Ascites

• The mechanisms responsible for the development of ascites are not completely understood.
• Portal hypertension and the resulting increase in capillary pressure and obstruction of venous blood flow through the damaged liver are contributing factors in the development of ascites.
• The nurse also assesses the patient's adherence to the treatment plan and the ability to buy, prepare, and eat appropriate foods.
• The nurse assesses the home environment and the availability of resources needed to adhere to the treatment plan, such as a scale to obtain daily weights, facilities to prepare and store appropriate foods, and resources to purchase needed medications.
• The nurse reinforces previous education and emphasizes the need for regular follow-up and the importance of keeping scheduled health care appointments.
• The vasodilation that occurs in the splanchnic circulation, which includes the arterial supply and venous drainage of the GI system from the distal esophagus to the middlerum, including the liver and spleen, is also a suspected contributing factor in the development of ascites.
• The failure of the liver to metabolize aldosterone increases sodium and water retention by the kidney, contributing to the movement of fluid from the vascular system into the peritoneal space.
• As a result of liver damage, large amounts of albumin-rich fluid, 20L or more, may accumulate in the peritoneal cavity as ascites.
• Ascites may also occur with disorders such as cancer, kidney disease, and heart failure.
• With the movement of albumin from the serum to the peritoneal cavity, the osmotic pressure of the serum decreases, combined with increased portal pressure, resulting in movement of fluid into the peritoneal cavity.
• Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites.
• Possible complications of diuretic therapy include fluid and electrolyte disturbances (including hypovolemia, hypo-kalemia, hyponatremia, and hypochloremic alkalosis) and encephalopathy.
• Ultrasound guidance may be indicated in some patients who are at high risk for bleeding because of an abnormal coagulation profile and in those who have had previous abdominal surgery and may have adhesions.
• Bed rest may be a useful therapy, especially for patients whose condition is refractory to diuretic agents.
• Daily weight loss should not exceed 1 kg (2.2 lb) in patients with ascites and peripheral edema or 0.5 to 0.75 kg (1.1 to 1.65 lb) in patients without edema.
• Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions.
• A sample of the ascitic fluid may be sent to the laboratory for cell count, albumin and total protein levels, culture, and other tests.
• In patients with ascites, an upright posture is associated with activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, causing reduced renal glomerular filtration and sodium excretion and a decreased response to loop diuretics.
• Large-volume (5 to 6 L) paracentesis is a safe method for treating patients with severe ascites.
• Fluid restriction is not attempted unless the serum sodium concentration is very low.
• Ammonium chloride and acetazolamide are contraindicated because of the possibility of precipitating hepatic encephalopathy and coma.
• When potassium stores are depleted, the amount of ammonia in the systemic circulation increases, which may cause impaired cerebral functioning and encephalopathy.
• Paracentesis was once considered a routine form of treatment for ascites, but it is now performed primarily for diagnostic examination of ascitic fluid; in treatment for massive ascites that is resistant to nutritional and diuretic therapy and is causing severe problems to the patient; and as a prelude to diagnostic imaging studies, peritoneal dialysis, or surgery.
• Encephalopathy may be precipitated by dehydration and hypovolemia.
• The patient may be short of breath and uncomfortable from the enlarged abdomen; striae and distended veins may be visible over the abdominal wall.
• Umbilical hernias also occur frequently in those patients with cirrhosis.
• Fluid and electrolyte imbalances are common in patients with ascites.
• The presence and extent of ascites are assessed by percussion of the abdomen.
• When fluid has accumulated in the peritoneal cavity, the flanks bulge when the patient assumes a supine position.
• TIPS is a second-line therapy for refractive ascites that continues to occur despite medical management.
• Patients considered candidates for liver transplantation may be referred for TIPS if paracentesis is contraindicated.
• The home visit enables the nurse to assess changes in the patient's condition and weight, abdominal girth, skin, and cognitive and emotional status.
• A referral for transitional, home, or community-based care may be warranted, especially if the patient lives alone or cannot provide self-care.
• In patients with ESLD, some with refractory ascites may be candidates for peritoneal catheters for palliation.
• The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of hepatic encephalopathy.
• The patient treated for ascites is likely to be discharged with some ascites still present.
• Nursing measures for a patient with ascites from liver dysfunction include assessment and documentation of intake and output, abdominal girth, and daily weight to assess fluid status.
• The nurse closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion.
• This procedure is rarely used due to the availability of newer, more effective therapies such as TIPS.
• Before hospital discharge, the nurse educates the patient and family about the treatment plan, including the need to avoid all alcohol intake, adhere to a low-sodium diet, take medications as prescribed, and check with the primary provider before taking any new medications, including OTC and herbal preparations.