Ascites Nursing Diagnosis and Nursing Care Plan

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

The classical sign of ascites is pronounced sudden increase in abdominal girth. Other associated clinical manifestations are as follows:

• 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.

The risk factors of ascites include:

• 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 Interventions	Rationales
Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g., denial of diagnosis or poor lifestyle habits).	To address the patient’s cognition and mental status towards the new diagnosis and to help the patient overcome blocks to learning.
Explain what ascites is and its symptoms. Avoid using medical jargons and explain in layman’s terms.	To provide information on ascites and its pathophysiology in the simplest way possible.
Educate the patient about his/her ascites treatment plan.  If patient is for medication therapy, explain each drug that will be administered, its purpose, risks, and possible side effects. If the patient is for surgery, explain the procedure to the patient.	To give the patient enough information on the treatment plan, so that he/she can provide or deny an informed consent.
Demonstrate how to perform input and output monitoring. Educate the patient on what water restriction and salt intake limit mean.	To empower patient to monitor his/her own intake and output monitoring. Sodium restriction of 20-30 mEq/dL in often included in the treatment plan for ascites.
Inform the patient the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) for supportive care, such as pain medications, anti-emetics and bowel medications. Explain how to properly self-administer each of them. Ask the patient to repeat or demonstrate the self-administration details to you.	To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.
Use open-ended questions to explore the patient’s lifestyle choices and behaviors that can be linked to the development of ascites. Teach the patient on how to modify these risk factors (e.g. smoking, excessive alcohol intake, low fiber and high fat diet, obesity, sedentary lifestyle, etc.)	To assist the patient in identifying and managing modifiable risk factors related to ascites.

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 Interventions	Rationale
Explore the patient’s daily nutritional intake and food habits (e.g., mealtimes, duration of each meal session, snacking, etc.)	To create a baseline of the patient’s nutritional status and preferences.
Create a daily weight chart and a food and fluid chart. Discuss with the patient the short term and long-term nutrition and weight goals.	To effectively monitory the patient’s daily nutritional intake and progress in weight goals.
Help the patient to select appropriate dietary choices to increase dietary fiber, caloric intake and alcohol and coffee intake.	To promote nutrition and healthy food habits, as well as to boost the energy levels of the patient. Dietary fiber can help reduce stool transit time, thus promoting regular bowel movement.
Refer the patient to the dietitian.	To provide a more specialized care for the patient in terms of nutrition and diet in relation to newly diagnosed ascites.
Symptom control: Administer the prescribed medications for abdominal cramping and pain, such as antispasmodics. Promote bowel emptying using laxatives as prescribed.	To reduce cramping, relieving the stomach pain and helping the patient to have a better appetite. To treat persistent and/or severe constipation, which is a common symptom of ascites.

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 Interventions	Rationales
Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.	To create a baseline of activity levels and mental status related to fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with 60-90 minutes of undisturbed rest.	To gradually increase the patient’s tolerance to physical activity.
Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.	To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.
Refer the patient to physiotherapy / occupational therapy team as required.	To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.
Educate the patient on energy conservation techniques, which include:Working or moving at an even pacePushing rather than pullingSliding rather than pullingSitting to perform some tasksUsing aids such as wheeled carts for shopping, laundry, and carrying thingsPositioning frequently used items within reachResting for about an hour or two post-meals before doing an activity	Energy conservation techniques help reduce the body’s demand for oxygen, which allows the patient to accomplish more ADLs.

Ascites Nursing Care Plan 4

Acute Pain

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.

Desired Outcomes:              

