Hepatic encephalopathy is a neurological (nervous system) disorder due to chronic hepatic disease. In chronic liver disease, toxins, which are substances produced by the catabolism of food, alcohol, drugs, and even muscles, are difficult to remove from the bloodstream, causing them to accumulate in the body.
These toxins travel to the brain, affecting its function, and eventually cause cognitive impairment. Hepatic encephalopathy patients may appear confused or struggle to process their thoughts.
These effects are reversible by toxin removal through treatment. The condition may worsen and become less treatable as the liver disease advances.
Signs and Symptoms of Hepatic Encephalopathy
Hepatic encephalopathy symptoms vary from person-to-person and depend on the underlying cause of hepatic damage.
- Moderate hepatic encephalopathy may present as:
- having trouble thinking
- poor concentration
- personality changes
- writing issues or a loss of other minor hand movements
- confusion
- forgetfulness
- faulty judgment
- a sweet or musty breath odor
- Severe hepatic encephalopathy may present as:
Causes of Hepatic Encephalopathy
In hepatic disease, the liver struggles to remove toxins from the body causing them to accumulate in the blood. Toxins in the bloodstream can reach the brain and temporarily (or occasionally permanently) impair cognitive function. Individuals with chronic liver disease are at risk for hepatic encephalopathy. Etiological factors that may trigger the development of hepatic encephalopathy include:
- alcohol consumption
- intake of drugs that have an effect on the neurological system (e.g., sleeping aids, antidepressants, analgesics, diuretics)
- non-compliance to medication
- constipation (being unable to pass stool, or defecate, normally)
- either electrolyte imbalance or dehydration (e.g., diarrhea, fluid restriction, diuretics, excessive paracentesis, vomiting)
- gastrointestinal bleeding (e.g., esophageal varices)
- excessive protein intake
- infection
- kidney disease
- transjugular intrahepatic portosystemic shunt (TIPS) procedure
Risk Factors to Hepatic Encephalopathy
About half of the patients with liver cirrhosis eventually develop hepatic encephalopathy. In liver cirrhosis, there is buildup of scar tissue which blocks blood flow and impairs the liver’s ability to filter hormones, toxins, and nutrients. The following are risk factors for the development of hepatic encephalopathy:
- Hyponatremia. In individuals with cirrhosis, hyponatremia is an independent risk factor for the development of hepatic encephalopathy.
- Renal failure in cirrhotic patients. Independent of the severity of cirrhosis, cirrhotic patients with renal impairment have also been demonstrated to have an elevated risk of developing hepatic encephalopathy.
- Other risk factorsof hepatic encephalopathy include:
- Hepatocellular failure
- Severe liver injury
- Increased serum ammonia levels from a high-protein diet, GI bleeding, uremia, or bacterial growth in the intestine
- Development of a portal shunt directly from the portal circulation to the systemic venous system
Complications of Hepatic Encephalopathy
Treatment for liver disease includes taking prescription drugs and making lifestyle modifications, such as abstaining from alcohol. In the absence of treatment for the underlying cause of liver disease, liver function declines and toxins accumulate. Patients who suffer from advanced hepatic encephalopathy pass out and enter into a state of hepatic coma. Irreversible complications of hepatic encephalopathy include:
- Cerebral edema. Acute liver failure (ALF), also known as fulminant hepatic failure, invariably causes central nervous system dysfunction. These symptoms may include encephalopathy, seizures, and brain edema. The onset of brain edema occurs simultaneously with the increase in cerebral blood flow.
- Cerebral herniation. Cerebral herniation is the leading cause of death in ALF. It follows cerebral edema together with intracranial hypertension.
- Organ failure. Permanent nervous system damage, cardiac failure, renal abnormalities, kidney failure, respiratory problems, and sepsis are among the most serious and potentially-fatal complications of cirrhosis.
Diagnosis of Hepatic Encephalopathy
Diagnostic tests for hepatic encephalopathy usually include:
- History taking and Physical examination. A comprehensive assessment of the patient’s vital signs and airway should be followed by a classification of the symptoms using the West-Haven Criteria to determine whether the patient has hepatic encephalopathy. Additionally, it’s critical to correctly distinguish between the existence of asterixis and trembling, which may be a sign of alcohol withdrawal or misuse.
- Blood tests. A complete blood count analyses the patient’s red blood cells, white blood cells, and platelets. A low red blood cell count is indicative of oxygen deficiency and blood loss. Blood tests can also monitor the levels of sodium, potassium, and ammonia in the patient’s bloodstream. Elevated levels of these indicators may suggest impairment of liver function. Blood tests can also identify bleeding and infections associated with the hepatic disease. A common finding in patients with hepatic encephalopathy is elevated blood ammonia levels.
