MANAGEMENT AND CARE OF

PATIENTS WITH ASCITES

PREPARED BY NISHA THOMAS

MSPU
 ASCITES
DEFINITION
Ascites is the abnormal buildup of fluid in the abdomen.
Technically, it is more than 25 mL of fluid in the peritoneal
cavity. The pressure blocks blood flow in the liver, which over
time keeps your kidneys from removing excess salt from your
body. This, in turn, causes fluid to build up.
CAUSES
 SYMPTOMS
Ascites is usually accompanied by a feeling of fullness, a ballooning belly,
and rapid weight gain. Other symptoms often include:
 Shortness of breath
 Nausea
 Swelling in legs and ankles
 Indigestion
 Vomiting
 Heartburn,
 Bloating
 Loss of appetite
 Fever
 Hernia
 Abdominal pain
If you have ascites, it’s often a sign of liver failure and occurs most often with
cirrhosis.
 ASSESSMENT
Before one can be diagnosed of having this condition the above
mentioned symptoms must set in one way or the other. The
following tests may also be conducted to assess the liver and
kidneys
• 24 hours urine collection
• checking of electrolyte levels
• kidney function test
• urinalysis etc.
Ascites exists in three grades:
Grade 1- mild, only visible on ultrasound
Grade 2-detectable with flanks budging and shifting dullness
Grade 3-directly visible, confirmed with the fluid wave test
 DIAGNOSTIC EVALUATION

 Ultrasound abdomen
 Physical examination
 CT scan abdomen
 A complete blood count, Coagulation abnormalities (prothrombin time)
may be abnormal because of liver dysfunction and inadequate production
of clotting proteins.
 For diagnostic purposes, a small amount (20cc, less than a tablespoon, for
example) may be enough for adequate testing. Larger amounts of up to a
few liters (large volume paracentesis) can be withdrawn if needed to
relieve symptoms associated with abdominal ascites.
 MANAGEMENT
 Diet: Managing ascites in patients with cirrhosis typically involves limiting
dietary sodium intake and prescribing diuretics (water pills). Restricting
dietary sodium (salt) intake .
 Medication: Diuretics increase water and salt excretion from the kidneys.
The recommended diuretic regimen in the setting of liver related ascites is
a combination of spironolactone (Aldactone) and furosemide (Lasix).
Single daily dose of 100 milligrams of spironolactone and 40 milligrams of
furosemide is the usual recommended initial dosage.
 Therapeutic paracentesis:
For patients who do not respond well to or cannot tolerate the above
regimen, frequent therapeutic paracentesis (a needle carefully is placed
into the abdominal area, under sterile conditions) can be performed to
remove large amounts of fluid. A few liters (up to 4 to 5 liters) of fluid can be
removed safely by this procedure each time.
 Liver transplant: Finally, liver transplantation for advanced cirrhosis may
be considered a treatment for ascites due to liver failure. Liver transplant
involves a very complicated and prolonged process and it requires very
close monitoring and management by transplant specialists.
 NURSING INTERVENTION
 Instruct patient regarding fluid restrictions as appropriate to help reduce
extracellular volume. For some patients, fluids may need to be restricted
to 1000ml per day.
 Restrict sodium intake.
 Instruct patient to take diuretics as prescribed. Diuretic therapy may
include several different types of agents for optimal therapy, depending
on the acuteness or chronicity of the problem.
a. For chronic patients, compliance is often difficult for patients trying to
maintain a normal lifestyle.
b. For acute patients ; consider admission to acute care setting for
hemofiltration or ultrafiltration. This is a very effective method to draw
off excess fluid.
 Weigh daily
 Measure abdominal girth every 8 hrs, marking level of measurement.
 Assist with repositioning every 2 hours if patient is not mobile.
NURSING INTERVENTION WITH
RATIONALE
 Complete vitals and respiratory assessment
Note impaired gas exchange and compromised respiratory function
Assess for decreased or labored breathing
 Monitor fluid and electrolyte balance: Daily weights, Assess for JVD [jugular vein
distension]
Liver impairment may also affect renal function. Ascites and dependent edema
may be indicators of hyponatremia.
Increasing weight and blood pressure may indicate vascular congestion
Decrease in weight and blood pressure may indicate effectiveness of
interventions
 Initiate bleeding precautions per facility protocol: No straight razors, Use soft
toothbrush and good oral hygiene, Use stool softeners to avoid straining with
bowel movements.
Coagulation chemicals such as prothrombin and fibrinogen. Damage to the liver
may alter the production of these chemicals and increase risk of bleeding.
 Promote rest to conserve energy
Impaired liver function can cause the patient to be easily fatigued. Encourage
rest periods and cluster care to conserve energy for nutrition and self-care.
CONTINUED….
 Assist with paracentesis as necessary
If ascites progresses, it may be necessary to perform paracentesis to
drain the abdominal fluid. Assist with set-up and positioning of
patient, post-procedure site assessments and monitoring.
 Administer medications appropriately: Diuretics, Lactulose, Analgesics,
Blood products, Vitamin K
Diuretics- are often given to manage the accumulation of fluid and
edema
Lactulose- a man-made sugar that is given to help reduce the amount
of ammonia in the blood and prevent hepatic encephalopathy
Analgesics- given to manage pain; avoid acetaminophen
Blood products- excessive bleeding and complications following
surgery may require blood transfusions
Vitamin K- helps to promote clotting and avoid complications from
bleeding
 Provide adequate nutrition and education, encourage lifestyle changes
Malnutrition is often a complication of liver disease but may go
unnoticed due to increase in weight. Encourage and educate patient
to maintain diet low in sodium and fat.
Avoid alcohol, seek treatment for alcohol dependence.