What should the nurse monitor in caring for the patient undergoing a paracentesis?

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This systematic review aimed to evaluate the efficacy of preventive and therapeutic approaches used in the management of ascites in liver cirrhosis.

Literature review was done in “Scopus, Web of Science, CINAHL, ScienceDirect, PubMed MEDLINE, Ulakbim National Database, and Cochrane Library” databases using the keywords, “ascites, refractory ascites, liver cirrhosis, intervention, prophylaxis, treatment, nursing management, prevention, ascites management, randomized controlled trials,” and 2,447 articles were obtained. The studies with low bias risk were included. This systematic review was planned by following the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement.

A total of 11 randomized controlled trials were included. When the included studies were examined, ascites treatment approaches were evaluated in all of the studies; however, preventive approaches were not evaluated. It was found that mannitol, a diuretic drug, helps ascites management by contributing to weight loss, decrease in abdominal circumference, and urinary sodium excretion. The automatic low-flow ascites pump also reduced the need for large-volume paracentesis. There was a decrease in weight and abdominal circumference measurements when band compression was applied to the umbilicus.

Therapeutic approaches were found to be effective. It was thought that the lack of nursing practices and the prevention of ascites formation in the abdomen was an important deficiency. Randomized controlled trials were recommended for the prevention of abdominal ascites formation and the side effects of treatment on the patient.

Keywords: Ascites, ascites management, liver cirrhosis, nursing management

Abdominal ascites is defined as the accumulation of excess fluid in the abdominal cavity. It can occur owing to liver diseases, malignancy, or heart failure and has been discussed in the perspective of liver cirrhosis in this systematic review. More than 50% of patients with liver cirrhosis develop ascites within 10 years (Biecker, 2011). Ascites development negatively affects the working and social life of the patient; escalates hospital admissions and chronic treatment costs; and causes problems such as spontaneous bacterial peritonitis, respiratory dysfunction, and umbilical hernia. Liver transplantation is recommended as the final treatment of ascites (European Association for the Study of the Liver, 2018). However, it cannot be performed in every patient with ascites because of the cost of the procedure, the low number of donors, and contraindications for liver transplantation in some patients (Zhao et al., 2018). There is no specific treatment for liver cirrhosis. Therefore, the aim of treatment is to minimize the progression of the disease and prevent complications. In this context, nurses play an important role as they provide comprehensive and continuous patient care as a member of the multidisciplinary team (Gimenes et al., 2017). Nurses need to access and evaluate evidence-based research results so that they can safely meet the comprehensive and complex needs of patients with liver cirrhosis, prevent complications, maintain their care, use critical thinking skills in improving patient outcomes and complication management, and reduce complication-related hospital admissions and hospitalizations. Formation of ascites in the abdomen can also lead to secondary symptoms, such as excess fluid volume, fluid-electrolyte imbalance, activity intolerance, anorexia, inadequate nutrition, dyspnea, the deterioration of skin integrity, risk of injury, chronic pain, or infection (Bulechek et al., 2017; Carpenito-Moyet, 2005; Gimenes et al., 2017). Therefore, preventive and therapeutic approaches to the development of ascites gain importance.

Sodium restriction and diuretic administration have an important place among the preventive approaches. In patients with ascites, a sodium-restricted diet of 4.6–6.9 g/day is recommended. It is stated that ascites can develop in patients at least 3 times in 12 months despite a sodium-restricted diet and diuretic treatment (European Association for the Study of the Liver, 2018). The development of ascites despite preventive measures brings therapeutic approaches to the fore. The methods used in the treatment of ascites are drug therapies, interventional methods, and liver transplantation. In addition to these, there are new treatment methods such as automated low-flow ascites pump (Arroyo, 2013; Stirnimann et al., 2017) and complementary approaches such as umbilical tape application (Xing et al., 2012).

