Synonym/Acronym
Ascites fluid analysis.
Rationale
To evaluate and classify the type of fluid within the peritoneal cavity to assist with diagnosis of cancer, infection, necrosis, and perforation.
Patient Preparation
There are no food, fluid, or activity restrictions unless by medical direction. Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken.
Normal Findings
Method: Spectrophotometry for glucose, amylase, and alkaline phosphatase; automated or manual cell count, macroscopic examination of cultured organisms, and microscopic examination of specimen for microbiology and cytology; microscopic examination of cultured microorganisms.
| Peritoneal Fluid | Reference Value |
|---|
| Appearance | Clear | | Color | Pale yellow | | Amylase | Parallels serum values | | Alkaline phosphatase | Parallels serum values | | Carcinoembryonic antigen (CEA) | Parallels serum values | | Glucose | Parallels serum values | | Red blood cell (RBC) count | None seen | | White blood cell (WBC) count | Less than 300 cells/microL | | Culture | No growth | | Acid-fast stain | No organisms seen | | Gram stain | No organisms seen | | Cytology | No abnormal cells seen |
|
Study type: Body fluid [peritoneal fluid] collected in a red- or green-top [heparin = tube for amylase, glucose, and alkaline phosphatase; lavender-top [EDTA] tube for cell count; sterile containers for microbiology specimens; fluid in a clear container with anticoagulant for cytology; related body system: Digestive and Immune systems. Ensure that there is an equal amount of fixative and fluid in the container for cytology.
The peritoneal cavity and organs within it are lined with a protective membrane. The fluid between the membranes is called serous fluid. Normally, only a small amount of fluid is present because the rates of fluid production and absorption are about the same. Many abnormal conditions can result in the buildup of fluid within the peritoneal cavity. Specific tests are usually ordered in addition to a common battery of tests used to distinguish a transudate from an exudate. Transudates are effusions that form as a result of a systemic disorder that disrupts the regulation of fluid balance, such as a suspected perforation. Exudates are caused by conditions involving the tissue of the membrane itself, such as an infection or malignancy. Fluid (ascites) is withdrawn from the peritoneal cavity by needle aspiration (paracentesis) and tested as listed in the previous and following tables.
Factors That May Alter the Results of the Study
- Bloody fluids may result from a traumatic tap.
Other Considerations
- Unknown hyperglycemia or hypoglycemia may be misleading in the comparison of fluid and serum glucose levels. Therefore, it is advisable to collect comparative serum samples a few hours before performing paracentesis.
Increased In
Condition/Test Showing Increased Result
- Abdominal malignancy (RBC count, carcinoembryonic antigen, abnormal cytology)
- Abdominal trauma (RBC count)
- Ascites caused by cirrhosis (WBC count, neutrophils greater than 25% but less than 50%)
- Bacterial peritonitis (WBC count, neutrophils greater than 50%)
- Peritoneal effusion due to gastric strangulation, perforation, or necrosis (amylase, ammonia, alkaline phosphatase)
- Peritoneal effusion due to pancreatitis, pancreatic trauma, or pancreatic pseudocyst (amylase)
- Rupture or perforation of urinary bladder (ammonia, creatinine, urea)
- Tuberculous effusion (elevated lymphocyte count, positive acid-fast bacillus smear and culture [25% to 50% of cases])
Decreased In
Condition/Test Showing Decreased Result
- Abdominal malignancy (glucose)
- Tuberculous effusion (glucose)
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist with evaluation of fluid surrounding the abdominal organs.
- Explain that this procedure takes about 20 to 60 min (depending on the amount of fluid to be removed) and is performed under sterile conditions.
- Explain that a peritoneal fluid sample is needed for the test.
- Review the procedure with the patient.
- Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing).
- Note that the patient’s weight and abdominal girth measurements will be taken for those with ascites.
- Discuss how there may be moments of discomfort or pain when the IV line or catheter is inserted, allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- Explain that any discomfort with the needle insertion will be minimized with local anesthetics and systemic analgesics. The anesthetic injection may cause an initial stinging sensation.
- Explain that after the skin has been anesthetized, a large needle will be inserted through the abdominal wall, and a “popping” sensation may be experienced as the needle penetrates the peritoneum.
- Discuss how reducing health-care-associated infections is an important patient safety goal, and a number of different safety practices will be implemented during the procedure.
- Explain that hair in the area near the catheter insertion site may be clipped and the area cleaned with an antiseptic solution to cleanse bacteria from the skin in order to reduce the risk for infection.
Procedural Information
- Note: The World Health Organization, Centers for Disease Control and Prevention, and Association of periOperative Registered Nurses recommend that hair not be removed at all unless it interferes with the incision site or other aspects of the procedure because hair removal by any means is associated with increased infection rates.
- Hair removal requires facilities to use a protocol that is based on scientific literature or the endorsement of a professional organization.
- Clipping immediately before the procedure and in a location outside the procedure area is preferred to shaving with a razor.
- Shaving creates a break in skin integrity and provides a way for bacteria on the skin to enter the incision site.
- Baseline vital signs are recorded and monitored throughout the procedure.
- Positioning for this procedure is in a seated comfortable position with feet and back supported or in high Fowler position.
- Prior to the administration of local anesthesia, the site is cleansed with an antiseptic solution and draped with sterile towels.
- A paracentesis needle is inserted 1 to 2 in. below the umbilicus, allowing fluid to be removed.
- The patient’s vital signs are monitored every 15 min for signs of hypovolemia or shock.
- The amount of fluid removed at a time may be 1,500 to 2,000 mL, but no more than 4,000 mL of fluid, even in the case of a therapeutic paracentesis, due to the risk of hypovolemia and shock.
- Once the needle is withdrawn, slight pressure is applied to the site, and the site is covered with a sterile dressing.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure where bleeding is a potential complication.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
Establishing an IV site and performing a paracentesis are invasive procedures that can cause rare complications. For additional information, see Appendix A: Patient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated With Diagnostic Procedures.
- Observe/assess the needle insertion site for bleeding, drainage, inflammation, or hematoma formation.
- Explain the importance of immediately reporting elevated WBC count, fever, malaise, tachycardia (indications of infection), severe abdominal pain, or abdominal rigidity. (Note: Rigidity of abdominal muscles indicates developing peritonitis.)
Treatment Considerations
- Follow postprocedure vital sign and assessment protocol.
- Resume the usual medications, as directed by the HCP.
- Inform the patient that 1 hr or more of bedrest is required after the procedure.
- Observe the puncture site each time vital signs are taken and daily thereafter for several days. Report to the HCP if bleeding is present.
- Obtain weight and measure abdominal girth if a large amount of fluid was removed.
- Observe for nausea and pain. Administer antiemetic and analgesic medications as needed and as directed by the HCP.
- Administer ordered antibiotics and instruct in the importance of completing the entire course of antibiotic therapy even if no symptoms are present.
Clinical Judgement
- Consider how to decrease the fear (needles, pain) associated with this procedure.
Follow-Up and Desired Outcomes
- Understands that further testing, along with a referral to another HCP, may be necessary to manage the disease process, and monitor the effectiveness of therapeutic interventions.