Ascites is the most common complication of liver cirrhosis occurring in about 60% of patients within 10 years of diagnosis (Ginés, et al., 2008). Ascites develops when there is an increase in the extracellular volume (ECF), therefore, understanding the regulation of body fluid volume is crucial in grasping the pathogenesis of ascites. In normal individuals, kidneys actively regulate the ECF volume by controlling reabsorption of water and sodium (Gerbes, 2011). However, in pathogenic conditions, such as cirrhosis and congestive heart failure, kidneys retain more water and sodium salts resulting in the buildup of the ECF volume. According to Moore & Van Thiel (2013), ascites is described as the abnormal accumulation of fluid in the peritoneal cavity usually observed in decompensated cirrhotic conditions. Though portal hypertension accounts to 85% of ascites cases (Gerbes, 2011), other causes include renal failure, pancreatitis, malignancy, congestive heart failure resulting from pulmonary hypertension, Budd-Chiari syndrome and constrictive pericarditis (Moore & Van Thiel, 2013). Cirrhosis, on the other hand, is linked to chronic alcoholism and smoking (Gao & Bataller, 2011: El-Zayadi, 2006). Notably, some of the symptoms of ascites include breathlessness, weight gain, pain and discomfort in the abdomen, nausea, indigestion and tiredness (Moore & Van Thiel, 2013). In the case analysis, the patient’s real name will be withheld in order to protect their privacy in accordance to the various legal frameworks available (NHS England, 2015). A patient’s privacy is important in a health set up as it shows respect and builds trust and confidence between the patient and the health care provider (Crouch & Meurier, 2005). The patient is a 60-year-old man with a history of smoking and alcoholism. Moreover, he has an end stage kidney disease due to type 2 diabetes and hypertension. From the case, the patient’s ascites could be from the renal failure and the history of smoking and alcoholism which predisposed him to liver cirrhosis, a leading cause of ascites (Gao & Bataller, 2011). It is, therefore, imperative to discuss the patient’s care plan and the complications of diabetes in a diabetic patient who is slowly losing his vision.

Care Plan

In the management of ascites, the desired outcome of the intervention would be to decrease abdominal distension, assist with paracentesis, and reassess the patient’s needs.

Assessment

• Abdominal distension
• Breathlessness after paracentesis
• fatigue

Diagnosis

The following nursing diagnosis were made for the patient:

• Excess fluid volume- this is related to electrolyte imbalance and hypoalbuminemia as manifested by ascites.
• Paracentesis-induced circulatory Dysfunction (PCID)- this is related to the large volume paracentesis and is manifested by breathlessness.
• Fatigue- is related to breathlessness and is manifested by inability to walk.

Expected Outcomes

• A daily decrease in abdominal girth by about 2 cm
• Demonstrate stabilized fluid volume, vital signs within patient’s normal range.
• Normal respiratory rate after paracentesis
• Limit the volume removed during paracentesis to decrease the incidence of PCID
• Patient to freely carry out their daily activities

Plan

• Measuring abdominal girth every 8hr.
• Limiting the volume removed during paracentesis to 5-6L.
• Bedrest after the procedure.
• Tailored dose of diuretics

Nursing Interventions and Rationale

• Monitor blood pressure and abdominal vein distention. Elevations in blood pressure are normally linked with excess extracellular fluid volume. Moreover, distension of abdominal veins can be as a result of abdominal congestion.
• This drains the excess ECF thus easing the fluid overload. It was recommended that the patient gets 2-3 drains per week so as to manage the ascites.
• Getting him a bed on the ward after every procedure. The patient reported fatigue and breathlessness after every procedure, hence there was the need to have him rest after each procedure.
• Reassessing the patient’s needs. This is meant to identify any underlying factors that could be impacting on his wellbeing. Assessment of needs also ensures that patient is involved in the therapeutic process, which improves the treatment outcome. Hospital transport needs to be provided for his treatments.

• Assessing the respiratory status and possibly dyspnea. This is indicative of pulmonary congestion.
• Restricting Sodium and fluid intake. Sodium intake is restricted to reduce the retention of fluids in the extravascular spaces.
• Potassium Sparing Diuretic medications need to be instituted. Though these are important for controlling oedema and ascites, they need to be used with caution.

