Ascites Nursing Diagnosis & Care Plan

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. Heart failure, tuberculosis, chronic alcohol use, IV drug use, obesity, type 2 diabetes, and severe malnutrition are other causes that increase the risk of developing ascites.

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.

Patients experience progressive abdominal distension, which may or may not be associated with pain or discomfort, a sudden increase in weight, early satiety, and shortness of breath due to increased abdominal pressure. Symptoms vary depending on the condition that caused ascites.

On physical examination, nurses may observe shifting dullness while palpating the abdomen. Paracentesis with ascitic fluid analysis is a cost-effective and quick method to identify the cause of ascites. Ultrasound and CT scans may also be used to detect fluid and the presences of masses.

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 Care Plans Related to 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.


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.


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

  1. Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice. (14th ed.). Lippincott Williams & Wilkins.
  2. Castro D, Patil SM, Keenaghan M. Arterial Blood Gas. [Updated 2022 Sep 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536919/
  3. Chiejina M, Kudaravalli P, Samant H. Ascites. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470482/
  4. Doenges, M. E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. (10th ed.). F.A. Davis.
  5. Jameson, L.J., et al. (2018). Harrison’s principles of internal medicine. (20th ed.). McGraw Hill.
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Maegan Wagner, BSN, RN, CCM

Maegan Wagner is a registered nurse with over 10 years of healthcare experience. She earned her BSN at Western Governors University. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public.