Medical Surgical Nursing

1. Maintain bed rest when

patient experiences

abdominal discomfort.

2. Administer antispasmodic

and analgesic agents as

prescribed.

3. Observe, record, and report

presence and character of

pain and discomfort.

4. Reduce sodium and fluid

intake if prescribed.

5. Prepare patient and assist

with paracentesis.

1. Reduces metabolic demands

and protects the liver

2. Reduces irritability of the

gastrointestinal tract and

decreases abdominal pain

and discomfort

3. Provides baseline to detect

further deterioration of status

and to evaluate interventions

4. Minimizes further formation

of ascites

5. Removal of ascites fluid may

decrease abdominal

discomfort

 Reports pain and discomfort

if present

 Maintains bed rest and

decreases activity in

presence of pain

 Takes antispasmodic and

analgesics as indicated and

as prescribed

 Reports decreased pain and

abdominal discomfort

 Reduces sodium and fluid

intake to prescribed levels if

indicated to treat ascites

 Exhibits decreased

abdominal girth and

appropriate weight changes

 Reports decreased

discomfort after

paracentesis

Nursing Diagnosis: Fluid volume excess related to ascites and edema formation
Goal: Restoration of normal fluid volume

1. Restrict sodium and fluid

intake if prescribed.

2. Administer diuretics,

potassium, and protein

supplements as prescribed.

3. Record intake and output

every 1 to 8 h depending on

response to interventions and

on patient acuity.

4. Measure and record

abdominal girth and weight

daily.

5. Explain rationale for sodium

and fluid restriction.

1. Minimizes formation of ascites

and edema

2. Promotes excretion of fluid

through the kidneys and

maintenance of normal fluid

and electrolyte balance

3. Indicates effectiveness of

treatment and adequacy of

fluid intake

4. Monitors changes in ascites

formation and fluid

accumulation

5. Promotes patient's

understanding of restriction

 Consumes diet low in

sodium and within

prescribed fluid restriction

 Takes diuretics, potassium,

and protein supplements as

indicated without

experiencing side effects

 Exhibits increased urine

output

 Exhibits decreasing

abdominal girth

 Exhibits no rapid increase in

weight

 Identifies rationale for