MASSIVE ASCITES To Be Printed

A CASE STUDY ON MASSIVE ASCITES
NICOLEEN MAE D. SIBAYAN
KATE B. SMITH
AULYN B. TANACIO
HANNAH LHYNE O. TAYAB
ROSANA L. TIANZA
ABELYN C. TIO-TIO
KENDRA B. TIWAKEN
JAZZYL KETH S. TONGAB
KRISTA DEE D. WAGAWAG
SHARALINA C. WALISEN
BENGUET STATE UNIVERSITY
LA TRINIDAD, BENGUET
BACHELOR OF SCIENCE IN NURSING
MARCH 2019
ABSTRACT
Title: A CASE STUDY ON MASSIVE ASCITES
Authors: Nicoleen Mae D. Sibayan, Kate B. Smith, Aulyn B. Tanacio, Hannah Lhyne O. Tayab, Rosana L.
Tianza, Abelyn C. Tio-tio, Kendra B. Tiwaken, Jazzyl Keth S. Tongab, Krista Dee D. Wagawag, Sharalina C.
Walisen, BSN IV
Keywords: Decompensated, liver, cardiovascular disease, HC IIC, hemorrhage
Overview of the Case: Patient Bvm’s condition started two years ago, when patient underwent repair of
inguinal hernia and angiography due to infection with emergency evacuation of scrotal hemorrhage few
days after first surgery. Since then, patient noticed increasing abdominal girth with associated oliguria
and urinary frequency. Six months prior to admission, patient’s symptoms persisted that urged him to
seek consultation at the Out Patient Department (OPD). Parenthesis was done to decrease fluid
accumulation in the abdominal area that provided a temporary relief. One week prior to admission,
complaints of haemorrhage in scrotal area then sought consultation in our institution and testing was
done. However sudden movement of the patient increased bleeding and stitching was done. This
prompted patient to seek consultation for further evaluation and management.
Abridged Drug Study: Treatment was given such as Lactulose to treat constipation and help to eliminate
ammonia in the blood via the stools to prevent hepatic coma encephalopathy. Tramadol is given also to
manage the client complaint of severe pain. Spironolactone is given to the client mainly because of
edema due to liver cirrhosis and also this is given to the client of high blood pressure this was prescribed
because it is potassium sparing diuretic; this drug can decrease blood pressure at the same time it can
prevent the eliminating of potassium.Laboratory test such as Complete blood count (CBC) may be
ordered to evaluate a patient’s red and white blood cells and platelets; anemia may be present if
bleeding has occurred, and platelets are often decreased with cirrhosis. Alanine aminotransferase (ALT)
is an enzyme found mainly in the liver. Values are increased with all types of liver injury, including
cirrhosis. Alkaline phosphatase (ALP) is an enzyme found along bile ducts. ALP is usually normal or mildly
elevated in cirrhosis.
Course in the by Ward: January 27, 2019: Patient is a known case of massive ascites secondary to
decompensated liver disease, HCVD in HCIIC, accompanied by his son. The patient was admitted
because of persistent increase of abdominal girth associated with oliguria and urinary frequency. After
admission, patient claims to experienced further increase in abdominal girth, severe pain, and unstable
blood pressure. Patient was showed some signs and symptoms of weakness, cold and clammy
extremities.
A CASE STUDY ON MASSIVE ASCITES 2

Conclusions: Massive ascites is a serious condition that needs immediate medical intervention. The
prognosis for patient with ascites due to liver disease depends on the underlying disorder, the degree of
reversibility of a given disease process, and the response to treatment. Ascites tends to occurs in a long
standing rather than in short lived disorders. It occurs commonly in cirrhosis, especially in cirrhosis
caused by alcoholism. It may occur in other liver disorders, such as severe alcoholic hepatitis without
cirrhosis, chronic hepatitis, and obstruction in the hepatic vein.
In the case of patient BVM with liver disease, development of ascites is an important landmark in the
natural history of cirrhosis. Adequate management of ascites is important, not only because it improves
quality of life in patients with cirrhosis, but also prevents serious complication such as SBP. However,
treatment of ascites does not significantly improve survival. Therefore, development of ascites should
be considered as an indication for transplantation. Liver transplantation is the ultimate treatment of
ascites and its complications.
Recommendations: The researchers recommend that the healthcare provider (HCP) be aware and
inform that liver disease is the leading cause of ascites. However, many serious conditions can lead to
the build-up of fluids in the abdomen. It is highly recommended to the patient to follow the discharge
plan given such as promote healthy diet especially sodium restrictions. Although dietary sodium should
be restricted to levels lower than urinary sodium excretion, sodium restriction to 2 g per day is realistic
goal particularly in an outpatient setting. Take diuretics as recommended by doctors. Patient should
limit the use of all medications including over-the-counter drugs, unless recommended by the doctors.
Bed rest is recommended for patients with ascites on the basis that upright posture increases
aldosterone levels, which is associated with sodium retention.

TABLE OF CONTENTS
Title Page . . . . . . . . . . . 1
Abstract . . . . . . . . . . . 2
Table of Contents . . . . . . . . . . 4
Acknowledgements . . . . . . . . . . 5
General Profile . . . . . . . . . . . 6
A. Chief Complaint . . . . . . . . . 6
B. Admitting Diagnosis . . . . . . . . 6
C. History of Present Illness . . . . . . . . 7
D. Past Medical History . . . . . . . . 7
E. Social and Environmental History . . . . . . . 7
F. Family History (Genogram) . . . . . . . . 8
Physical Examination . . . . . . . . . . 9
A. Review of Systems . . . . . . . . . 9-20

B. Gordon’s Typology Of 11 Functional Health Patterns . . . . . 21-22
Diagnostic and Laboratory Procedure . . . . . . . . 23-29
Case Study . . . . . . . . . . . 30-32
Pathophysiology . . . . . . . . . 30
Treatment. . . . . . . . . . . . 33-39
Discharge Plan . . . . . . . . . . . 40-42
Conclusions and Recommendations . . . . . . . . 43-44
Nursing Care Plans . . . . . . . . . . 45
References . . . . . . . . . . . 46

ACKNOWLEDGEMENT
We, the Group U Level IV nurse learners, would like to express our gratitude to all the people who, read
and offered comments and remarks in editing this case study especially Ma’am Doris Natividad.
This case study wouldn’t be possible without the aid of the following:
To Sir Gerard Rebolledo who guided us during our clinical duty and selecting a patient for our case
study.
To our parents and guardians who have always been supportive all throughout the start of the
duty until the end.
Lastly, to God, for giving us the strength and wisdom in realizing and fulfilling our duties in the
clinical area.

