NORTHERN LUZON ADVENTIST COLLEGE

Artacho Sison, Pangasinan

Nursing Department

CASE ANALYSIS

MASSIVE ASCITES

Submitted By:

Kristelle P. Dacuscus

Submitted To:

Ms. Mae Allison Viernes RN., RM.

I. INTRODUCTION

Ascites refers to the abnormal (pathologic) build up of fluid in the peritoneal (abdominal) cavity.
Normally there should be almost no fluid here (i.e., surrounding the intestines and organs such as the liver
and spleen). Ascites occurs because of one of four general problems: 1) there is a disease in the peritoneal
cavity that is producing excessive fluid (e.g., infections or cancer); 2) there is fluid back up from the liver
or large blood vessels into the peritoneal cavity -- known as portal hypertension; 3) low protein state in the
body; and 4) miscellaneous.

II DEMOGRAPHIC INFORMATION

This is the case of Patient Z, a 31 years old male, single, born on July 29, 1978 and presently
residing at Bauang, La Union. He is engineering instructor in one of the college school in La Union. He
was admitted on November 25, 2009 @ 4:30 pm @ Ilocos Regional Training and Medical Center (ITRMC)
with the chief complaints of difficulty of breathing.

III. MEDICAL HISTORY

Past Medical History

This is the second time the patient was admitted @ ITRMC. Patient Z has a history of childhood
asthma, and was diagnosed with Diabetes Mellitus (DM) last year (2008) and with liver cirrhosis last
month (October 2009).

Present Medical History

The patient condition started about two weeks PTA where the patient went to the OPD @ ITRMC
regarding increased in the size of abdomen. Ultrasound findings revealed liver cirrhosis. He was given
spironolactone 100 mg 1 tab. OD and propanolol 10 mg 1 tab. OD for relief. A noticeable edema unto the
facial area with gradual enlargement of the abdomen where patient has episode of difficulty of breathing.
One day prior to admission, patient complaints of fever and chills (undocumented) where he has painful
urination. No medicines taken, no consult was done. Patient still have anasarca with difficulty of breathing.
Persistence of condition prompted. Consulted and hence admitted.
IV.SIMPLE PATHOPHYSIOLOGY (paradigm)

Predisposing Factors: Risk Factors:

>Age: 31 years old >lifestyle

(alcohol)

>Gender: Male >environment

>age

Blockage of blood flow to liver

sinusoids to the hepatic vein and vena cava

hydrostatic pressure in portal venous system

cirrhosis

portal pressure loss of plasma

protein

plasma leaks directly decongested portal vein oncotic pressure

in

to liver capsule vascular

compartment

hepatocellular damage peritoneal cavity

liver’s sensitization of vascular ability to hold

onto and/

normal amounts of albumin collect water

albumin level (15.45 g/L)

sodium & water retention

hypoalbuminemia

ASCITES & EDEMA

colloidal osmotic pressure -- intra-abdominal pressure in

the
abdomen

aldosterone secreation DOB (RR-30

bpm) -- skin impairment (edema,
kidney become stimulated ascites and itching)
V. NURSING CARE PLANS

Nursing Problem: Difficulty of breathing

CUES NURSING RATIONAL PLANNING INTERVENTIONS RATIONALE EVALUATI

DIAGNOSIS E ON
s> “Mahihirapan Ineffective Edema in the After 2 hours >Assessed for crackles and >identifies fluids Goal met. The
akong breathing form of of appropriate increased respiration. in the lungs. patient can
huminga,” as pattern r/t ascites, nursing now breathe
verbalized by pressure on besides interventions, easily without
the patient. diaphragm compressing the patient will complaints of
reduced lung the liver and breathe with >Placed the client in semi difficulty.
o> RR-30 bpm capacity thus affects minimal fowler’s position with arms >to relives
>nasal flaring secondary to its functions, difficulty. supported with pillows. pressure on
>use of ascites and may also diaphragm.
accessory edema. cause
muscles shallow
>anasarca breathing and >Maintained calm attitude
>ascites impaired gas while dealing with client
>(+) crackles exchange and to significant others. >to limit the level
upon resulting in of anxiety.
auscultation respiratory
compromise.
>Encouraged adequate rest
periods between activities.

>Instructed patient to avoid >to limit fatigue

overeating/gas-forming
foods.

