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.

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).

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. Patients 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.

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 patients 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.

PROCEDURE
PREPERATION OF THE EQUIPMENTS
EQUIPMENTS A covered sterile tray containing: 2 ml-Syringe-1 25G.X 1"needle-2 23G.X 1'/4needle-1 Small bowls-2 5" dissecting forceps or sponge holder-1 Cotton balls-6 Gauze pads-2 Scalpel-1 Trocar and cannula-1 Pint measure-1 Fenesiraied towel-1 To administer local anesthetic. RATIONALE

To clean the skin.

To make an incision, to insert into abdominal cavity and to drain out fluid. To measure the abdominal fluid. To cover the area and maintain sterile field and to expose only the required path. To prepare the skin and disinfect the local area for a sterile procedure.

Surgical drape 12 rubber tubing 1 Screw clamp 1 A skin preparation tray A sterile surgical towel A dressing set A bowl of warm water 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 A mackintosh A treatment towel A paper bag Basin Sponge cloth Jugs 2 Bucket - 2

To prepare the skin.

To protect bed linen and discard waste.

For cleaning.

Sterile glove -1 pair A sterile gauze mask Local anesthetic Sterile specimen bottles 3 Many tailed binder 1 Many tailed binder 1 Safety pins 1 Back rest 1 Spirit, iodine, Tr. Benzoin, sponge holding forceps, gauzes pieces A screen

To keep the hands sterile by using gloves. To anaesthetize the part. To collect specimen. To collect specimen. To provide abdominal comfort. To secure the binder. To give a propped up position. To prepare a sterile field. To cleanse the part. 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 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 SCIENTIFIC PRINCIPLES Assemble equipment To save time, energy and bring to the and material. bedside. Explain the To prevent fear and Psychology procedure to the to seek cooperation. patient. Ask the patient to Prevents injury to the Anatomy and void or catheterize, if bladder. physiology necessary Follow strict aseptic To prevent cross Microbiology techniques during infection the procedure Keep the patient To prevent Physiology warm and peripheral comfortable vasoconstriction and shock. Keep drugs and Shock is one of the Chemistry equipment ready to complications so the treat shock drugs should be kept ready. Take consent To have legal safety Place the screen To maintain privacy. Prepare the skin i.e. Insertion is made in Microbiology, 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 and Anatomy and to treat it at an early physiology stage. Sudden withdrawal of RATIONALE NURSING PRINCIPLES Economy of time, material and energy Individuality

Safety

Safety

Comfort and safety

Safety

Safety Comfort Safety

Safety

abdominal fluid which may cause shock. Change the clients Prevents Microbiology and 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 Fanfold the top linen down to the public area Expose the area below the nipple up to the public area Place the bucket in position to receive the abdominal fluid Place the client in Fowlers position RATIONALE To expose the area and prevent interference To minimize exposure of the patient and keep him warm To prevent spillage and have accurate measurement Comfortable for the client and full expansion of thoracic cavity To protect bed linen. To prevent cross infection To assist the physician and avoid cross infection SCIENTIFIC PRINCIPLES Psychology

Comfort.

NURSING PRINCIPLES Comfort

Psychology

Comfort

Physics

Comfort

Anatomy and physiology

Safety

Place draw sheet and mackintosh Wash hands and open the sterile tray. Open the clean dressing set and takes forceps and hand over the surgical towel from the sterile tray to the doctor for wiping hands.

Comfort Microbiology Microbiology Safety Safety

Assist the doctor in drawing local anesthetic. After infiltration of the area with local anesthetic the doctor will insert trocar and canula half way between umbilicus and anterior, superior iliac spine. Trocar is removed by the doctor and rubber tubing is attached to the canula to drain out fluid. Place the rubber tubing in a sterile pint measure and adjust the rate of flow with a screw clamp.

To anaesthetize the Anatomy and site of paracentesis. physiology Local anesthetic drug helps in preventing local pain due to the procedure.

Comfort

To drain out the Physics abdominal fluid. Fluid drains due to gravity

Therapeutic effectiveness

Helps in measuring Microbiology and the drained out fluid physics and prevents cross infection. Provides a sterile field and prevents ascending infection. Specimens are to be For diagnostic Microbiology sent collect the purpose. abdominal fluid in the specified sample bottles. When the desired To prevent leakage Microbiology 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 bandage over the and collapse. To physiology abdomen. maintain intra abdominal pressure. Place the client in a To make the patient Anatomy and comfortable position comfortable and physiology

Safety and comfort.

Safety and therapeutic effectiveness.

Safety and comfort

Safety and comfort

Safety and comfort.

in the bed. Check pulse and BP.

check nay untoward signs and symptoms.

CARE AFTER THE PROCEDURE STEPS The equipment to be removed from bed side, tidy up the unit after making the client comfortable. If the abdominal fluid is collected in a bucket measure accurately with a pint measure, note the characteristics of fluid and record. Wash, dry and replace the equipment. Check the vital signs every hour for two hours every hour for four hours and every four hours for 24 hours. Observe the dressing for excessive soakage. Observe for Complications, hypovolemia, RATIONALE SCIENTIFIC PRINCIPLES For neatness and to Microbiology and clean the psychology equipment. NURSING PRINCIPLES Safety and comfort

To measure Microbiology accurately. To know the amount, color and consistency of fluid. Prevents cross infection To detect shock in early stages and treat. Microbiology Anatomy and physiology

Therapeutic effectiveness

Fine workmanship. Therapeutic effectiveness

As there is incision, Microbiology abdominal fluid may leak. There are Psychology complications which are possible. So the

Safety

Safety and comfort

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collapse. Infection and peritonitis Injury to blood vessels and other abdominal organs. Renal failure due to systemic circulation collapse. Record in the nurses notes the time of the procedure, vital signs and nay complications noted and inform the doctor.

complications need to be detected and treated at an early stage.

For communication

Therapeutic effectiveness.

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 falsenegative 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 ultrasoundguided 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?URLhealt hgate=%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-bleedingtendency-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 1st edition 2005 Pp 567570.

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