D. E. Society’s Smt. Subhadra K.

Jindal
College of Nursing

PRACTICE TEACHING
DEMONSTRATION
ON
ASSISTING WITH ABDOMINAL
PARACENTESIS

SUBMITTED TO SUBMITTED BY
Mrs. Jaslin Jose Meghavarsha Lakra
Clinical Instructor First year MSc. Nursing

DATE OF SUBMISSION
13/03/2020
 ASSISTING WITH ABDOMINAL PARACENTESIS

NAME OF THE STUDENT : MEGHAVARSHA LAKRA

NAME OF THE GUIDE : Mrs. JASLIN JOSE

SUBJECT : MEDICAL-SURGICAL NURSING

UNIT : IX

DATE : 20/02/2020

TIME : 45 min

VENUE : CLASSROOM, FOUNDATION

LABORATORY

CLASS TAUGHT : 2nd YEAR B.Sc NURSING

METHOD OF TEACHING : LECTURE CUM DEMONSTRATION

AUDIO-VISUAL AIDS : CHARTS, FLASH CARDS, HANDOUT

PREVIOUS KNOWLEDGE : THE GROUP WILL HAVE PREVIOUS

KNOWLEDGE ABOUT ABDOMINAL
PROBLEMS INCLUDING ASCITIS, ETC.

ASSISTING WITH ABDOMINAL PARACENTESIS

GENERAL OBJECTIVE :

At the end of the procedure demonstration, students will have an in depth

knowledge on assisting with abdominal paracentesis, and will be able to apply this
knowledge in clinical field.

SPECIFIC OBJECTIVE :

At the end of the procedure demonstration, students will be able to :

1. Define abdominal paracentesis.

2. Explain the purposes of abdominal paracentesis.
3. State the scientific principles of abdominal paracentesis.
4. Enlist the indications and contra-indications of abdominal paracentesis.
5. List down the articles required for assisting in abdominal paracentesis.
6. Demonstrate and explain procedure of assisting with abdominal paracentesis with
rationale.
7. Enumerate the complications of abdominal paracentesis.

ASSISTING WITH ABDOMINAL PARACENTESIS

PARACENTESIS
DEFINITION
Paracentesis is the removal of fluid from peritoneal cavity through a small puncture
made through the abdominal wall under sterile condition.

TYPES
1. Diagnostic: small quantity of fluid is removed for testing.
2. Therapeutic: >5 litres of fluid is removed to reduce intraabdominal pressure and
relieve the associated symptoms like dyspnoea, abdominal pain and early satiety.

PURPOSES
1. To relieve pressure on the abdominal and chest organs due to ascites.
2. To study chemical, bacteriological and cellular composition of peritoneal fluid for
diagnosis of disease.
3. To drain exudate in peritonitis.
4. To prepare for procedures like peritoneal dialysis.
INDICATIONS
1. For evaluation of new onset ascites.
 2. Testing of ascitic fluid.
3. For evaluation of patient with ascitis who has signs of clinical deterioration like fever,
abdominal pain, hepatic encephalopathy, decreased renal function and metabolic
acidosis.
4. Paracentesis can identify unexpected diagnosis such as chylous, hemorrhagic or
eosinophilic ascites useful to know etiology and antibiotic susceptibility.

CONTRAINDICATIONS

1. Patient with DIC – risk is decreased by administering platelets or FFPs.

2. Primary fibrinolysis (patient with 3 dimensional bruises) treat with aminocaproic acid
or IV tranexamic acid.
3. Massive ileus with bowel distension.
4. Pregnancy
5. Distended urinary bladder
6. Abdominal wall cellulitis
7. Distended bowel
8. Intra-abdominal adhesions
9. Near the surgical scar because scars are associated with tethering of bowel to
abdominal wall and will cause bowel perforation.
10. Infections

PATIENT PREPARATION

 Explain the procedure & Obtain Consent.

 No fasting before Procedure.

EQUIPMENTS AND STAFF

 Clinician & Assistant

 Bottles should be labelled for tests prior doing paracentesis
 Bacterial culture is done in pts with SBP

CHOICE OF NEEDLE

 DIAGNOSTIC: 1.5 Inch, 22 Gauge needle

For Obese :3.5 Inch, 22 Gauge spinal needle
 THERAPEUTIC: 15/ 16 Gauge needle to speed up the removal.
 KIMBERLY – CLARK QUICK TAP
PARACENTESIS TRAY CONTAINS
 CADWELL NEEDLE which has a sharp inner trocar & blunt outer metal cannula
with side holes to permit withdrawal of fluid if end hole is occluded by bowel/
Omentum.

