Nursing Responsibilities
Assessing Abdomen
Before
1.Nurse should prepare all materials needed
2.Patient should not have a full bladder
3.Ensure patient comfort
4.The patient should keep arms at the sides or folded across
the chest and not over their heads to avoid stretching and
tightening the abdominal wall.
5.Explain the procedures
6.Nurse should maintain a sterile environment at all times.
During
1.Before palpation, ask the patient to point out any areas of
pain and examine those areas the last.
2.Monitor assessment by observing patient’s facial
expressions for discomfort.
3.Have warm hands, warm stethoscope and short
fingernails.
4.Approach slowly and avoid abrupt movements
5.Distract patient if necessary with conversation or
questions.
6.Nurse should maintain a sterile environment at all times.
After
1.Do after care
2.Ensure client health education
3.Nurse should maintain a sterile environment at all times
Assessing the Anus, Rectum, and Prostate
Male
1.Position
a. Your client must be positioned well for effective
assessment.
b. Positions include the
i. Side-lying position- most common position as it
allows good views of the perianal and
saccrococcygeal areas.
ii. Lithotomy position- may help a nurse reach
cancer in rectum; also permits a bimanual
examination, enabling a nurse to demonstrate a
pelvic mass.
iii. Standing position- preferred by most clinicians
2.Inspection
a. Inspection of the Perianal Area
i. Skin
1.Inspect for lumps, ulcers, inflammations,
rashes, or excorciations
2.Adult perianal skin is normally pigmented and
somewhat coarser than the skin over the
buttocks
3.Palpate and abnormal areas; note lumps and
tenderness
ii. Anal opening
1.Lubricate your gloved index finger before
proceeding and explain to patient that the
examination may make him feel as if he were
moving his bowels but that he not dos so.
2.Note any lesions
3.Gently place the pad of lubricated and gloved
index finger over anus. As sphincter relaxes,
gently insert fingertip into the anal canal,
direction pointing towards the umbilicus.
4.Pause if sphincter tightens and reassure
patient.
5.In case of sever tenderness preventing further
examination of anus, place your fingers on
both side of the anus, gently spread the
orifice, ask the patient to strain down. Look
for a lesion, such as an anal fissure, that
might explain the tenderness.
6.Note:
a. Sphincter tone of anus: Normally,
muscles close snugly around finger.
b. Tenderness, if any
c. Induration that may be due to
inflammation, scarring, or malignancy.
d. Irregularities or nodules
iii. Sacrococcygeal area
iv. Valsalva maneuver
b. Palpation of the Anus and Rectum
i. Palpation technique
1.Canal wall
a. Insert finger into rectum as far as
possible. Rotate hand clockwise to
palpate rectal surface posteriorly and on
the patient’s left side.
i. Note any nodules, irregularities, or
induration
2.Perianal tissue
3.Rectal wall
4.Prostate gland
a. Rotate hand further counterclockwise so
that finger can examine the posterior
surface of the prostate gland
b. Sweep finger carefully over the prostate
gland.
i. Note:
1.Size
2.Shape
3.Surface
4.Consistency
5.Mobility
6.Tenderness
ii. Normal prostate is rubbery and
nontender.
c. If possible, extend finger to above the
prostate to the region of seminal vesicles
and peritoneal cavity.
i. Note for nodules or tenderness
ii. Examination of stool for occult blood
1.Gently withdraw finger and wipe patients anus
or give him tissues to do it himself.
2.Note color of any fecal matter on your gloves
Female
The rectum is usually examined after the female genitalia,
while the patient is in lithotomy position.
If only rectal examination is indicated, lateral position is
recommended as it gives a much better view of the
perianal and sacrococcygeal areas.
The technique is basically similar to that described of
males. The cervix is usually felt readily through the anterior
rectal wall. Sometimes, a retroverted uterus can be
palpable. Neither of these, nor a vaginal tampon should be
mistaken for a tumor.
