PROCEDURE

116 Paracentesis (Assist)

Eleanor Fitzpatrick
PURPO SE: Abdominal paracentesis is performed to remove fluid from the
peritoneal cavity for diagnostic or therapeutic purposes.

PREREQUISITE NURSING • Paracentesis is contraindicated in patients with an acute

abdomen, who need immediate surgery. Coagulopathies
KNOWLEDGE and thrombocytopenia are considered relative contra-
• Knowledge of anatomy and physiology of the abdomen is indications. Coagulopathy should preclude paracentesis
important to avoid unexpected outcomes. only in the case of clinically evident fibrinolysis or clini-
• Intestines and bladder lie immediately beneath the abdom- cally evident disseminated intravascular coagulation.3,10
inal surface. Absolute contraindications include an acute abdomen,
• Large volumes of ascitic fluid tend to float the air-filled an uncooperative patient, and disseminated intravas-
bowel toward the midline, where it may be easily perfo- cular coagulopathy. Relative contraindications include
rated during the procedure. coagulopathy, abdominal adhesions, infected abdominal
• The cecum is relatively fixed and is much less mobile wall at the entry site, distended bowel or bladder, and
than the sigmoid colon; therefore bowel perforations pregnancy.15
are more frequent in the right lower quadrant than in • Caution should be used when paracentesis is performed
the left. in patients with severe bowel distention, previous abdomi-
• Peritoneal fluid is normally straw-colored, serous fluid nal surgery (especially pelvic surgery), pregnancy (use
secreted by the cells of the peritoneum. Grossly bloody open technique after first trimester), distended bladder that
fluid in the abdomen is abnormal. cannot be emptied with a Foley catheter, or obvious infec-
• The peritoneal fluid collected is used to evaluate and diag- tion at intended site of insertion (cellulitis or abscess).
nose the cause of ascites, acute abdominal conditions such • The insertion site should be midline one third the distance
as peritonitis or pancreatitis, and blunt or penetrating from the umbilicus to the symphysis (2 to 3 cm below the
trauma to the abdomen. umbilicus; see Fig. 115-1). An alternate position is a point
• Therapeutic paracentesis is used to reduce intraabdominal one third the distance from the umbilicus to the anterior
and diaphragmatic pressures to relieve dyspnea and respi- iliac crest (left side preferred especially in the obese
ratory compromise and to prevent hernia formation and patient or in those requiring removal of large volumes of
diaphragmatic rupture.2,8,11 These complications are seen fluid).2,10,11,13
in those patients with tense, refractory ascites with failed • Ultrasound scan can be used before paracentesis to locate
medical interventions, such as sodium restriction and fluid and during the procedure to guide insertion of the
diuresis.2,3,5,11,15 catheter. If ascitic fluid is difficult to localize with physical
• Cirrhosis is the most common cause of ascites formation. examination due to obesity or other conditions, ultrasound
However, ascitic fluid is produced as a result of a variety is effective in identifying the fluid and critical structures
of other conditions.2,5,7,10 These conditions may include which are to be avoided during the procedure.10,12
interference in venous return because of heart failure, • Endoscopic transgastric ultrasound scan has also been
constrictive pericarditis, or tricuspid valve insufficiency; used in the diagnosis of malignant ascites.2,13
obstruction of flow in the vena cava or portal vein; distur- • A semipermanent catheter or a shunt may be an option for
bance in electrolyte balance, such as sodium retention; patients with rapidly reaccumulating ascites.2,3,10
depletion of plasma proteins because of nephrotic syn- • When large-volume paracentesis (>5 L) is performed in
drome or starvation; lymphoma, leukemia, or neoplasms patients with cirrhosis and other disorders, the infusion of
that involve the liver or mediastinum; ovarian malignant albumin, (6 to 8 g/L) of fluid removed, may prevent the
disease; and chronic pancreatitis. onset of circulatory compromise associated with massive
• Analysis of the ascitic fluid can determine the cause fluid shifting.3,9,10,11,15 Albumin administration may be
of ascites. A serum-to-ascites albumin gradient should effective in preventing paracentesis-induced circulatory
be calculated by subtracting the ascitic fluid albumin dysfunction, the most common complication after the pro-
level from the serum albumin. This calculation differen- cedure.13–15 Albumin infusion is recommended with large-
tiates portal hypertensive from nonportal hypertensive volume paracentesis as its use has shown improved
ascites.2,3,5,9,11 survival.1