POSITION
 Mostly Supine
 Head may be elevated
 Knee elbow position for removal of minimal fluid in dependent area

SITES
 Left lower Quadrant (Dullness on percussion)
 3cm medial & 2cm above the anterior superior Iliac spine
 Not near umbilicus because of presence of collateral vessels
 Surgical scars & visible veins should be avoided.

WHY LEFT???
 Abdominal wall is thinner.
  Pool of fluid is more.
 Patient can be rolled easily to left for drainage.
WHY NOT RIGHT???

 Appedicectomy scar,
 caecum filled with gas in pts taking lactulose.
 Care must be taken not to injure inferior epigastic artery which bleeds massively &
which is located near pubic tubercle

SKIN STERILIZATION

 Mark the site as “X” & positions  Solution starting from X using
12, 3, 6, 9 a few centimeters from widening circular motions.
“X”
 Sterilise with Iodine or
Chlorhexidine

LOCAL ANAESTHEASIA

 Anaesthetise using 3- 5 ml of 1% Lignocaine solution in a “Z” track technique.

 Needle used for it is 1.5inch which is sufficiently long.
 Choose the site & pass the needle tangentially, raising a wheal with Lignocaine.
 “Z” track creates a non-linear pathway between the skin and ascitic fluid & minimise
the chance of leakage.
  With one hand pull the abdominal wall and with other hand operate the syringe. Hand
on the abdominal wall should not be removed until the needle enters the fluid.
 Insert the needle and syringe 5mm deep

Pull the plunger back with each advancement to see if any blood is aspirated

Then inject the lignocaine solution Continue the same procedure until the needle
enters fluid.
 Aspiration should be intermittent not continuous.
 Cont. may pull the bowel or omentum onto needle tip, occluding the tip.
 Yellow color fluid indicates needle is in the peritoneal cavity.

NEEDLE INSERTION:
 Needle is inserted along anesthetised pathway after nick is given with 11 no. blade.
Fliud should drip from the hub of the needle.
 Larger the nick greater the post paracentesis leak.
 Ultrasound guidance cab be used to guide the procedure.
 During laproscopy parietal peritoneum may form tenting over needle n fluid doesn’t
come.
 Operator cant see this n may mis interpret as DRY TAP.
 Rotating the needle for 90 degrees or more will pierce the peritoneum and help the
drainage.
INITIATING FLOW OF FLUID
 Small amount of fluid may be difficult to drain because omentum/bowel may block
the end of needle. So multi hole needles are helpful.
 Misconception of poor flow is LOCULATION.
 True loculation is seen in peritoneal carcinomatosis with malignant adhesions or
bowel rupture with surgical peritonitis.
 Loculation never occur in cirrhosis or heart failure with ascites or SBP.
 Stable needle n depth of penetration of needle are crucial for successful paracentesis.
TESTING
 25 ml fluid is enough for cell count, different count, chemical testing n bacterial
culture.
 In TB 50ml for cytology
 50ml for smear n culture.

LARGE VOLUME PARACENTESIS

 It is removal of >5 lit of fluid.
 In refractory ascites, removal of as much fluid as possible with sodium restricted diet
and diuretics will extend the interval to next paracentesis.
REMOVAL OF NEEDLE
 Needle is removed with one rapid smooth withdrawal motion.
 Distract the patient by asking him to cough because cough will prevent pain sensation.

ARTICLES
A sterile tray containing (abdominal tapping set):
1. Sponge holding forceps
2. 5 ml syringe with needle
3. 20 ml syringe with Leur-Lock
4. Three-way adapter and tubing
5. Trocar and cannula or aspiration needles
6. BP handle with blade (optional)
7. Suturing needles (if incision is made)
8. Dissecting forceps
9. Specimen bottles
10. Sterile dressing articles
11. Artery clamp
12. Surgical towel
A clean tray containing:
1. Mackintosh and towel
2. Kidney tray
3. Spirit, iodine, tincture benzoin
4. Lignocaine 2%.
5. Apron.
6. Drainage receptacle.
7. Pint measure.
8. Measuring tape.
9. IV set.
10. IV bottle.
11. Gloves, gown and mask.

Additional Articles
1. Backrest.
2. Low stool.
3. Additional pillows

PROCEDURE

Nursing action Rationale

1. Identify the patient and explain the Wins confidence and cooperation from patient.
procedure to the patient and relatives.

