Hepatic encephalopathy (HE) is a change in brain function caused by liver failure or by blood bypassing the liver, so toxins such as ammonia reach the brain. It ranges from subtle trouble concentrating to confusion, drowsiness, and coma, and it is reversible when the cause is found and treated. The nursing diagnoses used most often are Acute Confusion, Risk for Adult Falls, Risk for Aspiration, and Inadequate Protein-Energy Nutritional Intake. Nursing care centers on tracking mental status, finding and fixing the trigger, giving lactulose safely, protecting the airway, preventing falls, and keeping nutrition up.
At a glance
- What it is
- A brain disorder caused by liver dysfunction, most often cirrhosis. The damaged liver cannot clear ammonia and other toxins from the blood, and they affect the brain. It is graded from covert (only seen on testing) to overt (confusion, drowsiness, coma).
- Common triggers
- Infection (including spontaneous bacterial peritonitis), GI bleeding, constipation, missed lactulose doses, dehydration or too much diuretic, low potassium or sodium, kidney injury, alcohol, and sedatives such as benzodiazepines and opioids.
- Key signs
- Sleep reversed (awake at night, sleepy by day), poor attention, personality change, confusion, slurred speech, asterixis (flapping tremor of the outstretched hands), sweet musty breath (fetor hepaticus), drowsiness, and in late stages coma.
- Nursing focus
- Neuro checks with a grading scale, stool count on lactulose, intake and output, electrolytes and glucose, airway and swallow safety, fall prevention, avoiding sedatives, nutrition without protein restriction, and family teaching.
- Act now
- A falling level of consciousness, inability to protect the airway, vomiting blood or black stools, fever or a tender abdomen, low blood glucose, or a seizure needs the provider or rapid response team right away.
Why hepatic encephalopathy happens
Bacteria in the gut break down protein and make ammonia. A healthy liver turns ammonia into urea, which the kidneys clear. In cirrhosis, the liver cells cannot keep up, and high pressure in the portal vein pushes blood around the liver through collateral vessels (portosystemic shunting). Ammonia and other gut toxins then reach the brain.
In the brain, astrocytes take up ammonia and swell. Inflammation, changes in brain chemicals, and low sodium add to the problem. The result is slowed thinking, confusion, and in severe cases cerebral edema and coma.
Anything that adds ammonia or stresses the brain can tip a client with cirrhosis into HE. Blood in the gut is a large protein load. Constipation gives bacteria more time to make ammonia. Low potassium and alkalosis increase ammonia production and help it cross into the brain. Infection, dehydration, kidney injury, and sedating drugs all make the brain more sensitive. Finding and treating the trigger is as important as lowering ammonia.
HE can also follow a TIPS procedure (a shunt placed to lower portal pressure), because more blood bypasses the liver. In acute liver failure, HE can progress quickly to brain swelling and is managed in intensive care.
How severe is it?
Nurses often hear HE graded with the West Haven criteria. Your facility may also use the Glasgow Coma Scale or another tool, especially in grades 3 and 4.
| Grade | What you see |
|---|---|
| Minimal (covert) | No obvious signs; changes show only on psychometric or neuro testing. Can still affect driving and work. |
| Grade 1 (covert) | Short attention span, mild confusion, anxiety or euphoria, trouble with simple math, sleep pattern changes |
| Grade 2 (overt) | Lethargy, disorientation to time, obvious personality change, inappropriate behavior, asterixis |
| Grade 3 (overt) | Very drowsy but responds to stimuli, confused, disoriented to place, bizarre behavior |
| Grade 4 (overt) | Coma; does not respond even to painful stimuli |
Grades 3 and 4 usually mean closer monitoring, often in intensive care, and the team decides whether the client needs airway protection.
