Procedure Care

1. Introduce and Explain: Greet the patient and clearly explain the procedure to obtain their consent and cooperation.

2. Ensure Privacy: Screen the patient and close doors/windows to maintain privacy.

3. Hand Hygiene: Wash hands thoroughly according to infection control guidelines.

4. Prepare Equipment: Gather all necessary supplies at the bedside.

5. Weigh Patient: Record the patient’s weight.

6. Baseline Vitals: Measure and document baseline blood pressure, pulse, temperature, and respiration.

7. Empty Bladder: Instruct the patient to empty their bladder immediately before the procedure.

8. Position Patient: Typically, position the patient supine with the head of the bed elevated to encourage fluid pooling in the lower abdomen.

9. Expose Abdomen: Remove the top linen to expose the procedure site.

10. Measure Abdominal Circumference: Use a tape measure to record the initial abdominal circumference.

11. Adjust Clothing: Loosen or remove clothing as needed to expose the area.

12. Apply Protective Layers: Place a dressing towel and mackintosh under the patient to protect the bedding. Place a floor mackintosh with a collection bottle on top nearby.

13. Clean Insertion Site: Thoroughly clean the intended insertion site.

14. Apply Sterile Drapes: Drape the area to maintain a sterile field.

15. Insert Cannula and Connect: Insert the cannula and connect it to the drainage tubing. Secure the cannula with tape or a dressing.

16. Collect and Label Samples: Obtain fluid samples, properly label them, and prepare them for lab transport.

17. Monitor Vitals and Drainage: Continuously monitor vital signs and the rate of fluid drainage throughout the procedure.

18. Disconnect and Secure: Once the desired amount of fluid is drained, disconnect the tubing and apply a sterile dressing to the insertion site.

19. Post-Procedure Measurements: Re-measure the patient’s weight and abdominal circumference. Record post-procedure vital signs.

20. Measure and Record Output: Measure the volume of aspirated fluid and document it.

21. Thank Patient: Thank the patient for their cooperation.

22. Ensure Comfort: Assist the patient in getting dressed, make the bed comfortable, and ensure they are in a comfortable position.

23. Clean Up and Document: Dispose of used materials appropriately and thoroughly document the procedure in the nursing notes.

Post-Procedure Care

1. Apply Abdominal Binder: Apply an abdominal binder tightly from the top down to support the abdomen and maintain intra-abdominal pressure.

2. Monitor Condition: Closely monitor the patient’s overall condition. Immediately report any changes in skin color, pulse, respiration, or blood pressure.

3. Check Dressing: Frequently examine the dressing at the puncture site for any leakage. Reinforce the dressing if needed.

4. Administer Analgesics: Provide pain medication as prescribed if the patient experiences pain.

5. Send Specimen to Lab: Ensure the collected fluid samples are sent to the laboratory with the appropriate requisition form.

6. Clean and Replace Supplies: Clean and properly store all used equipment and supplies.

7. Hand Hygiene: Wash hands thoroughly.

8. Record Procedure: Document all aspects of the procedure in the nursing notes.

Complications

1. Fainting (Syncope): Can occur due to rapid fluid removal. An abdominal binder helps prevent this.

2. Peritonitis: Infection of the peritoneal lining.

3. Significant Bleeding: Bleeding at the insertion site or internally.

4. Infection: Infection at the insertion site.

5. Renal Failure: Can occur due to decreased blood flow to the kidneys.

6. Hyponatremia: Low sodium levels in the blood, potentially from repeated paracentesis.

7. Hepatic Encephalopathy: Brain dysfunction due to liver failure.

8. Bowel Perforation: Accidental puncture of the bowel.

9. Paracentesis Leak: Leakage of ascitic fluid from the puncture site.

10. Organ Injury: Injury to abdominal organs during needle insertion.

11. Hypovolemia: Low blood volume, potentially leading to shock if fluid is removed too quickly.

Sites and Positioning for Abdominal Paracentesis

Insertion Sites

• Midline Site: The most common insertion point is on the midline of the abdomen, halfway between the pubic bone and the belly button. This location is preferred to minimize the risk of injury to the bladder and other internal organs.

• Alternative Site: Another option is a point located two-thirds of the way along a line drawn from the belly button to the bony prominence on the front of the hip (anterior superior iliac spine).

Patient Positioning

The patient is typically positioned in Fowler’s position (sitting upright with the torso raised), supported with a backrest and pillows, near the edge of the bed.

Precautions

1. Maintain Aseptic Conditions: Strict sterile conditions are essential throughout the procedure to prevent infection of the abdominal cavity. Limit the duration of catheter drainage to less than 6-8 hours (some guidelines suggest four hours) to further reduce infection risk.

2. Procedure Setting: Paracentesis can be safely performed in settings like hospices or outpatient clinics as long as sterile precautions are meticulously followed, potentially avoiding the need for hospitalization.

General Instructions

1. Explain the Procedure: Clearly explain the procedure to the patient to build trust and encourage cooperation, which is crucial for preventing accidental injury to internal organs.

2. Strict Aseptic Technique: Adhere to strict sterile procedures to prevent infection.

3. Bladder Emptying: Instruct the patient to urinate 5 minutes before the procedure to minimize the risk of bladder puncture. If there’s any doubt about bladder emptiness, catheterization should be performed.

4. Patient Comfort: Ensure the patient is kept warm and comfortable to prevent chills.

5. Preventing Shock: Be prepared to manage potential shock:

   • Withdraw fluid slowly and use clamps to control the drainage flow.

   • Remove small amounts of fluid at a time.

   • Apply manual pressure to the abdomen or use a many-tailed bandage, tightening it from top to bottom as fluid is drained.

   • Keep the patient warm.

   • Continuously monitor vital signs during the procedure.

6. Drainage Management:

   • Raising the drainage container increases the drainage speed and the risk of shock. Keep the container at an appropriate level.

   • Use a smaller gauge needle or catheter to minimize the puncture size and the risk of post-procedure leakage.

   • Control fluid flow using clamps on the tubing.

   • The nurse should remain with the patient throughout the procedure, observing their general condition and immediately reporting any changes in color, pulse, breathing, or blood pressure to the doctor, as these could indicate vascular shock.

7. Post-Procedure Care:

   • Repeated fluid drainage can lead to low protein levels in the blood (hypoproteinemia); administer plasma protein if necessary.

   • Seal the puncture site immediately after the procedure to prevent infection and fluid leakage.

   • Send collected fluid samples to the lab promptly.

Aftercare of the Patient

Wound Care: Apply a sterile dressing and a pressure bandage to the puncture site immediately after removing the needle to prevent fluid leakage.

1. Abdominal Binder: Tighten the abdominal binder to provide support and maintain pressure within the abdomen.

2. Monitoring: Closely monitor the patient’s overall condition after the procedure.

   • Report any changes in skin color, pulse, breathing, or blood pressure immediately.

   • Check vital signs every half-hour for the first two hours, then hourly for the next four hours, followed by every four hours for 24 hours.

3. Specimen Handling: Send collected fluid samples to the lab with proper labels and a request form.

4. Dressing Check: Regularly check the dressing at the puncture site for any leakage and reinforce it if needed.

5. Monitor Protein Levels: Assess serum protein levels to detect hypoproteinemia and administer plasma proteins if necessary.

6. Documentation: Record the procedure in the nursing notes, including the date and time, the amount and characteristics of the drained fluid (color, etc.), and the patient’s response to the treatment.

7. Equipment Cleaning: Clean all reusable equipment by rinsing with cold water, then washing with warm soapy water, followed by a clean water rinse. Dry the equipment and send it for sterilization (autoclaving).