REPUBLIC OF THE PHILIPPINES

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Catarman Northern Samar
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCE

In Partial Fulfillment of the Course Requirements

In NCM 109- High Risk Pedia
Related Learning Experience

Ascites Secondary to Liver Enlargement

Presented to:
2nd year level Clinical Instructor

Presented by:
OBJECTIVE:

The objective of the nursing case presentation is to provide a thorough

examination of the patient, who has been diagnosed with ascites secondary to liver
enlargement. Our aim is to present the patient's clinical history, pertinent symptoms,
diagnostic results, and current treatment regimen. Through this presentation, we
intend to elucidate the underlying pathophysiology of ascites secondary to liver
enlargement in pediatric patients, emphasizing its clinical significance. Additionally,
we will discuss the nursing interventions employed to manage the patient's condition,
encompassing aspects such as fluid balance optimization, nutritional support, and
patient education. Our goal is to deepen our understanding of pediatric hepatobiliary
disorders and exemplify our ability to deliver proficient nursing care tailored to the
unique needs of the patient.

INTRODUCTION:
Ascites, the accumulation of fluid in the peritoneal cavity, is a common
complication of liver disease, particularly when associated with liver enlargement.
This case presentation aims to provide an in-depth understanding of ascites
secondary to liver enlargement, exploring its etiology, pathophysiology, clinical
manifestations, diagnostic approach, and management strategies.
Ascites secondary to liver enlargement primarily arises from chronic liver
diseases, including cirrhosis, hepatitis, and hepatocellular carcinoma. These
conditions lead to portal hypertension, impairing the liver's ability to maintain fluid
balance and resulting in fluid accumulation within the abdominal cavity.
Patients with ascites secondary to liver enlargement may present with
abdominal distension, discomfort, and increased abdominal girth. Additionally, they
may experience symptoms related to underlying liver disease, such as jaundice,
fatigue, and hepatic encephalopathy. In severe cases, complications such as
spontaneous bacterial peritonitis and hepatorenal syndrome may occur.
Futhermore, Ascites secondary to liver enlargement is a significant clinical
manifestation of advanced liver disease, necessitating a multidisciplinary approach
for optimal management. By understanding the underlying pathophysiology and
implementing appropriate diagnostic and therapeutic interventions, healthcare
providers can effectively address this challenging complication and improve patient
outcomes that will all be discussed afterwards.
PATIENT’S PROFILE:
Name:
Age: 7
Sex: Male
B-day: April 16, 2016
Address:
Religion: Roman Catholic
Date of Admission: March 20, 2024
Admitting Diagnosis: Ascites secondary to liver enlargement
Attending Physician:
Mother’s Occupation:
Father’s Occupation:
Source of Information: Mother

CHIEF COMPLAIN:
“ Masuol ak tiyan na malan gin tusok- tusok, didi sa pusod nagtikang” as verbalized
by the patient

HEALTH HISTORY OF PRESENT ILLNESS:

3 months prior to first admission, on December 2023, the patient started to feel pain
in his abdomen leads to his first hospitalization with the same chief complain and
diagnosis. On March 19, 2024 one day prior to second admission the child started to
feel a stabbing pain in his navel and spread in his entire abdomen. This symptom
persisted throughout that day, prompting the parents to seek medical attention.
According to the parents, before the admission they did not treat the child at home or
do home remedies and just let the child to rest in bed and drinks lot of water. Theres
no other complaint from the child except for his abdominal pain.

PAST HISTORY:
This was the second time that the patient was admitted to the hospital with same
chief complain and diagnosis. The child had few fevers in the past that last 3-5 days.
Moreover, the mother states that there are no problems at birth of the patient. The
patient did not undergo any surgeries. There are no accidents happened to the child.
There were no known allergies.
FAMILY HEALTH HISTORY:
The mother specified that she and her husband’s family have no known history of
illnesses.