GENERAL PROFILE
A. Personal Profile:
Name: Bvm
Age: 48
Sex: Male
Marital Status: Married
Occupation: Laborer
Address: Baguio City
Educational Attainment: High School
Nationality: Filipino
Religious Affiliation: Roman Catholic
Date of Birth: September 3, 1970
Place of Birth: Baguio City
A. Chief Complaint
Patient Bvm, a 48-year-old male, was accompanied by his mother for his medical check-
up due to abdominal pain on January 17, 2019.
B. Admitting Diagnosis
Massive ascites secondary to decompensated liver disease, hypertensive cardiovascular

disease in HC IIC.

C. History of Present Illness
Patient Bvm’s condition started two years ago, when patient underwent repair of inguinal
hernia and angiography due to infection with emergency evacuation of scrotal hemorrhage few
days after first surgery. Since then, patient noticed increasing abdominal girth with associated
oliguria and urinary frequency.
Six months prior to admission, patient’s symptoms persisted that urged him to seek
consultation at the Out Patient Department (OPD). Parenthesis was done to decrease fluid
accumulation in the abdominal area that provided a temporary relief.
One week prior to admission, complaints of hemorrhage in scrotal area then sought
consultation in our institution and testing was done. However sudden movement of the patient
increased bleeding and stitching was done. This prompted patient to seek consultation for further
evaluation and management.
D. Past Medical History
Patient was admitted in the year 2017, hence underwent repair of inguinal hernia and
angiography. Few days after his surgery an emergency evacuation of scrotal hemorrhage was
done due to infection. Since then, he noticed an increasing abdominal girth with associated
oliguria and urinary frequency. He then consulted at the Out Patient Department due to persistent
increase of abdominal girth.
E. Social and Environmental History

Patient Bvm is a high school graduate at Baguio City National High School. Their house is
located at San Carlos Irisan, Baguio City where he lives with his family. To augment his family’s
needs, he worked as a laborer. Whenever someone calls for a workman, he volunteers himself.
He stated that sometimes he drinks liquor with his colleagues after they finished their work. He
also admitted that he smokes and drink during his free time. He has different workplace but he
described it as an open space surrounded by platform, cements, and other materials.

F. Family History
GENOGRAM
OLD AGE OLD AGE OLD AGE OLD AGE
60 76
Heart Attack Hypertension
53 51 50
Hypertension Alive & Alive &
Well Well
LEGEND:
- Male - Deceased
- Female - Deceased
- Patient
Patient Bvm is the last child among the four siblings and according to him. They have no history
of DM or cancer but his mother is hypertensive. He also mentioned that his father died of heart attack
at the age of 60. He is not aware of any food and medicine allergies. His older brother is also
hypertensive. Patient Bvm is currently admitted at the hospital.

PHYSICAL EXAMINATION
ASSESSMENT OF HEAD, FACE, NECK, EYES
HEAD
Shape: Round Size: 56 cm
Lesions: None Type: None Location: None
HAIR:
Distribution: Loosely distributed Color: Black Quantity: Hair is growing and thin
Infestations: None
SCALP:
Lesions: None Type: None Location: None
FACE:
Shape: Round Type: None Location: None
EYES:
Symmetry: Symmetrical Alignment: Aligned
SCLERA:
Color: Yellowish
CONJUNCTIVA:
Palpebral: Pale Bulbar: White

PUPILS:
Shape: Round Symmetry: Symmetrical
Pupil reaction to light Pupil has equal reaction to light
Pupil reaction to accommodation Pupil has equal reaction to accommodation
IRIS:
Color: Dark brown Symmetry: Symmetrical
VISUAL ACUITY:
Pain: None Tenderness: None Location: None
Extra ocular movement: Normal
Peripheral Vision: Normal
EYEBROWS:
Symmetry: Symmetrical Distribution: Well- distributed
Lesions: None Type: None
EYELASHES:
Symmetry: Symmetrical Distribution: Well- distributed
EYELIDS:
Color: Brown
Inflammation or presence of edema: None
Adequacy with which the eyelids close: Normal

EARS:
Auricle: Ornamental style Symmetry: Symmetrical Position: Aligned to the Tip of

the Eyebrows
Color: Brown Size: Normal
Lesions: None Tenderness: None
Ear canal Patency: Patent
Tympanic Membrane: Visible Contour: Normal Color: Pearly grey
Discharges: None Pain: None
Swelling: None Hearing Problems: None
Rinne test: Normal: Air conduction is better than bone conduction
Webber test: Normal: Heard equal on both ears
Whisper test: Normal: Able to hear on both eras
NOSE:
Symmetry: Symmetrical Position: Midline Color: Brown
Lesions: None Nasal discharge: None
Patency: Patent Tenderness: None
Nasal cavities: Normal Color: Pinkish Moisture: Moist
Discharge: None Lesions: None
Mass: None Polyps: None
Nasal septum: Patent Position: Midline Integrity: Normal
MOUTH:
Color: Pale Moisture: Dry Integrity: Normal
Swelling: None Lesions: None Tenderness: None

ORAL CAVITY:
Gums Color: Pale Hydration: Dry Integrity: Normal
Buccal mucosa Color: Bright pink Hydration: Dry Integrity: Normal
Hard palate Color: Bright pink Hydration: Dry Integrity: Normal
Soft palate Color: Bright red Hydration: Dry Integrity: Normal
Tonsils: Color: Reddish Grade: 2
Uvula: Color: Reddish
Teeth: Natural: Yes Artificial: No Color: White
Orthodontic appliance: None
Position or alignment: Up and Down
Decay: None
Tongue: Symmetry: Position: Rested behind the front teeth

Symmetrical
NECK:
Color: Brown Symmetry: Symmetrical
Lesions: Negative Type: N/A
Lymph nodes: Negative Location: N/A
Pain/tenderness: Negative JVD: Negative
Thyroid gland Consistency: No tenderness
Position: Lies between the Adam’s apple and

along the windpipe.

ASSESMENT OF THORAX AND LUNGS:
Shape of thorax: Side to side symmetric chest shape
Presence of superficial veins: None
Chest wall: Normal chest wall expansion
Respiratory Rate: 26cpm Pattern: Difficulty of breathing
Symmetry Symmetrical
Audibility of breathing: Audible breath sounds
Mode of breathing: Tachypneic
Abnormalities: Tachypneic with difficulty of breathing
Breath sounds: Normal: Clear lung fields
Pain/tenderness: Abdomen
Lesions: None
Position in respiration: Orthopnea
Lung expansion: Normal
Tactile expansion: Normal
Tactile fremitus: None
Diaphragmatic excursion: 1-2 centimeters
Spine: No abnormalities noted