It is recommended that the use of diuretics, which is among the drug treatment methods, should be planned in a way that the daily weight loss will not be more than 0.5 kg in patients without peripheral edema and 1 kg in patients with edema (European Association for the Study of the Liver, 2018). Midodrine and satavaptan are other treatment options used in ascites management (Biecker, 2011; European Association for the Study of the Liver, 2018). Large-volume paracentesis application, which is one of the interventional methods, is recommended as the first treatment option in the management of excessive ascites. The use of diuretics or large-volume paracentesis application provides a symptomatic improvement in ascites management instead of an ultimate treatment (European Association for the Study of the Liver, 2018). Transjugular intrahepatic portosystemic shunt (TIPS) is recommended for ascites management if paracentesis is not tolerated after 4 or more applications, patients do not improve, or there is a contraindication (Moore et al., 2003; Zhao et al., 2018). Transjugular intrahepatic portosystemic shunt helps refractory ascites recovery by reducing portal venous pressure (Rössle & Gerbes, 2010). With the automated low-flow ascites pump, one of the new treatment methods, the ascites fluid in the abdominal cavity is discharged through the bladder. It is stated that in patients with decompensated cirrhosis or refractory ascites, the automated low-flow ascites pump reduces the ascites fluid and the need for paracentesis (European Association for the Study of the Liver, 2018).

Nurses caring for patients with liver cirrhosis have responsibilities in the prevention and treatment of ascites. Prevention interventions include training on nutrition, abstinence from alcohol, and monitoring the side effects of diuretic medications, kidney function, and hepatic encephalopathy symptoms, weight, abdominal circumference, and the amount of fluid intake and excretion. It has been stated that nurses should follow patients closely at home in the treatment of ascites. They are recommended to evaluate electrolyte values and renal functions after paracentesis and to question for abdominal discomfort or bleeding (Fullwood & Purushothaman, 2014). This systematic review aimed to evaluate the effectiveness of preventive and therapeutic approaches used in the management of abdominal ascites in patients with liver cirrhosis.

The study was designed as a systematic review.

This systematic review was planned by following the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement (Moher et al., 2015).

Studies included in this systematic review were selected according to the PICOS Model proposed by the Joanna Briggs Institute (P: Population (the type of participants), characteristics of the participants; I: Intervention (the type of interventions), characteristics of the intervention; C: Comparison (the type of comparisons), characteristics of comparison groups; O: Outcome (the type of outcomes), outcomes; S: Study designs (the type of studies), study design) (The Joanna Briggs Institute, 2014).

P: Regardless of sex, race, socio-economic class, and etiology, patients aged more than 18 years with liver cirrhosis associated with ascites development constituted the target group of this systematic review.

I: The use of preventive and therapeutic interventions in patients with cirrhosis constituted the intervention groups of this systematic review.

C: The studies included in the systematic review were compared in terms of evaluating the effectiveness of preventive and therapeutic interventions in patients with cirrhosis.

O: The effects of interventions implemented to prevent and treat ascites development in patients with cirrhosis on ascites-related parameters such as the decreased need for paracentesis, weight loss, and decreased abdominal circumference measurement were examined.

S: Studies that used a randomized controlled trial design, published in the English language, and whose full text could be accessed were included in the study.

For this systematic review, a literature review was carried out between June and August 2019 with no year limitation on Scopus, Web of Science, CINAHL, Science-Direct, PubMed, Medline, Ulakbim National Database, and Cochrane Library databases using “ascites, refractory ascites, liver cirrhosis, intervention, prophylaxis, treatment, nursing management, prevention, ascites management, randomized controlled trials” as keywords and their Turkish translations. As a result of the review, 2447 articles were found. The number of studies found as a result of the review was categorized according to databases and shown in the PRISMA-P flow chart (Figure 1). Repetitive studies were sorted out with the EndNote X7 (v. X7; Clarivate, 22 Thomson Place, 36T3 Boston, MA 02210), the titles and abstracts of the studies were examined, and studies that met the inclusion criteria were independently evaluated by the researchers. A total of 11 randomized controlled trials (RCTs) were included in the systematic review. The bias risk assessment of the studies was made, and were found to be low.