REVIEW OF SYSTEMS: by GORDONS

1.Health perception -Health Pattern

 Upon discussion with the parents, it became apparent that they have limited
understanding of their son's diagnosis of ascites secondary to liver enlargement.
They struggled to articulate the condition's causes, symptoms, and treatment
options.
 The family expressed significant financial instability, with the father working in the
construction and the mother is a housewife. They mentioned difficulties in
affording healthcare expenses and voiced concerns about the cost of
medications and medical appointments.
 The parents admitted to infrequent healthcare visits for their son due to financial
constraints. They acknowledged occasional lapses in medication adherence and
dietary recommendations, attributing them to the cost of prescriptions and limited
access to nutritious foods.

2. Nutritional Metabolic Pattern

 The patient's dietary intake is significantly impacted by financial limitations,
resulting in inconsistent access to nutritious foods. Meals often lack variety and
may be insufficient in quantity, leading to potential nutritional deficiencies.
 The patient exhibits signs of malnutrition, with recent decreased muscle mass.
 Due to limited resources, the parents have minimal understanding of the
importance of nutrition in managing their son's condition. They express
uncertainty about which foods are most beneficial and struggle to afford
recommended dietary modifications.
 The family faces challenges in accessing clean and safe drinking water, often
resorting to water from a pump with rust. This compromises the quality of the
water consumed
3. Elimination Pattern:
 The child urinates approximately 5-6 times a day, with additional trips to the
bathroom during the night.
 Urine is pale yellow in color, clear, and has a mild odor.
 The child does experience discomfort during urination which exacerbated during
trips to the bathroom.
4. Activity - Exercise Pattern
• the patient does not do any physical activity he just lay down all day because of
abdominal pain.
 the patient can't feed, bath, toilet, bed mobility dressing grooming herself and
require assistance or supervision from another person.

5. Sleep pattern
• Usual sleep pattern (time on bed - 8pm)
(time awaken - 6am)
• As the mother verbalize the quality of sleep of patient is not good. Due to
abdominal pain, the patient sometimes wake up at dawn crying which indicate
sleep distrubance

6. Cognitive - perceptual pattern

 the patient has no difficulty in Hearing
 the patient vision is normal by able to see and recognize mother from stranger
 the patient stated that he suffered for abdominal discomfort , the only
management he takes is to don't move much to ease pain.

7. Self - Perception - Self Concept pattern

• the patient is suffering from abdominal pain which makes him irritable
• As observed the patient was doing minimal movement to ease abdominal pain,
thus the patient is not able to perform the things that the children his age can do
which makes him sad about it.
• The patient undergo lots changes since the illness started which includes severe
decrease muscle mass and weakening and enlargement of the abdomen.

8. Role Relationship Pattern

•The patient live with both of his parents together
• The both parents openly communicate and collaborate to find solutions.
• The patient need support from the parents for assistance in his daily activities.
• The patient is wary of strangers.
9. Coping - Stress Tolerance Pattern

 The patient primarily copes with stress by expressing emotions through crying
episodes with their mother. This release of emotions may serve as a cathartic outlet
for the child to process their feelings of fear, frustration, or uncertainty about their
illness.
 The parents demonstrate strong support for their son by providing emotional comfort
and reassurance during his crying episodes. They engage in open communication with
their son, patiently explaining the situation and offering positive words of
encouragement to instill hope and resilience.
 Despite the challenges they face, the family maintains a positive attitude and fosters a
supportive environment for their son. They encourage him to express his emotions
openly and provide validation and comfort in response to his distress.
 The family's cultural and spiritual beliefs likely influence their coping strategies,
emphasizing the importance of family cohesion, emotional expression, and faith in
overcoming adversity.