>they can cause

abdominal
distention.
Nursing Problem: skin itching

CUES NURSING DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

s>"Makati Impaired skin integrity r/t When edema is After >kept the area clean and >to assists body’s Goal partially
yung balat skin itching, edema and present in the appropriate dry, prevent infection & natural process of met. The client
ko sa paa at ascites. liver disease, nursing stimulate circulation to has no complaints
kamay, pati the client is at interventions, surrounding areas.
repair. of itching and can
sa katawaan risk for the patient sleep without
ko kaya pag development of will maintain >encouraged >promotes interruption but
minsan hindi skin skin integrity ambulation/mobilization. circulation& still (+) jaundice
ako impairment and & without reduces risk of the skin &
nakakatulog possibly complaints of sclera, & (+)
ng maayos,” infected skin itching.
associated with anasarca.
as verbalized lesions. immobility.
by the
patient.
>maintained clothing and
>to minimize
o>disruption beddings dry. Removed
wet linens. itching. Moisture
of epidermis
potentiates itching.
>jaundice of
sclera and
skin >to minimize
>instructed to avoid itching and
>anasarca; activities that promotes vasodilation.
ascites sweating.

>kept nails short and

>prevents breaking
smooth. skin integrity when
scratching.
Nursing Problem: fluid retention

CUES NURSING DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

s> Fluid volume excess r/t Fluid volume After appropriate >Maintained accurate I&O. >decrease renal perfusion, Goal partially
“Nahihirapan excess fluid intake excess (FVE) nsg. Note decreased urinary output, cardiac insufficiency, and met. The patient
akong secondary to edema. occurs when Interventions, the (+) fluid balance, (intake fluid shift may caused has stabilized
huminga the body will demonstrate greater than output decreased urinary output & fluid volume as
dahil sa laki retains both stabilize fluid edema formation. evidence by
ng tyan ko,” water and volume as balance I&O, v/s
as verbalized sodium in evidence by >one liter of fluid retention within normal
by the similar balanced I&O, >Weighed as indicated. Be equals a weight gain of 22lbs. limits, but still
patient. proportions to v/s within alert for acute or sudden wt. (+) edema,
normal ECF. normal limits, gain. anasarca and wt.
o>edema, FVE is always and free from >help to decrease ascites and gain.
anasarca secondary to signs of edema. edema
an increase in >Followed sodium & fluid
total body restrictions.
>RR-30 bpm
water, because
both water and >fluid restrictions, as well as
>restlessness sodium extracellular shifts, can
concentration >given oral fluids & IVF as aggravate drying of mucous
>easy remains indicated with caution.
fatigaility membranes and patient may
essentially desire more fluids than are
normal and the . prudent.
excess volume
of fluid is
isotonic.

>promotes excretions of
>Administered diuretics as fluids.
ordered.
Nursing Problem: changes in body image

CUES NURSING DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

s> “Ang laki Disturbed body image r/t When edema After appropriate >Assessed the client’s >determines the extent of Goal met. The
laki na ng jaundice of the skin and is present, the nsg. response to body changes. body image disturbance. patient accepted
katawan ko, sclera secondary to edema client is at risk Interventions, the and understand
nakakahiya sa and ascites. for patient will changes in his
nga studyante development verbalize self & in
ko pag of body image understanding & >Promoted accepting & non- >respect’s the client’s situation.
nagturo ako disturbance. acceptance in judgmental attitude. sensitivity to body image
ulet,” as body changes & changes.
verbalized by of self in
the patient. situation within
the shift. >helps the client feel valued.
o> not >encouraged ventilation of
looking @ his feelings.
body, noted
>different situations are
upsetting to different people,
>unintentiona depending on individual
l hiding of >Listened to client’s comments coping skills and past
body and response to the situation. experiences.

>changes in
social
involvement
>provides opportunity for
istening to concerns and
>jaundice os >Visited client frequently & questions.
the skin and acknowledge the individual as
sclera someone who is worthwhile.
Nursing Problem: body weakness

CUES NURSING DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

s> “Konting Activity intolerance r/t After appropriate >alternated rest & sleep >conserve energy & Goal met. The
galaw o lakad ascites, and muscle nsg. activity. reduces demands on client can
ko lang wasting Interventions, the tolerate activity
napapagod na patient will feel
liver. better and can
ako, ang dal rested with fewer perform more
kongmanghina,” complaints of >Assisted with activities of
>increase activity ADL’s &
as verbalized by fatigue & daily living (ADL) intolerance & endurance. experience less
the patient. increase Conserves energy & dyspnea &
tolerance in tachycardia.
activity.
reduces demand son
lives
o>easy
>Noted client report on >symptoms may be
weakness, fatigue, pain, result of & or contribute
fatigability, difficulty accomplishing tasks.
noted to intolerance of activity
pattern.
>body
weakness, noted
>Provided positive
atmosphere. >helps to minimize
>PR-120 bpm frustrations &
rechanneled energy.
RR-30 bpm

>Promoted comfort measures

& provided for the relief of
pain.
>to enhance ability to
participate in the
activity.
VI.DRUG STUDY

1. SPIRONOLACTONE

>aldactone, novospirotone

100mg 1tab. BID

Action: Potassium-sparing diuretics; antagonizes aldosterone in the distal tubules, increasing sodium & water
excretion.