ASSESSMENT OF THE CARDIOVASCULAR SYSTEM:
Color of nail bed: Pale Capillary refill: 4-5 seconds
Precordial movement: Normal PMI: Heard on the 5th left midclavicular

intercostal space
Radial pulse: 84 bpm Apical pulse: 89 bpm
Aortic: 2nd intercostal space just right of the Erb’s: Heard on the 3rd intercostal space left
sternum sternal border
Pulmonic: 2nd intercostal space just left of the

sternum
Tricuspid: 4th intercostal space left lower sternal Mitral: 5th intercostal space left mid clavicular
border line
S1: Heard over the apex using the JVD measurement: None
stethoscope’s diaphragm at the beginning of
systolic
S2: Heard during expiration and disappears

during inspiration

ASSESSMENT OF THE ABDOMEN:
INSPECTION:
Skin color: Brown Abdominal symmetry: Asymmetric
Vascularity: none Lesions/scars: None
Umbilicus: Midline Abdominal contour: Globular and distended
Abdominal Girth: 106 cm
AUSCULTATION
Friction rub: Heard over the liver Vascular sounds: Normal
LLQ sound: Borborygmus sound RLQ sound: Borborygmus sound noted

noted
LUQ sound: Borborygmus sound RUQ sound: Borborygmus sound noted

noted
PALPATION:
RLQ: Positive tenderness LLQ: Positive tenderness
RUQ: No tenderness LUQ: No tenderness
Special procedures:
Rebound tenderness: Negative Rovsing’s sign: Negative
Psoas sign: Negative Obturator sign: Negative
Murphy’s sign: Negative Hypersensitivity: None
Abdominal reflex: Normal Cullen’s sign: Negative

ASSESSMENT OF UPPER EXTREMITIES:
Hands and Appearance: Normal Color: Brown

fingers
Shape: Symmetrical Others: None
Nails: Color: Pale Shape: Round Texture: Firm
Capillary refill: 3-4 Others: None

seconds
Muscles Muscle tone: 0 (Modified Ashworth Muscle strengths: Muscle grade of 5/5
Scale)
Reflexes: +2 Shoulders: +1
ROM: Able to flex
Sensation: Light sensation: Normal
Pain sensation: Normal
Vibration: Normal
Position sensation: Normal
Temperature sensation: Normal

ASSESSMENT OF LOWER EXTREMITY:
Left and Right

Appearance: Normal Skin Temperature: Cold clammy skin
Leg and feet
Skin Moisture: Dry Varicosities: None
Bipedal edema: Positive and pitting
Nails:
Color: Pale Shape: Round Texture: Firm
Capillary refill: 3-4 Others: None

seconds
Muscles Muscle tone: 0 Modified Ashworth Muscle strengths: Muscle grade of 5/5
Scale)
Reflexes: +2
Joints Left ROM: Able to flex ( but not fully flexed) Dorsalispedis: +1
Posterior tibial: +1 Peripheral pulses: +2
Homan’s sign: Negative Babinski reflex: Negative
Inflammation: None
Sensation:
Light sensation: Normal
Pain sensation: Normal
Vibration: Normal
Position sensation: Normal
Temperature sensation: Normal

REVIEW OF SYSTEMS:
SKIN, HAIR AND NAILS Rashes: None
Infestations: None
Deformities, injuries: None
HEENT Head Headaches: None Dizziness: None
Neck Stiffness: None Difficulty with Swallowing: Positive
Enlarged lymph nodes: Negative
Ears Pain: None Tinnitus: None Drainage: None
Difficulty hearing: None
Type of Hearing Aid: None
Date new batteries needed: None
EYES Pain: None Redness: Positive Tearing: None
Blurring: None Date of last exam: None
Glasses: None Contact lenses: None
Black spots: None Halos: None Flashes: None
Surgeries: None
Throat, Sore throat: None Hoarseness: None

mouth, nose,
and sinuses Mouth pain: Positive Lesions: None
Speech difficulties: None Swallowing Difficulties: Positive
Last dental exam: 2015 Dentures: None
Fixtures: None
Allergic rhinitis: None Type of allergen: None
Relief measures: None
Frequency of cold per year: 3
Nose bleeds: None
Sinus problems: None

THORAX AND LUNGS Pain: None DOB: Positive SOB: Positive
Orthopnea: Positive DOE: None PND: None
Cough: None Sputum: None
Hemoptysis: None Last chest X-ray: None
Activity intolerance: Positive
BREASTS AND REGIONAL Pain: None Lumps: None Dimpling: None

LYMPHATICS
Change in size: None Discharges: None
Swollen lymph nodes in the axilla: None
HEART AND NECK VESSELS Chest pain: None Palpitations: None
Edema: None
Last BP: 60/40mmHg Last ECG: February 12, 2019
JVD: None
PERIPHERAL VASCULAR Leg or feet pain: None Swelling of legs or feet: None
Sores: None Numbness: None
Change in color: None Tingling: None
Changes in hair distribution on extremities: None
ABDOMEN Pain: Positive Indigestion: None N/V: None
Difficulty swallowing: Positive Gas: None
Appetite: Decreased
Jaundice: None Hernias: None
GENITALIA Dysuria: None Frequency: Positive
Hematuria: None Urgency: None
Pyuria: None Hesitancy: None
Nocturia: None Incontinence: None
Anuria; None Dribbling: None
Penile lesions: None Penile pain: None
Oliguria: Positive

GENITALIA Scrotal swelling: Difficulty with erection: None
Difficulty with ejaculation: None
Exposure to STIs: None
ANUS, RECTUM AND Pain with defecation: None

PROSTATE
Diarrhea: Positive Constipation: Positive Hemorrhoids: None
Melena: None Hematochezia: None
Use of laxatives: None Colostomy: None
Ileostomy: None
Prostate problems: None
Last DRE: None
MUSCULOSKELETAL Pain: None Redness: None Swelling: None
NEUROLOGICAL Stiffness: None Strength: Upper Extremity- Left: 5/5 Right: 5/5
Lower Extremity- Left: 5/5 Right: 5/5
Difficulty with ambulating: None
Ambulation Aids-Present Cane: NA
Crutches: NA
Walker: NA
Wheelchair: NA
Alert: Yes Confused: No Disoriented: No
Mood: Good Behavior: Good Depression: None

NEUROLOGICAL Anger: No Headaches: None Concussions: none
Loss of sensation: None Contusions: none
Loss of strength: None Difficulty with speech:

Positive
Difficulty with recall or memory: Strange voices: None

None
Strange visions: None
Difficulty with learning or reading: Strange thoughts: None

None

LIFESTYLE AND HEALTH PATTERNS:
HABITS Alcohol: Yes Smoking: Yes Drugs: No
Duration of each: Alcohol: Occasionally
Smoking: Consume 3 sticks in a week : Gradually stopped
NUTRITION 24H diet: Three times a day with snacks in between
EXERCISE Jogging: None Walking: None Gym: None Others: Range of motion exercises
HABITS
SLEEP AND Times asleep: 9PM Time awake: 6AM Sleep problems: None
REST
WORK Nature of work: None Satisfaction: None Stressors: None

