1.Assessment of Anus and RectumMaria Carmela L. Domocmat, RN, MSNInstructor, Nursing Health AssessmentSchool of NursingNorthern Luzon Adventist College

2. Objectives:At the end of the lecture the student will be ableto:Specify the important anatomy and physiologyof the anus, rectum, and prostate.Enumerate at least three interviewtopics/questions.Identify normal assessment findings in theanus, rectum, and prostate. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 2 3. ANUS AND RECTUMAnatomy and PhysiologyTechniques of ExaminationRelated Abnormalities 4. Anatomy andPhysiology6/26/2011 Maria Carmela L. Domocmat, RN, MSN 4 5. Female Male6/26/2011 Maria Carmela L. Domocmat, RN, MSN 5 6. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 6 7. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 7 8. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 8 9. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 9 10. CollectingSubjective DataHistory of present health concernPast Health HistoryFamily HistoryLifestyle and Health Practices 11. Collecting Subjective DataProvide clues to clients overall healthand whether he is at risk for diseasesand disorders of the anus, rectum, orprostate. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 11 12. Collecting Subjective DataA good time to teach client about the riskfactors related to diseases, such ascolorectal or prostate cancer, and aboutways to decrease those risks. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 12 13. Collecting Subjective DataNote: Can be embarrassing to both the examiner and the client. It is important to ease the clients anxiety as much as possible Ask questions in straightforward manner, and let the client voice any concerns throughout assessment. RN, MSN 6/26/2011Maria Carmela L. Domocmat, 13 14. Collecting Subjective DataNote: In some cultural groups, only nurses of the same gender will be considered acceptable assessors of intimate bodies. Clients comfort and privacy 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 14 15. History of present healthconcernCOLDSPABowel 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 6/26/2011Maria Carmela L. constipation? 15 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. History of present healthconcernStool 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. History of present healthconcernPattern 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, MSN18 19. History of present healthconcernPattern 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, MSN19 20. Past Health HistoryHave you ever had anal or rectal traumaor surgery? Were you born with anycongenital deformities of the anus orrectum? Have you had prostate surgery?Have you had hemorrhoids or surgery forhemorrhoids? 6/26/2011Maria Carmela L. Domocmat, RN, MSN 20 21. Past Health HistoryWhen was the last time you had a stooltest to detect blood?Have you ever hadproctosigmoidoscopy?When was the last time you had DRE bya physician? 6/26/2011Maria Carmela L. Domocmat, RN, MSN 21 22. Past Health HistoryHave you ever had blood taken for aprostate screening, which measures thelevel of prostate-specific antigen (PSA) in prostate-your blood? When was the test and whatwas the result? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 22 23. Family HistoryIs there a history of polyps, colon, orrectal cancer, or prostate cancer in yourfamily? 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 23 24. Lifestyle and HealthPracticesDo you use any laxatives, stoolsofteners, enemas, or other bowelmovement-movement-enhancing medications?Do you engage in anal sex?Do you take any medications for yourprostate? 6/26/2011Maria Carmela L. Domocmat, RN, MSN 24 25. Lifestyle and HealthPracticesHow much high-fiber food and roughagehigh-do you consume everyday? Do you eatfoods high in saturated fat?Do you engage in regular exercise?Do you use calcium supplements? 6/26/2011Maria Carmela L. Domocmat, RN, MSN 25 26. Lifestyle and HealthPracticesFor postmenopausal women: do you usehormone replacement therapy?Has any anal or rectal problem affectedyour normal activities of daily living(working and engaging in recreation)? 