Question

THIRD SPACE EDEMA

A patient with portal hypertension secondary to chronic liver cirrhosis was admitted in the surgical ward. The patient presented with emaciated body build, distended abdomen with prominent veins, and jaundice. The doctor ordered paracentesis and the following laboratory tests prior the procedure: Prothrombin time (PT), Activated Partial Thromboplastin Time (APTT), Total Protein, Albumin-Globulin ratio, AST, ALT.

List down two (2) nursing diagnoses and create a hypothetical FDAR for the patient.

Why is there a need to check the PT and APTT levels of the patient prior paracentesis?

What is the rationale behind the order of checking the Total Protein, Albumin-Globulin ratio?

Enumerate the following regarding the nursing role in assisting with paracentesis:

Position of choice

Site of insertion

At least three (3) nursing considerations.

Answer 1

Nursing Diagnosis and DAR

Assesment	Nursing Diagnosis	planning	intervension	Rationale	Evaluation
Subjective Data Patient complains that he feels vry tired. Objective Data Pallor Weak in appearance Jaundice Abdominal distention noted Bipedal edema Irritability noted Abdominal girth of 32 DOB with RR of 29 bpm.	Fluid volume excess related to compromised regulatory mechanism secondary to cirrosis of the liver manifested by pallor,weak in appearance,jaundice,abdominal distention,edema,irritability,DOB with RR of 29 and abdominal girth of 32.	After 6 hours of the nursing interventions, patient will demonstrate stabilized fluid volume and decreased edema and abdominal girth	Monitor Vital signs Measure intake and output Monitor BP Asses Respiratory status Monitor abdominal girth Provide occasional ice chips if NPO. Restrict Na and fluids as ordered.	Established Baseline data Reflex Circulating volume status,developing fluid shifts,and in responce to therapy BP elevations are usually associated with fluid volume excess. Indicative of pulmonary congestion/edema Reflex accumulation of fluid(ascites) Decreases sensation of thirst,expecially when fluid intake is restricted. Na may br restricted to minimize fluid retension in extra vascular spaces	After 6 hrs of nursing interventions,the patient demonstated stabilized fluid volume and decreased edema and abdominal girth Goal met

Assessment	Nursing Diagnosis	Planning	Interventions	Rationale	evaluation
Subjective Data Thepatient verbalised that He is unable to act and not feels ing to have food. Objetive Data Weak in appearance Refusal to eat Irritability noted poor muscle tone Jaundice noted Emaciated abdominal distention noted Pallor noted	Imbalanced nutrition less than body requirements related to loss of appitite secondary to ascites as evidenced by refusal to eat,weak in apperance,irritability,poor muscle tone,emaciated and abdominal distension	After 5 hrs of nursing interventions,patient's will improve from appetite 2 tbsp per meal.	Monitor vital signs. assisst in oral hygiene before meals discuss eating habits including likes and dislikes of the patient Serve favorite foods that are not contraindicated Prevent or minimise unpleasant odors during meal time Serve foods that are attractive and palatable. Recommend small,freequent meals. Restrict the intake of caffine,gas producing or spicy and excessively hot or cold foods. Provide assistance with activity as needed.Promote undisturbed rest periods,especially before meals Advice to consume nutritious foods.	Foe baseline data a clean mouth enhances appetite To appeal to client likes and dislikes To stimulate the appetite May have negative effect on appetite To stimulate the appetite Poor tolerance to larger meals may be due to increased intra abdominal pressure, ascites Aids in reducing gastric irritation and abdominal discomfort that may impaire oral intake/diagestion Conserving energy reduces metabolic demands on the liver and promote the cellular regeneration	After 8 hrs of nursing interventions, patient's appetite improved from 2 table spoon -5 table spoon per meal. goal met

Question: Why there is a need of PT & APTT test prior to paracentesis?

Answer: Prior to paracentesis we need to test prothrombin time (PT), activated partial thrompoplastin time(aPTT) and also platelet count becouse paracentesis is procedure in which a needle is inserted in to the peritonial cavity to remove ascitic fluid, so there is a chance of bleeding.

Question: What is the rationale behind the order of checking Total Protien, Albumin-Globulin ratio?

Answer: The reason for checking Total Protein , Albumin-Globulin ratio is to determine whether ascitic fluid was transudate or exudate.

Nurse's Role in assisting Paracentesis

Positioning The patient

The patient should be placed in supine position and slightly rotated to the side of the procedure to further minimise the risk of perforation during paracentesis. Because the cecum is relatively fixed on the right side , the left-lateral approach is most commonly used. The patient head should be elevated at 45-60 degree to allow fluid to accumulate in the lower abdomen.

Site of Insertion of needle in paracentesis

The incertions sites may be midline or through the oblique transversus muscle, which is lateral to the thicker rectus abdominus muscles.

• Check the drain site hourly and monitor the fluid balance.
• Check the vital signs of the patient
• Observe any signs of complications such as leakage of ascitic fluid,infection,bladder and bowel perforation and bleeding.