10. Value belief pattern:

• The family demonstrates a strong belief in maintaining a positive outlook and drawing
strength from their spirituality in coping with their child's diagnosis of ascites
secondary to liver enlargement.
• Despite the challenges they face, the family maintains a hopeful attitude and fosters a
supportive environment for their child. They emphasize the importance of faith and
optimism in overcoming adversity and finding meaning in their circumstances.
• The family's cultural and spiritual beliefs strongly influence their coping strategies,
providing a foundation for resilience and emotional strength in navigating the
challenges of illness.
HEAD TO TOE NARRATIVE REPORT

The patient presented with signs and symptoms suggestive of ascites secondary to
liver enlargement. Upon assessment, the following findings were noted:
The patient exhibited mild jaundice, with yellowing of the sclera and skin.
There were signs of respiratory distress- rapid deep breathing; however, the patient
reported mild discomfort upon deep inspiration, likely due to abdominal distention
exerting pressure on the diaphragm. Blood pressure was within normal limits, but
jugular venous distention was observed, indicating possible fluid overload.
Abdominal examination revealed significant distention with bulging flanks. Palpation
elicited a fluid wave and shifting dullness, consistent with ascites. The liver edge was
palpable below the right costal margin, indicative of hepatomegaly.
Bilateral lower extremity edema was noted, further suggesting fluid retention.
No striae or abdominal wall hernias were observed.
The patient was alert and oriented, with no signs of hepatic encephalopathy.
Based on the clinical findings, the patient's ascites is likely secondary to liver
enlargement, possibly due to underlying liver pathology such as cirrhosis or
hepatocellular carcinoma. Further diagnostic evaluation, including laboratory tests
(e.g., liver function tests, albumin levels) and imaging studies (e.g., ultrasound, CT
scan), is recommended to confirm the diagnosis and guide management.

Growth and Development

According to Piaget's theory of cognitive development, a 7-year old child
typically enters the concrete operational stage. During this stage, they start to think
more logically and systematically. They also begin to grasp concepts like
classification and seriation, allowing them to sort objects based on multiple criteria
and order items by size, length, or other attributes. Additionally, their understanding
of cause and effect becomes more sophisticated, enabling them to solve problems
and understand the consequences of their actions more effectively.
The patient demonstrates significant growth in logical thinking and problem-
solving abilities compared to earlier developmental stages. The social and emotional
growth of the patient is also notable as he become more empathetic and
understanding of others' perspectives, which helps navigate social interactions more
effectively.
REVIEW OF ANATOMY AND PHYSIOLOLOGY:

ascites can affect multiple organ systems, disrupting their normal functions
and potentially leading to complications such as respiratory compromise,
renal impairment, and electrolyte imbalances

. Here are the main organs and body parts affected, along with their
functions:

1. Liver:
The primary organ affected, showing enlargement possibly due to underlying liver
pathology such as cirrhosis or hepatocellular carcinoma. The liver's impaired ability
to maintain fluid balance leads to fluid accumulation within the abdominal cavity,
resulting in ascites.
2. Kidneys:
While not directly mentioned, renal sodium and water retention play a significant role
in the development of ascites, as indicated by the pathophysiology section
discussing the activation of the RAAS system and increased levels of antidiuretic
hormone (ADH). This indicates that the kidneys' function and the hormonal
regulation involved in fluid balance are part of the underlying mechanism causing
ascites.
3. Cardiovascular System:
The presence of jugular venous distention and bilateral lower extremity edema
suggests fluid overload, which could indicate heart involvement, especially in the
context of fluid management and distribution in the body. Although the direct cause
of ascites is related to liver enlargement and portal hypertension, cardiovascular
system health impacts fluid accumulation and management.
4. Gastrointestinal System:
The presence of abdominal distension and discomfort, as well as the dietary and
nutritional challenges addressed, suggest the gastrointestinal system is affected due
to the physical impact of ascites on digestion and nutrition.
5. Peritoneum:
The accumulation of fluid in the peritoneal cavity directly indicates that the
peritoneum is affected, as ascites is the accumulation of fluid in this specific area,
leading to symptoms such as abdominal distension and discomfort.
 Ascites Secondary To Liver

Malnutrition and financial problems

•Age and gender Dietary factors (consumption of salty

foods and junk foods)
Low physical activity

Inflammatory
cytokines and
Hepatic Steatosis
oxidative

Liver enlargement and fatty liver

disease

Increased pressure in increased resistance to Development of

the portal vein and its blood flow within the collateral vessels
branches liver.