6/26/2011Maria Carmela L. Domocmat, RN, MSN 26 27. Important topics for healthpromotion and counselingScreening for prostate cancerScreening for polyps and colorectalcancer 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 27 28. Collecting ObjectiveData: Techniques ofExamination 29. Preparing the client Client positioning Standing Knee- Knee-chest Squatting Left lateral Lithotomy 6/26/2011Maria Carmela L. Domocmat, RN, MSN 29 30. Techniques ofExaminationInspection of Perineum andSacrococcygeal Area 31. Positions forRectalExamination6/26/2011 Maria Carmela L. Domocmat, RN, MSN 31 32. Equipments needed Gloves Lubricant Guaiac Testing Equipment Tissue 6/26/2011Maria Carmela L. Domocmat, RN, MSN 32 33. Inspection of Perineum andSacrococcygeal AreaInspect the buttocks and sacral region forlesions, swelling, inflammation, andtenderness. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 33 34. Male Female6/26/2011 Maria Carmela L. Domocmat, RN, MSN 34 35. Normal FindingsArea should be smooth and free oflesions, swelling, inflammation, andtenderness.There should be no evidence of feces ormucus on the perianal skin.No additional opening 6/26/2011Maria Carmela L. Domocmat, RN, MSN 35 36. Palpation of CoccygealAreaPalpate the coccygeal areaNormal FindingNo tenderness 6/26/2011Maria Carmela L. Domocmat, RN, MSN 36 37. Pilonidal Sinus 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 37 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 6/26/2011Maria Carmela L. Domocmat, RN, MSN 38Watch video 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. 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. Lets Watch:Examining the Anusand Anal Sphincter 42. Abnormal FindingsImperforate AnusHemorrhoidSkin TagVenereal WartsAnorectal Fistula HerpesAnal FissureGonococcal ProctitisRectal Prolapse Carcinoma 43. ImperforateSkin Tag anus6/26/2011 Maria Carmela L. Domocmat, RN, MSN 43 44. Fistula-in-Fistula-in-AnorectalanofistulaFistula-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 inspectionMaria Carmela L. Domocmat, RN, MSNidentify this papular area. The woodenFistulas are frequently associated with perirectal 6/26/2011 allowed the physician to44abscesses, 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. Anal Fissure Rectal Prolapse 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 45 46. External hemorrhoid6/26/2011 Maria Carmela L. Domocmat, RN, MSN 46 47. Prolapsed InternalThrombosed HemorrhoidExternal Hemorrhoid6/26/2011 Maria Carmela L. Domocmat, RN, MSN 47 48. Condylomata Perianalacuminatumherpes(Venereal warts) Rectal HSV infection with perianal ulcers 6/26/2011 Maria Carmela L. Domocmat, RN, MSN48 49. Gonococcal proctitis 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 49 50. Anal Carcinoma6/26/2011 Maria Carmela L. Domocmat, RN, MSN 50 51. Palpation of Anus andRectum 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. Palpation of Anus andRectum 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 53 54. Palpation of Anus andRectumWhile the client strains, place glovedand lubricated finger at anal openingas sphincter relaxesSlowly insert the flexed tip of yourfinger into the anal sphincter pointingtoward clients umbilicus 6/26/2011Maria Carmela L. Domocmat, RN, MSN 54 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. The gloved, lubricated finger isslowlyflexed and introduced in the direction of the umbilicus6/26/2011 Maria Carmela L. Domocmat, RN, MSN 56 57. Avoid thisincorrect approach at a rightangle tothe sphincterIt causes discomfort for the clientDoes not promote relaxation 6/26/2011Maria Carmela L. Domocmat, RN, MSN 57 58. If the client tightens the sphincter,remove your finger, reassure the client,and try again, using a relaxationtechnique such as deep breathingFeel the sphincter relax. Insert as far asit will go.Note anal sphincter tone.6/26/2011Maria Carmela L. Domocmat, RN, MSN 58 59. Subcutaneuos portion of the externalsphincter is palpated between thumband index finger 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 59 60. Digital exploration of the deepexternal sphincter6/26/2011 Maria Carmela L. Domocmat, RN, MSN 60 61. Palpation of the levator animuscle 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 61 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. 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. Normal FindingsSmoothNo mass, nodules,tendernessEven pressure on fingerContinuous, smoothsurface with minimaldiscomfort to client 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 64 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. 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. Lets Watch:Palpating Posteriorand Lateral RectalWalls 68. Anoscopy 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 68 69. Abnormal Findings Rectal polyps Pedunculated Sessile 70. Pedunculated polyps6/26/2011 Maria Carmela L. Domocmat, RN, MSN 70 71. Sessile, multilobulated polyp 6/26/2011Maria Carmela L. Domocmat, RN, MSN 71On biopsy, turned out to be a benign tubularadenoma. 