Provides baseline data.

2. Measure abdominal girth and weight of
the patient.
Avoids legal problems.
3. Obtain informed consent.
Prevents risk of injury to bladder.
4. Instruct the patient to void 5 minutes
before the procedure.
Promotes good body mechanics and Fowler's
position helps in shifting fluid down.
5. Bring the patient to the edge of bed.
Place him in Fowler's position/Assist
him to sitting position in a chair with
legs supported.
Hypotension may occur.
6. Place sphygmomanometer cuff around
patient's arm to monitor BP during the
procedure. Prevents transmission of infection.

7. Wash hands and put on gloves. Reduces risk of infections.

8. Clean the area with antiseptic solution

and assist the physician to administer
local anesthesia. Drape patient with
sterile towels. The greater the vertical distance between the
needle and the receptacle the greater will be the
pull on the fluid that the cavity is drained more
9. Assist the physician in inserting trocar quickly and the patient may develop
and cannula into the abdomen below hypotension.
the umbilicus. Remove the trocar and
attach the cannula to the tubing which
reaches the receptacle which is placed
on a low stool.
Pressure dressing and bandage helps to prevent
10. Collect specimen in sterile bottles. leakage of fluid.

11. After enough fluid is withdrawn (1-2

liters) remove the cannula and place a
tincture benzoin seal, sterile dressing
and pressure bandage over puncture
site.

12. Check the patient's general condition

after procedure. Vital signs are checked
every 15 minutes for 2 hours; then 30
minutes for 2 hours. Examine the To rule out bacteriological and chemical
composition of fluid and to diagnose the
dressing for any leakage.
disease.

13. Measure and describe the fluid

collected and send the specimen to
laboratory with labels and requisition
forms.

14. Record the procedure, date, time,

amount of fluid collected, nature of
fluid, color and general condition of
patient during and after procedure. Prevents cross infection.
Include amount of fluid tapped in the
patient's 24 hours output.
 15. Clean all articles used. Wash with
soapy water, rinse and dry it. Send for
autoclaving.

COMPLICATIONS

 Ascitic fluid leak:

 improper Z track
 using large bore needle
 large skin nick

Rx: keep ostomy bag over nick.

 Bleeding:
 artery or vein

In inferior epigastric bleed figure of 8 suture is placed surrounding the needle site.

 Rarely laprotomy is needed to control bleeding in patients with renal failure and
hyperfibrinolysis.
 Bowel perforation
 Infections
 Catheter residue broken into abdominal wall.

SUMMARY
Abdominal paracentesis is a bed side clinical procedure in which needle is inserted into
peritoneal cavity and ascitic fluid is removed. Abdominal paracentesis is a procedure to
remove abnormal fluid buildup in the abdomen. Fluid builds up because of liver problems,
such as swelling and scarring. Heart failure, kidney disease, a mass, or problems with your
pancreas may also cause fluid buildup. Diagnostic paracentesis refers to the removal of a
small quantity of fluid for testing. Therapeutic paracentesis refers to the removal of five liters
or more of fluid to reduce intra-abdominal pressure and relieve the associated dyspnea,
abdominal pain, and early satiety. Paracentesis can be performed safely by any clinician who
has received proper training. Some hospitals have a dedicated procedure team that performs
simple procedures such as paracentesis and central line insertion. These teams, which
typically include an experienced clinician or mid-level provider and an assistant, often use an
ultrasound machine to guide the procedure.
 CONCLUSION
The procedure demonstration on the topic Assisting with abdominal paracentesis was
given to the second year BSc nursing students. The students will be able to use it in the
clinical field. The objectives of the demonstration were covered during the presentation.

REFERANCES
Book :
1. Annamma Jacob, “Clinical nursing procedures - The art of nursing practice”, 3rd
edition, Jaypee publication, Page no.- 239 to 240.
2. B.T. Basavanthappa, “Fundamentals of nursing”, 2nd edition, Jaypee publication, Page
no. – 491 to 495.
3. PR Ashalata, “Textbook of anatomy and physiology”, 4th edition, Jaypee publication,
page no. – 383 to 431
- 567 to 574

Online ;
1. www.opentextbc.ca/clinicalskills/chapter/10-2-assisting-with-abdominal-
paracentesisn
2. www.abdominal.paracentesis.com/The-Procedure
3. www.cincinnatichildrens.org/health/abdominal.paracentesis