1. General information
    1. Accumulation of free fluid in the abdominal cavity
    2. Most frequently caused by cirrhotic liver damage, which produces hypoalbuminemia, increased portal venous pressure, and hyperaldosteronism
    3. May also be caused by CHF
  2. Medical management
    1. Supportive: modify diet, bed rest, salt-poor albumin
    2. Diuretic therapy (see Antihypertensive Drugs, Table 2.17, in Unit 2)
    3. Surgery
      1. Paracentesis: insertion of a needle into the peritoneal cavity through the abdomen to remove abnormally large amounts of peritoneal fluid.
        1. peritoneal fluid assessed for cell count, specific gravity, protein, and microorganisms.
        2. used in clients with acute respiratory or abdominal distress secondary to ascites.
      2. LeVeen shunt (peritoneal-venous shunt): used in chronic, unmanageable ascites
        1. permits continuous reinfusion of ascitic fluid back into the venous system through a silicone catheter with a one-way pressure-sensitive valve.
        2. one end of the catheter is implanted into the peritoneal cavity and is channeled through the subcutaneous tissue to the superior vena cava, where the other end of the catheter is implanted; the valve opens when pressure in the peritoneal cavity is 3-5 cm of water higher than in superior vena cava, thereby allowing ascitic fluid to flow into the venous system.
  3. Assessment findings
    1. Anorexia, nausea and vomiting, fatigue, weakness, changes in mental functioning
    2. Positive fluid wave and shifting dullness on percussion, flat or protruding umbilicus, abdominal distension/tautness with striae and prominent veins, abdominal pain
    3. Peripheral edema, shortness of breath
    4. Diagnostic tests
      1. Potassium and serum albumin decreased
      2. PT prolonged
      3. LDH, SGOT (AST), SGPT (ALT), BUN, sodium increased
  4. Nursing interventions
    1. Monitor nutritional status/provide adequate nutrition with modified diet.
      1. Restrict sodium to 200-500 mg/day.
      2. Restrict fluids to 1000-1500 ml/day.
      3. Promote high-calorie foods/snacks.
    2. Monitor/prevent increasing edema.
      1. Administer diuretics as ordered and monitor for effects.
      2. Measure I&O.
      3. Monitor peripheral pulses.
      4. Measure abdominal girth.
      5. Inspect/palpate extremities, sacrum.
      6. Administer salt-poor albumin to replace vascular volume.
    3. Monitor/promote skin integrity.
      1. Reposition frequently.
      2. Apply lotions to stretched areas.
      3. Assess for redness, breakdown.
    4. Promote comfort: place client in mid- to high-Fowler's and reposition frequently.
    5. Provide nursing care for the client undergoing paracentesis.
      1. Confirm that client has signed a consent form.
      2. Instruct client to empty bladder before the procedure to prevent inadvertent puncture of the bladder during insertion of trocar.
      3. Inform client that a local anesthetic will be provided to decrease pain.
      4. Place in sitting position to facilitate the flow of fluid by gravity.
      5. Measure abdominal girth and weight before and after the procedure.
      6. Record color, amount, and consistency of fluid withdrawn and client tolerance during procedure.
      7. Assess insertion site for leakage.
    6. Provide routine pre- and post-op care for the client with LeVeen shunt.