ABDOMINAL PARACENTESIS

Paracentesis or Peritoneal Tap or Abdominal Tap: Surgical puncture of the peritoneal membrane of the abdominal cavity for the purpose of removing fluid.

Indications:

• • To relieve abdominal pressure from ascites: If ascites exists and is causing respiratory distress
  • To diagnose spontaneous bacterial peritonitis and other infection (abdominal TB)
  • To diagnose metastatic cancer
  • To diagnose blood in peritoneal space in trauma

What causes the build up of fluid?

There are several possible reasons for this build up of fluid:

• If cancer cells have spread to the lining of the abdomen they can cause irritation, leading to the build up of fluid
• If the liver is affected by cancer it can cause a blockage in the blood circulating through it, leading to a build up of fluid in the abdomen. Alternatively liver damage can change the body’s fluid balance, causing fluids to build up in the body’s tissues, including the abdomen.
• Cancer can also affect the lymphatic system. This is made up of the tissues and organs that produce the stored lymph, as well as the network of vessels carrying lymph fluid throughout the body

S/Sx of fluid build up?

• Swelling of the abdomen, with associated pain or discomfort
• Difficulty in moving or sitting comfortably
• Breathlessness
• Tiredness
• Nausea and vomiting
• Indigestion
• Reduced appetite
• Altered bowel habit

Risks:

• If a large quantity of fluid is removed, there is a slight risk of lowered blood pressure. Watch out for signs of Shock
• The tube draining fluid can become blocked. If this happens you maybe be asked to move around, as this can sometimes clear the blockage. If this does not work then the tube might have to be removed and another one put in.
• The site of the drain can become infected. Check VS frequently
• There is a slight chance that your bowel might be punctured during the procedure. This may cause bleeding or infection and could require an operation

Contraindications:

Mild hematologic abnormalities do not increase the risk of bleeding. The risk of bleeding may be increased if:

• Prothrombin time: > 21 seconds
• INR: > 1.6
• Platelet Count: < 50,000 per cubic millimeter

Pregnancy

Distended urinary bladder

Abdominal wall cellulites

Distended bowel

Intra-abdominal adhesions

The two recommended areas of abdominal wall entry for paracentesis are as follows:

• Two centimeters below the umbilicus in the midline (through the linea alba)
  Five centimeters superior and medial to the anterior superior iliac spines on either side

Nursing Care:

1. Explain the procedure; obtain consent
2. Have the client void prior to procedure to avoid accidental trauma to the bladder
3. Measure abdominal girth, weight, and baseline vital signs.
4. Note that the client is positioned upright on the edge of the bed, with the back supported and feet resting on a stool. (Fowler’s position is used for the client confined to bed)
5. Assist in removing the shirt to expose the abdomen.
6. Use skin prep solution to cleanse skin over the proposed puncture site, and drape to define a sterile field
7. Anesthesize the size over the proposed puncture site with the lidocaine or other local anesthetic agents drawn up in the 5 cc syringe with the attached 25 gauge needle. Anesthesize down the peritoneum.
8. Attach 18 gauge needle to free end of blood collection tubing or the secondary IV tubing. Leave capped. Close valve tightly on the tubing. Puncture the rubber stopper of the vacuum bottle with the other end of the tubing.

9. Insert the 18 gauge need perpendicularly through the anesthesized abdominal wall, and advance until hub of needle is 5mm - 1 cm from the skin surface. Open up the tubing clamp.
10. When paracentesis is done, simply remove needle from abdominal wall. Place a small pressure dressing on puncture site. Have the client remain supine for 2-4 hours
11. Observe for signs of shock; sudden fluid shifts can result in hypotension
12. Chart the amount and characteristics of fluid withdrawn
13. Apply a dry sterile dressing to the puncture site
14. Properly label the specimen if required and send to the laboratory
15. Evaluate client’s response to the procedure.

NURSING ALERT: Monitor for hematuria caused by bladder trauma. Instruct the client to notify the physician if the urine becomes bloody, pink, or red.

Complications:

• Failed attempt to collect peritoneal fluid
• Persistent leak from the puncture site
• Wound infection
• Abdominal wall hematoma

Sample Questions:
The physician orders a paracentesis for a client with ascites. Before the procedure, the nurse should instruct the client to:

1. Empty the bladder
2. Eat foods low in fat
3. Remain NPO for 24 hours
4. Assume the supine position

A client who is experiencing ascites is admitted to the hospital and will be undergoing a paracentesis. What should be included in the nursing care plan?

a. Place client in Trendelenburg position for the procedure

b. Monitor client closely for evidence of vascular collapse

c. Have the client remain on bed rest for 24 hours following the procedure

d. Encourage the client to drink plenty of fluids to distend the bladder prior to procedure

A client has just undergone a paracentesis procedure for severe ascites because of liver failure. What is the most important question from the nurse to ask the client immediately after paracentesis?

a. Are you in pain?

b. Do you feel dizzy?

c. Is your belly less full?

d. Do you need to urinate?