• 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 Interventions	Rationale
1. Perform a comprehensive assessment of the patient’s pain by determining the: Location of pain Characteristics of pain Onset of pain Duration of pain Frequency of pain Quality of pain Severity of pain	The patient’s report of pain gives a reliable source of information that can help the nurse properly plan an optimal pain management strategy. The following can help the nurse during the pain assessment: Ask the patient about the provoking factors which include the factors that make the pain better or worse.Ask the patient about the quality and characteristics of pain.Ask the patient about the region or the location of the pain.Ask the patient about the severity of pain by asking the pain scale from 1 as the lowest and 10 as the highest.
2. Use a chart or drawing to assess the location of pain and ask the patient to point to the site that feels discomfort.	Using charts and drawings will help the nurse easily determine the specific pain locations. Using charts and drawings will help the patient, especially patients with a limited vocabulary to clarify and pinpoint the exact location of the pain.
3. Ask the patient about his or her perception of pain and ascites.	Asking the patient about the pain history will help in providing the patient an opportunity to express the pain in their own words. The patient’s perception of pain and ascites should also be asked to evaluate the patient’s understanding of the pain and the condition.
4. Check and monitor for any changes in the patient’s vital signs.	The nurse needs to monitor the patient’s vital signs because vital signs are usually affected by the patient’s pain.
5. Instruct and teach the patient about relaxation and breathing techniques.	The relaxation and breathing techniques will help the patient to produce a sense of tranquility that will help the patient to reduce pain related to tension and stress.
6. Promote and provide periods of rest for the patient and always maintain a quiet and resting environment.	Having enough rest is important for the patient because fatigue can contribute to pain. A room with quiet, darkened room with minimal noise and interruptions will help the patient to have enough rest and will help in reducing pain.
7. Provide pain relief medication to the patient as ordered and evaluate the pain medications’ effectiveness and observe the side effects.	Pain medications have different effects on a patient’s metabolism and the efficacy of the medication should properly be evaluated. Checking and monitoring the side effects is important to maintain the comfort and safety of the patient.
8. Teach the patient about non-pharmacological pain management that includes physical, cognitive-behavioral strategies, and lifestyle pain management.	Non-pharmacological pain management will help in decreasing the patient’s fear, distress, and anxiety. Non-pharmacological pain management will help in reducing pain and will provide a sense of control for the patient.
9. If the patient reports pain, respond immediately and do not delay intervention.	A quick response to pain will reduce the patient’s anxiety and will promote trust.
10. Evaluate the effectiveness of the interventions and medications as ordered.	The effectiveness of the pain medication should be evaluated individually for patients because medications are absorbed ad metabolized differently.

Ascites Nursing Care Plan 5

Ineffective Breathing Pattern

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.

Desired Outcomes:

• 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 Interventions	Rationale
1. Check and record the patient’s respiratory rate and depth and assess for signs of a compromised respiratory system.	The nurse should keep in mind that an adult has an average respiration rate of 10 to 20 breaths per minute. Assessing for any alteration in breathing pattern and signs of the compromised respiratory system is important to avoid complications.
2. Check and monitor the patient’s arterial blood gas level(ABGs).	To help the nurse in checking the patient’s oxygenation and ventilation status it is important to check the arterial blood gas level. Arterial blood gas (ABG) requires a blood sample from the patient’s artery that will measure the levels of oxygen and carbon dioxide in the patient’s blood.
3. Check and monitor the patient’s breathing pattern for the presence of unusual breathing that is caused by ascites.	Unusual and abnormal breathing patterns may indicate a disease process and dysfunction and indicate a problem in the patient’s lungs and airways.
4. Check the patient breath sounds by auscultation at least every 4 hours.	Auscultation is done to detect adventitiously and decreased breath sounds which include: BronchospasmExpiratory grunt RalesRhonchiStridorwheezes
5. Check and note for the use of accessory muscle and observe for retractions and flaring of the patient’s nostrils.	When lung compliance decreases the work of breathing increases. Using of accessory muscle signifies that the forced expiratory volume is decreased.
6. Check for the presence of paradoxical motion or diaphragmatic fatigue or weakness.	An inward versus outward movement during inspiration or paradoxical movement of the abdomen indicates respiratory fatigue and weakness.
7. Use a pulse oximeter to check the patient’s oxygen saturation and pulse rate.	To detect alterations in oxygenation pulse oximetry is helpful. Pulse oximetry is a non-invasive procedure that will help in estimating oxygenation that will allow the detection of sudden changes in a patient’s clinical status.
8. Check for the patient’s capacity to mobilize secretions. Check for the presence of sputum including the amount, color, and consistency.	If the patient is not capable of mobilizing secretion the patient’s breathing pattern may be altered.
9. Assess and evaluate the patient’s level of anxiety and note the changes in the patient’s level of consciousness.	It is important to check the patient’s level of anxiety because anxiety may cause frightening and may worsen the patient’s hypoxia. The patient’s level of consciousness may be changed, and restlessness, confusion, and irritability may happen. These changes may is an indicator of insufficient oxygen to the patient’s brain.
10. Assess and note the patient’s skin color, temperature, and capillary refill. Observe the patient’s central nervous versus peripheral cyanosis.	If the patient is experiencing a lack of oxygen, the patient may experience cyanosis of the lips, tongue, and fingers. Cyanosis is the change in the patient’s body tissue color to bluish or purplish as a result of poor oxygenation in the patient’s blood.
11. Check the patient’s nutritional status including the weight, albumin level, and electrolyte levels.	Respiratory mass and strength may be reduced because of malnutrition which increases the risk of respiratory failure. A loss of appetite may be seen in patients with ascites that will affect the patient’s nutrition which includes weight, albumin level, and electrolyte levels.
12. Teach the patient the proper ways of doing pursed lip breathing, abdominal breathing, and relaxation techniques.	Pursed-lip breathing, abdominal breathing, and relaxation techniques will allow the patient to participate in maintaining his or her health status which will help in improving the patient’s ventilation.