- Imaging studies. A computed tomography (CT) scan, magnetic resonance imaging (MRI), or electroencephalogram (EEG) can be used to check for bleeding in the brain or other abnormalities in the brain. Imaging studies can also aid in ruling out conditions that present similar symptoms with hepatic encephalopathy, such as brain tumor or stroke.
- Liver function tests. Tests for liver function examine elevated enzyme levels. An increase in enzymes might be a sign of liver injury or stress.
Treatment for Hepatic Encephalopathy
The severity and underlying etiology of hepatic encephalopathy will determine the best course of treatment. The management of hepatic encephalopathy usually include:
- Dietary protein restriction. The management of all hepatic encephalopathy grades depends on the modification of nitrogen metabolism, therefore nutritional alternatives are pertinent. If consuming too much protein contributes to the disease, then dietary protein intake must be controlled. A dietitian or doctor can design a diet that will allow the patient to receive adequate protein without making the symptoms worse because protein is still essential to perform bodily functions. High-protein rich foods such as red meat, poultry, eggs, and fish must be avoided. Chronic protein restriction is harmful because the patients’ protein needs are disproportionately higher than those of normal individuals and they are at risk of developing increased rates of fasting metabolism.
- Antibiotics. Due to the frequency of infection as an underlying cause, antibiotics are often given empirically. When ingested food is digested, bacteria in the body produces natural toxins. Administration of antibiotics is vital to stop bacterial growth, which in turn, decreases toxin production.
- Laxatives. Administration of laxatives, such as lactulose oral solution, draws toxins into the colon. The laxative induces regular bowel movements that aid in the body’s detoxification process. Lactulose dosing should be commenced with 25 milliliters of lactulose syrup every one to two hours until at least two soft or loose bowel movements per day are generated. The dosage is then adjusted to maintain 2-3 bowel movements daily.
- Intubation and ICU monitoring. Prophylactic intubation and close observation in the ICU are recommended for patients who are at risk for aspiration or respiratory compromise.
- Avoidance of CNS depressants. It is best to avoid using drugs that depress the central nervous system, such as benzodiazepines, on individuals who are also experiencing concurrent alcohol withdrawal.
- Control of precipitating factors. Since approximately 90% of patients can be cured by simply correcting the precipitating factor, controlling precipitating variables is crucial in the therapy of overt hepatic encephalopathy.
Hepatic Encephalopathy Nursing Diagnosis
Hepatic Encephalopathy Nursing Care Plan 1
Nursing Diagnosis: Acute Confusion related to toxin accumulation secondary to hepatic encephalopathy as manifested by impaired cognition, misconceived notions, increased irritability, a shift in the sleep-wake cycle, and hallucinations.
Desired Outcomes:
- The patient will verbalize an understanding of individualized causative/risk factors of the disease.
- The patient will demonstrate adequate motor function.
- The patient will demonstrate normal reality perception and level of consciousness.
- The patient will initiate lifestyle modifications and behavioral changes to prevent the recurrence of the condition.
- The patient will engage in activities of daily living (ADLs).
| Hepatic Encephalopathy Nursing Interventions | Rationale |
| Orient the patient to his/her environment, hospital staff, and necessary activities. Present the reality to the patient in a straightforward manner. | Orienting the patient provides a higher level of safety. Challenging the patient’s illogical thinking must be avoided as this may result in defensive reactions. |
| Remove unnecessary stimuli and noise to create a calm atmosphere. Adjust sensory exposure. | Hepatic encephalopathy patients may misinterpret elevated levels of auditory and visual stimulation. |
| Encourage the patient’s family and significant other to participate in the reorientation process and provide input such as current events and family happenings. | Hepatic encephalopathy patients are confused and have impaired comprehension, thus they may not have a full grasp of what is going on. The patient’s level of comfort may increase with the presence of his/her family and the patient’s significant other. |
| Assist the family and the patient’s significant other in enhancing coping strategies. | To maximize the patient’s level of functioning and quality of life, their family and patient’s significant other must allow them to engage in activities of daily living. |
| Educate the patient’s family to acknowledge warning signs of confusion. Once identified, encourage them to seek medical attention. | Prompt intervention aids in avoiding the exacerbation of complications associated with hepatic encephalopathy. |
Hepatic Encephalopathy Nursing Care Plan 2
Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related hypermetabolic state (increased caloric needs), alterations in food absorption and metabolism, reduced peristalsis, insufficient intake to meet metabolic demands (i.e., nausea, vomiting, anorexia) secondary to hepatic encephalopathy as manifested by altered taste sensation, aversion to eating, abdominal pain, and poor muscle tone.