72. Prostatic andCowpers GlandPalpation 73. Palpation of Prostate 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 73 74. Palpate the posteriorsurface of the prostategland.Note the size, shape,consistency, sensitivityand mobility of theprostate.Note whether themedian sulcus ispalpable.6/26/2011Maria Carmela L. Domocmat, RN, MSN 74 75. Normal Findings Approximately 4 cm (1 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. 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 inch or 3 cm into the rectal lumen6/26/2011Maria Carmela L. Domocmat, RN, MSN 76 77. Lets Watch:Palpating theAnterior Rectal Walland Prostate 78. AbnormalitiesBenign Prostatic HypertrophyProstate Cancer 79. Benign Prostatic Hypertrophy 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 79 80. Prostrate Cancer: Single nodule 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 80 81. Prostrate Cancer: Multiplenodules 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 81 82. Bidigital Examination ofthe Bulbourethral GlandReassure the client that sensations ofurination and defecation are commonduring the prostatic assessment.Use a well-lubricated, gloved indexwell-finger.Insert the gloved index finger and followthe steps 3 to 6 above 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 82 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.6/26/2011Maria Carmela L. Domocmat, RN, MSN 83 84. Bidigital Examination ofthe Bulbourethral GlandPhoto 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 84 85. Normal FindingBulbourethral Gland Nontender 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 85 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. Normal FindingsNormally, too softto be palpated.Proximal portionscan sometimesbe palpated ascorrugatedstructures abovethe lateral to themidpoint of thegland. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 87 88. Lets Watch:Palpating the AnteriorRectal Wall SeminalVesicle & CowpersGland 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 wipeoff any remaining lubricant.6/26/2011 Maria Carmela L. Domocmat, RN, MSN 89 90. Normal FindingsStoolBrownSoftNo mucus 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 90 91. Fecal Occult Blood Test Stool Guaiac Test 92. Stool Guaiac TestOther names:Guaiac smear testFecal occult blood test - guaiac smearStool occult blood test - guaiac smear 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 92 93. Guaiac Testing Equipment 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 93 94. Stool Guaiac TestPurposeFinds hidden (occult) blood in thestool. 6/26/2011Maria Carmela L. Domocmat, RN, MSN 94 95. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 95 96. stool guaiac testa small sample of stool is placed on apaper card and a drop or two of testingsolution is added.A color change is a sign of blood in thestool. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 96 97. How to Prepare for theTestDo not eat red meat, any blood-containing food,blood-cantaloupe, uncooked broccoli, turnip, radish, orhorseradish for 3 days before the test. These foods cansometimes interfere with the test. test.You may need to stop taking medicines that caninterfere with the test. These include vitamin C andnonsteroidal anti-inflammatory medicines (NSAIDs)anti-such as ibuprofen and aspirin. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN97 98. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 98 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.jpg6/26/2011Maria Carmela L. Domocmat, RN, MSN 99 100. Normal FindingNegative. No blood in the stool 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 100 101. Documentation samplesNo 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. 6/26/2011Maria Carmela L. Domocmat, RN, MSN 101 102. Documentation samplesPerirectal area inflamed; no ulcerations,warts, or discharge. Cannot examineexternal sphincter, rectal vault, orprostate because of spasm or externalsphincter and marked inflammation andtenderness of anal canal. 6/26/2011Maria Carmela L. Domocmat, RN, MSN 102 103. Documentation samplesNo 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. 6/26/2011Maria Carmela L. Domocmat, RN, MSN 103 104. 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 guideto physical examination and history taking(4th ed). New York: Lippincott Williams and ed).Wilkins. 6/26/2011Maria Carmela L. Domocmat, RN, MSN 104 105. Have a blessed Day!6/26/2011 Maria Carmela L. Domocmat, RN, MSN 105 106. Have a blessed Day!6/26/2011 Maria Carmela L. Domocmat, RN, MSN 106