Ascites Nursing Care Plan 6

Nausea

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.

Desired Outcomes:

• 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.

Ascites Nursing Interventions	Rationale
1. Check and identify the cause of nausea.	The nurse should assess the cause of nausea which will help the nurse choose the interventions that should be used. If the stimulus is eliminated, treatment may not be needed. Patients with ascites often experience nausea because of the fluids in the patient’s abdomen.
2. Identify the characteristics of nausea that includes: Previous history of nauseaDuration FrequencySeverityPrecipitating factorsMedicationsMeasure that is used to alleviate the problem	Proper assessment and evaluation of nausea will help the nurse to determine proper interventions that will help in decreasing or easing the problem.
3. Check and record the patient’s weight, hydration status, blood pressure, intake and output, and skin turgor.	The patient’s hydration and nutritional status may be affected by nausea and vomiting due to fluid loss.
4. Teach and assist the patient with proper oral hygiene.	Oral hygiene is important to facilitate and promote the patient’s comfort because anorexia and excessive salivation may happen to the patient because of nausea.
5.  Decrease and eliminate strong odors from the patient’s surroundings such as perfumes, dressing, and emesis.	Nausea may be triggered because of the strong and noxious odors in the patient’s environment.
6. Provide sufficient hydration and maintain a fluid balance for patients at risk.	Sufficient hydration and fluid balance are needed for patients experiencing nausea. Give the patient fresh water and oral fluids preferred by the patient to promote hydration.
7. Advise and instruct the patient to use non-pharmacological nausea control techniques that include relaxation, guided imagery, music therapy, distraction, or deep breathing exercises.	To alleviate nausea, non-pharmacological nausea control techniques are important and should be instructed to the patient to alleviate nausea.
8. Provide cold water, ice chips, ginger products, and bouillon if tolerated and appropriate for the patient.	These will help in the patient’s hydration. Ginger, cold water, ice chips, and other ginger products will relieve nausea.
9. Advise the patient to eat frequently with a small number of foods, and give foods like crackers or toast, bland simple foods such as broth, rice, and bananas.	Small frequent meals will help in maintaining the patient’s nutritional status.  Crackers, bland, and simple foods are needed when nausea is present to maintain nutrition.
10. Place the patient in an upright position when eating and 1 to 2 hours after eating.	Placing the patient in an upright position will decrease the risk of aspiration. Upright position also helps to facilitate tension of the abdominal muscles that will help improve breathing.
11. Give antiemetic medications as needed and as prescribed by the physician.	Anti-emetic medications are used to block the receptors that respond to neurotransmitter molecules that cause nausea and vomiting.
12. Instruct the patient and the caregiver about the proper fluid and dietary options for patients with ascites who are experiencing nausea.	The patient and the caregiver should promote hydration and nutritional status and acknowledge dietary points that should be considered to reduce nausea.
13. Instruct the patient to take the medications for ascites and nausea as prescribed by the physician properly.	It is important to instruct the patient to take the medication correctly and on time to reduce episodes of nausea.
14. Instruct and assist the patient to change position slowly and calmly.	An abrupt and gross movement may aggravate nausea in patients with ascites.
15. Evaluate the patient’s response to antiemetic medications and interventions.	Evaluation of the interventions will help in determining the effectiveness of interventions and medications.
16. Advise the patient and the caregiver to seek medical care if nausea develops or persists.	If the patient still experiences persistent vomiting may result in dehydration, electrolyte imbalance, and nutritional deficiencies.

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

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