Portal hypertension

Increased pressure in
Increased capillary Decreased colloid
the portal vein and its
permeability osmotic pressure
branches

Ascites Formation
Here’s an outline for the pathophysiology of ascites secondary to liver
enlargement:

1. Modifiable and Non-modifiable factors

Age
As individuals age, their cumulative exposure to risk factors such as metabolic
conditions, malnutrition, and dietary habits, including the consumption of salty foods,
can have a profound impact on liver health. Liver diseases such as cirrhosis,
hepatitis, and liver cancer tend to manifest and progress over time, with age
exacerbating the effects. Even in young individuals, such as a 7-year-old boy whose
liver is still developing, prolonged exposure to risk factors like malnutrition can
heighten the susceptibility to liver injury and disease. Additionally, aging is
associated with structural and functional changes in the liver, including decreased
regeneration capacity, which further predisposes individuals to liver enlargement and
the development of conditions such as ascites.

Gender
Gender differences exist in the prevalence, progression, and outcomes of liver
diseases associated with liver enlargement and ascites. For example:
- Men tend to have a higher prevalence of liver diseases such as alcoholic liver
disease and hepatitis C, which are major contributors to liver enlargement and
ascites.
- Women may have a lower tolerance for alcohol and a higher risk of liver injury
from lower levels of alcohol consumption compared to men.
- Hormonal factors, such as estrogen levels, may also play a role in liver disease
progression. For example, estrogen has been implicated in the pathogenesis of
certain liver diseases, including autoimmune hepatitis and primary biliary cholangitis.

Malnutrition and financial problems:

Malnutrition, often influenced by socioeconomic factors and access to nutritious
food, can lead to liver enlargement due to fatty liver disease. Financial problems,
such as poverty or limited access to healthcare and healthy food options, can
exacerbate malnutrition and contribute to liver-related complications. While efforts to
improve nutrition and address financial barriers are essential, certain factors may be
challenging to modify directly and may require broader systemic interventions and
support mechanisms.

Dietary factors (consumption of salty foods and junk foods):

- Excessive intake of salty and high-fat foods, such as junk foods, can contribute to
obesity, hypertension, and metabolic syndrome.
- These dietary habits can lead to insulin resistance, dyslipidemia, and
inflammation, which are risk factors for liver diseases such as non-alcoholic fatty liver
disease (NAFLD) and non-alcoholic steatohepatitis (NASH).
- High sodium intake can also lead to fluid retention and increased blood pressure,
further exacerbating liver damage and dysfunction.

Low physical activity:

Physical activity levels are modifiable factors that can influence overall health and
liver function. Sedentary behavior and low physical activity levels contribute to
obesity,

2. Liver enlargement and fatty liver disease

Chronic consumption of salty foods and junk foods contributes to the development
of hepatic steatosis, characterized by the accumulation of fat within liver cells.
- Hepatic steatosis can progress to more severe liver conditions, such as NAFLD
and NASH, in which inflammation and liver cell injury occur.
- Inflammatory cytokines and oxidative stress further contribute to liver damage
and dysfunction, leading to liver enlargement and impaired liver function.
- Liver enlargement leads to increased resistance to blood flow within the liver,
particularly in the portal vein system.
- This increased resistance causes elevated pressure in the portal vein, a condition
known as portal hypertension.

3. Portal Hypertension
 - As liver disease progresses, liver tissue becomes fibrotic and nodular, leading to
increased resistance to blood flow within the liver.
- Portal hypertension develops as a result of increased pressure in the portal vein
and its branches, which carry blood from the digestive organs to the liver.
- Portal hypertension leads to congestion of blood within the liver sinusoids and
collateral vessels, further impairing liver function and exacerbating liver enlargement.

- Elevated portal pressure leads to fluid leakage from the hepatic sinusoids into the
space surrounding the liver.
- This fluid accumulation in the peritoneal cavity results in ascites.

