ABDOMINAL PARACENTESIS

INTRODUCTION

Abdominal paracentesis is performed as a diagnostic procedure to establish the etiology

of new-onset ascites or to rule out spontaneous bacterial peritonitis in patients with
preexisting ascites. Large-volume paracentesis is performed in hemodynamically stable
patients with tense or refractory ascites to alleviate discomfort or respiratory
compromise. Usually, there is very little fluid in the abdominal cavity. However, there are
a number of conditions that can cause fluid to accumulate in the abdomen, a condition
called ascites. When fluid accumulates, an abdominal paracentesis may be done.

DEFINITION

Abdominal paracentesis is the removal of fluid from peritoneal cavity or abdominal

cavity. It is also called peritoneal tap.

ANATOMY AND PHYSIOLOGY RELATED TO THE PROCEDURE

The peritoneal cavity is formed by two layers of serous membranes - the visceral layer
surrounding the abdominal organs and a parital layer lining the abdominal cavity.
Normally the peritoneal cavity is only a potential cavity separated by a thin film of serous
fluid to lubricate the surfaces of peritoneum and prevent friction. In healthy body, the
fluid formed in the peritoneal cavity is absorbed into the lymph circulation through the
lymph vessels in the peritoneum. In disease processes, fluid accumulates within this
cavity and cause ascites. Methods of treatment include restriction of sodium intake,
administration of diuretics and occasionally an abdominal paracentesis.

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PURPOSES

1) To relieve pressure on the abdominal and chest organs if a transudate collects

as a result of renal, cardiac or liver diseases.

2) To study chemical, bacteriological and cellular composition of the peritoneal fluid

for the diagnosis of diseases.

3) To drain an exudate in peritonitis.

4) To remove fluid and instill air to create artificial pneumo-peritoneum as a

treatment for pulmonary tuberculosis affecting the base of the lungs.

INDICATIONS

1. Evaluation of the etiology of ascites.

2. Detection of perforated viscous in a patient with an acute- abdomen or following
blunt trauma to the abdomen.
3. Therapy for massive ascites. (e.g. unresponsive to diuretics or interfering with
respiration).

 CONTRAINDICATIONS

1. Disorder of blood coagulation:

a. Prothrombin time>5 sec of control
b. platelet count <50,000/mm3
2. Intestinal obstruction.
3. Pregnancy for fear of puncturing the uterus.
4. Know pneumo-peritoneum (paracentesis is generally unnecessary since the
patient is likely to be considered for surgery for ruptured viscous).
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 5. Infection of the abdominal wall.
6. Relative contraindication:
a. poor patient cooperation
b. history of multiple abdominal surgeries

SITE AND POSITIONING OF THE PATIENT FOR AN ABDOMINAL

PARACENTESIS

The primary object of selecting a site is to avoid injury to the urinary bladder and other
abdominal organs. A common site is the midway between the symphysis pubis and the
umbilicus on the midline. Another site may be a point two-third along a line from the
umbilicus to the anterior superior, iliac spine. The patient is positioned in Fowler's
position supported by the rest and pillows near the edge of the bed.

GENERAL INSTRUCTIONS

1. Give adequate explanations to win the confidence and co-operation of the patient.
Patient’s co-operation is very necessary for the prevention of injury to the adjacent
organs.

2. Strict aseptic technique should be followed to prevent introduction of infection into

the peritoneal cavity.

3. Ask the patient to void five minutes before the procedure to prevent injury to the
bladder. Catheterize the patient if any doubt exists.

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4. Keep the patient warm and comfortable to prevent chills.

5. Be prepared to treat shock. Shock can be prevented by :

(a) Withdrawing the fluid slowly. Apply clamps on the tubing.

(b) Withdrawing small quantity of fluid at a time.
(c) Applying pressure on the abdomen with many tailed bandage and tightening it
from above downwards as the fluid is drained.
(d) Keeping the patient warm.
(e) Observing the vital signs continuously during the procedure.

6. The drainage receptacle should be raised on the stool. The greater the vertical
distance between the tapping needle and the end of the tubing in the drainage
receptacle, the greater is the pull on the fluid in the cavity and more quickly the
cavity is drained and the patient may go into a state of shock.

7. Use a tapping needle/trocar of smaller gauge possible. This will reduce the
puncture wound as small as possible and thereby reduce the chances of fluid
leaking from the peritoneal cavity after the procedure is over.

8. The flow of fluid can be controlled by the application of clamps on the tubing.

9. The nurse should remain with the patient throughout the procedure to observe the
patient’s general condition. Changes in color, pulse, respiration, blood pressure
etc. should be noted and reported to the doctor immediately. These are the
indications that the patient is going into vascular shock and collapse.