Nursing assessment
Subjective data
- From the client and family: changes in sleep, attention, mood, personality, handwriting, or ability to manage money or medicines
- When the change started and how fast it is getting worse
- Number of bowel movements per day, last bowel movement, and whether lactulose doses were missed or stopped
- Black or bloody stools, vomiting blood, abdominal pain, or fever
- Alcohol use, new medicines, sleeping pills, pain pills, or anxiety medicines
- Appetite, usual diet, and whether the client has been told to cut protein
- Falls, dizziness, and how much fluid the client has been drinking or losing
Objective data
- Level of consciousness, orientation, attention, and speech, scored with the West Haven grade or Glasgow Coma Scale and trended
- Asterixis: ask the client to hold arms out with wrists bent back and watch for a flapping tremor
- Fetor hepaticus, jaundice, ascites, spider angiomas, and bruising
- Temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation, plus gag reflex and ability to swallow safely
- Stool count and consistency, intake and output, and daily weight
- Signs of GI bleeding: melena, hematemesis, falling blood pressure, or rising heart rate
- Lab results as ordered: sodium, potassium, glucose, kidney function, CBC, INR, bilirubin, albumin, ammonia, blood and urine cultures, and paracentesis fluid results if ascites is present
- Diagnostics as ordered: head CT if a fall, stroke, or bleed in the brain is possible, since many other conditions can look like HE
Nursing diagnoses used with hepatic encephalopathy
- Acute Confusion — sudden changes in attention, thinking, and sleep from toxins reaching the brain
- Risk for Adult Falls — confusion, asterixis, weakness, and frequent urgent stools from lactulose
- Risk for Aspiration — drowsiness, a weaker gag reflex, and oral medicines and meals
- Inadequate Protein-Energy Nutritional Intake — poor appetite, muscle loss, and unneeded protein restriction
- Risk for Electrolyte Imbalance — diarrhea from lactulose, diuretics, and liver disease
- Risk for Bleeding — low platelets, poor clotting, and varices
- Risk for Impaired Skin Integrity — frequent loose stools, immobility, and edema
- Caregiver Role Strain — repeat admissions and caring for a confused family member at home
Worked care plans
Four plans in the same ADPIE shape. The scenario is a 58-year-old man with alcohol-associated cirrhosis who has not had alcohol for a year. He was taking lactulose at home but stopped it a week ago because of the loose stools, and he has had one hard stool in the last four days. His wife brought him in because for two days he has slept most of the day, been awake at night, and “isn’t making sense.” He is drowsy but wakes easily, knows his name and where he is but not the date, follows simple commands, and has asterixis. Temperature is 37.0°C (98.6°F), heart rate 92, blood pressure 108/66, respiratory rate 16, and oxygen saturation 96% on room air. His gag reflex is present, but he coughs on thin liquids at the first sip. Labs show sodium 132 mEq/L, potassium 3.3 mEq/L, glucose 104 mg/dL, INR 1.6, platelets 82,000/mm³, albumin 2.8 g/dL, and a raised ammonia level. His hemoglobin is stable, his stool is negative for blood, and his ascitic fluid shows no infection. He is admitted with grade 2 hepatic encephalopathy triggered by constipation and stopping lactulose, and started on lactulose, potassium replacement, and rifaximin as ordered.
1. Acute Confusion
Problem-focusedSubjective: Wife: “He’s been up all night and asleep all day, and he keeps asking the same questions. This happened last year when he stopped his medicine.”
Objective: Drowsy but wakes to voice. Oriented to person and place, not time. Cannot count backward from 20. Asterixis present. West Haven grade 2. Ammonia raised, potassium 3.3 mEq/L, one hard stool in four days.
Acute Confusion related to buildup of ammonia and other toxins from impaired liver function, worsened by constipation and stopped lactulose, as evidenced by disorientation to time, poor attention, reversed sleep pattern, and asterixis.
- Client returns to his usual mental status, oriented to person, place, and time, within the timeframe the team expects
- Client has the number of soft stools per day the provider sets
- Any decline in level of consciousness is found and reported at once
- Assess level of consciousness, orientation, attention, and asterixis at the ordered frequency using the same scale each time, and report any decline
- Give lactulose as ordered and count every stool; tell the provider if he has fewer or more stools than the target
- Give rifaximin as ordered
- Monitor potassium, sodium, glucose, and kidney function, and give potassium replacement as ordered
- Avoid benzodiazepines, opioids, and other sedating drugs unless the provider specifically orders them for this client
- Reorient him calmly, keep a clock and calendar in view, and have his wife stay and bring familiar items
- Keep lights on and the room active by day and dark and quiet at night to help reset his sleep pattern
By day 3 he was having 2 to 3 soft stools a day, was oriented to person, place, and time, had no asterixis, and was awake during the day. Goal met; continue lactulose and monitoring.
2. Risk for Adult Falls
Risk diagnosis- Confusion and poor judgment
- Asterixis and muscle weakness
- Urgent, frequent stools from lactulose, often at night
- Blood pressure on the low side, with diuretics at home
- Low platelets and poor clotting, so a fall could cause serious bleeding
No “as evidenced by” — he has not fallen. The plan prevents a fall and catches one early if it happens.
