Ascites Nursing Diagnosis and Nursing Care Plan

Ascites Nursing Care Plans Diagnosis and Interventions

Ascites NCLEX Review and Nursing Care Plans

Ascites is the medical term to describe the accumulation of fluid in the abdomen. Ascites is often associated with severe liver disease, but its causes may vary.

Ascites usually presents with marked swelling of the patients’ abdomen, increased abdominal girth and sudden weight gain.

If left untreated, this condition will compromise the patients’ breathing, and may lead to death.

Signs and Symptoms of Ascites

• Feeling bloated
• Sudden weight gain
• Shortness of breath
• Nausea and vomiting
• Swelling of the lower extremities, especially the ankles and legs
• Indigestion and heartburn
• Loss of appetite
• Abdominal pain
• Fever at times

Causes and Risk Factors of Ascites

The causes of ascites fall into three categories or etiological theories:

1. Under filling. This suggests that it is due to the inappropriate draining of fluid within the splanchnic vascular bed. Portal hypertension and the eventual decrease in satisfactory blood volume circulation is the causative factor in this theory.
2. Overflow. This theory speculates on the renal retention of sodium and water arising from the deficiency in fluid volume depletion. This is often associated and observed for patients with cirrhosis, indicative of intravascular hypervolemia over hypovolemia.
3. Peripheral arterial vasodilation. This combines components of the two previous theories. It speculates that portal hypertension results to vasodilation, in turn causing deficient and ineffective arterial blood volume. As the condition progresses, more sodium in the body remains, hence the plasma volume expands. The end result is the overflowing of fluid in the peritoneal cavity, hence the development of ascites.

• Viral infections of the liver – e.g. Hepatitis B infection
• Alcohol abuse
• Cancer in the organs of the abdomen – either primary or metastatic in origin
• Renal failure
• Congestive heart failure

Although there are many pathogenic causes of ascites, 75% of cases arise from liver cirrhosis, with 25% comprised of either infective, inflammatory, or infiltrative circumstances.

Complications of Ascites

Patients who are able to ambulate but present with episodic cirrhotic ascites have mortality rates of 50% on a 3-year basis.

However, patients who develop refractory ascites (that is, ascites that recurs after intervention), have a survival rate of less than 50% in a one-year basis.

The prognosis for patients with ascites caused by liver impairment depends on the underlying condition, the chance for reversibility of the disease, and the response to the treatment regimen.

Diagnosis of Ascites

Diagnosing ascites involves the following:

1. Comprehensive history and physical exam – to assess presumptive cause and extent of the condition.
2. Laboratory studies for the aspirated ascitic fluid.
3. Inspection of ascites fluid – mostly transparent and yellow-tinged; a pink or blood-tinged aspirate can either be due to traumatic aspiration or malignancy. Cloudy ascitic fluid with purulent consistency signifies infection.
4. Cell count – a polymorphonuclear leukocyte count (PMN) of greater than 250 cells/uL is suggestive for bacterial peritonitis.
5. Serum ascites albumin gradient (SAAG) – single best test for classifying ascites into portal hypertension (SAAG >1.1g/dL) with an accuracy of 97% in differentiating between high-albumin gradient and low-albumin gradient.
6. Total protein – provides clues when used together with SAAG. An elevated SAAG and high protein levels are hallmarks of ascites that is hepatic congestion in origin. Low SAAG and high protein levels are suggestive of malignant ascites.
7. Culture and gram stain – to detect the causative agent to direct antibiotic therapy
8. Cytology – shows 58-75% sensitive for detecting malignant ascites.
9. Ascitic amylase cultures/PCR – to assess for suspected pancreatitis and mycobacterial cultures/PCR for tuberculosis.
10. Imaging studies
11. Chest and abdominal x-rays – opacities in the x-ray would suggest for ascites when viewed and interpreted.
12. Ultrasound – to indicate the type, amount the specific location of the ascitic fluid in the abdomen.
13. CT scan of the abdomen – more thorough scans of the abdomen may also reveal malignancy that are otherwise too small to be detected that are causing the ascites.