10. Repeated aspirations of the ascetic fluid will result in hypoproteinaemia. The
patient should be given plasma proteins if he develops such a condition.

11. The wound should be sealed immediately after the procedure to prevent infection
and leakage of peritoneal fluid.

12. The specimens collected should be sent to the laboratory without delay. The usual
tests that are carried out are specific gravity, cell count, bacterial count, protein
concentrations, culture, and acid fast stain. In most disorders, the fluid is clear and
straw colored. Turbidity suggests infection. Sanguinous fluid usually signals
neoplasm or tuberculosis. The rare milky (chyloust fluid is due to lymphoma. A
protein concentration of less than 3 gm/100 ml suggests liver diseases or a
systemic disorder; higher protein content suggests an exudative cause such as
tumor or an infection.

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PROCEDURE
PREPERATION OF THE EQUIPMENTS
EQUIPMENTS RATIONALE

A covered sterile tray containing:

• 2 ml-Syringe-1 To administer local anesthetic.

• 25G.X 1"needle-2
• 23G.X 1'/4needle-1
• Small bowls-2
• 5" dissecting forceps or sponge holder-1 To clean the skin.
• Cotton balls-6
• Gauze pads-2
• Scalpel-1 To make an incision, to insert into
• Trocar and cannula-1 abdominal cavity and to drain out
fluid.
• Pint measure-1 To measure the abdominal fluid.

• Fenesiraied towel-1 To cover the area and maintain

sterile field and to expose only the
required path.
 Surgical drape To prepare the skin and disinfect the
 12” rubber tubing – 1 local area for a sterile procedure.
 Screw clamp – 1
 A skin preparation tray
 A sterile surgical towel
 A dressing set
 A bowl of warm water
To prepare the skin.
 Razor set with blade
 A bowl with 6 cotton balls
 6 gauze squares
 A soap dish with soap
 Savlon 1:30 in a bottle
 torch
 A kidney tray To protect bed linen and discard
 A mackintosh waste.
 A treatment towel
 A paper bag
 Basin For cleaning.
 Sponge cloth
 Jugs – 2
 Bucket - 2
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  Sterile glove -1 pair To keep the hands sterile by using
 A sterile gauze mask gloves.
 Local anesthetic
To anaesthetize the part.
 Sterile specimen bottles – 3 To collect specimen.
 Many tailed binder – 1 To collect specimen.
 Many tailed binder – 1 To provide abdominal comfort.
 Safety pins – 1 To secure the binder.
 Back rest – 1 To give a propped up position.
 Spirit, iodine, Tr. Benzoin, sponge To prepare a sterile field.
holding forceps, gauzes pieces To cleanse the part.
 A screen To maintain privacy.

PREPARATION OF THE PATIENT

a) Explain the procedure to the patient and his relatives to obtain their
understanding, co-operation and acceptance of the treatment.

b) Get a written consent from the patient or his relatives.

c) Prepare the skin as for a surgical procedure.

d) Record the blood pressure, pulse, respiration and weight of the patient on the
nurse's record before sending the patient to the operation room. This may be
used to compare the similar data obtained during or after the procedure and to
determine the effect of the procedure on the patient.

e) Empty the bladder just before the procedure to prevent injury to the distended
bladder. When there is doubt, catheterize the bladder.

f) Protect the patient from chills by keeping him warm. Cover the patient with a
blanket. Close the windows and doors to prevent draught. Put off the fan.
g) Change the patient's garments^ with hospital dress. Put on loose gowns. The
upper garments may be pinned up to prevent its falling over the abdomen during
the procedure.

h) Bring the patient to the edge of the bed to prevent over reaching. Place him in a
Fowler's position supported with a back rest and pillows.

i) Maintain privacy with screens and drapes. Drape the patient exposing the
abdomen only.

j) Protect the bedding with a mackintosh and towel.

k) Place a many tailed bandage under the patient to apply over the abdomen during
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 the procedure in order to maintain the intra-abdominal pressure. This will help to
prevent shock and collapse as the fluid is drained from the abdominal cavity.

l) The nurse should remain with the patient throughout the procedure encouraging
him to co-operate and diverting his attention away from the procedure. She
should note the color, pulse, respiration and blood pressure during the
procedure, to detect the early signs of shock and collapse.