Desired Outcomes:
- The patient will demonstrate behaviors and lifestyle modifications to restore or maintain a weight that is within the normal range.
- The patient will demonstrate progressive weight gain toward the goal with normalization of laboratory values and absence of malnutrition.
| Hepatic Encephalopathy Nursing Interventions | Rationale |
| Encourage small frequent feedings and serve the “biggest” meal in the morning. Encourage the patient to consume a late night snack. | When a patient is anorexic, large meals are challenging to handle. Additionally, anorexia can deteriorate during the day, making eating later in the day difficult. Frequent meals eliminates the need for a patient to experience excessive hunger throughout the day by the use of glycogen stores, increased release of amino acids, and elevation in ammonia levels. Having a late-night snack offers an additional source of calories, which reduces the gap between meals. |
| Encourage oral hygiene before eating. | This increases appetite by getting rid of bad tastes. |
| Encourage consumption of fruit juices, carbonated drinks, and hard candy throughout the day. | These foods have more calories and might be tolerated or digested more readily than other foods. |
| Consult a nutritionist and the nutritional support team to prepare a diet tailored to the patient’s requirements, with as much protein and fat as is acceptable. | This is vital in creating a diet plan to suit a person’s demands. Protein restriction may be necessary in cases of severe illness (fulminant hepatitis) because the buildup of protein metabolism’s waste products might exacerbate hepatic encephalopathy. However, it is worth noting that protein restriction is only used in extremely protein-intolerant people or for very brief periods in patients who are experiencing GI bleeding until symptoms subside. Protein deficit can lead to muscle breakdown, which increases the release of amino acids and ammonia production, exacerbating or developing hepatic encephalopathy. |
| Encourage the patient to consume a fiber-rich diet. | A fiber-rich diet is advised to promote fecal ammonia excretion and prevent diarrhea in patients who already take lactulose. Diarrhea can potentially complicate hepatic encephalopathy in these patients. |
| Monitor the patient’s calorie count and dietary intake. | Patients with hepatic encephalopathy should get nutritional support that consists of maintaining an energy intake of 35–40 kcal/kg/day and a protein intake of 1.2–1.5 g/kg/day. |
Hepatic Encephalopathy Nursing Care Plan 3
Nursing Diagnosis: Deficient Knowledge related to misinterpretation of information, lack of exposure/recall, and unfamiliarity with resources secondary to hepatic encephalopathy as manifested by verbalization of questions or statements of misconception, inaccurate follow-through of instructions, request for information, and development of preventable complications.
Desired Outcomes:
- The patient will verbalize an understanding of the disease process, prognosis, and potential complications.
- The patient will identify the relationship of signs/symptoms to the disease and associate these symptoms with causative factors.
- The patient will initiate necessary lifestyle modifications and participate in the treatment regimen.
- The patient will verbalize an understanding of therapeutic needs.
| Hepatic Encephalopathy Nursing Interventions | Rationale |
| Determine the patient’s level of knowledge about the disease process, their expectations and prognosis, and potential treatment options. | This identifies knowledge gaps or sources of false information and offers the chance to clarify if appropriate. A complete and thorough nursing assessment should serve as the foundation for the management and educational plan of hepatic encephalopathy. |
| Review with the patient the requirement of abstaining from alcohol for at least 6 to 12 months, or longer depending on personal tolerance. | Increased liver inflammation may compromise the patient’s recovery. |
| Educate both the patient and his/her family regarding the disease process, precipitating factors, treatment options, and preventive measures. | The patient’s family or primary caregiver should be involved in health education because the patient may have cognitive deficiencies. A broad overview of hepatic encephalopathy and helpful advice on incorporating treatments like lactulose administration and preventing complications like dehydration and infection into daily activities assist both the patient and family. |
| Educate the patient about the importance of diligently taking medications. | To avoid missing any doses, patients should complete their prescriptions as soon as they are released from the hospital. Effective home management requires knowledge of the justification for taking the drugs, what to do if a dosage is missed, and how to titrate lactulose. |
| Educate the patient regarding polypharmacy. | Polypharmacy, which is the concurrent use of several pharmaceuticals to treat one or more medical diseases, is linked to poor medication adherence and increases the likelihood of medication misunderstanding between patients and clinicians. Patients with liver illness are more likely to take many medications and potentially have multiple comorbidities. |
| Emphasize the importance of weight tracking even after discharge. | Weight monitoring is very crucial and ought to be documented and examined at doctor appointments. The patient needs to get in touch with their provider if they have a significant weight change of more than 10 pounds in a week. |
| Discuss to the patient the dangers of taking OTC and prescribed drugs (e.g., aspirin, ibuprofen, acetaminophen) | Patients should refrain from taking medications that damage the liver such as aspirin, ibuprofen, and acetaminophen. They should always talk to a doctor before taking any of these. |
| Emphasize the importance of practicing proper hygiene and good sanitation. | Avoiding sick contacts and frequent observation of proper washing hands can reduce the patient’s risk of contracting an infection. |
Hepatic Encephalopathy Nursing Care Plan 4
Risk for Deficient Fluid Volume
Nursing Diagnosis: Risk for Deficient Fluid Volume related to third-space shift, excessive fluid losses through vomiting and diarrhea, and alteration in the clotting process secondary to hepatic encephalopathy.
