A patient with gross ascites is positioned in high semi-Fowler’s. What is the nurse’s priority assessment for this patient?

• A. Respiratory assessment related to increased thoracic pressure
• B. Peripheral vascular assessment related to immobility
• C. Skin assessment related to increase in bile salts
• D. Urinary output related to increased sodium retention

Answer: (A)

The key idea here is that massive ascites directly impairs breathing by pushing up on the diaphragm, which reduces lung expansion and can lead to hypoventilation and hypoxemia. In high semi-Fowler’s position, the chest has better expansion, but the most important ongoing assessment is the patient’s respiratory status. Monitor rate, depth, rhythm, work of breathing, breath sounds, and oxygen saturation, and be alert for signs of dyspnea or increasing fatigue. These findings guide immediate interventions to maintain adequate ventilation.

Peripheral circulation and skin changes from bile salts are important in cirrhosis, but they don’t pose the immediate threat to oxygenation that respiratory compromise does in this scenario. Urinary output and sodium retention are part of fluid balance but are not the priority when the risk is impaired breathing.