The inclusion criteria of this systematic review targeted studies

• with sample groups consisting of patients aged more than 18 years with liver cirrhosis, regardless of sex, race, socioeconomic status, and etiology;

• in which anti-ascitic and therapeutic interventions were administered to patients with ascites associated with liver cirrhosis;

• in which results related to ascites, such as ascites development, need for paracentesis, decrease in weight and abdominal circumference, as a result of interventions were evaluated, and that used a randomized controlled trial method and were published in Turkish and English languages, with no year limitation.

The quality evaluation of the studies included in a systematic review should be done with valid and reliable tools to reach high evidence results. The studies included in this systematic review were evaluated using the “bias assessment tool for RCTs” proposed by the Cochrane Library. In this assessment tool, studies are evaluated using criteria, such as the type of the randomization method, hiding randomization information, participant and practitioner blinding, blinding in the evaluation of results, incomplete results data, and elective reporting criteria. According to these criteria, the studies are judged as low risk, high risk, or vague. In the assessment tool, low-risk judgment is denoted with a ‘+,’ high-risk judgment with a ‘−,’ and situations that are not fully explained in the study are shown with a ‘?’ A high number of low-risk situations indicates that the study has a low bias (Higgins et al., 2011). The bias evaluation of the studies included in this systematic review is given in Figure 2. The bias risks of the studies included in this systematic review were found to be low.

A total of 11 RCTs were included in this systematic review that was carried out to evaluate the effectiveness of preventive and therapeutic approaches in the management of abdominal ascites in patients with liver cirrhosis. The studies were conducted between June 2000 and June 2018. All the studies were found to evaluate therapeutic approaches to ascites, but did not include preventive approaches. This systematic study focused on the evaluation of the effectiveness of preventive and therapeutic approaches in ascites management in individuals with liver cirrhosis, and the keywords for the database search had been chosen accordingly. Although no studies evaluating preventive approaches could be included in the systematic review, we decided to include the phrase “preventive approaches” in the title of the study so that we would not take sides and could emphasize the lack of preventive approaches in practice. The therapeutic approaches in this systematic review were grouped under the following titles: pharmaceutical applications, interventional practices, and complementary approaches. Summaries of the studies are presented in Table 1.

Results of Studies Including Therapeutic Approaches Used in Ascites Management in Patients with Liver Cirrhosis

Features of the Studies

Of the studies included in the systematic review, 5 evaluated the efficiency of drugs used in ascites treatment in patients with liver cirrhosis. Albumin, diuretics, midodrine, and satavaptan were used for ascites management. The studies covered the period between August 2010 and June 2018.

Results of the Studies

The study in which albumin infusion was administered to the intervention group, paracentesis was required in 71 of the 176 patients in the intervention group and in 116 of 172 patients in the control group (p < .001) (Caraceni et al., 2018). The study in which the effects of the use of midodrine and rifaximin together with diuretic treatment on diuresis, ascites control, and weight loss was compared with diuretic use alone found that although diuresis and weight loss were higher in the intervention group, the need for paracentesis was low (p < .001) (Hanafya & Hassaneen, 2016). In the study evaluating the effect of octreotide and midodrine use on ascites formation after large-volume paracentesis intervention, compared with albumin use, ascites was observed to form earlier in the octreotide and midodrine group (Bari et al., 2012). In the study evaluating the effect of mannitol use on natriuresis, urine volume, weight, and abdominal circumference, it was observed that the amount of sodium excreted in urine (p < .001), weight loss (p < .05), and the decrease in abdominal circumference (p < .001) were higher in the intervention group (Raza et al., 2011). In the study evaluating the efficiency of satavaptan in ascites management, the sample had been divided into 4 study groups, of which 3 groups were administered 5 mg, 12.5 mg, and 25 mg satavaptan, and the fourth group was administered a placebo. The mean increase in the volume of ascites was higher in the placebo group than in the other groups. The mean increase in ascites was 2.82 ± .48/week in the placebo group, whereas it was 2.12 ± .40, 2.14 ± .33, 2.06 ± .40/week in the groups using 5, 12.5, and 25 mg satavaptan, respectively. The frequency of paracentesis was found to decrease in all groups using satavaptan (p < .05) (Wong et al., 2010).