Desired Outcomes:
- The patient will maintain adequate hydration, as evidenced by good skin turgor, stable vital signs, normal capillary refill time, strong peripheral pulses, and urinary output within the patient’s normal range.
- The patient will demonstrate absence of signs of hemorrhage with clotting times within the normal limits.
| Hepatic Encephalopathy Nursing Interventions | Rationale |
| Monitor the patient’s input and output and compare it with their periodic weight. | Another potential cause of hepatic encephalopathy is dehydration and hypovolemia, thus fluid loss through bowel movements or loose stools needs to be carefully managed. Because the patient may be a poor historian, daily weights and precise tracking of intake and output are necessary. This also provides information regarding the effects of therapy and replacement needs. |
| Assess periodic values of these laboratory tests: Hb/Hct, sodium, potassium, albumin, and clotting time. | This demonstrates hydration and highlights sodium retention and protein deficiencies, which may cause the development of edema. Hemorrhage and bleeding risk are increased by clotting deficiencies. Patients who are hypovolemic may also develop hyperkalemia or hypokalemia. |
| Take note of gastrointestinal losses such as nausea and diarrhea. | Diarrhea can be a temporary flu-like reaction to a viral infection, it can signify a more serious issue such as blocked portal blood flow and vascular congestion in the GI tract, or it can be the intended side effect of medication (neomycin, lactulose) use to lower serum ammonia levels in the presence of hepatic encephalopathy. |
| Monitor patients who are taking laxatives (lactulose) for diarrhea. | Since disaccharides (lactulose) eliminate ammonia through the GI tract, patients who are put on them should have an increase in bowel movements. Although the patient must have bowel movements to eliminate the ammonia, it is crucial to keep an eye out for diarrhea because it can cause electrolyte imbalances and dehydration. |
| Evaluate the patient’s vital signs, peripheral pulses, capillary refill time, skin turgor, and mucous membranes. | These are indicators of tissue perfusion and effective circulating volume. |
Hepatic Encephalopathy Nursing Care Plan 5
Nursing Diagnosis: Risk for Injury related to cognition changes, hypoxia, toxin accumulation, and physical impediments secondary to hepatic encephalopathy.
Desired Outcomes:
- The patient will identify causes that may potentially increase the risk of injury and demonstrate behaviors that avoid injury within 8 hours of nursing diagnosis and treatment.
- The patient will demonstrate absence of injuries within 4 hours of nursing diagnosis and treatment.
| Hepatic Encephalopathy Nursing Interventions | Rationale |
| Assist the patient in becoming familiar with his/her environment. Place the call light in an easily accessible location and educate the patient on how to use it to call for help. | The patient must be familiar with the environment’s layout to avoid accidents. Items that are not easily accessible may pose a risk to the patient. |
| Determine the patient’s age, health status, developmental stage, impaired communication, lifestyle, and decision-making ability. | These factors must be thoroughly evaluated when developing a care plan or educating patients about safety precautions as these may influence the patient’s ability to protect themselves from harm. |
| Maintain a reality orientation when interacting with the patient. | Reality orientation may help in limiting or reducing the patient’s confusion when they become agitated. This in turn can decrease the risk of injury. |
| Identify patients correctly. | To verify the patient’s identity during hospital admission, use at least two identifiers (e.g., patient’s name, date of birth). |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
Disclaimer:
Please follow your facility’s guidelines, policies, and procedures.
The medical information on this site is provided as an information resource only and should not be used or relied on for diagnostic or treatment purposes.
This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.
