Examination of a stoma

 Confirm pt details
 Explain procedure and gain consent
 Expose patient and position at 45 degrees
 “Do you have any pain in your tummy?”
 “Have you had any problems with your stoma?”
 Inspection
o Site
 LIF: colostomy
 RIF: ileostomy or urostomy
o Number of lumens
 1 and in RIF: end ileostomy or urostomy
 1 and in LIF: end colostomy
 2 joined and in RIF: loop ileostomy
 2 joined and in LIF: loop colostomy
o Spout
 Spout present:
 Ileostomy
 Urostomy
 No spout:
 Colostomy
o Effluent (what’s coming out)
 Hard stool – colostomy
 Soft stool – ileostomy
 Urine – urostomy
 Remember to feel the bag!
o Surrounding skin quality
 Any inflammation or excoriations? – infection/poor stoma maintenance
o Any evidence of complications?
 Haemorrhage – peristomal skin inflammation
 Parastomal hernia – risk of bowel strangulation and necrosis
 Prolapse – high output
 Retraction – obstruction
 Auscultation
o Auscultate for bowel sounds
 Absent bowel sounds – ileus
 High-pitched tinkling – obstruction
 Wash hands, thank patient
 Summarise findings
o Some Naughty Surgeons Never Stay in the Evenings and Like Porches
 Site
 Number of lumens
 Spout
 Nature of effluent
 State of surrounding skin
 Evidence of complication
 Likely type of stoma
 Possible pathology/procedure
o “This patient has a stoma in the left iliac fossa with one lumen and no spout. The effluent is solid faeces and the
surrounding skin is intact with no evidence of inflammation. There is no evidence of complications. This is most
likely an end colostomy. To complete my examination I would perform a full gastrointestinal exam.”
Examination of a hernia
 Confirm pt details
 Explain procedure:
o “Today I need to perform an examination of the lump you are concerned about, which will involve me having a
look and feel of the lump.”
o “It shouldn’t be painful, however, it might be a little uncomfortable. If at any point you are in pain or would like
me to stop, just let me know.”
o “for this examination, I will need you to have your trousers and underwear off to allow me to assess the lump. If
you feel uncomfortable at any point, let me know and we can stop the examination.”
o “For this examination one of the nursing staff will be present acting as a chaperone”
o “Do you understand everything I’ve explained?”
o “Do you have any questions? Are you happy for me to perform the procedure?”
o “Are you currently experiencing any pain anywhere?”
 Inspection
o Standing and lying down
o General inspection
 Evidence of pain e.g. stance, grimacing
 Note patient’s overall colour e.g. pallor secondary to anaemia or jaundice
 Evidence of abdominal distension (may suggest bowel obstruction, possibly due to an incarcerated
hernia)
 Note any muscle wasting or cachexia suggestive of underlying malignancy
 Look around the bed for evidence of vomit bowls or medication
o Close inspection
 Inspect patient from front and sides, looking for:
 Asymmetry
 Scars on the abdomen and in the groin
 Obvious lumps protruding from the abdomen or groin
 Any testicular lumps or swellings
 Ask the patient to cough
 Assessing a lump
o Site
o Size
o Shape
o Colour
o Contour
o Consistency
o Tenderness
o Temperature
o Tethering
o Cough impulse
o Transillumination
o Bruit
o Lymphadenopathy
 Types of hernia
o Inguinal hernia
 Superomedial to the pubic tubercle, at exit of the superficial inguinal ring
 Locate the deep inguinal ring (midday between ASIS and pubic tubercle)
 Try to reduce hernia by inferiorly compressing the lump towards the deep inguinal ring
 Once reduced, apply pressure over the deep inguinal ring
 Ask the patient to cough
 If hernia reappears, more likely to be a direct inguinal hernia. If not, more likely to be indirect
 Release pressure from the deep inguinal ring and observe for the hernia reappearing (further
supporting likely to be indirect)
 o Femoral hernia
 Inferolateral to the pubic tubercle, medial to the femoral pulse
o Umbilical hernia
o Incisional hernia
 Reducibility
o Hernias are typically reducible, but if painful and irreducible suggests strangulation
 Scrotal examination
o Typically, an inguinal hernia will present as a testicular lump that you cannot get above
 Auscultation
 Summarise findings
o “On examination of Mr Smith, a 52-year-old gentleman, there was a round mass visible in the left groin above
and medial to the pubic tubercle. It was non-tender, approximately 2cm in diameter, soft in consistency and
reducible. There was a positive cough impulse and the hernia recurred despite pressure over the deep inguinal
ring. There was no extension to the scrotum and no associated lymphadenopathy. The most likely diagnosis
based on my clinical findings is a direct inguinal hernia. ”
 Further investigations:
o Abdominal examination
o Testicular examination
o Assessment of inguinal lymph nodes
o Further imaging e.g. USS/CT

A Talk to the patient +/- airway manoeuvre

+/- airway adjuncts
B RR, IPPA, sats +/- O2 (ask medical conditions)
C BP, PR, JVP, CR, UO, temp +/- IV cannulae
Take bloods
Fluids
D AVPU, pupil, glucose, pain, ask allergies +/- airway
Painkillers
E Abdo exam, head-toe, environment