HEPATIC ENCEPHALOPATHY

definition:
Hepatic encephalopathy is brain and
nervous system damage that occurs
as a complication of liver disorders.
It is characterized by various
neurologic symptoms including
changes in reflexes, changes in
consciousness, and behavior
changes that can range from mild to
severe.
ASSESSMENT:
Grading of the symptoms of hepatic encephalopathy is as
follows:
Grade 0 - Clinically normal mental status but minimal
changes in memory, concentration, intellectual function,
and coordination

Grade 1 - Mild confusion, euphoria, or depression; decreased

attention; slowing of ability to perform mental tasks;
irritability; and disordered sleep pattern, such as inverted
sleep cycle

Grade 2 - Drowsiness, lethargy, gross deficits in ability to

perform mental tasks, obvious personality changes,
inappropriate behavior, and intermittent disorientation,
usually regarding time

Grade 3 - Somnolent but can be aroused, unable to perform

mental tasks, disorientation about time and place,
marked confusion, amnesia, occasional fits of rage,
present but incomprehensible speech
Grade 4 - Coma with or without response to painful stimuli

Patients with mild and moderate hepatic encephalopathy

demonstrate decreased short-term memory and
concentration upon mental status testing. They may
show signs of asterixis, although the flapping tremor of
the extremities is also observed in patients with uremia,
pulmonary insufficiency, and barbiturate toxicity.

Some patients show evidence of fetor hepaticus, a sweet

musty aroma of the breath that is believed to be
secondary to the exhalation of mercaptans.

Other potential physical examination findings include

hyperventilation and decreased body temperature.
• Si gn s a nd Sy mp toms :
• changes in mental state, consciousness, behavior,
personality
• forgetfulness
• confusion, disorientation
• delirium (acute, severe confusion with fluctuating
level of consciousness)
• dementia (loss of memory, intellect, reasoning, and
other functions)
• changes in mood
• decreased alertness, daytime sleepiness
• decreased responsiveness, progressive stupor
• coma
• decreased self-care ability
• deterioration of handwriting or loss of other small hand
movements
• coarse muscle tremors
• muscle stiffness or rigidity
• seizures (rare)
• speech impairment
• movement, uncontrollable
• movement, dysfunctional
• agitation
LAB TESTS:
• Blood chemistry may show low albumin,
high bilirubin, or other abnormalities.
• Serum ammonia levels are commonly high.
• Prothrombin time may be prolonged and
not correctable with Vitamin K.
• CT scan of the head may be normal, or may
show general atrophy (loss of tissue).
• EEG (electroencephalogram, a reading of
electrical activity in the brain) shows
characteristic abnormalities.
DIAGNOSIS AND PLAN:
NURSING MANAGEMENT:
1. Reduce protein in the intestine.
• recommend total elimination of dietary protein with an
intake of fruit and intravenous fluids.
• -protein may be restricted to 20-40 gm/day.
• -assess or signs of gastrointestinal bleeding. Check for
bright blood in the stool or for black tarry stools.
Bleeding results in protein accumulation in the GIT,
which exacerbates hepatic encephalopathy.

2. Reduce bacterial production of ammonia.

• -neomycin and lactulose are useful pharmacologic
agents for this purpose. Since neomycin is not
absorbed into the circulation, it exerts a powerful
effect in the intestinal bacteria responsible for
ammonia production.
3. Eliminate fluid and electrolyte imbalance, hypoxia,
infection, sedation
• -maintain and monitor fluid balance to prevent further
hepatic injury and reduced renal perfusion.
• -deliver intravenous fluids evenly over a period of time.
• -monitor vital signs and central venous pressure
frequently.
• -measure urine output hourly if necessary.
• -be alert to possible harmful accumulation of ammonia
due to diuretic therapy. Hypokalemia from the use of
diuretics contributes to hepatic encephalopathy by
increasing ammonia production in the kidney.

4. Maintain function in the unconscious person.

• -turn the person frequently and promote lung aeration
to prevent pneumonia and skin breakdown.
COMPLICATIONS:
• cerebral edema (brain swelling)
• Brain herniation
• progressive, irreversible coma
• permanent neurologic losses (movement,
sensation, or mental state)
• increased risk of:
• sepsis
• respiratory failure
• cardiovascular collapse
• Kidney failure