Prepare For Abdominis Paracentesis (Abdominal Tapping)

Prepare For Abdominis Paracentesis (Abdominal Tapping)

Abdominal Paracentesis

ABDOMINAL PARACENTESIS
Definition: This is sterile surgical procedure in which a needle is inserted into the peritoneal cavity in
order to drain out excess ascitic/peritoneal fluid.                  OR     is the removal of fluid from the peritoneal
cavity

Paracentesis: it’s removal fluid from the belly. It is commonly called a ‟tap”.

Tapping of ascites is usually undertaken to take off small volumes of ascites for analysis. This is in comparison to paracentesis where a
drain is inserted whereby larger volumes can be removed.

Indications
  •  Diagnostic purposes. To study chemical, bacteriological and cellular composition of the
    peritoneal fluid for diagnosis of the disease
  • Relieve pressure symptoms like difficulty in breathing, pain discomfort, a feeling of fullness.
  • To drain an exudate in peritonitis 
  •  To remove fluid and instill air to create an artificial pneumoperitoneum as a treatment for
    pulmonary tuberculosis affecting the base of the lungs.
  • To remove blood or pus.
  • Diagnostic (via either ascitic tap or paracentesis)
  • New-onset ascites:
  • To determine aetiology.
  • To differentiate transudate versus exudate.
  • To detect cancerous cells.
  • Suspected spontaneous or secondary bacterial peritonitis

Therapeutic (usually via paracentesis)
• To relieve respiratory distress or abdominal pain resulting from
ascites.

Contra-indications

• Bleeding & severe jaundice with impending hepatic coma coze
tapping may precipitate hepatic coma
• An uncooperative patient.
• Skin infection at the proposed puncture site.
• Pregnancy.
• Severe bowel distension.
• Coagulopathy (opinion is divided – some feel only precluded where
there is clinically evident fibrinolysis or disseminated intravascular coagulation (DIC).

 

Investigations

Prior to tap
Before tapping, there are certain investigations that should be
undertaken:

FBC and clotting screen – if thrombocytopenia is present and severe, most clinicians would give pooled platelets to reduce the risk of bleeding. Fresh frozen plasma may be used if there is evidence of coagulopathy.
U&E, creatinine, and LFTs.
Abdominal ultrasound – this is not always necessary prior to tap. It is used to review liver, pancreas, spleen and lymph nodes. Ultrasound is a very sensitive means of assessing the extent of ascites and may also show the causative pathology such as carcinoma of ovary or metastatic liver disease.

 

Routine investigation
  • Specific gravity, cell count, bacterial count, protein concentrations,
    culture & acid test strain.
  • In most disorders, the fluid is clear and straw colored. Turbidity
    suggests infection.
  • Anguinous fluid usually signals neoplasm or tuberculosis.
  • A protein concentration less than 3 gram/100ml suggests liver disease
    or systemic disorder.
  • Higher protein content suggests an exudates cause such as tumor or an
    infection.
After a diagnostic tap the following investigations may be requested.
  •  Microscopy: white cell count, red cell count, Gram stain
  • Spontaneous bacterial peritonitis (SBP) can occur in patients with cirrhosis and ascites admitted to hospital. Neutrophil count of >250 cells/mm3are diagnostic of SBP. 
  • The red blood cell count is usually <1,000 cells/mm3 – higher levels raise the suspicion of an underlying malignancy – eg, hepatocellular carcinoma. 
  • Gram stain of ascitic fluid is a quick process but rarely helpful. Samples should also be sent for culture and sensitivity. These should be inoculated into blood culture bottles as soon as the sample is taken. This has almost double the yield of ascitic fluid sent in sterile containers. 
  • Albumin or protein levels Traditionally ascites was labelled as an exudate if the protein levels were >25 g/L, or a transudate if protein levels were <25 g/L. This has been superseded by the serum ascites-albumin gradient (SA-AG) which is a better measure.
  • SA-AG = serum albumin concentration – ascitic albumin concentration 
  • SA-AG ≥11 g/L: likely causes – cirrhosis, cardiac failure, nephrotic syndrome 
  • SA-AG <11 g/L : likely causes – malignancy, pancreatitis and tuberculosis 
  • Amylase This will be high in pancreatitis associated ascites.
  • Cytology The yield is greater with larger-volume samples (>100 ml), especially when concentration techniques are used. It is not so valuable for the diagnosis of primary hepatocellular carcinoma.

 

Requirements to perform Abdominal Paracentesis

Trolley
Top shelf (with sterile trays)

  • Bowl with two draper towels:1 fenestrated, 1 non fenestrated
  •  Bowl with sterile gauze swabs
  •  Bowl with sterile cotton swabs
  •  Galipot for antiseptic lotion
  • Receiver with sponge holding forceps, cannula, sterile bottle for specimen if need be.
  •  Sterile towel for hand drying
  •  Sterile gloves
  •  Giving set/sterile drainage tube
  •  Drs sterile gown.
  •  Sterile calibrated Drainage bottle.
  • Sterile tray containing ( sponge holding forceps, Window towel, 2 Small bowels, Swabs, cotton, 2 ml syringe, Subcutaneous needle, Scalpel blade, Trocar & cannula (Thompson’s ascites brocar & cannula), Suture materials (suture & skin needle, suture, scissors, tissue forceps & artery forceps) 

Bottom Shelf (tray containing)