Indications: Edema, hypertension,diuretic-induced hypokalemia, to detect primary hyperaldosteronism, to manage

primary hyperaldosteronism, heart failure as adjunct to ACE inhibitor or loop diretic, with or without cardiac
glycoside, hirsutism in women, PMS, acne vulgaris.

2. FUROSEMIDE

>Apo-Furosemide, Furoside

400mg/tab ½ tab TID

Action: A potent loop that inhibits sodium & chloride reabsorption @ the proximal distal tubules & ascending loop
of Henle.

Indications: acute pulmonary edema, edema, hyperentension

3. PROPANOLOL HYDROCHLORIDE

>Apo-propanolol, Deralin

10mg/tab TID

Action: A non selective beta-blocker that reduces cardiac oxygen demand by blocking catecholamine-induced
increases in heart rate, BP, and force of myocardial contraction. Depresses renin secretion and prevents vasodilation
of cerebral arteries.

Indications: angina pectoris, to decrease risk of death after MI, suprventricular; ventricular and arterial arrhythmias,
hyperthyroidism, hypertension,to prevent frequent severe uncontrollable or disabling migraine or vascular headache,
essential tremor, hypertropic subaortic stenosis, adjunct therapy in pheochromocytoma.

4. CIPROFLOXACIN

>Cipro, Ciproxin

500mg 1tab BID

Action: Inhibits bacterial DNA synthesis, mainly by blocking DNA gyrase; bactericidal.

Indications: Mild to moderate UTI, severe or complicated UTI, chronic bacterial prostatitis, complicated intra-
abdominal infections, acyte complicated cystitis, inhalation anthrax ( postexposure).
VII.RECOMENDATIONS/CONCLUSION

Liver disease can manifest in many different ways. Characteristic manifestations include
jaundice (a yellowish discoloration of the skin and whites of the eyes), cholestasis (reduction or
stoppage of bile flow), liver enlargement, portal hypertension (abnormally high blood pressure in
the veins that bring blood from the intestine to the liver), ascites (accumulation of fluid in the
abdominal cavity), hepatic encephalopathy (deterioration of brain function due to buildup of
toxic substances normally removed by the brain), and liver failure.

Sometimes the manifestations of liver disease are not obvious. For example, symptoms
may include fatigue, a feeling of unwellness, loss of appetite, and mild weight loss. However,
these symptoms are also typical of many other diseases. Thus, liver disease can easily be
overlooked, particularly in its early stages.

Ascites tends to occur in long-standing (chronic) rather than in short-lived (acute)

disorders. It occurs most commonly in cirrhosis (severe scarring of the liver), especially in
cirrhosis caused by alcoholism or viral hepatitis. It may occur in other liver disorders, such as
severe alcoholic hepatitis without cirrhosis, chronic hepatitis, and obstruction of the hepatic vein
(Budd-Chiari syndrome). Ascites can also occur in disorders unrelated to the liver, such as
cancer, heart failure, kidney failure, inflammation of the pancreas (pancreatitis), and tuberculosis
affecting the lining of the abdominal cavity.

In people with a liver disorder, ascitic fluid leaks from the surface of the liver and
intestine. A combination of factors is responsible. They include portal hypertension, decreased
ability of the blood vessels to retain fluid, fluid retention by the kidneys, and alterations in
various hormones and chemicals that regulate bodily fluids

VIII.PROGNOSIS

The predicted outcome depends on the underlying disease process. Since ascites is
usually caused by a chronic, progressive disease process, the outlook is not good unless
something can be done to correct the underlying disease. Of those with ascites secondary to liver
failure, 50% will die within 2 years regardless of therapeutic intervention.
Therapeutic paracentesis is safe and effective in removing small to moderate amounts of
ascitic fluid. Because this procedure carries the risk of abdominal infection and can cause low
blood pressure or shock, it may not be appropriate for those with severe or refractory ascites.
Peritoneovenous shunting is effective in reducing the ascites but carries an operative mortality
rate of up to 30%. While relatively new, TIPS is a procedure that effectively reduces ascites in
over 50% of the cases without the risk of surgery. However, following the TIPS procedure, over
30% developed shunt failure due to occlusion, and over 20% developed metabolic brain
dysfunction (encephalopathy).
Outcome and survival vary following liver transplantation. The 6-month survival after
liver transplantation in clinically stable individuals with chronic liver failure is as high as 90%.
Critically ill individuals at the time of transplantation have a 6-month survival of only 65%