s-e-x-u-al relations/practices, lifestyle and diets).
· Present conditions (medical, surgical, mental), precautions mentioned above.

· 3 things to assess in the prostate glands: asymmetry (lack of balance in size and shape), nodularity (bumpiness: presence of tumor nodules), induration (firmness).

Procedure

· Examiner. A physician, usually urologist, or any skilled health care professional.
· Time. The DRE takes about 5 seconds and should be done at the end of the physical examination, if it’s a series of head-to-toe procedures.

· Position. The patient can (1) stand, flex his hips, and lean (bent) over an exam table with his upper body resting across the table; (2) lie on his left side in a fetal position (left side-lying knee-chest/left lateral decubitus position); or (3) kneel face-down on top of the exam table (prone knee-chest position).

· Initially, with gloved hands, the buttocks are separated and the anus is visually inspected (observe anal area prior to finger insertion) for evidence of skin soreness, excoriation, swelling, hemorrhoids, rectal prolapse and infestation. Pruritus or incontinence may be indicated. Swelling: possible mass or abscess. Abnormalities: report before any exam.

· A gloved well-lubricated index finger is then gently inserted into the anus, in a direction pointing to the umbilicus, making note of the anal sphincter tone; resistance should be felt (it indicates good sphincter tone; poor resistance: the opposite).

· Digital exam may feel fecal matter within the rectum; note consistency of any fecal matter (may establish loaded rectum and indicate constipation and the need for rectal medication).

· With the finger inserted into the rectum as far as possible, the examiner’s hand is rotated clockwise, then counterclockwise, palpating the anterior and posterior surfaces. Rotating the hand further clockwise allows examination of the posterior surface of the prostate gland (anterior wall of rectum) to assess for symmetry and texture.

Nursing Cares

a. Before the Procedure
· Greet the patient and explain the assessment techniques to be used.
· Entertain and answer patient’s questions and anticipate the following statements.

Possible Situations for DRE:

“What! A digital stuff or a finger into my but? Look, I’m still a virgin.”

“Mmm, is the procedure painful?”

“Hey, easy… Ouch! How long will this test take place?”

“Nurse Tina, what should I do/prepare prior to my digital rectal exam?”

“What should I do and shouldn’t do before and after this procedure?”

“Can I eat and drink before I come here to do this?”

· Ask the patient for allergies (e.g. latex) and any discomfort to express feelings.

· Ensure that the examination room is at a warm, comfortable temperature to prevent patient chilling and shivering. Assess patient’s body temperature.

· Ensure that the light in the room provides sufficient brightness to adequately observe the patient. It may be helpful to have a goose-neck lamp available for additional lighting when lesions are observed.

· Instruct the patient to void and, if possible, to defecate prior to the assessment. Ask questions related to urination (difficulty, frequency, and sensation) and bowel movement (e.g. constipation).

· Instruct patient to remove pants and underwear, to cover up with a drape sheet.

· A nurse is responsible to help the physician or examiner in preparing the patient for the entire course of DRE.

· Wash hand with bactericidal soap and water or bactericidal alcohol handrub and put on disposable (clean/unsterile) gloves.

b. During the Procedure

· For inspection, place the patient in the left lateral decubitus (side-lying knee-chest) position and visualize the perianal skin. This position can also be used for palpation.

· For palpation, have the patient stand at the end of the examination table, bend over the end of the table, rest the elbows on the table, and spread the legs slightly apart, or

· For patient who cannot stand, have him assume the knee-chest position.

· Inform the patient that the procedure is about to proceed to assist patient’s cooperation with the procedure.

· Don unsterile gloves (the field is not sterile).

· Check perianal and perianal area for signs of rectal prolapsed, hemorrhoids, anal skin tags, or lesions, foreign bodies, or infestations; note condition of skin as well as the type and amount of any discharge or leakage. If any of these abnormalities are seen, DRE should not be carried out until advice is taken from a specialist nurse, medical practitioner, or physician/urologist.

· Proceed from the anus to the prostate (in men), to assess the anal sphincter function and tone first before assessing the prostate gland’s status.

c. After the Procedure

· Clean anal area after the procedure to prevent irritation and soreness occurring and preserves patient’s dignity and personal hygiene.

· Remove gloves and dispose of equipment in appropriate clinical waste bin. Wash hands with bactericidal soap and water to minimize the risk of cross-infection.

· Assist patient into a comfortable position and offer toilet facilities as appropriate to promote comfort.

· Document findings and report to medical team to ensure continuity of care and assist in nursing diagnosis so appropriate corrective action may be initiated.