4. Renal Sodium and Water Retention:

- Activation of the RAAS and increased levels of antidiuretic hormone (ADH) lead
to renal sodium and water retention.
- This further contributes to the expansion of intravascular volume and exacerbates
ascites formation.

5. Development of Ascites:
 Increased pressure within the portal vein and sinusoids causes fluid to leak
out of the blood vessels and into the abdominal cavity, leading to ascites.
o Ascites is characterized by the accumulation of fluid within the
peritoneal cavity, resulting in abdominal distension and discomfort.
o The development of ascites signifies advanced liver disease and is
associated with poor prognosis if left untreated.

- The combination of liver enlargement, portal hypertension, renal sodium and

water retention results in the accumulation of fluid within the peritoneal cavity,
manifesting as ascites.

Understanding the pathophysiology of ascites secondary to liver enlargement helps

in the management and treatment of patients
LABORATORY AND DIAGNOSTIC EXAMS:
• Glucose concentration: White blood cells, bacteria, and malignant cells
consume glucose; thus, the concentration of glucose may be low in peritoneal
carcinomatosis and bowel perforation.
• Lactate dehydrogenase (LDH) concentration: The ascitic fluid/serum (AF/S)
ratio of LDH is about 0.4 in cirrhotic ascites without infection. In SBP, the ascitic
fluid LDH level rises such that the ascitic fluid/serum (AF/S) ratio of LDH
approaches 1.0. In the case of bowel perforation, or peritoneal carcinomatosis,
the ascitic fluid/serum (AF/S) ratio of LDH is greater than 1.0.
• Gram stain: The sensitivity of ascitic fluid gram stain is only 10%. The main
benefit of gram stain of ascitic fluid is to differentiate between SBP and bowel
perforation where there is polymicrobial growth in bowel perforation and
monomicrobial growth in SBP.
• Amylase concentration: The ascitic fluid amylase concentration is increased in
pancreatitis or bowel perforation reaching approximately 2000 unit/L.
• Tests for tuberculous peritonitis: A variety of tests have been used for the
detection of tuberculous peritonitis including direct smear, culture, cell count with
predominance of mononuclear cells, and adenosine deaminase. Only patients at
high risk for tuberculous peritonitis should have testing for mycobacteria on the
first ascitic fluid specimen. The sensitivity of smear of ascitic fluid for
mycobacteria is almost zero [43], while the sensitivity of fluid culture for
mycobacteria reaches 50%. Polymerase chain reaction testing for mycobacteria,
laparoscopy with biopsy, and mycobacterial culture of tubercles are the most
rapid and accurate methods of diagnosing tuberculous peritonitis.
• Cytology: It should be requested only if malignant ascites is suspected. The
sensitivity of ascitic fluid cytology in peritoneal carcinomatosis is approximately
100%. However, because not all cases of malignant ascites are associated with
peritoneal carcinomatosis, the overall sensitivity of cytology smears for the
detection of malignant ascites is 58–75%. Hepatocellular carcinoma (HCC) rarely
metastasizes to the peritoneum.
• Triglyceride concentration: Chylous ascites has a triglyceride content greater
than 200 mg/dL (2.26 mmol/L) and usually greater than 1000 mg/dL (11.3
mmol/L).
• Bilirubin concentration: Ascitic fluid bilirubin value greater than the serum
suggests bowel perforation or biliary leak.
 DRUG STUDY:

#1
Name of Drug: Acetaminophen
Brand Name: Paracetamol
Specific Action: thought to produce analgesia by inhibiting prostaglandin and other
substances that synthesizes pain receptors. Drug may relieve fever through central
action in the hypothalamic heat-regulating center.
Indication: help treat pain and reduce high temperature
Contraindication: patiets hypersensitivity to drugs, use cautiously in patients with
any type of liver disease and long-term alcohol use.
Adverse Effects: agitation, anxiety, fatigue, headache, insomnia, pyrexia,
hypotension, peripheral edema, periorbital edema, tachycardia, nausea, vomiting,
abdominal pain, diarrhea, constipation, oliguria, hemolytic anemia, leukopenia,
neutropenia, anemia, jaundice
Drug Interaction: Barbiturates, carbamazepine, hydartoins, rifampin, busulfan,
dasatinib
Nursing Responsibilities: use caution when prescribing, preparing, and
administering acetaminophen to avoid dosing errors leading to accidental overdose
and death, and consider reducing total daily dose and increasing dosing intervals in
patients with hepatic or renal impairment.
#2

