By: Michelle Russell Case Study Presentation NUR 4216L 12-4-12
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Understand the pathophysiology of hepatic encephalopathy
Recogonize the signs/ symptoms Understand relevance to clinical
setting and patient scenarios 2
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Hepatic Encephalopathy is a brain disorder that can occur when
the liver is unable to remove toxins from the blood Can be acute or
chronic; and range from mild to severe; may progress slowly or
rapid Can be a medical emergency, patients usually hospitalized
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Caused by disorders that affect the liver: Commonly hepatitis
or cirrhosis Disorders that cause blood circulation to decrease to
the liver 4
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MILD SEVERE Breath with a musty or sweet odor Change in sleep
patterns Changes in thinking Confusion that is mild Forgetfulness
Mental fogginess Personality or mood changes Poor concentration
Poor judgment Worsening of handwriting or loss of other small hand
movements Abnormal movements or shaking of hands or arms Agitation,
excitement, or seizures (occur rarely) Disorientation Drowsiness or
confusion Inappropriate behavior or severe personality changes
Slurred speech Slowed or sluggish movement 5
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Brain swelling Permanent nervous system damage Increased risk
of heart failure, kidney failure, respiratory failure and sepsis
(blood poisoning) unconscious, unresponsive or coma Death 6
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Alcohol intoxication Complicated alcohol withdrawal Meningitis
Metabolic abnormalities such as low blood glucose Sedative overdose
Subdural hematoma Wernicke-Korsakoff syndrome 7
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Asterixis liver flap Ask patient to hold their hands out in
front of them, it will jerk
http://www.youtube.com/watch?v=1yFRzxbJnqQ Neuro examination CT
scan or MRI of head EEG Liver function tests Serum ammonia levels
PT/INR Potassium/ sodium levels 8
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Grade 0 - Minimal hepatic encephalopathy, asterixis not
present; mild cognitive impairment Grade 1 - Trivial lack of
awareness. Asterixis can be detected. Grade 2 - Lethargy or apathy.
Disorientation. Obvious asterixis. Grade 3 - Somnolent but can be
aroused Grade 4 - Coma with or without response to painful stimuli
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Life support if in coma Electrolyte/ fluid balance Reduce
protein level to lower ammonia level- possible long term diet
change Lactulose- prevent intestinal bacteria from creating ammonia
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Can be treatable Chronic typically gets worse, or comes back If
patient is put into a coma, 8 out of 10 patients die 11
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Altered level of consciousness Impaired nutrition Fluid/
electrolyte imbalance 12
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Interventions Temporarily decrease protein intake and increase
carb intake Intestinal cleaning to remove nitrogen containing
sources as a possible source of ammonia Lactulose Antibacterials
influence ammonia flora, therefore decrease ammonia level
Antipsychotics- theory (still inconclusive) that certain drugs
preventing the binding of GABA decrease HE 13
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Interventions Diagnosis of exclusion Correct underlying cause
(if applicable) Lactulose (should be titrated to 3-4 loose stools
daily, about 30-60g) Supports bacterial growth Antibiotics such as
neomycin lower ammonia levels in gut Establish healthcare proxy
Education recognize S/S, when to notify provider prevent falls,
skin breakdown, aspiration 14
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A client is admitted with an elevated serum ammonia level and
iron- deficiency anemia. The nurse knows this client has some
degree of liver failure because: A. The liver is the storage center
for iron B. The client is in acute renal failure and liver failure
follows C. The liver converts ammonia to the harmless substance of
urea D. Both A and C are correct 16
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D. Both A and C are correct The liver is the major storage
center for iron. The liver is responsible for converting ammonia
into urea for excretion by the kidneys. 17
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A client is admitted with an alteration in neurological status
and is in the process of being diagnosed with hepatic
encephalopathy. Which of the following is known about this
diagnosis? A. It is caused by a build up of urea B. It is caused by
the build up of ammonia and protein metabolism malfunction C.
reduced cardiac output is the leading cause of death in these
clients D. It is caused by carbohydrate metabolism dysfunction
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B. It is caused by the build up of ammonia and protein
metabolism malfunction This is the hallmark symptom of acute
hepatic failure. Also termed hepatic coma, this is caused by a
buildup of ammonia. Cerebral edema is the leading cause of death in
this condition. 19
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A client with acute hepatitis is prescribed lactulose. The
nurse knows this medication will: A. Mobilize iron stores from the
liver. B. Remove bilirubin from the blood. C. Prevent the
absorption of ammonia from the bowel D. Prevent hypoglycemia.
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C. Prevent the absorption of ammonia from the bowel Lactulose
helps prevent the absorption of ammonia from the bowel because it
will cause frequent bowel movements, which facilitates the removal
of ammonia from the intestines. 21
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Exact cause of HE is unknown It is still inconclusive about
correct interventions Recognize S/S and risk factors in patients
Change in LOC Suspected in liver failure patients 22
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American liver foundation. (2012, July 17). Retrieved from
http://www.liverfoundation.org/abouttheliver/in
fo/hepaticencephalopathy/ Gerber, T., & Schomerus, H. (n.d.).
Hepatic encephalopathy in liver cirrhosis. Disease Management,
1353-1367 Longstreth, G. (2011, October 16). Medline plus.
Retrieved fromhttp://www.nlm.nih.gov/medlineplus/en
cy/article/000302.htm Wilson Childers, J., & Arnold, R. M.
(2008). Hepatic encephalopathy in end-stage liver disease. Fast
Facts and Concepts, 1341-1342 Wolf, D. (2011, March 9). Medscape.
Retrieved from http://emedicine.medscape.com/article/186101-
overview 23