Risk for Adult Falls related to acute confusion, impaired coordination, urgent stools, and low blood pressure.
- Client has no falls during the hospital stay
- Client calls for help, or is checked often enough, before getting up to the bathroom
- Family can name the fall precautions to use at home
- Complete a fall risk assessment with your facility’s tool on admission and with any change in condition
- Keep the bed low and locked, use a bed or chair alarm per policy, and keep the call light and urinal within reach
- Offer toileting on a schedule, especially after lactulose doses, and keep a bedside commode close
- Use non-slip socks, good lighting, and a clear path to the bathroom
- Check orthostatic blood pressure as ordered and have him sit before standing
- Use the least restrictive measures; avoid physical restraints, which increase agitation and injury
- If a fall happens, assess for head injury and bleeding and tell the provider right away; his clotting is impaired
He had no falls. By day 3 he called for help before getting up, and his wife described the home safety plan. Goal met; continue precautions until discharge.
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Fifty questions with a written rationale on every option, scored by section so you can see which content area is weakest. Sent as a PDF.
3. Risk for Aspiration
Risk diagnosis- Decreased level of consciousness
- Coughing on thin liquids at the first sip
- Large volumes of oral lactulose and fluids
- Ascites pushing up on the diaphragm and stomach
No “as evidenced by” — his lungs are clear, his oxygen saturation is 96% on room air, and he has no fever. He has not aspirated; the plan keeps it that way.
Risk for Aspiration related to decreased level of consciousness, impaired swallowing, and increased abdominal pressure from ascites.
- Lungs stay clear and oxygen saturation stays at the level the provider sets
- Client takes oral medicines and meals only when awake and able to swallow safely
- Any decline in airway protection is found and reported at once
- Before each oral dose or meal, check that he is awake, sitting upright, and able to swallow; follow your facility’s swallow screen
- If he cannot swallow safely, hold the oral dose and ask the provider for another route, such as a feeding tube or a lactulose retention enema
- Keep the head of the bed raised at least 30 degrees unless ordered otherwise, and position him on his side if very drowsy
- Refer to speech-language pathology for a swallow evaluation as ordered and use the diet texture they advise
- Keep suction set up at the bedside and check lung sounds and oxygen saturation every shift
- Report a weak gag or cough, gurgling breathing, new fever, or falling oxygen saturation right away
His lungs stayed clear and oxygen saturation stayed at 95% to 97% on room air. He passed the swallow evaluation on day 2 as his alertness improved and moved to thin liquids. Goal met; continue upright positioning for meals.
4. Inadequate Protein-Energy Nutritional Intake
Problem-focusedSubjective: Wife: “After last time, we cut out meat and eggs because we heard protein causes the confusion. He hardly eats anything now.”
Objective: Eats about a quarter of each meal. Thin arms and temples with obvious muscle loss. Albumin 2.8 g/dL, which reflects liver disease as much as nutrition, so intake and muscle mass guide the plan.
Inadequate Protein-Energy Nutritional Intake related to poor appetite and self-imposed protein restriction, as evidenced by eating about a quarter of meals and visible muscle wasting.
- Client eats at least half of each meal plus snacks by day 4
- Client and wife state that protein should not be cut out
- Client and wife describe a plan for small, frequent meals and a bedtime snack
- Screen nutrition with your facility’s tool and refer to a dietitian
- Record intake at every meal and weigh daily, keeping in mind that ascites and edema hide weight loss
- Offer small, frequent meals and a late-evening snack with carbohydrate and protein
- Explain that current guidelines do not restrict protein in hepatic encephalopathy, and that the dietitian sets the amount
- Suggest dairy and plant proteins, which some clients tolerate better, if the dietitian advises
- Give oral nutrition supplements, vitamins, or other supplements as ordered, and follow the sodium limit ordered for ascites
- Check blood glucose as ordered, because a failing liver stores and releases less glucose
By day 4 he was eating about half of each meal plus a bedtime snack and one supplement drink a day. His wife said, “So we don’t cut protein, we spread it out.” Goal partly met; continue with dietitian follow-up.