PATTERNS

GORDON’S TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS
HEALTH PERCEPTION AND HEALTH Prior to admission he admits that he occasionally drinks liquor
MANAGEMENT and used to be a smoker and can smoke 1 pack of cigarette a
week.
During hospitalization, he was anxious and started to doubt if

he will get well because of the presence of the bag valve mask.
Patient is dependent in medications and in the actions of the
healthcare team. He still believes that he will soon to be treat
after series of treatment and all he need is patience.
NUTRITION AND METABOLISM Prior to admission his body build is appropriate for age. He
eats nutritious and protein rich foods. He eats without any
problem but has watery defecation. He eats his meal three
times a day and drinks 5-6 glasses of water per day. He stated
that his meal mostly consist of meat products and vegetables.
He stated that his urine is less than the amount of water he
drink.
During hospitalization he has difficulty of swallowing. He

claimed that sometimes he loses his appetite and skip his
meals.
ELIMINATION Prior to admission He urinates 4 times a day to dark yellow

urine. He defecates two to three times a day which is clay
colored and mushy consistency with ragged edges.
During hospitalization he defecates every other day or was. He

claims that he experiences alternate diarrhea and
constipation.
ACTIVITY AND EXERCISE Prior to admission His leisure activity is watching television. He
does not exercise because he considers physical activity such
as carrying heavy loads as a form of exercise.
During hospitalization he cannot do extraneous activities. He

does simple exercises on the upper and lower extremities by
means of shaking, stretching, flexion, hyper extension,
adduction, abduction of hands and fingers. Patient had
decreased optimal conditioning where he cannot do
extraneous activities because of his current condition.

COGNITION AND PERCEPTION No sensory deficits and functions accordingly to his age. He has
normal thought process and oriented to people, time and
place. He is not able to respond verbally because of the bag
valve mask so he expresses his feelings by writing in a piece of
paper.
SLEEP AND REST He sleeps 9 in the evening, and wakes up at 6 in the morning.
He wakes up feeling well and rested. When he was admitted in
the hospital, he claimed that there are interruptions in his
sleep because of the noise from other patient or watcher. He
also stated that he is not able to rest because of the
uncomfortable environment.
SELF-PERCEPTION AND SELF- He was compliant to what the doctors and nurses say because
CONCEPT he believes that it can help him recover. He always uses his
blanket to warm his body. He claims that he feels good about
himself but sometimes he loses hope because of his condition.
ROLES AND RELATIONSHIPS He lives with his family and he is close to his children. In the
past he works industriously to support his family needs but
cannot do it nowadays due to his condition. Sometimes he
wants to go home and do things to help his family. He is well
supported and loved by her family. He considers his family as
his life and his motivation to live. Also claims that he values
efforts coming from them.
SEXUALITY AND REPRODUCTION He claims that his sexual functioning changed ever since he had
ascites.
COPING AND STRESS TOLERANCE The most helpful person in his life when problems occur is his
family. He stated that seeing his children happy is enough to
forget his problem.
VALUES AND BELIEFS He is Roman Catholic and religion is important to his family. He
has so many plans for the future especially for his children. He
wants to get well soon for his family.

DIAGNOSTIC AND LABORATORY PROCEDURES
This section of the study focuses on the diagnostic and laboratory tests ordered by the
physician, vital to the process of understanding and management of the condition of the patient.
PROCEDURE DESCRIPTION RESULT REFERENCE RANGE
January 27, 2019 Complete Blood Count Hemoglobin:135 Hemoglobin (140-180

4:31 helps in detecting any g/L)
abnormal increase or
decrease in blood
Hematocrit: 0.41 Hematocrit (0.40-0.54
Complete Blood Count count. It is a test used
to screen and evaluate L/L)
presence for certain WBC Count : 5.21 WBC Count (5.0-10.0)
diseases and blood
related disorders that Neutrophils : 74 % Neutrophils (50-70%)
could negatively impact
health. Lymphocytes: 15% Lymphocytes (20-40%)
Monocytes: 7% Monocytes (0-10%)
Eosinophils: 3% Eosinophils: 0-7%
Basophils: 1 Basophils: 0-1
RBC Count: 4.39 RBC Count (4.69--6.13

x 1012/L)
Platelet Count:271 Platelet Count (150-

400 x 109/L)
RBC INDICES
MCV: 93.20 MCV:80-100fL
MCH:30.60 MCH:27-31pg
MCHC:329.00 MCHC:310-361g/L
RDW-CV:15.00 RDW-CV:11-16%
RDW-SD:50.90 RDW-SD:35-56fL
Table 1.1 Complete Blood Count
Complete blood count (CBC) was ordered to the patient evaluate a patient’s red and white blood
cells and platelets. In cases of liver cirrhosis, platelet count often decreases. Meanwhile, result of the test
shows that Neutrophils are high while Lymphocytes are low. This indicates that there is weakening of
immune system and presence of bacterial infection.

January 27, 2019 Routine chemistry is Sodium:140.70 Sodium:136-

8:36 the biochemical 145mmol/L
analysis of body fluids. Potassium:4.88
It is done to detect and Potassium:3.5-
Routine Chemistry quantify different 5.1mmol/L
compounds in blood Ionized Calcium:1.34 Ionized Calcium: 1.1-
and urine. This is done 1.35mmol/L
routinely to monitor
patients condition. Magnesium:0.99
Magnesium:0.73-
1.06mmol/L
Blood Urea
Nitrogen:22.89 Blood Urea
Nitrogen:2.8-
Albumin: 39.13 7.2mmol/L
Albumin:35-52g/L
Table 1.2 Routine Chemistry
The result shows a high BUN level that is probably caused by low blood flow to the kidneys caused
by heart failure. Persistent high BUN level is associated with increased cardiovascular mortality.
Normalization of BUN during hospitalization may improve long-term clinical outcomes. Albumin is a
protein made by the liver that is often decreased in cirrhosis.

January 27, 2019 Routine chemistry is Creatinine:140.40 Creatinine:71-

4:34 the bio chemical 115umol/L
analysis of body fluids.
SGOT/AST:42.6 SGOT/AST:0-36U/L
It is done to detect and
Routine Chemistry quantify different SGPT/ALT:24.50 SGPT/ALT:0-40U/L
compounds in blood
and urine. Total Bilirubin:34.50 Total Bilirubin:3-
17umol/L
Direct Bilirubin:21.81 Direct Bilirubin:0-

3umol/L
Indirect Bilirubin:12.69
Indirect Bilirubin: 1.7-
17.1umol/L
Table 1.3 Routine Chemistry
Alanine aminotransferase (ALT) is an enzyme found mainly in the liver. Values are increased with
all types of liver injury, including cirrhosis.Alkaline phosphatase (ALP) is an enzyme found along bile ducts.
ALP is usually normal or mildly elevated in cirrhosis. Total bilirubin is a substance produced exclusively in
the liver. It is increased with many liver diseases. Bilirubin is usually normal or slightly elevated until
cirrhosis becomes far advanced.