1036
 116 Paracentesis (Assist) 1037

EQUIPMENT • Identify the presence of any allergies to medication or

other substances. Rationale: Patients may have allergies
• Commercially prepared paracentesis kit if available to skin preparations or anesthetics used before the inva-
• Nonsterile gloves, sterile gloves, mask, goggles, and sive procedure is performed. Identification assists the
gown practitioner in choosing the most appropriate skin prepa-
• Antiseptic solution (e.g., 2% chlorhexidine-based ration and anesthetic.
preparation) • Assess respiratory status (i.e., rate, depth, excursion, gas
• Sterile marking pen exchange, use of accessory muscles, and pulse oximetry).
• Sterile towels or sterile drape Rationale: Paracentesis may be indicated to decrease the
• Local anesthetic for injection: 1% or 2% lidocaine with work of breathing.
epinephrine • Obtain baseline vital signs. Rationale: Hypotension and
• 5- or 10-mL syringe with 21- or 25-gauge needle for dysrhythmias may occur with rapid changes in the intraab-
anesthetic dominal pressure.
• Trocar with stylet, needle (16-, 18-, or 20-gauge), or • Obtain a baseline pain assessment. Rationale: Changes in
angiocatheter, depending on abdominal wall thickness the level of pain during or after the procedure may be an
• 25- or 27-gauge 1 1 2 -inch needle indicator of complications.
• 20- or 22-gauge spinal needles • Obtain baseline fluid and electrolyte status. Rationale:
• 20-mL syringe for diagnostic tap Removal of peritoneal fluid may cause compartment shift-
• 50-mL syringe if using stopcock technique ing of intravascular volume, electrolytes, and proteins,
• Four sterile tubes for specimens leading to a decreased circulating volume.
• Scalpel and No. 11 knife blade • Assess bowel or bladder distention. Rationale: Distension
• Three-way stopcock increases the risk for bowel or bladder perforation during
• Sterile 1-L collection bottles with connecting tubing the procedure.
• Nylon skin suture material on cutting needle (4-0 or 5-0) • Assess abdominal girth. Rationale: Information on
and needle holder changes in fluid accumulation within the peritoneal cavity
• Mayo scissors and straight scissors is provided.
• Four to six sterile 4 × 4 gauze pads • Obtain coagulation study results (i.e., prothrombin time,
• Sterile gauze dressing with tape or adhesive strip partial thromboplastin time, and platelets). Rationale:
Additional equipment, to have available as needed, includes Abnormal clotting may increase the risk for bleeding
the following: during and after the procedure, although this complication
• Soft wrist restraints is rare.2,10 Therapy may be necessary to correct clotting
• Stoma bag abnormalities before the procedure, particularly if the
• Ultrasound equipment international normalized ratio is over 2.5.10,11,13
Patient Preparation
PATIENT AND FAMILY EDUCATION
• Verify that the patient is the correct patient using two
• Explain the indications, procedure, and risks to the patient identifiers. Rationale: Before performing a procedure, the
and family. Rationale: Explanation may decrease patient nurse should ensure the correct identification of the patient
anxiety and encourages patient and family cooperation for the intended intervention.
and understanding of the procedure. • Ensure that the patient understands preprocedural infor-
• Explain the patient’s role in assisting with the procedure mation. Answer questions as they arise, and reinforce
and postprocedure care. Rationale: Patient cooperation information as needed. Rationale: Understanding of pre-
during and after the procedure is elicited. viously taught information is evaluated and reinforced.
• Explain the signs and symptoms to report, such as fever, • Ensure that a written informed consent form has been
abdominal pain, decreased urine output, bleeding, and obtained by the practitioner performing the procedure.
leakage of fluid from surgical wound site. Rationale: The assisting practitioner may be a witness to the signing
Unexpected outcomes may not manifest themselves for a of the consent if needed. Rationale: Paracentesis is an
period of time after the procedure. invasive procedure and requires a signed informed consent
form.
• Decompress the bladder either by having the patient void
PATIENT ASSESSMENT AND or by inserting a Foley catheter. Rationale: A distended
PREPARATION bladder increases the risk for bladder perforation during
the procedure.
Patient Assessment • The physician or advanced practice nurse orders plain and
• Obtain the medical history and a review of systems for upright radiographs of the abdomen before the procedure
abdominal injury, major gastrointestinal pathology, liver is performed. Rationale: Air is introduced during the pro-
disease, and portal hypertension. Rationale: Certain con- cedure and may confuse the diagnosis later.
ditions of the gastrointestinal tract may be diagnosed and • Perform a preprocedure verification and time out with the
treated with paracentesis. Contraindications to paracente- physician or advanced practice nurse, if nonemergent.
sis may be identified. Rationale: Ensures patient safety.
1038 Unit IV Gastrointestinal System