Evaluation

• Abdominal girth decreased suggesting a reduction in the ECF volume
• Normal breathing patterns after paracentesis
• Ability of the patient to resume daily activities

Research and own observation

The provision of a quality care requires a good understanding of the nursing process (Crouch & Meurier, 2005). This means that the nurse has to follow the 5 keys steps in the nursing process involving assessment, diagnosis, planning, implementation and evaluation phases (Crouch & Meurier, 2005). Notably, the nursing process is guided by the conceptual framework as discussed by Crouch & Meurier (2015). The conceptual framework gives a representation of the patient, the causes of the problem and possible intervention, the nature of assessment process and the focus of nursing intervention during the implementation of the care plan (Basford & Slevin, 2003). Abdominal distension in the patient is caused by the presence of fluid in the peritoneal cavity. Usually, the degree of distension is used to grade the ascites (Gines, et al., 2010). Three grades have been established namely 1, 2 and 3 (Gines, et al., 2010). In grade 3, there is a gross abdominal distension as compared to stage 2 in which there is a moderate distension. Hence, the patient has a grade 3 ascites. The patient’s abdomen was carefully inspected for signs of signs of injury, the presence of prominent veins or shiny, taut skin. The size, distension and symmetry of the abdomen was also noted. Moreover, abdominal auscultation was carried out to detect any rumbling suggesting gut peristalsis. Usually, this is performed before palpitation and percussion since such examinations can lead to a momentary cessation of peristalsis (First Nations and Inuit Health Branch (FNIH), 2011). Palpitation was done to detect pain or tenderness in the abdomen. During the assessment, percussion was carried out reveal the accumulation of the fluid (First Nations and Inuit Health Branch (FNIH), 2011). This is usually done in both supine position and when the patient is lying on the side. Successful management of ascites depends on the etiological treatment of the underlying liver disease (Tsochatzis & Gerbes, 2017). In this case, if the ascites was as a result of alcohol related cirrhosis, then immediate alcohol cessation needs to be effected. Moreover, there is the need to advise the patient on the importance of smoking cessation. Alcohol abstinence can reverse portal hypertension and sodium retention in alcohol-related liver disease (Runyon, 2013). Though ascites is associated with fluid buildup in the ECF, there are no studies that demonstrate benefit of fluid restriction in its management (Runyon, 2013). The patient’s care plan involved a large volume paracentesis that was done 2-3 times weekly through the ascites tap. The drainage suggests that patient had a grade 3 ascites causing a large accumulation of fluid (Gines, et al., 2010). The frequency of drainage suggests a possible re-accumulation of ascites. This procedure has a low risk of bleeding, hence, there is no need to do a haemogram prior to the procedure (Pache & Bilodeau, 2005). The patient’s breathlessness after the procedure could be due to PCID. This is a complication of the large volume paracentesis; hence the interventional radiologist should be conversant with it in the management of ascites (Lindsay, et al., 2014). During the large volume paracentesis, there is the need to include a plasma volume expander such as albumin. This has been found to decrease the incidence of PCID to 15% (Lindsay, et al., 2014). Paracentesis without the inclusion of albumin has a higher chance of PCID, about 80% (Lindsay, et al., 2014). Since the patient has a large volume paracentesis, a minimum dose of diuretic regimen needs to be instituted to prevent the re-accumulation of ascites (Dooley, et al., 2011). In tailoring the diuretic treatment, urinary electrolysis should be done (Tsochatzis & Gerbes, 2017). A 24-hour bedrest was suggested for the patient to give him time to rest before resuming the normal duties. This is a crucial part of the treatment outcome as reassessing a patient’s needs ensures compliance to the treatment (Beena & Jose, 2011). Moreover, the patient will have a means of transportation to and from the hospital during the treatment days.

Diabetes retinopathy

Diabetes retinopathy is a common complication of diabetes. The complication occurs when the high blood sugar level damages blood vessels in the retina making them swell and leak or even stopping the circulation of blood (Wu, 2012). Diabetic retinopathy has been established as the leading cause of blindness among Americans between 21-64 years (Wu, 2012). In diabetes, the onset of diabetes retinopathy is marked by a decrease in vision on physical examination (Wu, 2012). Diabetic retinopathy can in some cases progress to diabetic macular edema (DME) (National Eye Institute, 2015). Currently, a number of research programs have been instituted to detect, treat and prevent loss of vision in diabetic patients. The Diabetic Retinopathy Clinical Research Network (DRCR) is currently researching on the new therapies for diabetic eye disease (National Eye Institute, 2015).

Conclusion

Ascites is a common complication of liver disease. The disease is characterised by an accumulation of fluid in the peritoneal cavity. In the management of ascites, it is important to establish the aetiology of  the liver disease causing the ascites. Owing to the diverse needs of each patient, there is the need to individualise care plans so as to have the best outcome. The care plan in our patient was individualised to take care of his diverse needs. For example, a bed and hospital transport was availed to him. Diabetic patients are at a risk of having a decreased vision. This is caused by diabetic related complications, such as diabetic retinopathy and DME.