January 27, 2019 Anti-HCV is a blood Anti-HCV:0.11 Anti-HCV:S/CO<1.00

5:25 test that looks for nonreactive|>=1.00
hepatitis C antibodies reactive
in the bloodstream.
Serology:Hepatitis C HBsAg:0.22 HBsAg: S/CO<1.00
HBsAg is a blood test nonreactive|>=1.00
antibody( Anti-HCV),
Hepatitis B surface that looks for hepatitis reactive
antigen (HBsAg), B in the bloodstream.
Anti-HBe: S/CO<=1.00
hepatitis B e-antigen Anti-HBeAg is an Anti-HBeAg:1.32 nonreactive|>=1.00
(Anti-HBeAg) antibody to the e reactive
antigen of the hepatitis
B virus. Its detection in
the blood indicates the
presence of a low-titer
hepatitis B infection
and decreased ability
of the infected person
to pass the virus on to
another person.
Table 1.4Serology:Anti-HCV,HBsAg,Anti-HBeSAg
A "positive" or "reactive" HBsAg test result means that the person is infected with hepatitis B. This
test can detect the actual presence of the hepatitis B virus (called the “surface antigen”) in your
blood. Hepatitis B and hepatitis C testing may be ordered to help diagnose the underlying cause of chronic
liver disease.
January 27,2019 Anti-HBs is a key

8:44 serological marker for
both vaccine-induced 0.65 MIU/mL<10.00
Serology: Anti-HBS immunity due to nonreactive|>+10.00
infection. reactive
Table 1.5Serology: Anti-HBS
A non-reactive" anti-HBs (or HBsAb) test result indicates that our patient is not protected against
the hepatitis B virus. This is done to patients as a confirmatory test to suspected Hapatitis B cases.

PROCEDURE DESCRIPTION AND RESULT
PURPOSE
January 30,2019 Gram staining is a Gramstain:

11:24 method commonly used
to determine the Pus cell: Positive One
Bacteriology: chemical makeup of the AFB: Negative for Acid Fast Bacilli
Gramstain, AFB cell wall of bacteria. The
cell wall can stain either
positive or negative,
depending on its
chemistry.
Acid-fast bacillus (AFB)

stain or a tuberculosis
(TB) smear is a test to
determine if a person has
tuberculosis (TB) or
another type of
mycobacterial infection.
Table 1.6 Bacteriology: Gramstain, AFB
Culture of the ascitic fluid for bacteria should be obtained routinely in patients with cirrhotic
ascites, in whom spontaneous bacterial peritonitis (SBP) can occur. Gram staining is useful in detecting
secondary peritonitis due to gut perforation but is only about 10 percent sensitive in detecting bacteria
early in spontaneous bacterial peritonitis (SBP).
Detection of Mycobacterium tuberculosis (MTB) in ascitic fluid by either acid-fast bacillus (AFB)
staining or culturing can confirm diagnosis of TB ascites.

PROCEDURE DESCRIPTION AND RESULT
PURPOSE
January 30,2019 A white blood cell Physical Examination:

10:22 count measures the
number of white blood Color: Red
cells in the blood, and Appearance: Turbid
Cell count and
a WBC differential
Differential count count determinesthe Volume: 24ml
percentage of each
Microscopic Examination
type of white blood
cell present in the No. of WBC:208
blood.
No. of RBC: Too Numerous to Count
A differential count
was also used to
detect immature white
blood cells and
abnormalities, both of
which are signs of
potential issues.
Table 1.7Cell Count and Differential Count
The cell count is the single most important test performed on the ascitic fluid. It provides
immediate information about the possible bacterial infection. Samples with a predominance of
neutrophils and an absolute neutrophil count of > 250 per cubic mm should be presumed to be infected.
An elevated ascetic fluid WBC count is seen in all inflammatory processes and malignant ascites

PROCEDURE DESCRIPTION AND RESULT REFERENCE RANGE
PURPOSE
February 12,2019 The complete blood Hemoglobin:146 Hemoglobin :140-180

4:00 count (CBC) is often (g/L)
used as a broad
screening test to
Hematocrit: 0.45 Hematocrit (0.40-0.54
Complete Blood Count determine an
individual's general L/L)
health status. It can be WBC Count : 8.95 WBC Count (5.0-10.0)
used to: Screen for a
wide range of Neutrophils : 72% Neutrophils (50-70%)
conditions and
diseases. Help diagnose Lymphocytes: 19% Lymphocytes (20-40%)
various conditions,
such as anemia,
infection, Monocytes: 6% Monocytes (0-10%)
inflammation, bleeding
disorder or leukemia. Eosinophils: 2% Eosinophils: 0-7%
Basophils: 1 Basophils: 0-1
RBC Count: 4.79 RBC Count (4.69--6.13

x 1012/L)
Platelet Count:406 Platelet Count (150-

400 x 109/L)
RBC INDICES
MCV: 94.90 MCV:80-100fL
MCH:30.50 MCH:27-31pg
MCHC:321.00 MCHC:310-361g/L
RDW-CV:15.40 RDW-CV:11-16%
RDW-SD:52.30 RDW-SD:35-56fL
Table 1.8 Complete Blood Count
Slightly increased in one type of white blood cell can cause a decrease in the percentage of other
types of white blood cells. An increased percentage of neutrophils and lymphocytes may be due to stress.

CASE STUDY
Medical Diagnosis:
Massive ascites secondary to decompensated liver disease, hypertensive cardiovascular disease

in Hypertrophic cardiomyopathy
Ascites
This is the accumulation of free or pathologic fluid in the peritoneal cavity or abdominal cavity.
Risk factors:
 Long term, heavy alcohol use

 Chronic Viral Hepatitis
Causative Factors:
 Portal hypertension
 Liver disease
Clinical Manifestations:
Symptoms vary from one patient to another but the following are from patient BVM’s case:
 Abdominal distension
 Shifting dullness on percussion and a fluid thrill
 Everted umbilicus
 Scrotal edema

PATHOPHYSIOLOGY
Precipitating Factor:
Decompensated liver disease (Cirrhosis) caused
by excessive alcohol intake and smoking
Increased lymph Portal hypertension Hepatocyte failure

production
Increased capillary
filtration pressure Decreased albumin Altered metabolism
Dilation of lymph
synthesis
channels draining liver
Peripheral arterial
vasodilation
Decreased capillary
Leakage of lymph into oncotic pressure
abdominal cavity
Increased renin
Decreased effective
aldosterone and
plasma volume
antidiuretic hormone
Leakage of plasma out of vascular

space
Increased renal
absorption of sodium
and water
Massive Ascites

Patient BVM is a 48 year old male who is a heavy drinker who can consume 3 bottles of gin a day
and smokes 10-15 sticks a day for almost 30 years. Due to his habits, he was diagnosed with
hypertensive cardiovascular disease, cirrhosis, and hepatitis B in the year 2017. Because of his medical
condition lymph production is increased since the lymphatic system is part of the circulatory system
and plays a key role in the normal vascular function of the liver (Chung & Iwakiri, 2013). The increase
in lymph production dilates the lymph channels that drains the liver thus, causes leakage of lymph
into the abdominal cavity. Another factor contributing to this is the presence of portal hypertension.
Because of this, it again increases capillary filtration. Furthermore, hepatocyte is not produced
because of the damaged liver. It then leads to: (1) Decreased albumin synthesis, which in anatomy,
albumin is an important protein because it acts as a colloid osmotic pressure that attracts or magnets
fluids intracellularly and (2) alters the metabolism which causes the increase of aldosterone and
antidiuretic hormone. Consequently, the decreased albumin synthesis also causes the capillary to
decrease its oncotic pressure that contributes to the leakage of fluid in the peritoneal or abdominal
cavity causing the ascites of patient BVM.

