- Excess Fluid Volume related to lower plasma colloidal osmotic pressure and Sodium and water retention as evidenced by Increased abdominal girth and Abdominal pain/discomfort
- Imbalanced Nutrition related to Abdominal distention and altered metabolism as evidenced by Bloating and lack of appetite
- Ineffective Breathing Pattern related to Increased abdominal pressure and Decreased lung expansion as evidenced by Shortness of breath/dyspnoea and Alterations in ABGs
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Difficulty breathing -Weight gain or swelling Objective data: -Shortness of breath, -Adventitious breath sounds -Abnormal electrolyte levels -High blood pressure -Increased central venous pressure -Jugular vein distention -Pulmonary congestion/edema | Excess Fluid Volume related to lower plasma colloidal osmotic pressure and Sodium and water retention as evidenced by Increased abdominal girth and Abdominal pain/discomfort | 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 | 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. | Patient manifested decreased abdominal girth. Patient reported decreased abdominal pain/discomfort. |
| Subjective data: Inadequate intake -Abdominal distention -Altered metabolism -Abdominal discomfort -Increased energy expenditure Objective data: -Abdominal cramping -Abdominal pain -Muscle wasting -Constipation -Bloating -Hypoactive bowel sounds -Nausea -Lack of appetite | Imbalanced Nutrition related to Abdominal distention and altered metabolism as evidenced by Bloating and lack of appetite | Patient will be able to identify nutritional requirements with appropriate food choices. Patient will report an increase in appetite and demonstrate an increase in muscle mass. | 1. Refer the patient to a dietitian. A carefully structured meal plan is essential to address nutrient deficits in patients with cirrhosis and ascites. Dietary counseling and nutritional support have been shown to increase nutritional intake and patient outcomes. 2. Encourage a high-protein diet and restrict sodium intake. A high protein diet and sodium restriction are considered standard practices for managing ascites. Protein intake of 1.2-1.5 g/kg/day is recommended. Even though sodium restriction should be restricted based on the patient’s urinary sodium excretion, a realistic goal in sodium restriction would be approximately 2 grams per day. 3. Incorporate branched chain amino acids. BCAAs have been shown to improve liver function, nutritional status, quality of life, and overall survival in patients who are malnourished due to cirrhosis. 4. Encourage small frequent meals and snacks. Patients with ascites tend to have poor tolerance to large meals due to increased abdominal pressure. 5-7 smaller meals and snacks are more tolerable. 5. Provide late-evening snacks. A late evening snack containing complex carbohydrates and protein is recommended to help compensate for the reduced glycogen storage and production and prevent muscle proteolysis in patients with cirrhosis and ascites. | Patient identified nutritional requirements with appropriate food choices. Patient reported increased appetite and demonstrated an increase in muscle mass. |
| Subjective data: -Difficulty breathing; shortness of breath or dyspnoea -Anxiety in relation to breathing Objective data: -Dyspnoea -Abnormal respiratory rate; tachypnoea or bradypnea -Poor oxygen saturation -Abnormal ABG results -Nasal flaring | Ineffective Breathing Pattern related to Increased abdominal pressure and Decreased lung expansion as evidenced by Shortness of breath/dyspnoea and Alterations in ABGs | 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 | 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 dyspnoea. 3. Prepare for TIPS procedure. Trans jugular 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. | Patient demonstrated effective respiratory pattern as indicated by a respiratory rate within 12-20 breaths/min with normal depth and absence of cyanosis. Patient expressed relieved from shortness of breath/dyspnoea. |