Ascites is the accumulation of fluid in the peritoneal cavity. Several diseases cause the condition, but more than half of cases are attributed to liver cirrhosis.
The worsening vasodilation brought on by an increase in portal pressure and nitric oxide levels leads to the elevation of vasoconstrictor hormones, renal function decline, and third space shifting of fluid to the peritoneal cavity forming ascites.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Imbalanced Nutrition: Less than Body Requirements Care Plan
- Ineffective Breathing Pattern
- Ineffective Tissue Perfusion
- Risk for Infection
Nursing Process
Ascites is a clinical manifestation of a larger diagnosis. Thus, interventions should concentrate on managing the etiology to relieve the fluid accumulated in the abdomen. Nurses can explain the paracentesis procedure, educate the patient and family about their disease condition and the corresponding therapeutic regimen, and encourage lifestyle changes as applicable.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section we will cover subjective and objective data related to ascites.
Review of Health History
1. Assess the patient’s general symptoms.
Note the patient’s complaints and general symptoms, such as:
- Distended, firm abdomen
- Abdominal pain
- Increased abdominal pressure
- Weight gain
- Early sense of fullness
- Bloating
- Loss of appetite (anorexia)
- Nausea
- Indigestion
- Constipation
- Shortness of breath
- Generalized edema (anasarca)
- Fatigue
- Sense of heaviness
2. Determine the causative factor.
Cirrhosis is the most prevalent condition that leads to ascites in patients. Other causes are:
- Cancer
- Ovarian lesions
- Heart failure
- Type 2 diabetes
- Hypercholesterolemia
- Tuberculosis
- Dialysis
- Nephrotic syndrome
- Pancreatitis
- Peritonitis
- Chronic alcohol use
- IV drug use
- Obesity
- Severe malnutrition
3. Identify the risk factors.
Conditions that damage or scar the liver frequently lead to ascites. Common ascites risk factors are:
- Liver cirrhosis
- Viral infections like hepatitis B or hepatitis C
- Excessive alcohol use over time
- Non-alcoholic steatohepatitis (fatty liver disease)
- Cancer in abdominal organs
- Portal vein thrombosis
- Kidney failure
Physical Assessment
1. Measure the abdominal girth.
Measure around the abdomen at the level of the umbilicus. This measurement can be compared over time to determine the presence of fluid buildup.
2. Monitor vital signs.
Fluid accumulation can alter vital signs. Too much fluid can result in increased blood pressure and bounding pulses. Fever may result if ascitic fluid is infected.
3. Do a physical examination.
- General appearance: Weight gain
- Gastrointestinal: Inverted umbilicus, distended, firm abdomen, bulging flanks when lying supine, tympany over the umbilicus, and dullness over the side and flank upon percussion
- Cardiovascular (if ascites is due to heart failure): jugular venous distension
- Respiratory (if ascites is due to heart failure): dyspnea, orthopnea, and pulmonary congestion
- Lymphatic: Peripheral edema
- Genitourinary: Scrotal edema
- Integumentary (if ascites is due to advanced liver disease): Spider angioma, jaundice, palmar erythema, muscle wasting, gynecomastia
4. Perform maneuvers to check for ascites.
Physical examination maneuvers for ascites detection are moderately sensitive and specific. At least two maneuvers are required for detecting ascites because no single maneuver is highly sensitive and specific.
- Bulging flanks are a positive finding when the patient’s flanks bulge outward when lying supine.
- Flank dullness is positive when the percussion note is tympanitic over the umbilicus and dull over the lateral and flank areas.
- Shifting dullness is positive when the dullness shifts to the dependent location. Tympany shifts upward.
- Fluid wave maneuver taps along one flank. The fluid is forced from one side of the abdomen to the other, causing the examiner to feel “a shock wave” of fluid traveling across the pressed fingertips down the opposite flank.
5. Track the fluid intake and output
It is important to monitor fluid intake, output, and balance. Document IV and oral intake and fluid output to accurately monitor fluid levels.
Diagnostic Procedures
1. Obtain ascitic fluid for analysis.
The most efficient method to determine the origin of ascites is through diagnostic abdominal paracentesis. Ascitic fluid is usually clear or yellow-tinged. A fluid sample can be cultured for the presence of pathogens or cancer cells.
2. Further investigate the ascitic fluid.
An initial blood cell count, including a total nucleated cell count and a polymorphonuclear neutrophils (PMN) count, and a bacterial culture should be done on the ascitic fluid.
