Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [178], C).
2. 2.Show
   Ensure privacy.
   To avoid unnecessary embarrassment to the patient and to promote dignity and privacy (NMC [178], C).
3. 3.Show
   Ensure that a bedpan, commode or toilet is readily available.
   DRE can stimulate the need for a bowel movement (Weisner and Bell [244], E).

Procedure

1. 4.Show
   Assist the patient to lie in the left lateral position with knees flexed, the upper knee higher up the bed than the lower knee, with the buttocks towards the edge of the bed.
   This allows ease of digital examination into the rectum by following the natural anatomy of the colon (RCN [206], C). Flexing the knees reduces discomfort as the examining finger passes the anal sphincter (Kyle et al. [121], E).
2. 5.Show
   Place a disposable incontinence pad beneath the patient's hips and buttocks.
   To reduce potential infection caused by soiled linen. To avoid embarrassing the patient if faecal staining occurs during or after the procedure. E
3. 6.Show
   Wash hands with soap and water or an alcohol‐based handrub and put on disposable gloves.
   For infection prevention and control (NHS England and NHSI [161], C).
4. 7.Show
   Observe the anal area prior to the insertion of the finger into the anus for evidence of skin soreness, excoriation, swelling, haemorrhoids, rectal prolapse or infestation.
   May indicate incontinence or pruritus. Swelling may be indicative of mass or abscess. Abnormalities such as bleeding, discharge or prolapse should be reported to medical staff before any examination is undertaken (RCN [206], C).
5. 8.Show
   Palpate the perianal area starting at 12 o'clock, moving clockwise to 6 o'clock and then moving from 12 o'clock anticlockwise to 6 o'clock.
   To assess for any irregularities, swelling, indurations, tenderness or abscesses in the perianal area (RCN [206], C).
6. 9.Show
   Place some lubricating gel on a gauze square and gloved index finger. Inform the patient you are about to proceed.
   To minimize discomfort as lubrication reduces friction and to ease insertion of the finger into the anus and rectum. Lubrication also helps to minimize anal mucosal trauma from digitization (Peate [194], E). Informing the patient assists with co‐operation during the procedure (NMC [178], C).
7. 10.Show
   Prior to insertion, encourage the patient to breathe out or talk, and/or place gloved index finger on the anus for a few seconds prior to insertion.
   To prevent spasm of the anal sphincter on insertion (RCN [206], C). Gently placing a finger on the anus initiates the anal reflex, causing the anus to contract and then relax (RCN [206], C).
8. 11.Show
   On insertion of the finger, assess for anal sphincter control; resistance should be felt.
   Digital insertion with resistance indicates good internal sphincter tone; poor resistance may indicate the opposite (RCN [206], C).
9. 12.Show
   With finger inserted in the anus, sweep clockwise then anticlockwise, noting any irregularities.
   Palpating around 360° enables the nurse to establish whether there is any swelling or tenderness within the rectum (RCN [206], C; Steggall [232], E).
10. 13.Show
    Digital examination may allow the nurse to feel faecal matter within the rectum; note the consistency of any faecal matter.
    May establish a loaded rectum and indicate constipation and the need for rectal medication (RCN [206], C).
11. 14.Show
    Carefully remove the finger and change gloves.
    To enable the cleaning of the patient. E
12. 15.Show
    Clean the anal area after the procedure.
    To prevent irritation and soreness occurring. To preserve the patient's dignity and personal hygiene. P

Post‐procedure

1. 16.Show
   Remove gloves and apron and dispose of equipment in an appropriate clinical waste bin. Wash hands with soap and water or an alcohol‐based handrub.
   For infection prevention and control (NHS England and NHSI [161], C).
2. 17.Show
   Assist the patient into a comfortable position and offer a bedpan, commode or toilet facilities as appropriate.
   To promote the patient's comfort. P
3. 18.Show
   Document the findings and report them to the appropriate members of the multidisciplinary team.
   To ensure continuity of care and ensure appropriate corrective action may be initiated (NMC [178], C; RCN [206], C).