HEPATIC ENCEPHALOPATHY AND to be restless and may experience

COMA insomnia.

DEFINITION STAGES OF HEPATIC

Also called as the portosystemic ENCEPHALOPATHY
encephalopathy, it is a life- STAGE 1
threatening complication of liver o CLINICAL SYMPTOMS
disease that occurs with profound Normal level of consciousness
liver failure. with periods of lethargy and
Patients may have no overt signs of euphoria
illness but may have abnormalities Reversal of day-night patterns
on neuropsychologic testing. o CLINICAL SIGNS
It is the neuropsychiatric Asterixis
manifestation of hepatic failure Impaired writing and ability to
associated with portal hypertension draw line figures.
and the shunting of blood from the STAGE 2
portal venous system into the o CLINICAL SYMPTOMS
systemic circulation. Increased drowsiness
Reversible metabolic form of Disorientation
encephalopathy can improve with Inappropriate behavior
the recovery of liver function Mood swings
Onset is often insidious and subtle Agitation
The disease is termed as subclinical o CLINICAL SIGNS
or minimal hepatic encephalopathy Asterixis
Fetor hepaticus
CLASSIFIED AS: STAGE 3
Acute and self-limiting or Chronic o CLINICAL SYMPTOMS
Stuporous
and progressive.
Difficult to rouse
Sleeps most of time
Patients with HE often have other Marked confusion
manifestations of end-stage liver Incoherent speech
disease, such as ascites, jaundice, o CLINICAL SIGNS
or gastrointestinal variceal Asterixis
bleeding. HE can also develop as Increase deep tendon reflexes
an isolated manifestation of Rigidity of extremities
decompensated cirrhosis. STAGE 4
o CLINICAL SYMPTOMS
CLINICAL MANIFESTATION Comatose
Earliest Symptom May not respond to painful
Mental status changes stimuli
Motor disturbances changes o CLINICAL SIGNS
Patient appears confused and Absence of asterixis
unkempt Absence of deep tendon
Has alterations in mood and sleep reflexes
patterns Flaccidity of extremities

SLEEP PATTERNS:
The patient tends to sleep during
day and at night the patient appears
ASTERIXIS
- a tremor of the hand when the wrist
is extended, sometimes said to
resemble a bird flapping its wings.
IMPAIRED HAND WRITING
RIGIDITY OF EXTREMITIES
ASSESSMENT
Several diagnostic algorithms ad a
variety of psychometric tests are
used I determining the presence
and severity of hepatic
encephalopathy.
ELECTROECEPHALOGRAM
- Shows the generalized slowing , an
increase in the amplitude of the
brain waves and characteristic
triphasic waves.
SURVIVAL RATE IS 40% after a first
episode of overt HE in patients with
cirrhosis.
Patients are referred for liver transplant
after the initial episode.
DIAGNOSIS
Diagnosis is clinical based on the
presence of cirrhosis or
portosystemic shunt with
symptoms of encephalopathy
Rare alternate diagnoses include
meningitis, infectious encephalitis,
Wernicke's encephalopathy and
Wilson disease
Blood Tests
A complete blood count may be
used to check your red blood cells,
white blood cells, and platelets. A
low red blood cell count indicates
blood loss and a lack of oxygen.
Blood tests may also be used to
check the sodium, potassium, and
ammonia levels in your blood.
Having too much of these
substances in the blood is a sign of
impaired liver function.
Imaging Tests
An imaging test, such as a head CT
scan or MRI, can check for
bleeding in your head or
abnormalities in your brain.
Liver Function Tests
Liver function tests may be given
to check for raised enzyme levels.
An increase in enzymes indicates
stress on the liver or liver damage.
Tell your doctor if you have kidney
disease or liver disease. The
symptoms youre experiencing
along with your medical history
can sometimes be enough to
diagnose hepatic encephalopathy.
MEDICAL MANAGEMENT
Lactulose is administered to reduce
serum ammonia levels.
Patient is closely monitored for
hypokalemia and dehydration.
IV administration of glucose to
minimize protein breakdown.
Administration of vitamins to
correct deficiencies.
Antibiotics may also be added to
the treatment regimen.
Neurologic status is assessed
frequently.
Mental status is monitored by
keeping a daily record of hand
writing and arithmetic
performance.
I&O and body weight are recorded
each day.
Vital signs are recorded every 4
hrs.
Potential sites of infection
(peritoneum, lungs) are assess
frequently and abnormal findings
are reported promptly.
Serum ammonia level is monitored
daily.
Protein intake is moderately
restricted only in patients who are
comatose or who have
encephalopathy that is refractory to
lactulose and antibiotic therapy
Patient and family are advised
about foods that are high in
proteins which may need to be
limited in the diet for the short term
to reduce production of ammonia.
Enteral feeding is provided for
patients whose encephalopathic
state persist.
Reduction in the absorption of
ammonia from the GI tract is
accomplished by the use of gastric
suction, enemas or oral antibiotics.
Electrolyte status is monitored and
corrected if abnormal.
Sedatives, tranquilizers and
analgesics medication are
discontinued.
Benzodiazepine antagonists such
as flumazenil may be administered
to improved encephalopathy.
NURSING MANAGEMENT
o Maintain safe environment to
prevent injury, bleeding and
infection.
o Administer prescribed treatments
and monitors patient for the
numerous potential complications.
o Encourage deep breathing and
position changes to prevent
atelectasis, pneumonia and other
respiratory complications.
o Communicate with patients
family to inform them about the
patients status and supports them
by explaining the procedures and
treatments that are part of the
patients care.
o Educate patient about self-care
o Assess patients physical and
mental status and collaborate
closely with the primary provider.
o Home visit
o Evaluate patients fluid volume
status and be alert for changes
indicative of hypovolemia due to
decrease intake and for decrease
urine output.
o Monitoring of laboratory values
continues to be important and the
home nurse must obtain
prescriptions to correct
abnormalities, especially
electrolyte imbalances which also
can worsen encephalopathy.
o Assess safety of home
environment.
o Reminds the patient and family
about the importance of dietary
restrictions, close monitoring and
follow-up.
o Observe patient for subtle
behavior changes of worsening
hepatic encephalopathy.