3. Perform radiology tests.
Radiology tests are:
- Chest x-ray shows the elevation of the diaphragm and any pleural effusions in the presence of severe ascites.
- Ultrasound is the easiest and most accurate test for ascites detection. Volumes as minimal as 5mL can be visualized.
- CT scan is used to diagnose ascites and may reveal malignancies.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section you’ll learn more about possible nursing interventions for a patient with ascites.
Manage Fluid Retention
1. Treat the underlying cause.
The cause of fluid retention determines the best course of treatment for ascites.
2. Minimize the ascitic fluid volume.
The goal of therapy in ascites patients is to reduce peripheral edema and ascites fluid volume without depleting intravascular volume.
3. Restrict sodium.
Potassium-containing salt substitutes should be avoided. This is due to the risk of increasing potassium levels from some medications (diuretics) for ascites. The recommended salt intake for persons with ascites is less than 2,000 mg per day.
4. Induce diuresis.
Diuretics aid in eliminating extra fluid from the body. Furosemide (potassium-wasting) and spironolactone (potassium-sparing) are the most common diuretics administered.
5. Drain the fluid.
Paracentesis allows the removal of large volumes of extra fluid with a needle into the abdomen. Patients with refractory ascites may receive paracentesis as a palliative treatment. An indwelling peritoneal catheter may be placed to drain fluid easily.
6. Prepare for surgical intervention.
For patients who are resistant to diuretics, a transjugular intrahepatic portosystemic shunt (TIPS) procedure places a stent from the jugular vein to the hepatic vein to relieve the pressure of blood flowing through the liver and the buildup of fluid.
7. Administer antibiotics.
Antibiotics may be required if ascites is related to bacterial peritonitis.
Manage Risk Factors
1. Monitor the weight.
Monitor the patient’s daily weight. Note if there is a significant gain of more than 10 pounds or more than 2 pounds per day for three days. Advise the patient to contact the healthcare provider.
2. Avoid alcohol.
Alcohol increases the risk of cirrhosis, the most common cause of ascites. Avoiding alcohol will reduce the ascites risk.
3. Refrain from NSAIDs.
The kidneys and liver are affected by nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen. NSAIDs can cause acute renal failure, hyponatremia, and lower the effects of diuretics in patients with cirrhosis.
4. Emphasize safe sex practices.
Reduce the risk of contracting hepatitis infection (one of the causes of ascites) by engaging in safe sex.
5. Restrict fluid intake.
To help prevent the recurrence of ascites, limit the daily fluid intake to less than one liter (only if hyponatremia is present).
Nursing Care Plans
Once the nurse identifies nursing diagnoses for ascites, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for ascites.
Excess Fluid Volume
The patient experiences fluid retention in the peritoneal cavity.
Nursing Diagnosis: Excess Fluid Volume
Related to:
- Compromised regulatory mechanisms
- Portal hypertension
- Lower plasma colloidal osmotic pressure
- Sodium and water retention
- Excessive sodium/fluid intake
- Dependent venous pooling
As evidenced by:
- Increased abdominal girth
- Abdominal pain/discomfort
- Bloating
- Increased blood pressure
- Weight gain
- Edema
- Weakness/fatigue
- Bounding pulse, tachycardia
- Neck vein distension
Expected outcomes:
- Patient will manifest a decrease in abdominal girth.
- Patient will report a decrease in abdominal pain/discomfort.
- Patient will demonstrate:
- Blood pressure: BP >90/60, <140/90 mmHg
- Heart rate: 60-100 beats/min
Assessment:
1. Monitor vital signs.
Increased heart rate and blood pressure may be observed due to the increasing portal hypertension.
2. Assess contributing and causative factors.
Identifying and managing the disease or situation that contributes to excess fluid volume is the key to resolving ascites.
3. Monitor abdominal girth.
This provides information on therapy response and the effectiveness of treatment.
Interventions:
1. Restrict sodium and fluid intake as appropriate.
Sodium restriction minimizes fluid retention in extravascular spaces.
2. Prepare for/assist with paracentesis.
Therapeutic paracentesis may be done for the symptomatic relief of ascites. Explain the procedure to the patient and assist with maintaining aseptic technique.
3. Administer medications.
Physicians may prescribe medications such as diuretics (e.g., spironolactone, furosemide) to control ascites and edema. Albumin may also be given as an adjunct to prevent fluid re-accumulation.
4. Educate on monitoring for fluid gain.
Patients can be instructed to monitor their weight at home and to contact their healthcare team for a significant weight gain in a week or symptoms of shortness of breath, bloating, or swelling in dependent extremities.
