Ascites Nursing Review

Ascites is the accumulation of fluid in the peritoneal cavity that causes abdominal distention. It is a common complication of cirrhosis but can also occur in other conditions such as cancer, heart failure, tuberculosis, and dialysis. Ascites can lead to significant problems for your patient, including respiratory compromise, hypotension, and even peritonitis. Want to listen to this info instead? Click here!

Anatomy review

The key anatomical structure in ascites are: 

• The liver
• Hepatic veins – The hepatic veins are three sets of veins that drain blood from the liver, moving it into the inferior vena cava
• Portal vein – The main vein leading into the liver, the portal vein provides about two-thirds of the liver’s blood supply. Blood coming through the portal vein carries oxygen as well as nutrients from the intestines.
• Hepatic artery – The hepatic artery provides about one-third of the liver’s blood supply. Blood in the hepatic artery comes from the heart and is full of oxygen.

The pathophysiology of ascites

In patients with cirrhosis, the liver becomes scarred, which leads to hypertension in the portal vein (a condition called portal hypertension). Portal hypertension is present when there is a difference in pressures between the portal vein and the inferior vena cava and/or hepatic vein. Usually, this difference is less than or equal to 5 mmHg, so a pressure gradient of 6 mmHg or higher between these vessels is indicative of portal hypertension. When the gradient passes 10 mmHg, this is considered clinically significant and the patient will show signs and symptoms related to portal hypertension (such as ascites).

The most recent and relevant theory for how ascites forms is the arterial vasodilation hypothesis. 

This theory suggests that portal hypertension leads to arterial vasodilation due to increased nitric oxide synthesis. Vasodilation causes a relative hypovolemia, meaning the amount of blood volume is deficient relative to the size of the vascular bed. Over time this leads to activation of the RAAS pathway, which leads to sodium retention and an increase in intravascular volume. This increased volume spills over into the peritoneal cavity, causing ascites.

Another factor that contributes to the development of ascites in patients with liver disease is hypoalbuminemia. Recall that albumin is a protein made in the liver, so patients with liver disease tend to have low albumin levels. This leads to reduced oncotic pressure in the vasculature, which, when combined with portal hypertension, causes fluid to “leak” into the abdominal cavity.

Signs and symptoms of ascites

• Abdominal distension with or without abdominal pain. Generally, larger volumes of fluid cause more pain.
• Weight gain due to hypervolemia.
• Early satiety due to increased pressure in the abdomen.
• Shortness of breath due to increased pressure in the abdomen.
• Everted umbilicus (an “outie” belly button).
• Diminished bowel sounds.
• Presence of a “fluid wave” detected by having an assistant (or patient) press down on the midline of the abdomen. The examiner taps one side and feels for fluid movement on the other.
• Dullness on percussion of the flanks
• If caused by cirrhosis, other signs of liver disease are often present such as spider angioma, caput medusae, palmar erythema, and jaundice.

Tests for ascites

The most cost-efficient and easy way to test for ascites is with ultrasound, though CT or MRI may be used, especially if the cause is unknown. The fluid from the abdominal cavity may also be evaluated to help determine the cause of ascites and to rule out peritonitis.

Complications of ascites

• Respiratory compromise – If the abdomen is severely enlarged, patients can suffer respiratory compromise and require oxygen therapy. Many times patients are tachypneic with shallow breaths. If the patient tires out, respiratory failure can result.
• Hypotension – If enough fluid leaks out of the vascular space and into the peritoneal cavity, hypotension can result.
• Peritonitis – Peritonitis can occur when the ascitic fluid becomes infected. Signs of peritonitis include a rigid and very painful abdomen, fever, and elevated WBC.
• Pleural effusion – Ascitic fluid can seep into the peritoneal space, causing a pleural effusion, which drastically affects lung volumes and can lead to significant respiratory compromise.
• Abdominal hernias – Abdominal hernias can occur in patients with ascites due to a combination of factors. Decreased nutritional intake leads to weakened muscles, which, when combined with increased abdominal pressure, can lead to the development of hernias. Hernias can become strangulated or even rupture, which leads to significant complications such as septic shock and death.

Treatment for ascites

Lifestyle therapy – Lifestyle therapies for a patient with cirrhosis-related ascites include avoiding alcohol (to prevent further liver damage) and following a low-sodium diet (to reduce fluid retention). 

Pharmacology – Diuretics can help remove the excess fluid associated with ascites. Furosemide and spironolactone are commonly utilized together. Albumin may be utilized in some cases to help increase oncotic pressure and pull fluid back into the vascular space.