  • Many tailed bandages
  • Safety pins
  • Adhesive tape/plaster
  • Bottle with antiseptic lotion
  • Lab request form
  • Specimen botttles
  • Tape measure
  •  Dressing towel and mackintosh
  •  Floor mackintosh
  •  Receiver for the used swabs
  • Weighing scale
  •  Plastic mackintosh
  •  Vital observation tray
  •  Emergency tray
  • Unsterile tray containing (Mackintosh & towel, Sterile gloves & masks, Tincture iodine, spirit & tincture benzoin,  Novocain 1-2%/Xylocaine 2%, Adhesive tape & scissors, Kidney basins, pint pressure, bucket, IV bottles, backrest & abdominal binder, Spacemen bottles, Patients file, Pillow )

At the bedside

  • IV stand
  • Screen for privacy
  • Hand washing materials.
  • Cardiac table (with, a bell, newspaper, small pillow)
Procedure
  1.  Greet the patient and explain the procedure to the patient to win consent and cooperation.
  2.  Provide privacy by screening, closing the nearby doors, windows.
  3. Wash hands for infection prevention and control
  4. Prepare the equipments and bring to the bed side.
  5. Weigh the patient
  6.  Take baseline vital observations. Bp, pulse, temp, respiration
  7. Ask the patient to empty the bladder just before the procedure.
  8. Position the patient, usually in the supine position with the
    head of the bed elevated to allow fluid to accumulate in the
    patient’s lower abdomen through the gravity pull.
  9. Remove the top linen
  10. Take the abdominal circumference using the tape measure.
  11. Undo the top clothing so as to expose the parts to be worked on.
  12.  Apply the dressing towel and mackintosh to protect the bed.
  13.  Set things right i.e place the floor mackintosh on the floor, bottle on top.
  14.  Clean the site
  15.  Apply sterile drapers
  16.  Insert the cannular and connect to tubbing
  17.  Secure at site with plaster
  18.  Pick sample, label ready for lab delivery
  19.  Monitor vital observation, out floor throughout.
  20.  When required amount of out is reached, disconnect and secure the site.
  21. Repeat weight, abdominal circumference measurement, post vital observations.
  22.  Measure the content and record.
  23.  Thank the patient
  24. Leave patient comfortable by redressing with clothes, beddings and position.
  25. Clear away and Document the the procedure.
Post procedure care
  • Apply abdominal binder tightly from top to bottom. It helps to maintain intraabdominal pressure.
  • Monitor the patient’s general condition. Any change in color, pulse, resp & BP
    should be reported immediately.
  • Examine the dressing at the puncture site frequently for any leakage,
    reinforce the dressing if leakage is present.
  • Give analgesics is pain is present.
  • The specimen collected should be sent to the lab with requisition form
  • Replace the article after use and make sure they are clean.
  • Wash hands thoroughly
  • Record the procedure in the nurses record sheet

Complications

  • Fainting may occur if large fluid is removed. Prevent this by applying abdominal binder.
  • Peritonitis
  • Serious Complications include;
  • Significant bleeding
  •  Infection
  • Renal failure due to reduce systemic circulation
  •  Hyponatremia as a result of repeated tapping
  • Hepatic encephalopathy
  • Complicated bowel perforation
  •  Paracentesis leak
  • Injuries to abdominal organs.
  • Hypovolemia leading to Shock if fluids are drained off rapidly
SITES AND POSITIONING A PATIENTS FOR 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 client is positioned in Fowler’s position supported by back rest and pillows near the edge of the bed.

Precautions
  • Paracentesis for symptom relief is common especially if there is tense ascites. Patients requiring frequent paracentesis need to be reviewed by specialists for consideration of trans jugular intrahepatic portosystemic shunt.
  • Paracentesis is performed under aseptic conditions, as there is a risk of introduction of infection into the peritoneal cavity. Infection risk can also be reduced by limiting catheter drainage time to less than 6-
    8 hours (some authorities suggest four hours).
  • Paracentesis can be performed in a hospice or in an ambulatory setting, provided that sterile precautions are taken preventing the need for admission to hospital.

GENERAL INSTRUCTIONS

  1. Give adequate explanations to win the confidence and cooperation of the client. Client cooperation is
    very necessary for prevention of the injury to the adjacent organs
  2. Strict aseptic technique should be followed to prevent introduction of infection into the peritoneal
    cavity.
  3.  Ask the client to void 5 minutes before the procedure to prevent injury to the bladder. Catheterize the
    client if any doubt exists.
  4.  Keep the client warm and comfortable to prevent chills.
  5.  Be prepared to treat shock. Shock can be prevented by:
    > Withdrawing the fluid slow. Apply clamps on the tubing.
    > Withdrawing small quantity of fluid at a time
    > Applying pressure on the abdomen with small tailed bandage and tightening it from above
    downwards as the fluid is drained
    > Keep the client warm
    > 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 client may go into the 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 peritoneal cavity after procedure is over
  8. The flow of the fluid can be controlled by the application of the clamps on the tubing.
  9. The nurse should remain with the client throughout the procedure to observe the client’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 client is going into vascular shock and collapse.
  10. Repeated aspirations of the ascitic fluid results hypoproteinemia, the client should be given plasma protein if he develops such 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.
AFTER CARE OF THE CLIENT
  1. 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
  2.  The abdominal bandage is tightened to maintain intra-abdominal pressure
  3.  Check the client’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.
  4.  The specimen collected should be sent to the laboratory with labels and requisition form
  5.  Examine the dressing at the puncture site frequently for any leakage. Re-enforce the dressing if
    leakage is present.
  6.  Serum proteins are estimated to detect hypoproteinemia. If hypoproteinemia is present,
    plasma proteins are administered.
  7. 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 the treatment on the client
  8.  Clean all the articles used. Wash with cold water and then with warm soapy water and rinse them in clean water. Dry and send for autoclaving.
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