Name of Drug: Hyoscine/Scopolamine

Specific Action: inhibits muscarinic actions of acetylcholine on autonomic effectors
innercated by post ganglionic cholinergic neurons. May affect neural pathways
originating in the inner ear to inhibit nausea and vomiting.
Indication: Gastrointestinal tract spasm, genitourinary spasm
Contraindication: Myasthenia gravis, narrow-angle glaucoma, tachycardia, mega
colon, hypersensitivity
Adverse Reactions: tachyarrhythmia, hypotension, increased intra-ocular pressure,
drowsiness, confusional states, visual hallucinations, blurred vision, eye pain,
idiosyncratic, epileptic seizures.
Drug Interactions: may decrease the absorption of oral medicines due to decrased
gastric motility and delayed gastric emptying. The sedative effect of hyoscine may be
enhanced by other CNS depressants. Other drugs with anticholinergic properties
(e.g amantadine, antihistamine) may enhance the effects of hyoscine.
Nursing Responsibilities: reorient patient as needed, monitor patient for decreased
GI motility and urine retention, monitor patient for withdrawal signs and symptoms,
stop drug if patient experiences signs and symptoms of angle-closure glaucoma or
has difficulty swallowing and tolerance may develop when therapy is prolonged.
#3

Name of Drug: Furosemide

Specific Action: inhibits sodium and chloride reabsorption at the proximal and distal
tubulles and the ascending loop of Henle
Indication: acute pulmonary edema, edema, HIN
Adverse Reaction: vertigo, headache, dizziness, paresthesia, weakness,
rstlessness, fever, orthostatic hypotension, thrombophlebitis with IV administration,
blurred or yellow vision, transient deafness, dehydration, anemia, oliguria, muscle
spasm
Contraindication: patient’s hypersensitivity to drug, use cautiously in patients with
hepatic cirrhosis and in those allergic to sulfonamides and premature infants
Drug Interaction: aminoglycosides, antibiotics, antidiabetics, antihypersensitives,
cardiac glycoside neuromuscular blockers, ethacrynic acid, propranolol, salicylates
Nursing Responsibilities: monitor weight, BP and pulse rate routinely with long
term use, stop if oliguria or azotemia develops or increases, monitor fluid intake and
output and electrolyte, consult prescriber and dietitian about a high potassium
supplements and monitor glucose levels with diabetic patients.
#4

Name of Drug: Metoclopramide hydrochloride

Specific Action: stimulates motility of upper GI tract, increases lower esophageal
sphiniter tone and blocks dopamine receptors at the chemoreceptor trigger zone.
Indication: GERD, delayed gastric emptying secondary to diabetic gastroparesis, to
facilitate small bowel intubation and to prevent or reduce nausea and vomiting from
emetogenic cancer chemotherapy.
Contraindication: in patient’s hypersensitivity to drugs and in those with
pheochromocytoma or other catecholamine-releasing paragangliomas or seizure
disorder, contraindicated in patients for whom stimulation of GI motility might be
dangerous, metaclopromide is not recommended for use in children due to the risk of
tarclive dyskinesia and other signs and symptoms as well as the risk of
methemoglobinemia in neonates.
Adverse Reaction: anxiety, drowsiness, dystonic reactions, fatigue, restlessness,
seizures, suicidal ideation, confusion, depression, dizziness, fever, hallucinations,
rash, libido loss, prolactin, amenorrhea
Drug Interaction: anticholinergics, opioid analgesics, antiparkinsonian drugs
(dopamine agonists) antipsychotics, CNS depressants, cyclosporine, digoxin,
phenothiazines
Nursing Responsibilities: monitor bowel sounds, safety and effectiveness of drug
have not been established for therapy lasting longer than 12 weeks, monitor patient
for fever, CNS, symptoms, irregular pulse, cardiac arrhythmia.
#5