TREATMENT
This section shows the treatment given to patient Phantom. This includes the drugs, intravenous
fluids, and blood transfusion with the description, purpose and nursing intervention of each treatment
given.
Drug Description and Purpose Nursing Interventions
Metoprolol 50 mg 1 Tab Metoprolol is an immediate- 1. Assess and monitor blood pressure

OD release and extended-release closely when starting the therapy.
oral tablets. This drug belongs to 2. Watch out for orthostatic
Date and time ordered : the drug classification known as hypotension.
February 05, 2019 beta blockers. It work by blocking 3. Monitor signs for signs and
the action of certain natural symptoms of hyperthyroidism.
chemical in the body, such as 4. Instruct to avoid strenuous
epinephrine, on the heart and activities because this drug causes
blood vessels. This effect lowers dizziness.
the heart rate, blood pressure,
and strain on the heart (Web
MD, n.d.)
Table1. Metoprolol
This is prescribed to the patient to treat severe chest pain and lowers the risk of heart attack. This
drug is also given to slow the heart beat and decrease the blood pressure. When the blood pressure is
lower, the amount of blood and oxygen is increases to the heart that relieved the angina (Micromedex,
n.d.). This is given 50 mg per day, given in single dose until optimum clinical response is achieved or there
is a pronounced slowing of the heart rate.

Lactulose 30 cc ODHS Lactulose is an osmotic laxative. 1. Mix with half glass of water and
This drug synthetic sugar used to may take up to 48 hours to act.
Date and Time treat constipation. It produces 2. Check for diarrhea because this
Ordered: osmotic effect, which increases may indicate that the dose is
February 05, 2019 water content in colon and too high.
enhances peristalsis. Breakdown 3. Assess amount, colour and
3:30 pm products in colon lead consistency of stool.
acidification of colonic content 4. Explain that lactulose may take
softening of stool, and decreased 2-3 days to effect. Advise that if
ammonia absorption from colon symptoms improve or worsen
to systemic circulation (Schull, notify and seek for medical
2013). attention.
5. Advise patient to drink plenty of
fluid while taking this medicine.
Table 2. Lactulose
Lactulose is given to treat constipation and help to eliminate ammonia in the blood via the stools
to prevent hepatic coma encephalopathy (Schull, 2013). This drug synthetic sugar used to treat
constipation. It is broken down in the colon into products that pull water out from the body and into the
colon. This water softens the stools (Lippincott, Williams 2008). Due to the clients liver cirrhosis the
ammonia in his blood is increase and it is manifested by decrease in level of consciousness, this drug is
given to the client to help in decreasing the ammonia by eliminating it through stools.

Tramadol 50mg IV q8 Tramadol is an opioid analgesic 1. Assess for hypersensitivity to drug.

for pain that is used to relieve moderate
to severe pain (Schull, 2013). 2. Measure and record regular weights
Date and Time to monitor fluid changes.
Ordered:
3. Administer drug early in the day so
February 10, 2019
increased urination will not disturb
3:30 pm sleep.
4. Monitor serum electrolytes,

hydration, and liver functioning during
long-term therapy.
5. Provide diet rich in potassium.

Table 3. Tramadol
Tramadol is similar to opioids analgesics. According to (Meghan Wehner, 2015) Opioids are the most
common drug class for analgesia, particularly moderate and severe pain or pain not relieved by acetaminophen
and NSAIDs. Opioids can contribute to significant complications with cirrhosis, including precipitating
encephalopathy. This is given to the patient for management due to the client complaint of severe pain.

Spironolactone 50mg 1 tab Spironolactone is a 1. Monitor blood pressure and

OD potassium-sparring hold the drug if the blood
diuretic. It prevents the pressure is less than 90/60.
(hold if BP <90/60) body from absorbing too
2. Assess for allergy on
much salts and keeps
Date and Time Ordered: potassium levels. This spironolactone, heperkalemia,
medicine is used to treat and renal disease.
February 05,2019 or prevent hypokalemia. 3. Check for renal function test,
(RxList, 2018). urinary output patterns.
3:30pm
4. Give daily doses.
5. Monitor electrolyte leves.
6. Measure and record regular
weight to monitor
mobilization of edema fluid.
7. Instruct patient to avoid
consuming food rich in
potassium.
8.
Table 4. Spironolactone
Aldosterone levels may be high in liver cirrhosis accompanied by Ascites, Spironolactone

(ALDACTONE) is indicated for maintenance therapy with bed rest and the restriction of fluid and sodium
(RxList, 2018). This medicine is used to treat of hypertension because lowering the blood pressure reduces
the risk of fatal and non-fatal cardiovascular implications primarily stroke and myocardial infarction. This
is administered to the client at a daily dosage of 50 mg for correction of hypokalemia and hypertension
(RxList, 2018). This is given to the client mainly because of edema due to liver cirrhosis and also this is
given to the client of high blood pressure this was prescribed because it is potassium sparing diuretic, this
drug can decrease blood pressure at the same time it can prevent the eliminating of potassium.

Trimetazidine 35 mg 1tab BID Trimetazidine is an anti- 1. Monitor blood pressure

ischemic (anti-anginal) because this medication
Date and Time Ordered: metabolic agent, which may cause hypotension.
February 05,2019 improves myocardial glucose 2. Instruct to avoid activities
utilization through inhibition that require heavy exertion
6:00 am of fatty acid metabolism, also because this drug may cause
known as fatty acid oxidation drowsiness.
inhibitor (Practo, 2017). 3. Instruct to swallow whole
with a glass of water. Do not
chew or crush because this
may inappropriate release
an absorption of the drug.
Table 5.Trimetazidine
This medication is given to the patient because it helps in aiding angina. This is use as a first line
agent for unstable angina or heart attack is not recommended. This medicine is also not indicated for use
as a curative treatment for angina (Practo, 2017).
Furosemide20mg 1tab Furosemide is a potent loop 1. Assess fluid status.