Imbalanced Nutrition: Less than Body Requirements Care Plan
Patients with ascites experience compromised nutrition due to a multitude of reasons.
Related to:
- Disease process
- Inflammation
- Food/taste aversion
- Inadequate intake
- Early satiety
- Abdominal distention
- Altered metabolism
- Abdominal discomfort
- Increased energy expenditure
As evidenced by:
- Abdominal cramping
- Abdominal pain
- Muscle wasting
- Constipation
- Bloating
- Hypoactive bowel sounds
- Nausea
- Lack of appetite
Expected outcomes:
- Patient will be able to identify nutritional requirements with appropriate food choices.
- Patient will report an increase in appetite and demonstrate an increase in muscle mass.
Assessment:
1. Assess the patient’s nutritional status.
The nutritional status of patients with ascites may require more than simply measuring the patient’s body weight due to fluid accumulation. The two recommended methods to assess the nutritional status of patients with cirrhosis and ascites are mid-arm muscle circumference (MAMC) and triceps skinfold (TSF).
2. Assess laboratory values for nutrient deficiencies.
Patients with cirrhosis and ascites have macronutrient and micronutrient deficiencies due to inadequate intake and malabsorption. Hypomagnesemia, zinc, folate, B6, and thiamine deficiencies are common, along with a deficiency in vitamins A, D, E, and K.
3. Assess for any barriers to eating.
Ascites can further compromise nutrition due to barriers to eating, like changes in taste, appetite suppression, early satiety, and the ability to eat comfortably.
Interventions:
1. Refer the patient to a dietitian.
A carefully structured meal plan is essential to address nutrient deficits in patients with cirrhosis and ascites. Dietary counseling and nutritional support have been shown to increase nutritional intake and patient outcomes.
2. Encourage a high-protein diet and restrict sodium intake.
A high protein diet and sodium restriction are considered standard practices for managing ascites. Protein intake of 1.2-1.5 g/kg/day is recommended. Even though sodium restriction should be restricted based on the patient’s urinary sodium excretion, a realistic goal in sodium restriction would be approximately 2 grams per day.
3. Incorporate branched chain amino acids.
BCAAs have been shown to improve liver function, nutritional status, quality of life, and overall survival in patients who are malnourished due to cirrhosis.
4. Encourage small frequent meals and snacks.
Patients with ascites tend to have poor tolerance to large meals due to increased abdominal pressure. 5-7 smaller meals and snacks are more tolerable.
5. Provide late-evening snacks.
A late evening snack containing complex carbohydrates and protein is recommended to help compensate for the reduced glycogen storage and production and prevent muscle proteolysis in patients with cirrhosis and ascites.
Ineffective Breathing Pattern
The patient’s diaphragm may be affected by the expanding fluid preventing adequate ventilation.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Increased abdominal pressure
- Decreased lung expansion
As evidenced by:
- Nasal flaring
- Tachypnea
- Orthopnea
- Fatigue
- Shortness of breath/dyspnea
- Respiratory depth changes
- Alterations in ABGs
Expected outcomes:
- Patient will demonstrate an effective respiratory pattern as indicated by a respiratory rate within 12-20 breaths/min with normal depth and absence of cyanosis.
- Patient will express the relief of shortness of breath/dyspnea.
- Patient will demonstrate arterial blood gas (ABG) values within normal limits:
- pH: 7.35-7.45
- PaO2: 75 to 100 mmHg
- PaCO2: 35 to 45 mmHg
- HCO3: 22-26 meq/L
Assessment:
1. Monitor respiratory rate, depth, and effort.
Alteration in the respiratory pattern may be observed due to the increasing abdominal distension.
2. Assess ABGs.
This provides therapy response information, reflects respiratory status changes, and detects impending pulmonary complications.
Interventions:
1. Place in semi-fowler’s position, as appropriate.
Keeping the head elevated facilitates breathing and eases pressure on the diaphragm.
2. Provide supplemental oxygen, as indicated.
Oxygen support may be necessary to treat hypoxia or dsypnea.
3. Prepare for TIPS procedure.
Transjugular intrahepatic portosystemic shunt (TIPS) involves inserting a stent to relieve pressure caused by cirrhosis to stop fluid retention. This may be necessary for patients with refractory ascites.
4. Instruct on lifestyle modifications.
A strict low-sodium diet, adherence to diuretics, and cessation of alcohol consumption are necessary to prevent ascites and its effect on the respiratory system.
