Rectal exam on Post-op Patient?

[LesBigoudis]

I am an experienced palliative pain and symptom management (PSM) nurse at a large hospital in Canada. On occasion I work as part of a PSM consultant team for inpatients at this hospital. This position entails providing consults and follow-ups for patients in any department of the hospital who require our services. (Med Surg, ICU, Oncology etc.). I am asking for some input from some experienced Surgical nurses regarding protocol and clinical decision making regarding a particular incident.

I was asked to see a patient who was 5 days post-op for a conservative colostomy due to a bowel obstruction. I knew this patient well as I had been following her in the outpatient setting prior to her admission. I was in fact the RN that identified her bowel obstruction - prevented a disaster by advocating for the patient when a physician ordered Relistor injections for her without first ruling a bowel obstruction (X-ray was done, bowel obstruction identified, Rx shredded and pt admitted). This patient had a Dx of primary peritoneal carcinomatosis with extensive disease within the abdominal cavity. While assessing this patient for symptoms (pain, nausea, bowels, dyspnea, fatigue etc.) she identified to me that she had passed some small hard stool on a few occasions since her surgery. While I was in the patient's room she requested assistance to the commode where she was able to void and also passed a small amount of hard stool which I observed. The patient then complained that "it feels like something is stuck and can't come out". I offered to examine her and she gratefully agreed. I first examined the rectal area for any indication of any surgery to the area, the orifice clearly did not show any indication that Sx had been performed to the area.

With the additional clinical proof that the patient was still passing stool this reinforced to me that she indeed still had her rectum and lower portion of her bowel intact. I chose to then perform a rectal exam to check for stool and/or hemmorhoids. I was able to feel some hard stool in the rectum but nothing else that was clinically significant. I think it important to mention that I have had a very similar patient in the past many years ago and at that time had a very detailed discussion with the physician as to whether it was indicated to perform a rectal on a patient who presented in the exact same manner. The physician explained to me at that time that it was safe to perform a rectal as long as the patient was passing stool rectally and that on occasion they can become constipated even after a colostomy is performed if all of the stool has not yet passed.

Important to note that this patient was not on any active chemo/treatment (in which case a rectal would be clearly contraindicated). Also important to note that within our facility it is not required that a RN obtain an order for performing a rectal exam on a patient, only for administering an enema or disimpacting.

My question is: For those of you with more surgical experience. With the information that I provided you, would you proceed with a rectal exam in this patient? I have colleagues who initially believed that a physician's order was necessary for this procedure (which they now agree is not the case) however now they are changing their focus and are insisting that the rectal exam should not have been performed on this patient because she was 5 days post op. I have scoured the texts and journals and have not been able to find this definitively. Everything that I come across states that it is up to the individual nurses's clinical judgement as to whether this procedure is appropriate or not for the given clinical situation and I cannot find anything stating that a rectal would be contraindicated in this particular situation. I would appreciate any feedback/links/info that any of you can provide. I based my decision on a careful clinical assessment of the patient, reviewing her history, symptoms and clinical presentation as well as linking to previous experience to make my decision to follow through with this procedure.

One can also learn from other's experience which is why I am turning to this forum. Thank you for all of your replies in advance.