Features of the studies

Of the studies included in the systematic review, 5 evaluated the efficiency of interventional treatments used for ascites treatment in patients with liver cirrhosis. Paracentesis, automated low-flow ascites pump, and TIPS application were among the interventional methods used. The studies were conducted between June 2000 and January 2017.

Results of the Studies

In the study evaluating the efficiency of the automated low-flow ascites pump, the need for the large-volume paracentesis emerged later in the intervention group (p < .001) (Bureau et al., 2017a)..Bureau et al. have compared the TIPS with large-volume paracentesis and found that the number of paracenteses required during the study was 32 in the TIPS group and 320 in the large-volume paracentesis group (Bureau et al., 2017b). The number of hospital presentations of patients in the large-volume paracentesis group was twice that of the TIPS group (p < .05). In another study that compared the efficiency of the TIPS application with the large-volume paracentesis application, it was stated that the TIPS application was more effective than the large-volume paracentesis application in the control of ascites (p < .01). However, the rate of hepatic encephalopathy development was higher in the TIPS group (Narahara et al., 2011). In another study, the development of ascites and hepatorenal syndrome was less in the group treated with TIPS than in the group treated with paracentesis, whereas the development of hepatic encephalopathy was higher in the group treated with TIPS (Ginès et al., 2002). In a study by Rössle et al. (2000) although patients in the TIPS group needed paracentesis 21 times during the study, patients in the paracentesis group required paracentesis 280 times. The daily dose of spironolactone decreased in the TIPS group (p < .05) (Rössle et al., 2000).

Features of the Studies

Of the studies included in the systematic review, 1 examined the effect of plaster compression applied on the umbilicus for ascites management. The study was conducted in January 2012 (Xing et al., 2012).

Results of the Study

In the placebo-controlled study, in which a cataplasm plaster application called Xiaozhang Tie was applied to the umbilicus, the compression was applied to the umbilicus using 7×7 cm long plasters. When change in the volume of ascites was evaluated with ultrasound in the intervention group, it was found that ascites fluid was not detected in 17 patients, it was eliminated in 14 patients, it was partially reduced in 15 patients, and there was only a slight decrease in 1 patient. In the placebo group, however, ascites could not be detected in 9 patients, it was eliminated in 10 patients, partially reduced in 16 patients, and a very slight decrease was observed in 10 patients. In the intervention group, the decrease in weight and abdominal circumference measurements (p < .01) and the increase in urine volume were found to be higher (p < .05). Although there was a decrease in bilirubin value (p < .05) and an increase in albumin value (p < .01) in the intervention group, there was statistically no significant change in the alanine aminotransferase (ALT) value. In the control group, although there was no statistically significant change in the bilirubin value, the ALT value was found to decrease (p < .05), and the albumin value increased (p < .01) (Xing et al., 2012).

Although chronic liver diseases are among the major global health problems, not much attention is paid by nurses to it compared with other chronic diseases, such as diabetes, chronic lung diseases, cardiovascular diseases, and neurological diseases. It is recommended that the education and training of nurses in the field of hepatology should be improved, and the number of nurses providing care to patients with chronic liver diseases in primary healthcare services and hospitals should be increased (Fabrellas et al., 2018). As health professionals, nurses play an important role in providing holistic care to patients with chronic liver diseases, providing pretreatment training, increasing the treatment compliance of patients, and providing control and evaluation during the treatment process (Shah & Abu-Amara, 2013).

