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.

• Signs and Symptoms:• 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