Encephalopathy as a result of ammonia accumulation secondary to liver dysfunction. The liver normally converts ammonia, a byproduct of protein metabolism, into urea which can then be excreted.
Assessment Findings
- Initial manifestations: behavioral and mental changes.
- Advanced stage findings: asterixis (flapping tremors), confusion/disorientation, delirium/hallucination, and fetor hepaticus (“breath of the dead”)
Diagnostic Examinations
- SGOT or AST (aspartate amino transferese), SGPT, LDH, and Alkaline Phosphatase are increased.
- Serum Bilirubin is increased
- Serum Albumin is decreased
- Hemoglobin and Hematocrit is decreased.
- Prothrombin Time (PT) is decreased.
Nursing Interventions
- Provide bed rest (with bathroom privileges) and comfort. Plan for gradual increase in activities with rest periods.
- Relieve pruritus: do not use soaps and detergents, bathe in tepid water, use of emollient lotions, the use of cool, light, non-restrictive clothing. Keep nails short to avoid harm from scratching. You may apply cool, moist compresses to pruritic areas.
- Promote appropriate nutrition: small frequent feedings;
- High-calorie
- High CHO
- Low/mod. CHON (ammonia is a byproduct of protein metabolism)
- Low fat (fat absorption is impaired due to implication of the biliary system)
- Vitamin therapy (A, B Complex, C, D, K)
- Prevent infection:
- Prevent skin breakdown
- Reverse Isolation for patients with leukopenia (monitor patient WBC). Caretakers should observe proper hand washing technique.
- Administer diuretics as ordered.
- Administer antibiotics (Neomycin) as ordered.
- Monitor and prevent bleeding due to Vitamin K deficiency and esophageal varices from portal hypertension.
- Supplement Vitamin K as ordered.
- Discharge Instructions:
- Avoid all hepatotoxic substances (alcohol, sedatives, opiates, etc.), other people with upper respiratory tract infections.
- Avoid straining during defecation, vigorous blowing of the nose, and coughing to prevent episodes of bleeding (esophageal/gastric varices).
- Education on how to measure abdominal girth and weight, recognition of signs of recurring illness (liver tenderness, progressing jaundice and fatigue, anorexia)
Medical Management
- Enema
- Paracentesis for ascites.
- Blood Transfusion
- Albumer (albumin) infusion
Pharmacologic Management
- Hepatic Protectors: Essentiale, Godex
- **Beta-Blockers
- Diuretics (?)
- Vitamin K to counteract deficiency and prevent bleeding.
- Antibiotics (Neomycin)
- Antihistamines (reduce/prevent pruritus)
- Laxatives