Hepatic Encephalopathy Nursing Diagnosis & Care Plan

Hepatic encephalopathy (HE) is a serious neuropsychiatric complication of liver disease characterized by cognitive impairment, altered level of consciousness, and neuromuscular changes. This nursing diagnosis focuses on identifying symptoms, preventing complications, and managing the condition effectively.

Causes (Related to)

Hepatic encephalopathy develops due to various factors that affect liver function and neurological status:

  • Liver cirrhosis or severe liver dysfunction
  • Elevated blood ammonia levels
  • Portal hypertension
  • Gastrointestinal bleeding
  • Medical conditions including:
  • Contributing factors such as:
    • High protein intake
    • Constipation
    • Sedative use
    • Metabolic disturbances

Signs and Symptoms (As evidenced by)

Hepatic encephalopathy presents with distinctive signs and symptoms that progress through various stages.

Subjective: (Patient/family reports)

  • Changes in sleep patterns
  • Personality changes
  • Memory problems
  • Confusion
  • Difficulty concentrating
  • Tremors
  • Drowsiness
  • Changes in behavior

Objective: (Nurse assesses)

  • Altered level of consciousness
  • Asterixis (flapping tremors)
  • Impaired cognitive function
  • Speech disturbances
  • Altered reflexes
  • Fetor hepaticus
  • Changes in vital signs
  • Elevated ammonia levels

Expected Outcomes

Success in managing hepatic encephalopathy is indicated by:

  • Improved mental status and consciousness level
  • Reduced ammonia levels
  • Maintained airway and breathing
  • Prevented complications
  • Enhanced nutritional status
  • Improved self-care ability
  • Better medication compliance
  • Reduced hospital readmissions

Nursing Assessment

Mental Status Evaluation

  • Assess consciousness level
  • Monitor orientation
  • Check cognitive function
  • Document behavioral changes
  • Evaluate speech patterns

Physical Assessment

  • Monitor vital signs
  • Check for asterixis
  • Assess muscle strength
  • Evaluate coordination
  • Monitor breathing pattern

Laboratory Monitoring

  • Track ammonia levels
  • Monitor electrolytes
  • Check liver function tests
  • Assess coagulation status
  • Monitor blood glucose

Nutritional Assessment

  • Evaluate dietary intake
  • Monitor weight changes
  • Check protein tolerance
  • Assess hydration status
  • Document appetite changes

Complication Monitoring

  • Watch for bleeding signs
  • Monitor for infections
  • Assess for aspiration risk
  • Check for pressure injuries
  • Evaluate fall risk

Nursing Care Plans

Nursing Care Plan 1: Impaired Mental Status

Nursing Diagnosis Statement:
Impaired Mental Status related to elevated ammonia levels secondary to hepatic dysfunction as evidenced by confusion, disorientation, and altered consciousness.

Related Factors:

  • Elevated ammonia levels
  • Hepatic dysfunction
  • Metabolic disturbances
  • Electrolyte imbalances

Nursing Interventions and Rationales:

  1. Monitor consciousness level q4h
    Rationale: Early detection of neurological deterioration
  2. Implement safety measures
    Rationale: Prevents injury during confusion episodes
  3. Provide orientation cues
    Rationale: Helps maintain temporal and spatial awareness

Desired Outcomes:

  • The patient will demonstrate improved mental status
  • The patient will maintain safety
  • The patient will show reduced confusion episodes

Nursing Care Plan 2: Risk for Injury

Nursing Diagnosis Statement:
Risk for Injury related to altered mental status and impaired physical mobility as evidenced by confusion and asterixis.

Related Factors:

  • Altered consciousness
  • Impaired coordination
  • Asterixis
  • Poor judgment

Nursing Interventions and Rationales:

  1. Implement fall precautions
    Rationale: Prevents accidents and injuries
  2. Maintain bed rails and safety devices
    Rationale: Ensures patient safety during confusion
  3. Provide constant supervision
    Rationale: Allows quick response to safety needs

Desired Outcomes:

  • The patient will remain free from injury
  • The patient will demonstrate safe mobility
  • The patient will maintain a stable environment

Nursing Care Plan 3: Imbalanced Nutrition

Nursing Diagnosis Statement:
Imbalanced Nutrition: Less than Body Requirements related to altered metabolism and decreased appetite as evidenced by weight loss and poor intake.

Related Factors:

  • Altered metabolism
  • Poor appetite
  • Dietary restrictions
  • Nausea

Nursing Interventions and Rationales:

  1. Monitor nutritional intake
    Rationale: Ensures adequate nutrition
  2. Administer prescribed supplements
    Rationale: Supports nutritional needs
  3. Schedule meals appropriately
    Rationale: Maximizes intake during alert periods

Desired Outcomes:

  • The patient will maintain adequate nutrition
  • The patient will demonstrate weight stability
  • The patient will show an improved appetite

Nursing Care Plan 4: Ineffective Breathing Pattern

Nursing Diagnosis Statement:
Ineffective Breathing Pattern related to neuromuscular impairment as evidenced by irregular respirations and decreased oxygen saturation.

Related Factors:

  • Neuromuscular dysfunction
  • Altered mental status
  • Fatigue
  • Metabolic alterations

Nursing Interventions and Rationales:

  1. Monitor respiratory status
    Rationale: Ensures adequate oxygenation
  2. Position appropriately
    Rationale: Optimizes breathing efficiency
  3. Suction as needed
    Rationale: Maintains airway clearance

Desired Outcomes:

  • The patient will maintain an effective breathing pattern
  • The patient will demonstrate improved oxygenation
  • The patient will maintain a clear airway

Nursing Care Plan 5: Risk for Impaired Skin Integrity

Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to altered mental status and decreased mobility as evidenced by pressure risk assessment scores.

Related Factors:

  • Immobility
  • Poor nutritional status
  • Incontinence
  • Altered consciousness

Nursing Interventions and Rationales:

  1. Implement turning schedule
    Rationale: Reduces pressure injury risk
  2. Maintain skin hygiene
    Rationale: Prevents skin breakdown
  3. Monitor skin condition
    Rationale: Enables early intervention

Desired Outcomes:

  • The patient will maintain skin integrity
  • The patient will remain free from pressure injuries
  • The patient will demonstrate improved mobility

References

  1. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. 
  2. Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
  3. Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
  4. Hoilat GJ, Suhail FK, Adhami T, John S. Evidence-based approach to management of hepatic encephalopathy in adults. World J Hepatol. 2022 Apr 27;14(4):670-681. doi: 10.4254/wjh.v14.i4.670. PMID: 35646276; PMCID: PMC9099111.
  5. Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
  6. Schiano TD. Clinical management of hepatic encephalopathy. Pharmacotherapy. 2010 May;30(5 Pt 2):10S-5S. doi: 10.1592/phco.30.pt2.10S. PMID: 20412035.
  7. Sharma K, Akre S, Chakole S, Wanjari MB. Hepatic Encephalopathy and Treatment Modalities: A Review Article. Cureus. 2022 Aug 14;14(8):e28016. doi: 10.7759/cureus.28016. PMID: 36134085; PMCID: PMC9470972.
  8. Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. 
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Anna Curran. RN, BSN, PHN

Anna Curran. RN, BSN, PHN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.

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