· Instruct the patient for observing his voiding pattern for dysuria, hematuria, and difficulty in producing stream of urine.

Interpretation & Significant Findings

Abnormalities of DRE associated with Prostate CA include induration, nodules, surface irregularity, and obliteration of usual landmarks, but probably not asymmetry. The induration and/or nodules palpable can be variable ranging from localized to diffuse, hard and stony, or minimal and indistinct, well circumscribed, irregular.

Specific characteristics of abnormalities do not always differentiate between benign or malignant conditions. Differential diagnoses for abnormalities include fibrous benign prostatic hypertrophy (BPH), calculi, inflammation, prostatitis, tuberculosis, postsurgical biopsy changes, and infarction. In the setting of a normal PSA and abnormal DRE, the examination should be repeated within a short period of time (4 to 6 weeks) to confirm persistence of the entire gland may feel firm. A prostate cancer may progress beyond the prostatic capsule, extending up into the seminal vesicle and/or laterally into the pelvic sidewall. Findings such as these on initial exam should prompt further evaluation with biopsy and other staging studies without delay.

Gambling with prostate cancer. Limitations of DRE include that a tumor must be sufficient size and located on the posterior or lateral surface to be palpable, and DRE characteristically underestimates tumor volume and progression. Likewise, there are concerns regarding clinical overestimation of extra organ extension on DRE, observed with discrepancies noted between clinical and pathological stages (e.g. postprostatectomy staging) that may result from postbiopsy inflammation, desmoplastic reaction to the tumor, preexisting pathologic changes, or experience of the examiner. Nonetheless, the combination of clinical evaluation with DRE and PSA increases the sensitivity of specificity of determining the presence and stage of prostate cancer, and has increased the lead time for diagnosis (Held-Warmkessel, 2006:85, 86). When used alone, DRE missed 40% of cancers detected during initial screenings; probability of increased significant intracapsular as well as extracapsular prostate tumors when DRE reveals abnormalities: induration, marked asymmetry, and frank nodularity (ibid: 51).

Projects. Note if the prostate projects more than 0.5 inch (1 cm) into the rectum. Estimate classification of prostate enlargement (Table 2 below). Note if there is asymmetry or if the median sulcus is obliterated; also note any tenderness, a boggy feeling, induration, irregularity, or nodules. A rubbery or boggy consistency may indicate benign hyperplasia. A stony-hard or nodular prostate may indicate carcinoma, prostate calculi, or fibrosis.

CLASSIFICATION OF PROSTATE ENLARGEMENT


References
Anderson, Douglas M. (Chief Lexicographer). (2002). Mosby’s Medical Dictionary, 6th Edition. Missouri, USA: Mosby, Inc.

Burnette, Tamera and Estes, Mary E.Z. (1998). Clinical Companion for Health Assessment and Physical Examination. New York, USA: Delmar Publishers.

Dougherty, Lisa and Lister, Sara M. (Editors). (2004). The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 6th Edition. Oxford, UK: The Royal Marsden Hospital and Blackwell Publishing.

Hecht, Frederick and Shiel, Jr., William C. (Co-Editor-in-Chiefs). (2003). Webster’s New WorldTM Medical Dictionary, 2nd Edition. New York, USA: MedicineNet.com and Wiley Publishing, Inc.

Held-Warmkessel, Jeanne. (2006). Contemporary Issues in Prostate Cancer: A Nursing Perspective, 2nd Edition. USA: Jones and Bartlett Publishers, Inc.

Nettina, Sandra M. (Editor). (2001). The Lippincott Manual of Nursing Practice, 7th Edition. Philadelphia: Lippincott Williams & Wilkins.

Smeltzer, Suzanne C., et al. (2008). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (11th Ed., Vol. 2). Philadelphia: Lippincott Williams & Wilkins.

Stokes, Mark. (2006). Prostate Cancer: Current and Emerging Trends in Detection and Treatment. New York, USA: The Rosen Publishing Group, Inc.

Thompson, June M., et al. (1989). Mosby’s Manual of Clinical Nursing, 2nd Edition. Missouri, USA: The C.V. Mosby Company.

Udan, Josie Q. (2009). Medical-Surgical Nursing: Concepts and Clinical Application, 2nd Edition. Manila, Philippines: Josie Quiambao-Udan and Educational Publishing House.

Wilson, Susan F. and Giddens, Jean F. (2005). Health Assessment for Nursing Practice, 3rd Edition. Philadelphia, USA: Mosby, Inc.
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