Background

I think ascites is a special case in this Medical & Geriatric ward, because I saw this only one case of ascites in this four weeks practicum. And it is my first time that care patient with ascites. Therefore, I interest and choose this case for studying the nursing care of ascites.

In this total patient care study, I will talk about the information and relevant clinical data about this case, the pathophysiology of ascites, the nursing assessment, care plan within patient hospitalize period 20-21/09/2010, plan for future management, and what I learn from this case.

Case presentation

Patient X is 72-year-old male. He lives in old age home, chair bound for activities of daily living. He is dependent Comprehensive Social Security Assistance, exsmoker and exdrinker. He was admission to Accident & Emergency at 20/09/2010. He complained that increased abdominal distension for 2 days, poor appetite, shortness of breath. Physcial condition: conscious, SaO2 95% under room air, afebrile, chest clear, no ankle edema. His primary diagnosis is cirrhosis and gross ascites. He has chronic renal impairment, diabetes mellitus, alcoholic cirrhosis of liver, and chronic ascites. Last time admitted from 05-07/09/2010 for ascites, therapeutic abdominal tap was done and 1.3L ascites fluid was removed.

Ascites is an accumulation of extracellular fluid in the peritoneal cavity abnormally. It is the most common major complication of portal hypertension following liver cirrhosis. Blocking the blood flow through the liver sinusoids to hepatic veins and vena cava lead to increased pressure in the portal venous system.

It results in plasma leaks out directly from the liver capsule and the congested portal vein into the peritoneal cavity. In addition, hepatocellular damage reduces the liver’s ability to synthesize normal amounts of albumin, which may deteriorate by leakage of protein in ascites. The evidence of hypoalbuminemia shows in the blood test that the albumin was 24g/L, which is a low level. Adlosterone cannot activate by liver to stimulate the kidneys to retain sodium and water due to hepatocellular damage. Thus, sodium and water are still retention, and the volume of peritoneal cavity fluid grows continue.

In this case, the medical management can be performed to patient X should be paracentesis or abdominal tap. This procedure involves using a thin needle to pull ascites fluid from the abdomen (George & Longstreth, 2009). Large-volume paracentensis repeated done in combination with Albumin administered intravenously, which can avoid a sudden drop in blood flow in the arteries and to replace each liter of removed ascitic fluid. The physician prescribed IV administration of Albumin 40g after tapping and 30g. 10500ml milk like in color of ascites fluid was removed. If ascites is recurrent, therapeutic abdominal tap may need to be done every two weeks or more frequently, and need to remove up to 10 liters ascites fluid (Cirrhosis – Ascites). Ascitic fluid analysis also done before for provides a sample of fluid for analysis, which help for determine the underlying cause of the ascites. No malignant cell was found.

An abdominal x-ray and ultrasonography study was done to comfier the presence of ascites. It may locate fluid in the peritoneal cavity. The result did not show dilated bowel.

A low sodium and protein diet with restriction of fluids 1L per day. Edema in the form of ascites brings about shallow breathing and impaired gas exchange, as a result of respiratory compromise. We need to Promote and maintain an effective breathing pattern, Arterial blood gas analysis and pulse oximetry monitor every four hours were ordered. Potassium- sparing diuretic Frusemide tablet 40mg twice a day was prescribed.

Nursing assessment

In abdominal assessment, inspect for skin integrity (pigmentation, lesions, scars, veins, and umbilicus, etc), contour (flat, rounded, etc), distension, respiratory movement, visible peristalsis, and pulsations.

Then to auscultation of the abdomen, warmed the stethoscope and the hands, light pressure act on the stethoscope is sufficient to detect bowel sounds and bruits.

Then perform percussion of the abdomen; abdominal percussion is aimed at detecting fluid in the ascites, gaseous distension, and masses within the abdomen. Percuss lightly on abdomen according to auscultation site at each abdominal guardant. The sound will be dull if the ascites is presence. Measure the abdominal girth circumference. Assess the amount of distress leaded by the ascites that ask the patient whether the fluid is interfering with sleeping, eating, and breathing (Head-To-Toe Assessment (R. Abdomen), 2008).

Nursing diagnosis

Excess fluid volume and deficient fluid volume related to fluid shifts secondary to portal hypertension, hypoalbuminemia. It is a combination of volume problem for patient with ascites.