In this systematic review, which evaluated the effectiveness of preventive and therapeutic approaches to the management of ascites in patients with liver cirrhosis, a literature review was conducted without a year limitation. The review revealed that although many studies were found, and there were keywords to detect studies on preventive approaches, none of the studies included in the study were found to address ascites-preventive approaches. However, it was stated that the rate of repeated hospitalizations owing to ascites varied between 13.8% (Tapper et al., 2016) and 26.9% within 30 days (Pate et al., 2019) and between 21% (Tapper et al., 2016) and 56% within 90 days (Shaheen et al., 2019). Reasons for repeated hospitalizations for ascites were reported as insufficient training on salt restriction and inadequate paracentesis administration before discharge (Tapper & Volk, 2017; Volk et al., 2012). Although salt consumption is one of the keystones in ascites management, a study reported that 48% of the participants thought that sea salt had less sodium than table salt (Volk et al., 2013). In the 2018 guidelines of the EASL, it was stated that the provision of training about salt consumption to patients with ascites would prevent hospitalizations caused by noncompliance with salt restriction (European Association for the Study of the Liver, 2018; Tapper & Volk, 2017). The primary role of nurses in the ascites management of patients with cirrhosis includes preventing ascites formation. Patient education provided by the nurse has an important place in the prevention of ascites formation. The content of patient education includes topics, such as eating a sodium-restricted diet, avoiding alcohol, ensuring compliance with medical treatment, maintaining fluid-electrolyte balance, and gaining skills that can provide ascites management outside the hospital (Fullwood & Purushothaman, 2014; Thomson et al., 2015). Nurses should inform patients that no salt should be added to foods and that daily salt consumption should be planned as 4.6–6.9 g (European Association for the Study of the Liver, 2010). The positive effect of avoiding alcohol on liver health should be explained, and patients should be guided to seek specialist support, if necessary, to stop alcohol use. Appropriate interventions should be planned for substance use disorder (Carpenito-Moyet, 2005). To maintain ascites management outside the hospital, the patients should gain the ability to follow intake and excretion, monitor weight with the same clothes at the same hour every day, and make abdominal circumference measurements (Thomson et al., 2015).

In the initial phase of ascites formation, nurses have responsibilities for the identification of ascites. The abdomen should be observed continuously, and a physical examination should be done. The patient should be evaluated in terms of enlargement, tension, and dryness of the skin, cracks, and umbilical hernia around the abdomen by inspection. Appropriate nursing interventions should be planned, according to nursing diagnosis, for impaired tissue integrity. The effects of change in physical appearance on the patient should be evaluated, and psychological support should be provided when necessary. Appropriate nursing interventions should be planned for body image discomfort per the nursing diagnosis (Bulechek et al., 2017). Symptoms, such as sensitivity and pain in the abdominal area, should be evaluated with palpation (Fullwood & Purushothaman, 2014). Appropriate nursing interventions should be planned for pain management per the nursing diagnosis. With fluid accumulation in the abdominal cavity, the space required for expansion of the lungs decreases, and the patients may experience dyspnea, especially in the supine position. Patients may restrict their physical activity owing to dyspnea and the feeling of weight created by the ascites fluid. The pressure of the fluid in the abdomen to the stomach may cause early satiety in patients; and therefore, they may eat less than they need. The compression of ascitic fluid on the intestines can reduce the blood flow to the abdominal organs, leading to a decrease in intestinal and renal functions, which can accelerate the development of hepatic encephalopathy (with decreased intestinal function) and hepatorenal syndrome (with decreased renal function) (Werner & Perez, 2012). The patients’ quality of life may decrease with the development of liver cirrhosis complications such as hepatic encephalopathy and hepatorenal syndrome in the pathogenesis of dyspnea, decreased mobility, decreased nutrition, body appearance, and ascites formation (Cox-North et al, 2013). Nurses should be sensitive to patients, patient education should be sustainable, and appropriate interventions should be planned by evaluating the psychological needs of patients. The patients should also be supported in activities that will help increase their comfort, such as listening to music, reading books, and meditation (Fullwood & Purushothaman, 2014). Appropriate nursing interventions should be planned according to the nursing diagnoses of ineffective breathing patterns, activity intolerance, inadequate nutrition, constipation, and excess fluid volume (Bulechek et al., 2017; Carpenito-Moyet, 2005).

