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:
- Electrolyte imbalances
- Infections
- Kidney dysfunction
- Medication side effects
- Dehydration
- 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:
- Monitor consciousness level q4h
Rationale: Early detection of neurological deterioration - Implement safety measures
Rationale: Prevents injury during confusion episodes - 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:
- Implement fall precautions
Rationale: Prevents accidents and injuries - Maintain bed rails and safety devices
Rationale: Ensures patient safety during confusion - 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:
- Monitor nutritional intake
Rationale: Ensures adequate nutrition - Administer prescribed supplements
Rationale: Supports nutritional needs - 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:
- Monitor respiratory status
Rationale: Ensures adequate oxygenation - Position appropriately
Rationale: Optimizes breathing efficiency - 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:
- Implement turning schedule
Rationale: Reduces pressure injury risk - Maintain skin hygiene
Rationale: Prevents skin breakdown - 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
- 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.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- 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.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- 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.
- 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.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