OD diuretic that is used to 2. Assess for depletion of electrolyte,
eliminate water and salt from confusion, anorexia, nausea and
(Hold if BP <90/60) the kidneys. This is also used to vomiting.
Date and Time Ordered: lowers the blood pressure. 3. Monitor blood pressure and pulse
before and during administration.
February 5,2019 4. Monitor weight daily, input and
output, lung sound, skin turgor, and
11:00 am
mucous membranes.
5. Instruct patient to move slowly
when rising to prevent sudden
blood pressure decrease.
Table 6. Furosemide
Loop diuretics inhibits sodium and chloride reabsorption in the proximal part of the ascending loop of
henle, promoting the excretion of sodium, water, chloride, and potassium. This drug also has an effect that
may be the result of renal and peripheral vasodilation and a temporary increase in glomerular filtration rate
and a decrease in vascular resistance that causes hypotension (Schull, 2013). This was given because the client
has generalized edema, and ascites caused by hepatic cirrhosis. And also this was given to help aid in high blood
pressure.

Digoxin 0.25 mg 1 tab OD Digoxin increases the force of 1. Before giving drug, take apical-
contraction of the muscle of radial pulse for 1 minute. ( A sudden
February 12, 2019 the heart by inhibiting the increase or decrease in pulse rate,
8:00 pm activity of an enzyme (ATPase) irregular beats and rhythm check BP
that controls movement of and obtain 12-lead EGC.)
calcium, sodium, and 2. Monitor digoxin level. Therapeutic
potassium into heart muscle. level ranges 0.8-2ng/ml
(MedicineNet 3. Excessively slow PR may be a sign of
digitalis toxicity, withhold drug.
Digoxin remains one of the 4. Instruct patient to report N&V,
most frequently prescribed diarrhea, loss of appetite and visual
drugs in the management of
disturbance may indicate toxicity
atrial fibrillation.
Table 7. Digoxin
This was prescribed because the patient has a atrial fibrillation with aberrant conduction and
ventricular premature complexes as seen in the ECG result. The drug was given for restoration of sinus
rhythm that prevents recurrence and slowing of the ventricular rate.
Ceftriaxone 2g IV OD Ceftriaxone is used to treat a 1. Monitor renal, hepatic,

February 2, 2019 wide variety of bacterial hematopoietic functions
infections. This medication (CI Penicillin allergic patients Hepatic or
10:15 am belongs to a class of drugs renal dysfunction)
known as cephalosporin
antibiotics. It works by 2. Before giving drug, ask patient if he
is allergic to penicillin’s or
stopping the growth of
cephalosporin.
bacteria. (webMD 2015)
3. Obtain specimen for culture and
sensitivity tests before giving first
dose.
Table 8. Ceftriaxone
Ceftriaxone injection is given before surgery to prevent infections that may develop after the
operation. (Rxlist 2018) Ceftriaxone was commonly utilized for pneumonia and it was also prescribed for
hepatic disorders (Mulugeta et.,al 2015)

Metronidazole 500mg Metronidazole is an antibiotic 1. Caution is needed in patients with

every 8 hours that is used to treat a wide severe hepatic impairment. The
variety of infections. It inhibits dose of metronidazole should be
February 2, 2019 reduced as necessary.
nucleic acid synthesis by
2. Liver function tests must be
10:15 am disrupting the DNA of performed just prior to the start of
microbial cells. therapy, throughout and after end
of treatment until liver function is
within normal ranges, or until the
baseline values are reached.
3. If the liver function tests become
markedly elevated during
treatment, the drug should be
discontinued.
Table 9. Metronidazole
Metronidazole works by entering bacterial and protozoal cells and interfering with their genetic
material (DNA). It damages the DNA and also prevents the bacteria and protozoa from forming new DNA.
This ultimately results in metronidazole killing the micro-organisms, which clears up the infection
(NetDoctor 2016). This antibiotic treats only certain bacterial and parasitic infections. (MPR 2019)

Tranexamic acid 500 mg Tranexamic acid is a synthetic 1. Assess for thromboembolic

IV every 8 hours February analog of the amino acid complications. Notify physician of
12, 2019 lysine. It serves as an positive Homans’ sign, leg pain
antifibrinolytic by reversibly hemorrhage, edema, hemoptysis,
10:10 am binding four to five lysine dyspnea, or chest pain.
receptor sites on plasminogen. 2. Monitor platelet count and clotting
factors prior to and periodically
Tranexamic acid works by throughout therapy.
slowing the breakdown of 3. Stabilize IV catheter to minimize
blood clots, which helps to thrombophlebitis. Monitor site
prevent prolonged bleeding. closely.
(Lippincott, Williams 2008) 4. Instruct patient to notify the nurse
immediately if bleeding recurs or if
thromboembolic symptoms
develop.
5. Caution patient to make position
changes slowly to avoid orthostatic
hypotension.
Table 10 Tranexamic Acid
The patient was diagnosed of decompensated liver disease so tranexamic acid was prescribed in
order prevent uncontrollable bleeding. In addition, tranexamic acid can further alleviate conditions of the
following; hepatic encephalopathy, sepsis and ascites liquid infection.

DISCHARGE PLAN
Discharge planning is a process that aims to improve the coordination of services after discharge
from hospital by considering the patient's needs in the community. It sought to bridge the gap between
hospital and the place to which the patient is discharged, reduce length of stay in hospital, and minimize
unplanned readmission to hospital.
Activity and Rest Encouraged to avoid extraneous activities like carrying heavy
weights and heavy exercises such as running, hiking and
playing basketball.
Advised to do light exercises that you can be done at home,
including some that you can do while sitting like Passive
ROM.
Encouraged to take a nap during the day if you feel tired this
can help to recharge your system and your body.
Medication and treatment Instructed take all medicines at the right time and with the
right dose.
Tranexamic acid 500 mg IV every 8 hours
Metronidazole 500mg every 8 hours
Digoxin 0.25 mg 1 tab OD
Trimetazidine 35 mg 1tab BID
Furosemide20mg 1tab OD
Spironolactone 50mg 1 tab OD
Preventing mouth sores:
1. Brush your teeth with soft-bristle toothbrush after

every meal.