STEPS OF PREOCEDURE

CARE BEFORE THE PROCEDURE

STEPS RATIONALE SCIENTIFIC NURSING

PRINCIPLES PRINCIPLES
Assemble equipment To save time, energy - Economy of time,
and bring to the and material. material and energy
bedside.
Explain the To prevent fear and Psychology Individuality
procedure to the to seek cooperation.
patient.
Ask the patient to Prevents injury to the Anatomy and Safety
void or catheterize, if bladder. physiology
necessary
Follow strict aseptic To prevent cross – Microbiology Safety
techniques during infection
the procedure
Keep the patient To prevent Physiology Comfort and safety
warm and peripheral
comfortable vasoconstriction and
shock.
Keep drugs and Shock is one of the Chemistry Safety
equipment ready to complications so the
treat shock drugs should be kept
ready.
Take consent To have legal safety - Safety
Place the screen To maintain privacy. - Comfort
Prepare the skin i.e. Insertion is made in Microbiology, Safety
from nipple line to this area to prevent anatomy and
pelvis. In female, cress – infection physiology
below the breast
Record vital signs To identify shock Anatomy and Safety
and to treat it at an physiology
early stage. Sudden
withdrawal of
abdominal fluid
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 which may cause
shock.
Change the client’s Prevents Microbiology and Comfort.
garments and put on inconvenient psychology
a loose gown and interference with the
pin up the gown procedure. Helps to
during the procedure keep clean and
prevent cross –
infection.

CARE DURING THE PROCEDURE

STEPS RATIONALE SCIENTIFIC NURSING

PRINCIPLES PRINCIPLES
Fanfold the top linen To expose the area Psychology Comfort
down to the public and prevent
area interference
Expose the area To minimize Psychology Comfort
below the nipple up exposure of the
to the public area patient and keep him
warm
Place the bucket in To prevent spillage Physics Comfort
position to receive and have accurate
the abdominal fluid measurement
Place the client in Comfortable for the Anatomy and Safety
Fowler’s position client and full physiology
expansion of
thoracic cavity
Place draw sheet To protect bed linen. Comfort
and mackintosh
Wash hands and To prevent cross – Microbiology Safety
open the sterile tray. infection
Open the clean To assist the Microbiology Safety
dressing set and physician and avoid
takes forceps and cross – infection
hand over the
surgical towel from
the sterile tray to the
doctor for wiping
hands.

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Assist the doctor in To anaesthetize the Anatomy and Comfort
drawing local site of paracentesis. physiology
anesthetic. After Local anesthetic
infiltration of the area drug helps in
with local anesthetic preventing local pain
the doctor will insert due to the
trocar and canula procedure.
half way between
umbilicus and
anterior, superior
iliac spine.

Trocar is removed by To drain out the Physics Therapeutic

the doctor and abdominal fluid. effectiveness
rubber tubing is Fluid drains due to
attached to the gravity
canula to drain out
fluid.
Place the rubber Helps in measuring Microbiology and Safety and comfort.
tubing in a sterile the drained out fluid physics
pint measure and and prevents cross –
adjust the rate of infection. Provides a
flow with a screw sterile field and
clamp. prevents ascending
infection.
Specimens are to be For diagnostic Microbiology Safety and
sent – collect the purpose. therapeutic
abdominal fluid in effectiveness.
the specified sample
bottles.
When the desired To prevent leakage Microbiology Safety and comfort
amount of fluid is of abdominal fluid.
removed or the To protect the
procedure is to be wound.
discontinued place
the gauze piece and
gauze pads after
cleaning with a
sterile cotton swab
over the wound.
Apply many tailed To prevent shock Anatomy and Safety and comfort
bandage over the and collapse. To physiology
abdomen. maintain intra –
abdominal pressure.
Place the client in a To make the patient Anatomy and Safety and comfort.
comfortable position comfortable and physiology

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in the bed. Check check nay untoward
pulse and BP. signs and symptoms.

CARE AFTER THE PROCEDURE

STEPS RATIONALE SCIENTIFIC NURSING

PRINCIPLES PRINCIPLES
The equipment to be For neatness and to Microbiology and Safety and comfort
removed from bed side, clean the psychology
tidy up the unit after equipment.
making the client
comfortable.
If the abdominal fluid is To measure Microbiology Therapeutic
collected in a bucket accurately. To know effectiveness
measure accurately with the amount, color
a pint measure, note the and consistency of
characteristics of fluid fluid.
and record.
Wash, dry and replace Prevents cross – Microbiology Fine workmanship.
the equipment. infection
Check the vital signs To detect shock in Anatomy and Therapeutic
every ½ hour for two early stages and physiology effectiveness
hours – every ½ hour for treat.
four hours and every
four hours for 24 hours.
Observe the dressing for As there is incision, Microbiology Safety
excessive soakage. abdominal fluid may
leak.
Observe for There are Psychology Safety and comfort
 Complications, complications which
hypovolemia, are possible. So the

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 collapse. complications need
 Infection and to be detected and
peritonitis treated at an early
 Injury to blood stage.
vessels and other
abdominal
organs.
 Renal failure due
to systemic
circulation
collapse.
Record in the nurse’s For communication - Therapeutic
notes the time of the effectiveness.
procedure, vital signs
and nay complications
noted and inform the
doctor.