Treatment of Ascites

The treatment of ascites involves both medical and surgical management. They are enumerated below:

Medical Management

• Sodium restriction of 20-30 mEq/dL
• Use of diuretics
• Water restriction for persistent hyponatremia
• Albumin infusion for every 5 liters of ascitic fluid aspirated decreases complications such as electrolyte imbalances, increases in creatinine levels, etc.
• 24 hour urinary sodium measurements for patients with ascites related to portal hypertension to assess sodium levels, response to diuretics and compliance to diet modifications.

Surgical Management

• Peritoneovenous shunt – shunt that directs the ascitic fluid to the central venous system to be drained and eliminated through the kidneys
• Transjugular intrahepatic portosystemic shunt (TIPS) – utilized for patients with diuretic resistant ascites wherein an interventional radiologist places a stent percutaneously from the right jugular vein into the hepatic vein, connecting two conjunctions.
• Automated pump system to remove ascites from the peritoneum to be drained to the bladder.
• Therapeutic paracentesis for rapid symptomatic relief of fluid build-up in the peritoneum. Can be done to for refractory ascites.

Nursing Diagnosis for Ascites

Ascites Nursing Care Plan 1

Nursing Diagnosis: Deficient Knowledge related to new diagnosis of ascites as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care”

Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of ascites and its management.

Ascites Nursing Care Plan 2

Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to abdominal pain and cramping secondary to ascites, as evidenced by abdominal cramping, stomach pain, bloating, weight loss, nausea and vomiting, and loss of appetite

Desired Outcome: The patient will be able to achieve a weight within his/her normal BMI range, demonstrating healthy eating patterns and choices.

Ascites Nursing Care Plan 3

Nursing Diagnosis: Activity intolerance related to fatigue and body malaise secondary to ascites, as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion

Desired Outcome: The patient will demonstrate active participation in necessary and desired activities and demonstrate increase in activity levels.

Ascites Nursing Care Plan 4

Nursing Diagnosis: Acute Pain related to damage to the body tissues secondary to ascites, as evidenced by the patient’s report of the pain of the affected part, facial grimaces, and increased vital signs.

• The patient will express understanding about the use of appropriate diversional activities and different skills that can be used for relaxation.
• The patient will express satisfactory pain control and decreased pain scale of 9 to 10 to 2 to 3.
• The patient’s well-being will be improved as evidenced by pulse, blood pressure, and respiratory rate within normal range, and will have improved muscle tone, body posture, and mood.
• The patient will verbalize comfort after using different pharmacological and non-pharmacological pain relief strategies.

Ascites Nursing Care Plan 5

Nursing Diagnosis: Ineffective Breathing Pattern related to airway obstruction, decreased lung expansion, and fluid build-up secondary to ascites as evidenced by rapid and shallow breathing and difficulty of breathing when lying down.

• The patient will maintain an effective breathing pattern evidenced by the absence of dyspnea, normal breathing rate and depth, and relaxed breathing.
• The respiratory rate of the patient will remain within established limits at all times.
• The patient’s arterial blood gas levels will return and remain within their normal limits.
• The patient will express a feeling of comfort when breathing.
• The patient will show and demonstrate maximum lung expansion with adequate ventilation.

Ascites Nursing Care Plan 6

Nursing Diagnosis: Nausea related to gastric distention and bowel obstruction secondary to ascites as evidenced by gagging sensation, excessive salivation, and patient’s reports of nausea.

• The patient will report decreased nausea episodes.
• The patient will be able to express knowledge about the methods that can be used to decrease nausea.

More Ascites Nursing Diagnosis

• Impaired skin integrity related to ascites-related pruritus
• Chronic pain
• Fluid volume excess

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.