2. Avoid using dental floss if you are risk for bleeding.
3. Use mouthwashes or rinses as instructed
Diet and Nutrition Advised that it is important to eat a well-balanced diet and
drink plenty of fluids.
Educated on diet restrictions which includes avoid table salt,
salty foods, salted butter and margarine, canned and frozen
foods. It is usually posited that in order to avoid fluid
retention, oral sodium intake must be significantly reduced
in order to achieve a negative sodium balance. Salt
restriction would further decrease fluid accumulation by
lowering portal pressure through vascular volume depletion.
Instructed that he will increase consumption of foods high
protein foods on his diet. To make liberal use of powdered,
low sodium milk and milk product. To eat Fruits, vegetables
and fresh meats such as lean red meat, poultry and seafood
are naturally low in sodium. Plain rice, pasta and other grains
also naturally low in sodium. Some breads and cereals are a
source of sodium. Read food labels to find the lowest sodium
options. Use lemon juice, vinegar, garlic, onion and herbs and
spices to add flavor to food.
Health Teaching Educate the patient and family about the treatment plan
including the need to avoid all alcohol intake, adhere to a low
sodium diet, take medications as prescribe and check with

the physician before taking any new medications. Patient
and family teaching addresses skin care and the need to
weigh the patient daily and to watch for and report signs and
symptoms of complications
Follow-up Follow up as advised by your healthcare provider. Keep all
follow-up appointments.
Due to the health teaching we have done to patient BVM we observed that some of the activities
were performed. Nurse learners have provided nurture and support needed to facilitate the adaptation
of health behaviors. This kind of help assures that the educational gains achieved by the client will be
maximized by a healthy living.
We conclude that the health teaching such as diet and nutrition, adequate rest period and
adherence to medication will produce a significant improvement to the patient.

CONCLUSIONS AND RECOMMENDATIONS
CONCLUSION
After assessing the patient's condition, activities, and intervention done we have conclude that
massive ascites is a serious condition that needs immediate medical intervention. This can cause death to
the client who diagnosed with this. The prognosis for patient with ascites due to liver disease depends on
the underlying disorder, the degree of reversibility of a given disease process, and the response to
treatment. Ascites tends to occurs in a long standing rather than in short lived disorders. It occurs
commonly in cirrhosis, especially in cirrhosis caused by alcoholism. It may occur in other liver disorders,
such as severe alcoholic hepatitis without cirrhosis, chronic hepatitis, and obstruction in the hepatic vein.
In the case of patient BVM with liver disease, development of ascites is an important landmark in
the natural history of cirrhosis. Adequate management of ascites is important, not only because it
improves quality of life in patients with cirrhosis, but also prevents serious complication such as SBP.
However, treatment of ascites does not significantly improve survival. Therefore, development of ascites
should be considered as an indication for transplantation. Liver transplantation is the ultimate treatment
of ascites and its complications.
RECOMMENDATION
Furthermore, the researchers recommend that the healthcare provider (HCP) be aware and
inform that liver disease is the leading cause of ascites. However, many serious conditions can lead to the
buildup of fluids in the abdomen. It is highly recommended to the patient to follow the discharge plan
given such as promote healthy diet especially sodium restrictions. Although dietary sodium should be
restricted to levels lower than urinary sodium excretion, sodium restriction to 2 g per day is realistic goal
particularly in an outpatient setting. Take diuretics as recommended by doctors. Patient should limit the
use of all medications including over-the-counter drugs, unless recommended by the doctors. Bed rest is

recommended for patients with ascites on the basis that upright posture increases aldosterone levels,
which is associated with sodium retention.

NURSING CARE PLAN
A. List of Problems as Prioritized using Maslow’s Hierarchy of Needs
1. Ineffective breathing pattern related to decreased lung expansion secondary to intra-
abdominal fluid collection (ascites)
2. Fluid volume excess r/t compromised regulatory mechanisms secondary to cirrhosis of the liver
as manifested by pallor, weak in appearance, jaundice, abdominal distention
3. Activity intolerance related ascites, and muscle wasting
4. Risk for Impaired Skin Integrity
5. Risk for fall
6. Disturbed Body Image

REFERENCES
Meghan Wehner, P. M. (2015). Pain Management considerations in cirrhosis. Pharmacist, 50.
Schull, P. D. (2013). McGraw-Hill Nurse's Drug Handbook. United States: Mc-Graw-Hill Education.

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A CASE STUDY ON MASSIVE ASCITES

NICOLEEN MAE D. SIBAYAN

HANNAH LHYNE O. TAYAB

JAZZYL KETH S. TONGAB

KRISTA DEE D. WAGAWAG

BENGUET STATE UNIVERSITY

BACHELOR OF SCIENCE IN NURSING

Title: A CASE STUDY ON MASSIVE ASCITES

Keywords: Decompensated, liver, cardiovascular disease, HC IIC, hemorrhage

A CASE STUDY ON MASSIVE ASCITES 2

A CASE STUDY ON MASSIVE ASCITES 3

A. Review of Systems . . . . . . . . . 9-20

Diagnostic and Laboratory Procedure . . . . . . . . 23-29

Case Study . . . . . . . . . . . 30-32

Discharge Plan . . . . . . . . . . . 40-42

Conclusions and Recommendations . . . . . . . . 43-44

Nursing Care Plans . . . . . . . . . . 45

A CASE STUDY ON MASSIVE ASCITES 4

A CASE STUDY ON MASSIVE ASCITES 5

Marital Status: Married

Address: Baguio City

Educational Attainment: High School

Religious Affiliation: Roman Catholic

Date of Birth: September 3, 1970

Place of Birth: Baguio City

Massive ascites secondary to decompensated liver disease, hypertensive cardiovascular

A CASE STUDY ON MASSIVE ASCITES 6

E. Social and Environmental History

A CASE STUDY ON MASSIVE ASCITES 7

OLD AGE OLD AGE OLD AGE OLD AGE

A CASE STUDY ON MASSIVE ASCITES 8

ASSESSMENT OF HEAD, FACE, NECK, EYES

Shape: Round Size: 56 cm

Lesions: None Type: None Location: None

Lesions: None Type: None Location: None

Shape: Round Type: None Location: None

Symmetry: Symmetrical Alignment: Aligned

A CASE STUDY ON MASSIVE ASCITES 9

Shape: Round Symmetry: Symmetrical

Pupil reaction to light Pupil has equal reaction to light

Pupil reaction to accommodation Pupil has equal reaction to accommodation

Color: Dark brown Symmetry: Symmetrical

Pain: None Tenderness: None Location: None

Extra ocular movement: Normal

Peripheral Vision: Normal

Symmetry: Symmetrical Distribution: Well- distributed

Lesions: None Type: None

Symmetry: Symmetrical Distribution: Well- distributed

Inflammation or presence of edema: None

Adequacy with which the eyelids close: Normal

A CASE STUDY ON MASSIVE ASCITES 10

Auricle: Ornamental style Symmetry: Symmetrical Position: Aligned to the Tip of

Color: Brown Size: Normal

Lesions: None Tenderness: None

Ear canal Patency: Patent

Tympanic Membrane: Visible Contour: Normal Color: Pearly grey

Discharges: None Pain: None

Swelling: None Hearing Problems: None

Rinne test: Normal: Air conduction is better than bone conduction

Webber test: Normal: Heard equal on both ears

Whisper test: Normal: Able to hear on both eras

Symmetry: Symmetrical Position: Midline Color: Brown

Lesions: None Nasal discharge: None