The expected outcomes of this care plan are that a normal balance of fluid in the peritoneal cavity will be maintained as evidenced by normal serum albumin levels, without of hypovolemia, decreased abdominal girth, and normal blood pressure measurement. Electrolyte or acid- base are balance.

For nursing intervention, monitor the intake and output of patient daily, and record the IO chart. Output should be equal to or exceed intake. Strictly restrict the patient’s fluid intake. If possible, administer medication with meals, so mealtime fluids can be used for taking medications. Assess the patient’s dietary intake and habits that may lead to fluid retention. Limit high sodium intake, because it can lead to increased water retention. Administer albumin and diuretics as physician prescribed. Aspirin and nonsteroidal anti-inflammatory drugs may inhibit prostaglandin synthesis and impair sodium excretion by the kidney. Thus, it needs to avoid administering them. Weight the client and measure the patient’s abdominal girth daily. Closely monitor the patient after paracentesis procedure. To ensure the client has tolerated the procedure well, check the vital signs frequently. Check the dressing carefully to ensure that there are no losing excessive amounts of fluid. Use a pouch to collect leaking fluid if necessary.

Ineffective breathing pattern related to increased intra-abdominal pressure on the diaphragm.

The expected outcomes of this care plan are that the patient express relief of feelings of faulty breathing pattern as a result of no shortness of breath and the presence of normal respiratory excursion. Patient has a normal respiratory rate, compared with baseline. (Lynda juall carpenito-moyet)

For nursing intervention, position the client in a high-Fowler position with an arm supported with pillows. It can facilitate breathing and relieves the pressure acting on diaphragm. “Monitor the client’s respiratory status (crackles and increased respirations) for the development of atelectasis or pneumonia to identifies fluid in lungs.” Encourage the patient to deep breathe and cough. Use an incentive spirometer to maintain and monitor the respiratory function. If the cough does not loosen to expectorate reparatory secretion, patient can receive ultrasound treatment

For improving gas exchange, administer oxygen and blood products as ordered.

Teach the patient some breathing techniques, such as pursed-lip breathing to overcome poor breathing patterns (Lynda juall carpenito-moyet).

To evaluation the outcome, treatments of ascites enable the client to breath with minimal difficulty.

Imbalanced nutrition: less than body requirements related to increased pressure on stomach and intestines, feeling of fullness, poor appetite.

The expected outcomes of this care plan are that patient X has appetite and he can keep or increase body weight to an ideal weight and consume sufficient nutrients. Identify deficiencies in daily intake.

For nursing intervention, measure the body weight daily to monitors the weight gain or loss. “Monitor hemoglobin, hematocrit, albumin, total protein values for monitoring the intake of nutrients, presence of anemia, and colloidal osmotic pressure.” Offer and encourage oral hygiene before meals, because poor oral hygiene may cause bad odor and taste, which can reduce appetite. Encourage the patient to rest before meals due to fatigue may decrease appetite and ability to eat. (Lynda juall carpenito-moyet) Provide small, frequent meals for patient instead of few large ones, because even distribution of intake can help to prevent feeling full and ensures enough nutritional intake. Determine food preferences and selected low or no protein and low salt (no more than 1500 mg/day of sodium). If possible, encourage the patient’s relative to bring permitted foods from home. Prevent constipation to reduce abdominal pressure and fullness. Administer Lactulose liquid 20mal three times a day as physician ordered.

Plan for management after discharge, patient x should back to the old age home and have follow up by community geriatric assessment service. Recommend short the follow up clinically admission if symptomatic ascites occur. Refer PCU home care nurse for visiting and symptom assessment, and admission clinically for symptom management.

Learning points

After this total patient care study, I have learnt that more understand the cause and care of ascites. And know that to provide a holistic care not only physical nursing care, but also we need to care the patient mental, social, finical condition, and discharge planning Make sure patient can have a complete care after discharge.

Word count: 1452

Black, J. M. & Hawks, J. H. (2009). Medical-Surgical nursing: Clinical management for positive outcomes. Missouri: Saunders.

George F. Longstreth MD

http://www.healthline.com/adamcontent/ascites#ixzz11s5PVSzi

Head-To-Toe Assessment (R. Abdomen)

(Head-To-Toe Assessment (R. Abdomen), 2008)

(Cirrhosis – Ascites).

http://www.healthcentral.com/ency/408/guides/000075_11.html