Ineffective Tissue Perfusion
Ascites may lead to an abdominal infection causing increased abdominal pressure and impaired tissue perfusion.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Increased abdominal pressure
- Infection
- Disease process
- Inflammatory process
As evidenced by:
- Abdominal distention
- Hypoactive or absent bowel sounds
- Nausea and vomiting
- Loss of peristalsis
- Bloating
- Shortness of breath
- Pain
Expected outcomes:
- Patient will remain free from abdominal pain and distention.
- Patient will verbalize understanding of the treatment regimen and lifestyle modifications to decrease complications like peritonitis, kidney failure, and abdominal hernia.
Assessment:
1. Assess the extent of the patient’s ascites.
Patients often report progressive abdominal distention along with other symptoms like abdominal discomfort, shortness of breath, early satiety, weight gain, and dyspnea due to increased fluid accumulation and abdominal pressure. Measure the patient’s abdominal girth and weight to create baseline data and comparison for the suspected progression of ascites.
2. Assess diagnostic values to confirm ascites diagnosis and its cause.
Abdominal paracentesis with ascitic fluid analysis can detect spontaneous bacterial peritonitis.
3. Inspect, auscultate, percuss, and palpate the abdomen.
A complete physical abdominal assessment is vital to assess the extent of decreased tissue perfusion in the gastrointestinal tract. Findings may initially show increased bowel sounds and then progress to the absence of bowel sounds. Eversion of the umbilicus and abdominal striae with distended abdominal veins may also be present.
4. Assess laboratory values.
Ascites formation is associated with hypoalbuminemia, which results from the liver’s decreased ability to synthesize albumin, leading to reduced colloidal oncotic pressure.
Interventions:
1. Monitor the patient’s intake and output.
Ascites is characterized by the accumulation of fluid in the abdomen. Monitoring the patient’s intake and output will help assess circulating volume status along with developing fluid shifts and response to the treatment regimen.
2. Evaluate and monitor the patient’s weight and abdominal girth.
Increasing weight and abdominal girth can indicate the progression of ascites. Increased abdominal pressure from excess fluid accumulation can result in gastrointestinal ischemia leading to decreased motility and paralytic ileus.
3. Provide supplemental oxygenation via nasal cannula.
Increasing fluid accumulation will increase pressure on the abdomen and chest, causing decreased tissue perfusion and respiratory distress. Supplemental oxygen can ensure adequate oxygen is distributed in the abdominal tissues.
4. Administer diuretics as indicated.
Diuretics can promote fluid excretion, reduce fluid accumulation and abdominal pressure, and resolve ineffective tissue perfusion in the gastrointestinal tract.
5. Restrict sodium and fluid intake as indicated.
Patients with ascites often develop hyperaldosteronism resulting in increased sodium reabsorption by the renal tubules. Sodium restriction is the standard medical management for ascites. Water restriction is essential if persistent hyponatremia is present.
Risk for Infection
The patient is at an increased risk of acquiring a health-care-related infection.
Nursing Diagnosis: Risk for Infection
Related to:
- Stasis of body fluid
- Chronic illness (i.e., cirrhosis, heart failure)
- Immunosuppression
- Invasive procedures
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will remain free from any infection.
- Patient will verbalize strategies to prevent infection.
Assessment:
1. Note the onset of abdominal pain or discomfort.
Patients with cirrhosis do not always complain of abdominal pain/discomfort, depending on the degree of ascites. New abdominal pain/discomfort onset may indicate a worsening condition such as spontaneous bacterial peritonitis.
2. Monitor temperature.
Fever may indicate infection but may not always be present in patients with immunocompromised states.
3. Assess lab values.
Monitor CBC, especially WBC with differential count, peritoneal fluid culture studies, and CRP levels for signs of infection.
Interventions:
1. Maintain a sterile technique for invasive procedures.
Maintaining sterile techniques in invasive procedures such as IV insertion, urinary catheter insertion, and some wound care reduces cross-contamination and the risk of healthcare-associated infections.
2. Obtain specimens for culture and sensitivities, as indicated.
Identifying the causative agent helps select the appropriate antibiotic therapy for the patient.
3. Administer antibiotics as appropriate.
Administering antibiotics as prescribed destroys the pathogen and prevents worsening complications.
4. Instruct the patient and family on proper handwashing.
Handwashing is the simplest, most effective way to prevent infection.
5. Instruct on vaccinations.
Immunocompromised patients, especially those with chronic liver diseases, are recommended to receive annual influenza vaccines, pneumococcal vaccines, and hepatitis vaccinations.
References
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