Name of Drug: Cefuroxime

Specific Action: inhibits cell-wall synthesis, promoting osmotic instability, usually
bacteriacidal.
Indication: infections, gonorrhea and lyme disease
Adverse Reaction: thrombophlebitis, diarrhea, nausea, anorexia, vomiting,
hemolytic anemia, rashes
Contraindication: in patients hypersensitive to drugs or other cephalosporins
Drug Interactions: aminoglycosides, antacids, live-veins vaccine, loop diuretics,
warfarin
Nursing Responsibility: monitor patients for signs and symptoms of superinfections
and diarrhea and tract appropriately, drug may increase LNR and risk of bleeding,
and don’t confuse drug with other cephalosporins that sound alike

LIST OF PRIORITIZE NURSING PROBLEMS:

Rapid and deep breathing
 NURSING CARE PLAN:
#1
Assessment Nursing Scientific Objectives Interventions Scientific Evaluation
Diagnosis Rationale Rationale
Subjective Hyperthermia Core body -After my 8- -Monitor vital -Obtain
Data: AEB body temperature hour duty, signs. baseline
“Mapas oak temperature above the normal the patient information
pamati.” of 38.1˚C, diurnal range will have a
tachypnea, due to failure of body
Objective tachycardia, thermoregulation temperatur -Perform -To prevent
Data: flushed and . e less than hand infection
Skin warm dry skin, and 38.1˚C. hygiene. from the
to touch. irritable care
Dry mood. provider to
complexion. the client.
Body
temperature -Loosen or -Exposing
of 38.1˚C. remove skin to
Pulse rate excess room air
of 135 bpm. clothing and decrease
And irritable covers. heat and
mood. increases
evaporative
cooling.
-Encourage
adequate -Cool
fluid intake.liquids help
lower the
body
-Cool tepid temperatur
sponge bath. e

-Heat loss
by
evaporation
-Provide a and
cool conduction.
environment.
-Heat loss
-Teach the by
SO as well convection.
as the
patient the -Increase
importance knowledge
of monitoring in families
temperature. and patient
enhances
the quality
 of health.
#2

Assessment Nursing Scientific Objectives Interventions Scientific Evaluation

Diagnosis Rationale Rationale
Subjective Ineffective Ascites or -After my -Monitor -Monitor for
Data: Breathing liver cirrhosis 8-hour breathe changes in
“Nakukurian Pattern r/t is associated duty, the sounds and lung sounds,
ak increase with patient will other vital RR and
paghinga.” pressure abdominal have a signs. depth, and
as on the fluid respiratory oxygen
verbalized diaphragm. accumulatio rate lower saturation
by the n and than or closely for
patient. distention, less than worsening on
increasing 42 bpm. improvement
Objective pressure on .
Data: the -Maintain a
Respiratory diaphragm calm attitude
rate of 42 making it while -To limit the
bpm. Rapid harder for dealing with level of
and deep the patient to the client anxiety.
breathing. breathe. and
significant
others.

-Position the
patient in -Patients
semi-fowler may
position for experience
comfort. dyspnea or
exertion or
when lying
down or flat
due to
-Encourage ascites.
the use of
pillows for -Promoting
support, comfort using
under the supportive
arms and pillows under
chest. the arms and
chest can
help patients
with ascites
breathe
-Evaluate comfortably.
and monitor
ABGs -Any
alterations in
ABG can
signal
respiratory
complication
s and enable
prompt
intervention.
 #3
Assessmen Nursing Scientific Objectives Interventions Scientific Evaluation
t Diagnosis Rationale Rationale
Subjective Ineffective Impaired -After my 8- -Assess the -The -Goals
Data: Breathing expansion hour duty, patient’s nutritional met
“Masuol ak Pattern r/t capacity of the patient nutritional status of
tiyan.” as increase the will report status. patient with
verbalized pressure stomach an increase ascites may
by the on the due to the in appetite require more
patient. diaphragm. presence and/or than simply
of clinically demonstrat measuring the
Objective evident e behavior patient’s body
Data: ascites changes to weight due to
Pain scale may lead regain and/ fluid
of 10 to an or maintain accumulation.
muscle inadequate appropriate The two
wasting, intake of weight. recommended
lack of nutrient. methods to
appetite assess the
and body nutritional
weight of 17 status of
kilograms. patients with
ascites are
mid-arm
muscle
circumference
(MAMC) and
triceps
skinfold
(TSF).

