Intrabladder pressure (IBP) monitoring is considered the method of choice for indirect IAP measurement due

to its accuracy and relative ease. IBP is measured through the patient's indwelling urinary Foley catheter,
utilizing the bladder wall as a passive transducing membrane.
Intra-abdominal Pressure Measurement/Monitoring

Preparation of monitoring equipment

1. Perform hand hygiene.

2. Clean trolley / work surface with detergent and water or detergent disinfectant wipe
3. Identify and collect all equipment for procedure
4. Perform hand hygiene 
5. Open procedure pack or tray by using external corners 
6. Prepare patient and caregivers – use gloves when appropriate e.g. removing dressings or soiled nappy.
Remove gloves if worn, perform hand hygiene and reapply new gloves
7. Using an aseptic non touch technique, prime the transducer set and monitoring lines with sterile 0.9%
sodium chloride only
8. The tubing must be free of kinks and air bubbles.
9. Connect drainage end of urinary Foley catheter (tip is already inserted in patients bladder) to the urine
drainage bag with connector and two, 3-way taps. (see photo below).
10. Attach pressure transducer to 3-way tap closest to the urinary catheter connector.
11. Ensure all connections are securely luer locked.
12. All transducer monitoring lines should be clearly labelled. 
13. Urine flow into the drainage bag should be unclamped and uninterrupted except during IAP
measurement. 
14. Refer to invasive haemodynamic monitoring guideline for more information.

Measurement of Intra-abdominal pressure

1. Patient should be placed in the supine position for measurement. 

- If this is not clinically feasible it is important to recognise that elevation of the head of the bed will
result in a higher IAP. 
- Document position and ensure all subsequent readings are taken in the same position.
- At end of measurement return all patients to head up/reverse trendelburg position 15 degrees or
greater to reduce risk of ventilator associated pneumonia (VAP).
2. Adjust the height of the transducers so that the top of the 3 way tap (atmospheric port) is levelled at the
cross section of the mid-axillary line and the iliac crest and zero the transducer. 
3. Clamp the drainage tube to the urine bag
4. Fill the bladder with 1mL/kg (minimum of 3 mL and maximum 25mLs) of 0.9% sterile sodium chloride
using the syringe.  The volume of fluid in the bladder should be constant for each measurement.
5. Close the stopcock of the syringe and allow 30 to 60seconds for equilibrium to occur. Obtain the mean
pressure reading upon end expiration (this minimises the effects of pulmonary pressures).
6. The abdominal blood flow should produce fluctuations in the waveform.  Factors that affect
measurements

 IAP increased with inspiration and decreases with expiration

 Higher body mass index is correlated with higher IAP in adults but not children
  Position of patient - have a higher IAP in prone and semi recumbent positions than when supine
 Tense abdominal muscles
 Volume of fluid instilled
 Presence of air bubbles in the fluid column
 Kinking of the monitoring lines
 Position of the transducer

Discontinuing monitoring

 Monitoring of IAP can cease when IAP is less than 10 mmHg for several hours and the patient is
clinically improving. The patient should continue to receive close clinical observation for deterioration
 The transducer/monitoring attachments can be disconnected and removed prior to the removal of the
patient's urinary catheter. Protecting key parts using an aseptic non touch technique.
 Perform hand hygiene & don gloves
 Using aseptic non-touch technique
 Detach the transducer at the 3 way tap
 Re-attach the end of urinary Foley catheter to the urinary drainage bag 
 Remove gloves and perform hand hygiene, clean work surface / trolley 
 Discard the transducer in the appropriate waste, perform hand hygiene. 

Special considerations

 0.9% sodium chloride should only be used to fill the patient's bladder when undertaking an intra-

abdominal pressure measurement.
 The tubing must be free of kinks and air bubbles.
 All transducer monitoring lines should be clearly labelled
 Transducer sets should be changed weekly.
 All connections should be securely luer locked.
 All interventions must be carried out using an aseptic technique

Documentation

 Order the Intra-abdominal pressure monitoring, including frequency on EPIC

 Document the IAP and APP in the patient's flow sheets on EPIC

Complications: Infection

Paracentesis is a procedure that removes fluid (peritoneal fluid) from the abdomen through a slender needle.
The collected fluid is then sent to a lab for analysis to determine what is causing the excess fluid. The most
common reasons to perform paracentesis is to: Diagnose an infection.

The role of the nurse is usually to monitor the patient throughout the procedure, administer treatment as
directed by the medical team and, depending on local policy, remove the drain at the end of the procedure.
 Implementation
 Perform hand hygiene and put on gloves.
 Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.
 Explain the procedure to the patient to ease his anxiety and promote cooperation. Reassure him that he
should feel no pain, but that he may feel a stinging sensation from the local anesthetic injection and pressure
from the needle or trocar and cannula insertion.
 Make sure that an informed consent has been obtained and is documented in the patient’s medical record.
 Instruct the patient to void before the procedure. Or, insert an indwelling urinary catheter, if ordered, to
minimize the risk of accidental bladder injury from the needle or trocar and cannula insertion.
 Conduct a preprocedure verification process to make sure that all relevant documentation, related
information, and equipment are available and correctly identified to the patient’s identifiers.
 Obtain and record baseline values: vital signs, weight, and abdominal girth. (Use the tape measure to
measure the patient’s abdominal girth at the umbilical level.) Indicate the abdominal area measured with a
felt-tipped marking pen. Baseline data will be used to monitor the patient’s status.
 Position the patient supine or on his side to allow the fluid to pool in dependent areas.
 Expose the patient’s abdomen from diaphragm to pubis. Keep the rest of the patient covered to avoid chilling
him.
 Make the patient as comfortable as possible, and place a linen-saver pad under him for protection from
drainage.
 Remind the patient to stay as still as possible during the procedure to prevent injury from the needle or trocar
and cannula.
 Remove and discard your gloves. Perform hand hygiene. Put on sterile gloves, a gown, and goggles to
prevent cross-contamination.