The most effective method in patients with ascites is liver transplantation. However, the impossibility of liver transplantation in all patients necessitates focusing on new approaches to treating ascites with the high success levels and minimal complications. The first of these approaches is drug therapy. Drug therapies used in the management of ascites include midodrine (European Association for the Study of the Liver, 2018) and satavaptan as well as diuretics and albumin (Wong et al., 2010). In their study comparing the use of midodrine together with octreotide with the use of albumin, Bari et al. (2012) have found that ascites formation occurred later in the group using albumin. In a study of Caraceni et al. (2018), it was reported that albumin infusion reduced the need for paracentesis. It has been stated that mannitol, a diuretic drug, helps ascites management by contributing to weight loss, decrease in abdominal circumference, and urinary sodium excretion (Raza et al., 2011). It has been found that some antibiotic drugs used in ascites treatment (European Association for the Study of the Liver, 2018), and the combination of rifaximin, an antibiotic used in liver diseases, with midodrine increases diuresis and weight loss and reduces the need for paracentesis (Hanafy & Hassaneen, 2016). In addition, the use of 5–25 mg of satavaptan may be beneficial in reducing ascites formation following the large-volume paracentesis (Wong et al., 2010).

When RCTs are examined, it is seen that various drug groups are used in ascites management. The nurses should know of the drug therapies used in ascites management and their effects and side effects. During drug treatment for ascites management, the patients should be informed by the nurses of the follow-up of daily weights and laboratory values. Daily weight loss should be targeted at 0.5 kg in patients without peripheral edema and 1 kg in patients with peripheral edema. Diuretic treatments should be reviewed if the weight loss is less than 2 kg a week (European Association for the Study of the Liver, 2010). The patients should be informed and followed up for the side effects of diuretic use, such as renal failure, electrolyte imbalances, muscle cramps, gynecomastia, and hepatic encephalopathy. Albumin, sodium, and potassium values should be followed up from laboratory values (Hampel et al., 2001). Appropriate nursing interventions regarding electrolyte management should be planned (Bulechek et al., 2017). The positive effect of albumin infusion on paracentesis requirement necessitates the storage, administration, and monitoring of the efficiency of albumin. The high efficiency of some drugs used in treatment, their positive effects on diuresis, weight loss, and paracentesis need along with salt restriction show the importance and necessity of nurses using this information for care and patient education. During the evaluation of the effectiveness of drug use in ascites treatment in patients with liver cirrhosis, the absence of RCTs on preventive measures and nursing interventions for the use and side effects of these drugs indicates that more studies are needed in this area.