-Assess for
any barriers -Ascites can
to eating. further
compromise
nutrition due
to barriers to
eating like
changes in
task, appetite
suppression,
early satiety,
and the ability
to eat
comfortably.
-Encourage
a high -A high
protein diet protein diet
and restrict and sodium
sodium restriction are
intake. considered
standard
practices for
managing
ascites.
-Encourage
small -Patients with
frequent ascites tend
meals and to have poor
snacks. tolerance to
large meals
due to
increased
abdominal
pressure, 5-7
smaller meals
and snacks
are more
tolerable.
-Provide
late-evening -A late
snacks. evening snack
containing
complex
carbohydrates
and protein is
recommended
to help
compensate
for the
reduced
glycogen
storage and
production
and present
muscle
proteolysis in
patients with
ascites.
-Refer the
patient to a -A carefully
dietitian structural
meal plan is
essential to
address
nutrient
deficits in
 patients with
ascites.
Dietary
counseling
and nutritional
intake and
patient
outcomes.

PLANNING DISCHARGE:
Medication: DEPEND ON THE DOCTORS ORDER
1. Explain the use and significance of each medications according to doctor’s order
such as Diuretics- furosemide to manage ascites and reduce fluid buildup.
2. Ensure the patient understands the dosage, frequency, and potential side effects
of the medication.
Exercise:
1. Recommend low-impact exercises such as walking, swimming, or cycling to
improve circulation and overall cardiovascular health.
2. Encourage the patient to engage in physical activity for at least 30 minutes most
days of the week, as tolerated.
3. Emphasize the importance of regular movement to prevent muscle wasting and
maintain mobility.
Treatment:
1. Discuss treatment options for ascites, such as therapeutic paracentesis or
placement of a transjugular intrahepatic portosystemic shunt (TIPS), if appropriate.
2. Provide information on lifestyle modifications, including dietary changes and
alcohol cessation, to manage underlying liver disease and prevent recurrence of
ascites.
3. Coordinate with other healthcare providers, such as hepatologists or
gastroenterologists, for specialized care and ongoing management.
Health Teachings:
1. Educate the patient on the importance of adhering to prescribed medications and
following up with their healthcare provider regularly.
2. Provide information on signs and symptoms to watch for, such as increased
abdominal distention, difficulty breathing, or changes in mental status, and when to
seek medical attention.
3. Offer resources for support groups or counseling services to address any
emotional or psychological challenges associated with the diagnosis and
management of ascites.

Observation:
1. Instruct the patient to monitor for signs of worsening ascites, such as increased
abdominal distention, weight gain, or difficulty breathing.
2. Encourage regular monitoring of vital signs, including blood pressure, heart rate,
and weight.
3. Advise the patient to keep a symptom diary and report any new or concerning
symptoms to their healthcare provider promptly.

Diet:
1. Recommend a low-sodium diet to reduce fluid retention and manage ascites. Limit
salt intake to <2,000 mg per day.
2. Encourage consumption of high-protein foods to support liver function and
promote healing.
3. Provide resources for meal planning and offer guidance on reading food labels to
identify hidden sources of sodium.

Spirituality and Sexuality:

1. Address any spiritual or existential concerns the patient may have related to their
illness, and offer support through chaplaincy services or spiritual counselors if
desired.