Paracentesis – Patients with large-volume ascites (a condition called “tense ascites”) have excess fluid removed via paracentesis. In many cases, the fluid is evaluated in the lab to determine the cause of the ascites (if unknown) and to rule out peritonitis. Paracentesis involves inserting a needle into the peritoneal cavity to drain the excess fluid. Local anesthetics are utilized to make the procedure as painless as possible, and most patients experience quick relief of symptoms once the fluid is removed. However, paracentesis complications can occur. These include bowel perforation, infection, electrolyte imbalances, pleural effusion, and bleeding.

Ascites Case Study and Care Plan

Physical Assessment – Bob appears jaundiced with yellowing of the skin and sclera. He complains of abdominal discomfort and distention. His abdomen is grossly distended with shifting dullness noted on percussion. Auscultation reveals diminished bowel sounds. He is tachypneic with a respiratory rate of 26 breaths per minute and has diminished breath sounds at the bases. HR is 92 bpm, BP is 127/63, SpO2 is 89% on RA, temp 36.9 C. Bob tells you he started feeling bad after enjoying fried chicken from his favorite fast food restaurant a few days ago.

Labs – Laboratory findings show elevated liver enzymes, low albumin levels, and prolonged prothrombin time.

Diagnosis – The MD diagnoses Bob with tense ascites secondary to cirrhosis and portal hypertension.

Treatments – Treatments for Bob include oxygen therapy, paracentesis, and pain medication prn.

🩺 Nursing Care Plan 

Diagnosis – Impaired gas exchange related to ascites aeb SpO2 89% on RA and RR 26 bpm.

SMART Goal – Bob will achieve SpO2 > 95% within one hour.

Interventions – Administer oxygen as needed, maintain position of comfort, monitor SpO2 and respiratory rate, prep patient for therapeutic paracentesis.

Diagnosis – Risk for infection r/t paracentesis

SMART Goal – Bob will show no signs of infection by time of discharge.

Interventions – Maintain clean and dry dressing at paracentesis puncture site, perform hand hygiene, teach patient how to properly perform hand hygiene, monitor dressing for purulent drainage, monitor Bob for signs of infection (fever, elevated WBC, tachypnea, tachycardia)

Diagnosis – Knowledge deficit r/t dietary guidelines aeb patient statement he ate fried chicken from a fast food restaurant

SMART Goal – Bob will state three types of food to avoid when following a low sodium diet by time of discharge.

Interventions – Assess Bob’s readiness to learn, assess what Bob already knows about a low sodium diet, educate Bob on high-sodium food to avoid, educate Bob on connection between sodium and fluid retention

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References:

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Chiejina, M., Kudaravalli, P., & Samant, H. (2024a). Ascites. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK470482/

Chiejina, M., Kudaravalli, P., & Samant, H. (2024b). Ascites. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK470482/

Cleveland Clinic. (2022, October 2). Portal Hypertension: Common Symptoms & Treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/4912-portal-hypertension

Jackson, W. (2024, May). Overview of Blood Vessel Disorders of the Liver – Liver and Gallbladder Disorders. Merck Manual Consumer Version. https://www.merckmanuals.com/home/liver-and-gallbladder-disorders/blood-vessel-disorders-of-the-liver/overview-of-blood-vessel-disorders-of-the-liver

Johns Hopkins Medicine. (2022, April 19). Portal Hypertension. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/portal-hypertension

Li, J., Shao, X., & Cheng, T. (2020). Inguinal hernia repair in cirrhotic patients with ascites. International Journal of Abdominal Wall and Hernia Surgery, 3(3), 87–93. https://journals.lww.com/rhaw/fulltext/2020/03030/inguinal_hernia_repair_in_cirrhotic_patients_with.2.aspx

Runyon, B. (2024a, March). Evaluation of adults with ascites. UpToDate. https://www.uptodate.com/contents/evaluation-of-adults-with-ascites#H341237666

Runyon, B. (2024b, July). Ascites in adults with cirrhosis: Initial therapy – UpToDate. UpToDate. https://www.uptodate.com/contents/ascites-in-adults-with-cirrhosis-initial-therapy?search=ascites%20treatment&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1

Shah, R. (2023, May 30). Ascites. MedScape. https://emedicine.medscape.com/article/170907-overview?form=fpf#a5

Tage-Jensen, U., Henriksen, J. H., Christensen, E., Widding, A., Ring-Larsen, H., & Christensen, N. J. (1988). Plasma catecholamine level and portal venous pressure as guides to prognosis in patients with cirrhosis. Journal of Hepatology, 6(3), 350–358. https://doi.org/10.1016/s0168-8278(88)80053-9

The Surgery Group. (2018, January 25). What Happens when a Hernia Goes Untreated? | The Surgery Group. The Surgery Group. https://thesurgerygroup.com/what-happens-when-a-hernia-goes-untreated/

Last Updated on August 22, 2024 by Maureen Osuna, MSN, RN