Interventional methods are required when repeated formation of ascites cannot be prevented despite drug treatments. In large-volume paracentesis application, which is one of the interventional methods, albumin infusion is administered to prevent circulatory shock after paracentesis (European Association for the Study of the Liver, 2018). The cost of albumin infusion; the inability to use the paracentesis procedure in patients who are not collaborative, have an abdominal infection, are pregnant, and have severe coagulopathy or intestinal distension; the inability to prevent recurrent ascites formation despite paracentesis application; and the necessity that patients should present to the hospital every 1–3 weeks require alternative methods to the paracentesis procedure (Arroyo, 2013; European Association for the Study of the Liver, 2018; Stirnimann et al., 2017). Therefore, TIPS application is recommended if paracentesis cannot be tolerated after 4 or more paracentesis applications or if there is a contraindication (Zhao et al., 2018). In large-volume paracentesis administration, nurses should ensure that the procedure is carried out in line with aseptic principles. Before the procedure, the pain assessment of the patient should be made, and the pain level should be questioned after the procedure. The vital signs of the patient must be evaluated before the procedure, their general condition must be observed during the procedure, and cardiac stability must be evaluated every 15–30 minutes. The patient should be in a comfortable position and calm during the procedure. Conditions, such as bleeding, circulatory shock, and infection that may develop after paracentesis, should be evaluated; and necessary interventions should be performed (European Association for the Study of the Liver, 2010). After the drainage catheter is removed, the intervention area should be covered with a clean and dry sponge and observed for bleeding. To prevent cardiovascular complications, appropriate fluid replacement and albumin infusion should be done when necessary (Bernardi et al., 2012). Renal functions should be checked to follow the development of hepatorenal syndrome. To prevent the recurrence of ascites after the procedure, the appropriate medication should be maintained, and electrolyte values and renal functions should be monitored. The patient should be encouraged to inform the healthcare staff if they have problems such as abdominal discomfort and/or bleeding at the site of the procedure area following the intervention (Werner & Perez, 2012).

Studies have shown that the use of TIPS reduces the need for paracentesis. In the study by Bureau et al., (2017b) the number of paracenteses required was 32 in the TIPS group, whereas it was 320 in the large-volume paracentesis group. It was reported that the paracentesis requirement of the large-volume paracentesis group was 10 times greater than in the TIPS group. In the study of Rössle et al. (2000) patients in the TIPS group required paracentesis 21 times in total, whereas the patients in the paracentesis group required paracentesis 280 times, which was more than 10 times of what the TIPS group required. Narahara et al. (2011) have stated that the TIPS application was more effective than the large-volume paracentesis application in ascites management. Because recurrent ascites development was high in the group in which large-volume paracentesis was applied, complications such as bleeding owing to increased portal pressure, increase in hospital admissions, and umbilical hernia because of the pressure and tension created by abdominal ascites were observed (Bureau et al., 2017b). TIPS is an effective method in ascites management, and it reduces hospitalizations owing to ascites; however, hepatic encephalopathy was found to be higher in patients who underwent TIPS. Ascites development was less in the group that was administered TIPS, whereas the rate of hepatic encephalopathy development of was observed to be high (Narahara et al., 2011). Nurses should evaluate patients who have undergone TIPS in terms of complications that may develop because of the interventional procedure and especially hepatic encephalopathy that can develop after the procedure. Although TIPS reduces hospital admissions, there is a need for different effective treatment options that increase patient comfort because of the inability to apply it in some patients, the complications related to the procedure, and the prevalence of hepatic encephalopathy. It has been stated that an automated low-flow ascites pump, which is a new method in the treatment of ascites, increases the quality of life of patients and reduces the need for paracentesis and hospital admissions (Bureau et al., 2017a). This pump automatically removes ascites fluid from the abdominal cavity in small amounts. Thus, albumin infusion is not required to prevent circulatory shock as in the large-volume paracentesis. This method is reported to reduce the cost and increase the comfort of the patient (Stirnimann et al., 2017). Results of RCTs on interventional applications show that the effectiveness of automated low-flow ascites pump and TIPS applications in ascites treatment is high. The automated low-flow ascites pump improves the quality of life by allowing patients to adjust the speed and amount of ascites fluid removal according to clinical and social requirements. However, it has some complications. Nurses should inform the patients about interventional problems that may arise during the insertion of the pump and complications such as infection, and catheter dislocation that may occur after the procedure. Nurses should evaluate patients in terms of these symptoms (Bellot et al., 2013). Positive contributions can be made to patient outcomes when nurses caring for patients with liver cirrhosis are aware of the results of RCTs regarding interventional practices, patient follow-up, patient education, and increase their knowledge.

