Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [112], C).
2. 2.Show
   Ask the patient to empty their bladder.
   If the bladder is full there is a chance of it being punctured when the trocar access needle is introduced (McGibbon et al. [92], E).
3. 3.Show
   Weigh the patient before the procedure and record their weight.
   To assess weight changes and fluid loss. E
4. 4.Show
   Ensure privacy.
   To maintain dignity (NMC [112], C).
5. 5.Show
   Measure the patient's girth around the umbilicus before the procedure and record it. Mark the position on the abdomen where the drain will be inserted using a skin marker.
   To provide an indication of fluid shift and how much fluid has reaccumulated. E
6. 6.Show
   Help the patient to lie supine in bed with their head raised 45–50 cm with a backrest.
   Normally the pressure in the peritoneal cavity is no greater than atmospheric pressure; however, when fluid is present, pressure becomes greater than atmospheric pressure. This position will aid gravity in the removal of fluid and the fluid will drain of its own accord until the pressure is equalized. E

Procedure

1. 7.Show
   Decontaminate hands.
   To minimize the risk of contamination (NHS Improvement [105], C).
2. 8.Show
   Perform the procedure using an aseptic technique. Always perform the procedure in hospital with a second, appropriately trained person.
   To minimize the risk of contamination. E

   To ensure patient safety at all times. E
3. 9.Show
   Bring the equipment to the bedside on a clean trolley. Remove the sterile abdominal paracentesis pack from its outer wrapping and open it on the trolley.
   To minimize the risk of infection. E
4. 10.Show
   Lay out the remaining equipment except the personal protective equipment.
   To facilitate access to the equipment. E

   To create a clean working area. E
5. 11.Show
   Put on sterile personal protective equipment.
   To protect the professional and patient from the risks of cross‐infection (NHS Improvement [105], C).
6. 12.Show
   Clean hands with an alcohol‐based handrub.
   To minimize the risk of infection. (NHS Improvement [105], C).
7. 13.Show
   Clean the skin thoroughly at the marked site for the paracentesis with an antiseptic or alcohol solution, and allow it to dry. Drape the area with sterile towels.
   To reduce the risk of local and/or systemic infection. The peritoneal cavity is normally sterile. E
8. 14.Show
   Administer a local anaesthetic.
   To minimize pain during the procedure. E
9. 15.Show
   Once the anaesthetic has taken effect, the practitioner performing the procedure should make an incision into the skin of the abdomen where previously marked.
   To minimize pain during the procedure and thus maximize patient comfort and facilitate co‐operation. E
10. 16.Show
    The trocar and cannula are inserted via the incision.
    To ensure correct insertion of the trocar and cannula. E
11. 17.Show
    The trocar is removed and disposed of in a sharps container.
    To reduce the risk of accidental needle stick injury (NHS Employers [103], C).
12. 18.Show
    Attach the closed drainage system to the cannula using a connector if appropriate. Apply a dry dressing to ensure the drain exit site is protected and the drain is taped firmly in position.
    A sterile container with a non‐return valve is necessary to maintain sterility. E
13. 19.Show
    Collect ascitic fluid from the cannula with a syringe (20–100 mL as instructed by the practitioner) and send it for cytology.
    If necessary, in order to diagnose the cause of ascites (Huang et al. [66], E).
14. 20.Show
    If the cannula is to remain in position, sutures may be inserted, by the practitioner, adjacent to the cannula and looped around it to prevent it becoming dislodged and to prevent local trauma to the patient.
    To ensure the cannula remains in situ. To reduce the risk of trauma to the patient. E

Post‐procedure

1. 21.Show
   Dispose of equipment as per local policy.
   To reduce the risk of environmental contamination (Loveday et al. [85], R).
2. 22.Show
   Monitor the patient's blood pressure, pulse and respirations hourly.
   To observe for signs of shock and/or infection. E
3. 23.Show
   Weigh the patient after the procedure and record their weight.
   To assess weight changes and fluid loss. E
4. 24.Show
   Measure the patient's girth around the umbilicus after the procedure and record it.
   This provides an indication of fluid shift and how much fluid has reaccumulated. E
5. 25.Show
   Observe the rate and nature of the drainage. Reduce the flow of fluid by clamping the drain if the patient complains of abdominal pain.
   To ensure safe and unobstructed drainage. E
6. 26.Show
   Monitor the patient's fluid balance daily, reviewing the intake and output. Review biochemistry results daily.
   After removal of large amounts of peritoneal fluid, fluid moves from the vascular space and reaccumulates in the peritoneal cavity. Ascitic fluid contains protein in addition to sodium and potassium. Problems relating to dehydration and electrolyte imbalance may be present. E