Gastric Decompression
By inserting a nasogastric tube, you are gaining access to the stomach and its contents. This enables you to
drain gastric contents, decompress the stomach, obtain a specimen of the gastric contents, or introduce a
passage into the GI tract. This will allow you to treat gastric immobility, and bowel obstruction.
How do you do gastric decompression?
Place the patient in a high Fowler's position and instruct them to swallow on command. Insert the tube into an
unobstructed nostril and slowly advance until at predetermined length. Check tube placement before
evacuation by air insufflation into the stomach with a large syringe.
What is Ryles tube used for?
It is a disposable polyvinyl chloride tube used for both therapeutic and diagnostic purposes. It is mainly used
for feeding in patients with lower cranial nerve palsies, in unconscious patients and in patients with PEM. It is
also used for doing gastric lavage in cases of poisoning.

Rectal Decompression
Rectal washouts are performed to decompress the lower intestine and deflate the abdomen by removing gas
and stool using small amounts of Sodium Chloride 0.9% (normal saline).
They are:

Procedure
Perform rectal washout as prescribed. The frequency of washouts is determined according to the effectiveness
of decompression of the bowel and treatment protocols should be individualised based on underlying condition.
Notify the surgical team if two successive washouts fail to achieve abdominal decompression.
Confirm orders with treating surgeon/doctor if they vary from the above guide

 60mL catheter tip syringe 

 Sodium Chloride 0.9% sachets
Ensure Sodium Chloride 0.9% sachets are warmed prior to use (warm to touch- Do Not use the
microwave).  Neonates, especially premature neonates may cool quite rapidly if the solution is cold. 
The volume of saline to be used is determined by the surgeons and should be written as an order.
 Lubricant
Use only water based lubricant.
 Gloves/incontinence sheets
Use incontinence sheets to protect soiling of the bed

Procedure 

 Ensure procedural consent obtained by treating surgical team before commencement

 Consider methods of patient distraction, such as sucrose or distraction.
 Consider second staff member or parent to assist with technique
 Perform hand hygiene
 Position neonate, usually on his/her back with legs in the frog position 
 Position older child on their left side 
 Swaddling of arms, comfort and play therapy techniques can be used
 Perform hand hygiene
 Select appropriately sized catheter for use
 Warm 0.9% Sodium Chloride sachets (in a jug of warm tap water) and prime catheter with solution 
 Lubricate tip of catheter and gently insert into the rectum 
 Length to be determined by surgical instructions
 Instill 0.9% Sodium Chloride solution in 10 - 20 ml aliquots (by pushing in with syringe plunger) over 1-2
minutes (there should be no resistance when injecting the normal saline
 Remove syringe and let fluid run into nappy/kidney dish. Procedure may be repeated twice if return is
not clear
 If there is 0.9% Sodium Chloride retention or return volume cannot be determined contact surgeon  
 Remove catheter from the rectum and leave the patient clean and dry
perform hand hygiene
 Note and record results of rectal washout accurately on fluid balance section of the EMR flow sheets
  Sucrose may be administered prior to and throughout the procedure as required
 Do not use excessive force if resistance is felt. Contact medical staff if unsure
 Do not pull back on syringe to aspirate, allow the saline to run out naturally. Sometimes manipulating
the catheter in and out a few centimeters gently and massaging the abdomen may encourage fluid
returns to be expelled. Do not exceed maximum of 20ml/kg or total of 250mL 

Documentation
Link to nursing documentation guideline
    1. Observe and document
Note any reduction in abdominal distension
Amount of decompression
    2. Washout result

 Volume, colour, consistency and type of substance; e.g. stool/meconium/instilled fluid

Complications
There is a risk of reabsorption of saline, especially if most of the solution is not expelled. In the case of
retention of instilled solution 

 contact the surgical/neonatal team 

 record volume of saline retained 
 consider taking blood to check electrolytes, if clinical situation is appropriate

Bowel perforation
Nausea and vomiting
Abdominal discomfort

Decompressive Laparotomy
• Used in cases of ACS (only definitive treatment)
• Should be performed when IAP>20 with new or progressive organ failure
• Recommended for the trauma or acute general surgical patient under physiologic stress: acidosis,
hypothermia, hypocoagulable state, prolonged hypotension
Benefits of Decompressive Laparotomy
• Decrease in intrathoracic pressure
• Improved oxygenation/ventilation
• Increased cardiac output
• Increased urine output
• Ease of re-exploration (2nd look)
• Control of abdominal contents
• Decrease in risk of IAH and ACS
• Fascial preservation for closure of the abdominal wall
Complications:
 Fluid Loss
 Protein Loss
 Fistula Formation
 Loss of Domain
 Hernia
 Infection
 Bleeding/hemorrhage