Complementary approaches are also used for ascites management in the studies reviewed. In a study evaluating umbilical band application, it was found that weight and abdominal circumference measurements decreased and urine volume increased in the group in which the band was applied. Although this is effective in ascites management, caution should be exercised when using complementary approaches (Xing et al., 2012). Nurses should be informed that the patients should avoid the use of drugs or supplements that may cause a decrease in kidney function or sodium retention and that may interact with the drugs used (Hampel et al., 2001). Nurses can contribute positively to patient care and education and patient outcomes when they have enough knowledge in this field. They should question the complementary approaches used by patients with liver disease, be careful about the negative effects of these approaches, and inform the patients and their families.

There are many different methods used to manage ascites in the abdomen. However, these methods can have positive and negative effects. Liver transplantation, which is stated to be the most effective method in ascites treatment, cannot be applied to all patients. Nurses should inform patients about liver transplantation as soon as ascites starts to form. The introduction of stem cell therapies for liver diseases and positive results show that there is hope for treatment without the need for liver transplantation in the future (Liang et al., 2012).

When the results of therapeutic approaches are examined, it is seen that the interest in innovative methods with low complications in ascites management, which will reduce hospital dependence and improve patient comfort, is increasing. However, despite these advances in treatment, the limited number of RCTs on the nursing care of patients with ascites is seen as an important deficiency. It is thought that studies that examine or compare the effectiveness of nursing interventions, such as preventing ascites in the abdomen, detecting it earlier, daily weight monitoring, abdominal circumference measurement, salt restriction, and medication management should be conducted and that nursing practices including effective patient monitoring systems should be expanded. Expected patient outcomes after nursing interventions for ascites management include prevention of ascites recurrence; increasing quality of life by maintaining adequate nutrition, respiratory functions, and mobility; prolonging survival until transplantation; prevention of ascites complications, such as spontaneous bacterial peritonitis, renal failure, and hepatic encephalopathy; and reducing the length of hospital stay and the frequency of readmissions because of the treatment and complications of ascites (Fitzpatric, 2010).

In this systematic review, preventive and therapeutic approaches to ascites were evaluated based on the results of RCTs with no year limitation. Although keywords related to preventive approaches were used in the literature review, no studies evaluating preventive approaches according to the inclusion criteria were found. The need for repetitive paracentesis in patients with abdominal ascites and repeat hospitalizations is quite common. It is thought that ascites-preventive nursing approaches, such as weight control, salt restriction, diet and medication compliance, and follow-up of drug side effects will contribute to the prevention of ascites formation. Contrary to preventive studies, it was observed that there were various studies on therapeutic approaches. Currently, the focus is on stem cell studies for liver diseases. It is expected that there will be a cure for liver diseases without the need for liver transplantation in the future.

Nurses who care for patients with cirrhosis have an important role before and during the formation of ascites and in every step of ascites treatment before, during, and after the procedure. Therefore, these nurses are recommended to plan their interventions under the guidance of nursing diagnoses, such as substance use disorder, excess fluid volume, pain, ineffective breathing pattern, activity intolerance, inadequate nutrition, constipation, electrolyte management, impaired tissue integrity, body image discomfort, or infection risk. We believe that this systematic review will contribute to the education of nurses who care for patients with cirrhosis and the nursing instructors about effective ascites management approaches. The nurses are recommended to follow evidence-based information in outpatient and clinical follow-ups of patients with cirrhosis, to conduct RCTs to prevent ascites in the abdomen, to follow up-to-date treatment methods and their effects, and to plan nursing interventions according to patient requirements for treatment methods to prevent complications and repeated hospitalizations.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept – F.C., H.B.; Design – F.C., H.B.; Supervision – H.B.; Resources – F.C., H.B.; Materials – F.C., H.B.; Data Collection and/or Processing – F.C., H.B.; Analysis and/or Interpretation – F.C., H.B.; Literature Search – F.C., H.B.; Writing Manuscript – F.C., H.B.; Critical Review – H.B.

Conflict of Interest: The authors have no conflicts of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

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