• Check that all relevant documents and studies are avail- and mark appropriately. Rationale: Shifting dullness indi-
able before the procedure is started. Rationale: This cates fluid.
measure ensures that the correct patient receives the • If the patient has altered mental status, soft wrist restraints
correct procedure. may be prescribed. Rationale: The patient must not move
• Place the patient in the supine position (may tilt to side of his or her hands into the sterile field once it has been
collection slightly for improved fluid positioning). established.
Rationale: Fluid accumulates in the dependent areas.
• The physician or advanced practice nurse will examine
the abdomen for areas of shifting dullness, find landmarks,

Procedure for Assisting With Paracentesis

Steps Rationale Special Considerations
1. HH
2. PE
3. Assist in preparing the equipment Provides a sterile field to Maintain aseptic technique.
and sterile field. Label all decrease risk for infection.
medications, medication containers
(e.g., syringes, medicine cups,
basins), and other solutions that are
to be used during the procedure.
4. As needed, assist the physician or Reduces risk for infection. Allergies should be identified before a skin
nurse practitioner to cleanse preparation product is chosen.
insertion site with antiseptic
solution (e.g., 2% chlorhexidine-
based preparation).4,6 (Level C*)
5. As needed, assist the physician or Provides sterile field to
advanced practice nurse with the decrease risk for infection.
application of sterile gloves, gown,
and mask as well as sterile drapes
to outline the area to be tapped.
6. As needed, assist the physician or Local anesthesia minimizes Usually 1% lidocaine is used, but 0.5%
advanced practice nurse to draw up pain and discomfort. lidocaine with 1 : 200,000 epinephrine has
local anesthetic (lidocaine with Epinephrine helps been shown to provide equivalent anesthetic
epinephrine preferred). eliminate unwanted effect as 1% lidocaine with 1 : 100,000
abdominal wall bleeding epinephrine. The maximum dosage is
and false-positive results. generally accepted to be 5 mg/kg of 1%
plain lidocaine and 7 mg/kg of 1%
lidocaine with epinephrine.16
Assess for anesthesia of area.
7. Assist in collection of peritoneal Assists in collecting fluid Usually diagnostic tests are ordered depending
fluid for laboratory analysis. for laboratory analysis. on patient’s status and reason for
paracentesis.2
Tests may include the following: tube 1:
lactate dehydrogenase, glucose, albumin;
tube 2: total protein, specific gravity; tube
3: cell count and differential; tube 4:
additional tests as needed.
If there is suspicion of infection: gram stain,
acid-fast bacillus stain, bacterial and fungal
cultures, amylase, and triglyceride tests may
be ordered.2,10,13 Also, collect a specimen for
cytology if malignancy is suspected.10

*Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results.
 116 Paracentesis (Assist) 1039

