Nursing care plan for abdominal paracentesis

Introduction

Abdominal paracentesis is a surgical procedure wherein a needle is used to remove the accumulated intra-abdominal fluid. This surgery, commonly referred to as abdominal tap or paracentesis, is done to diagnose and treat conditions such as cirrhosis, ascites, and peritonitis. A nursing care plan for abdominal paracentesis must be developed to ensure that the patient receives the life-saving care required.

Assessment

Chief Complaint: Patient has abdominal discomfort.

History of Present Illness: Patient has been having abdominal discomfort for 3 weeks, accompanied by thrice a day vomiting. Mild dry cough was also reported.

Past Medical History: Patient has a history of diabetes and hypertension.

Medication History: Patient was being treated with metformin and enteric coated aspirin.

Physical Assessment: Patient appeared pale and dehydrated. Patient was found to have shallow respirations and tachycardia.

Nursing Diagnosis

The nursing diagnosis for abdominal paracentesis includes:

• Risk for Fluid Volume Deficit – due to the presence of ascites.
• Risk for Injury – due to presence of ascites and the use of needle.
• Pain – due to abdominal discomfort.

Outcomes

The outputs of this care plan should involve:

• Reduction in volume of ascites.
• Reversal of the effects of volume overload.
• Improvement in the overall condition of the patient.
• Relief of abdominal discomfort.

Interventions

The interventions which are important to include in the case plan are as follows:

1. Monitor vital signs and intake/output assigned shifts.
2. Evaluate amount and type of chest pain or abdominal discomfort present before, during and after procedure.
3. Administer medication as prescribed before or during the procedure.
4. Provide skin preparation for paracentesis site before the procedure.
5. Perform abdominal paracentesis according to the protocol.
6. After completion of the procedure, monitor patient's response.
7. Provide comfort measures to relieve pain.

Rationales

The rationales for each intervention are as follows:

• Monitoring of vital signs helps to assess the amount of fluid loss.
• Evaluating pain helps to assess response to the procedure.
• Administering medications help to reduce pain or anxiety.
• The skin preparation helps in providing a sterile environment.
• The abdominal paracentesis helps in removing the fluid.
• Monitoring the response to the procedure is essential to assess effectiveness of the procedure.
• Providing comfort measure helps in relieving pain and providing relaxation to the patient.

Evaluation

The successful evaluation of abdominal paracentesis would be when all of the following objectives are met:

• Patient's volume deficit is reversed.
• Patient shows improvement in abdominal discomfort.
• Patient is able to cope with anxiety and fear.

Conclusion

Nursing care plans are essential in providing quality care to patients undergoing procedures like abdominal paracentesis, as they provide clear goals, objectives, and interventions. With the proper evaluation and monitoring, successful outcomes can be ensured prior to, during and after the procedure.

FAQs

• What is abdominal paracentesis?Abdominal paracentesis is a surgical procedure wherein a needle is used to remove the accumulated intra-abdominal fluid.
• What is the purpose of the procedure? The main purpose is to diagnose and treat conditions such as cirrhosis, ascites, and peritonitis.
• How long does the procedure typically take? The procedure typically takes 20-30 minutes, depending on the patient's condition and the complexity of the procedure.
• Are there any risks associated with the procedure? Yes, there are serious risks associated with the procedure. These include infection, bleeding and reaction to anesthetics.
• How is the procedure performed? A needle is inserted through the abdominal wall to allow removal of the accumulated fluid. The process is monitored throughout, and monitored according to the protocol.