Interventions and rationales
Client and family teaching
- Take lactulose every day, even when you feel well; the goal is the number of soft stools your provider gave you, often 2 to 3 a day
- Do not stop lactulose because of loose stools; call your provider to adjust the dose instead
- Take rifaximin with lactulose if it is prescribed, not in place of it
- Call your provider if there are fewer soft stools than your target, or if you have constipation
- Do not drink alcohol, and ask before taking any sleeping pill, anxiety medicine, pain medicine, or herbal product
- Do not cut out protein; eat small, frequent meals and a snack at bedtime, as your dietitian advises
- Follow your sodium and fluid limits for ascites, and weigh yourself daily if your provider asks
- Family: watch for early signs such as sleeping all day, confusion, personality change, poor handwriting, or a hand tremor, and call the provider early
- Do not drive after an episode of HE until your provider says it is safe
- Seek emergency care for black or bloody stools, vomiting blood, fever with belly pain, a very drowsy person who is hard to wake, or a seizure
NurseStudyPrep.com
You’ve read the care plan. Now answer one.
A priority item in the NCLEX format. On Prep, every option gets a written rationale — including the three that are wrong.
A client with cirrhosis is admitted with hepatic encephalopathy. The client is drowsy but wakes to voice, is disoriented to time, and has asterixis. The nurse has an order for oral lactulose. Which action should the nurse take first?
Why B. A drowsy client may not protect the airway, so swallow safety comes before any oral dose. If the client cannot swallow, the nurse holds the dose and asks for another route. A large drink adds to aspiration risk, holding lactulose lets ammonia keep building, and sedatives can deepen hepatic encephalopathy. Prep also explains why each wrong option looks reasonable.
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Frequently asked questions
What is the priority nursing diagnosis for hepatic encephalopathy?
Acute Confusion is the main problem, but safety comes first: if the client is drowsy, Risk for Aspiration and airway protection take priority, followed by Risk for Adult Falls. Any sign of GI bleeding, infection, or a falling level of consciousness needs immediate action.
How does lactulose work, and how do you know it is working?
Lactulose acidifies the colon so ammonia is trapped and passed in the stool, and it speeds up bowel movements. It is working when the client has the number of soft stools the provider sets, often 2 to 3 a day, and mental status improves.
What is asterixis?
A flapping tremor seen when the client holds the arms out with the wrists bent back. The hands drop forward and jerk back up. It is common in grade 2 and 3 hepatic encephalopathy but is not specific to it; it can also occur with kidney failure and some other metabolic problems.
Should a client with hepatic encephalopathy be on a low-protein diet?
No. Current guidelines do not restrict protein. Clients with cirrhosis lose muscle easily, and muscle helps clear ammonia. Small, frequent meals and a bedtime snack are encouraged, with the amount set by the dietitian and provider.
Does the ammonia level show how bad hepatic encephalopathy is?
Not reliably. A high level supports the diagnosis, but it does not match the degree of confusion, and it is not used alone to grade or track HE. Bedside assessment of mental status is what the team trends.
What triggers hepatic encephalopathy?
Common triggers are infection, GI bleeding, constipation, missed lactulose, dehydration or too much diuretic, low potassium or sodium, kidney injury, alcohol, and sedating drugs. A TIPS procedure can also bring it on.
References
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification, 2024–2026. Thieme.
- Vilstrup, H., Amodio, P., Bajaj, J., et al. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology, 2014;60(2):715–735.
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of hepatic encephalopathy. Journal of Hepatology, 2022;77(3):807–824.
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. Journal of Hepatology, 2019;70(1):172–193.
- Bass, N. M., Mullen, K. D., Sanyal, A., et al. Rifaximin treatment in hepatic encephalopathy. New England Journal of Medicine, 2010;362(12):1071–1081.
- Hoilat, G. J., Suhail, F. K., Adhami, T., & John, S. Evidence-based approach to management of hepatic encephalopathy in adults. World Journal of Hepatology, 2022;14(4):670–681.
- Sharma, K., Akre, S., Chakole, S., & Wanjari, M. B. Hepatic encephalopathy and treatment modalities: a review article. Cureus, 2022;14(8):e28016.
- Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (13th ed.). Elsevier, 2023.
- Harding, M. M., Kwong, J., & Hagler, D. Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems (12th ed.). Elsevier, 2023.
Grading scales, vital sign and lab reference ranges, ammonia sample handling, lactulose and rifaximin doses and stool targets, electrolyte replacement, sedative use, swallow screening and diet textures, protein and sodium targets, fall precautions, and criteria for intensive care or airway protection vary by client, by provider, and by facility. Follow the provider’s written orders and your own institution’s policies. This page supports study and does not replace course instruction or clinical judgment.