Procedure for Assisting With Paracentesis—Continued

Steps Rationale Special Considerations
8. Assist the physician or advanced Initiates therapy. Monitor the amount of fluid removed.
practice nurse in attaching syringes Removal of large amounts of fluid (>5 L)
or stopcock and tubing and may cause hypotension.5,13,15 If large volume
aspirating or siphoning fluid via paracentesis is performed (>5–6 L) an
gravity or vacuum into the albumin infusion of 6–8 g/L of fluid
collection device. A flexible removed improves survival and is
catheter/drain can be thread into recommended to prevent circulatory
the abdominal cavity over the dysfunction.1,3,5,10,13,15 (Level A*)
needle and left in place if needed.
Drains may be left in and allowed
to drain for 6–12 hours.11,13
(Level E*)
9. After the fluid and catheter are Keeps the insertion site Inspect catheter to ensure it is intact.
removed, apply pressure to the clean. Reduces the risk If significant leakage is found, apply a stoma
wound. If the wound is still for infection. bag over the site until drainage becomes
leaking fluid after 5 minutes of minimal.
direct pressure, the physician or
advanced practice nurse may suture
the puncture site (see Procedure
124) and apply a pressure dressing.
10. Assist with applying a sterile Provides a barrier to
dressing to the wound site. infection and collects fluid
that may leak from wound
site.
11. Remove PE and sterile equipment Standard Precautions.
used during the procedure in
appropriate receptacles.
12. HH

*Level A: Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or
treatment (including systematic review of randomized controlled trials).
*Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to
support recommendations.

Expected Outcomes Unexpected Outcomes

• Evacuation of peritoneal fluid for laboratory analysis • Perforation of bowel, bladder, or stomach
• Decompression of peritoneal cavity • Lacerations of major vessels (mesenteric, iliac, aorta)
• Relief of respiratory compromise • Abdominal wall hematomas
• Relief of abdominal discomfort • Laceration of catheter and loss in peritoneal cavity
• Incisional hernias
• Local or systemic infection
• Hypovolemia, hypotension, shock
• Bleeding from insertion site
• Ascitic fluid leak from insertion site
• Peritonitis

Patient Monitoring and Care

Steps Rationale Reportable Conditions
These conditions should be reported if
they persist despite nursing
interventions.
1. Evaluate changes in abdominal Provides evidence of fluid • Increasing abdominal girth
girth. reaccumulation.
Procedure continues on following page
1040 Unit IV Gastrointestinal System

Patient Monitoring and Care —Continued

Steps Rationale Reportable Conditions
2. Monitor for changes in the Removal of ascitic fluid should • Respiratory rate >24 breaths per
respiratory status. relieve pressure on the diaphragm minute or significant increase from
and the resulting respiratory baseline
distress. • Increased depth of breathing
• Irregular breathing pattern
• Pulse oximetry <92%, or significant
decrease from baseline
3. Monitor for potential Paracentesis interrupts the integrity • Hematuria
complications, including bowel of the skin and underlying • Hypotension
or bladder perforation, bleeding, peritoneum. • Tachycardia
and intravascular volume loss.
4. Monitor vital signs, Rapid changes in intraabdominal • Hypotension
temperature, and insertion site pressure may affect heart rate and • Dysrhythmias
for drainage or evidence of blood pressure. • Increased temperature
infection. Infection is a complication of • Purulent drainage from insertion site
paracentesis. • Redness, swelling at insertion site
• Abnormal laboratory results (increased
white blood cell [WBC] count)
5. Monitor intake and output. Provides data for evaluation of the • Inappropriate fluid balance or changes
fluid balance status. from baseline fluid status
6. Monitor abdominal pain and Patients often feel weak and have • Continued pain despite pain
level of weakness. Follow abdominal discomfort for a few interventions, if performed
institutional standards for hours after the procedure. Identifies
assessing pain. need for pain interventions.
7. Evaluate the laboratory data Provides for evaluation of the • Red blood cell count >100,000/mm3
when returned. condition and aids in diagnosis. • Amylase value >2.5 times normal
• Alkaline phosphatase value >5.5 mg/dL
• WBC count >100/mm3
• Positive culture results10,13

Documentation
Documentation should include the following:
• Patient and family education • Postprocedure vital signs, respiratory status
• The date and time of the procedure • Postprocedure comfort/pain level
• Patient tolerance of the procedure • Abdominal girth
• Assessment of the insertion site after the procedure • Unexpected outcomes
• The amount and characteristics of fluid removed • Nursing interventions
• Specimens sent for laboratory analysis

References and Additional Readings

For a complete list of references and additional readings for
this procedure, scan this QR code with any freely available
smartphone code reader app, or visit
http://booksite.elsevier.com/9780323376624.