AFTER CARE OF THE PATIENT

 As soon as the needle is removed, a sterile dressing and a pressure bandage is

applied at the puncture site to prevent leakage of fluid.

 The abdominal bandage is tightened to maintain intra-abdominal pressure.

 Check the patient's general condition after the procedure. Any change in the
color, pulse, respiration and blood pressure should be reported immediately.
The vital signs are checked half hourly for two hours; then hourly for 4 hours
followed by 4 hourly for 24 hours.

 The specimens collected should be sent to the laboratory with labels and a

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 requisition form.

 Examine the dressing at the puncture site frequently for any leakage. Re-inforce
the dressing if leakage is present.

 Serum proteins are estimated to detect hypoproteinaemia. If hypo proteinaemia

is present, plasma proteins are administered.

 Record the procedure on the nurse's record with date and time. Note the
amount and character of the fluid drained, its color, effects of treatment on the
patient ('both desired and undesired effects) and the general condition of the
patient during and after the treatment.

 Clean all articles used. Wash with cold water and then with warm soapy water
and rinse them in clean water. Dry and send for autoclaving.

COMPLICATIONS

1. Hypovolemia leading to shock and collapse.

2. Infection (peritonitis)
3. Injury to the blood vessels and other abdominal organs.
4. Renal failure due to reduced systemic circulation.
5. Hypoproteinaemia as a result of repeated tapping.

RESEARCHES

1) Diagnostic abdominal paracentesis was performed in 43 patients in whom the

diagnosis was uncertain. It was found to be particularly useful in abdominal pain
resulting from trauma. In 12 patients the findings led to their being spared a
laparotomy while in several other patients they led to very early diagnosis of the
lesion responsible enabling early surgical treatment to be undertaken. A false-
negative result was obtained in only one patient. It is concluded that diagnostic
abdominal paracentesis is an extremely reliable diagnostic aid and can lead to
improved surgical care of the patient with atypical acute abdominal pain.

2) This study was conducted to evaluate the complications and bleeding associated
with either thrombocytopenia or prolongation of prothrombin time for ultrasound-
guided abdominal paracentesis in the emergency department.
CONCLUSION:
Bleeding complication of ultrasound-guided abdominal paracentesis is
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 uncommon and appears to be very mild, regardless of pre-procedure
international normalised ratio or platelet count. Routine correction of prolonged
international normalised ratio or thrombocytopenia before abdominal
paracentesis may not be necessary.

KEYWORDS

 Cholang: Pertaining to bile duct

 Cholangiography: X – rays study of the bile ducts

 Chole: Pertaining to bile

 Cholecyst: Pertaining to gall bladder

 Cholecystisis: Inflammation of gall bladder

 Choledactolithiasis: Gall stones in common bile duct

 Choledocho: Pertaining to common bile duct

 Choleith: Gall stone

 Choletithiasis: Presence of gall stones

 Colonscopy: Visualization of the colon with the help of a colonscope.

 Dysphagia: Difficulty in swallowing

 Endoscopy: Visualization of internal body organs with the help of an endoscope

 Fluoroscopy: Examination of the inner parts of the body by a fluoroscope.

 Gag reflex: A reflex that is necessary for swallowing.

 Gastroscopy: Visualization of stomach with the help of a gastriscope.

 Laxative: Mildly cathartic, having the action of loosening the bowel

 Polyp: A general descriptive term used with reference to nay mss of tissue that
bulges or projects outward or upward, from the normal surface level being visible
as a hemispheroidal, spheroidal or irregularly mound like structure.

 Purgative: Cathartic to cause a copious evacuation.

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  Roentgenography: Examination of any part of the body for diagnostic purposes
by means of Roentgen rays, the record of findings being impressed on a
photographic plate.

REFERENCES

 http://www.aurorahealthcare.org/yourhealth/healthgate/getcontent.asp?
URLhealthgate=%2214758.html%22

 http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/003896.htm

 http://content.nejm.org/cgi/content/short/355/19/e21

 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1787566

 http://jama.ama-assn.org/cgi/reprint/299/10/1216.pdf

 http://www.find-health-articles.com/rec_pub_16185942-should-bleeding-
tendency-deter-abdominal-paracentesis.htm

 Dr. Patel B. Mansukh, “Ward Procedures” 4th edition 2004 Elsevier India Private
Limited New Delhi Pp 370-372.

 Sr. Nancy “Principles and practice of nursing, Senior Nursing Procedures Vol II”
3rd editon 2000 N.R Publishing House Pp 300-305.

 TNAI “Fundamentals of Nursing A Procedure Mannual” 1 st edition 2005 Pp 567-

570.

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