Nursing care plan for hepatic encephalopathy

Introduction

Hepatic encephalopathy (HE) is a clinical condition that is caused by the toxic effects of endogenous and exogenous agents on the central nervous system. It is also known as portosystemic encephalopathy. It is a common complication in patients with cirrhosis of the liver, in which there is an abnormal accumulation of toxins in the brain due to an impaired detoxification process of the liver.

Assessment

Liver function tests: Liver function tests, such as albumin and bilirubin levels, are done to determine if the patient has any underlying liver disease that may be causing the HE.

Neurological examination: Neurological assessment involves testing for altered mental status, including irritability, confusion, personality changes, coma, and other cognitive deficits.

CT scan or MRI: Imaging tests, such as CT scans or MRIs, are used to rule out any other possible causes of altered mental status, such as a tumor or stroke.

Nursing Diagnosis

Ineffective peripheral tissue perfusion related to decreased hepatic blood flow: This diagnosis occurs when insufficient numbers of red blood cells are produced and oxygen transport to the tissues is impaired.

Altered thought process related to increased intracranial pressure: This diagnosis describes the cognitive changes that result from increased pressure in the brain.

Risk for injury related to decreased consciousness level: This diagnosis describes the risk of injury that can occur if the patient has a decreased level of consciousness.

Outcomes

Decrease in confusion: The patient will show increased clarity in thinking, decreased agitation, and improved concentration.

Decrease in risk for injury: The patient will exhibit appropriate behavior and positioning at all times, with no self-injurious behaviors.

Improves Urine Output: The patient will maintain an urine output within normal limits and demonstrate improved kidney function.

Interventions

Monitor the patient’s vital signs: Vital signs such as temperature, pulse, respirations, and blood pressure should be monitored frequently to assess changes in the patient’s condition.

Administer prescribed medications: Medications such as diuretics, laxatives, and anti-anxiety medications should be administered as prescribed.

Encourage rest and relaxation: The patient should be encouraged to have adequate sleep and rest periods to reduce stress and improve overall health.

Rationales

Monitoring vital signs: Monitoring vital signs can help identify any changes in the patient’s condition that may indicate a worsening of their condition.

Administering medications: Medications can help reduce symptoms of HE and/or prevent further complications.

Encouraging rest: Adequate rest and relaxation will help reduce stress and improve overall health.

Evaluation

The nurse will evaluate the effectiveness of the nursing interventions taken by determining if the patient’s symptoms have improved, if their risk for injury has decreased, and if their urine output is within normal limits.

Conclusion

Hepatic encephalopathy is a serious complication that can have devastating results if not treated promptly and properly. Nursing care plans for hepatic encephalopathy usually include monitoring the patient’s vital signs, administering prescribed medications, and encouraging rest and relaxation. With proper nursing care, the patient’s symptoms should improve and their risk for injury should decrease.

FAQs

• What is hepatic encephalopathy? - Hepatic encephalopathy is a clinical condition that is caused by the toxic effects of endogenous and exogenous agents on the central nervous system.
• What are the nursing interventions for hepatic encephalopathy? - The nursing interventions for hepatic encephalopathy include monitoring the patient’s vital signs, administering prescribed medications, and encouraging rest and relaxation.
• What is the goal of nursing interventions for hepatic encephalopathy? - The goal of nursing interventions for hepatic encephalopathy is to reduce symptoms, prevent further complications, and improve overall health.
• What is included in a nursing care plan for hepatic encephalopathy? - A nursing care plan for hepatic encephalopathy includes assessment, nursing diagnosis, outcomes, interventions, Rationales and evaluation.
• What are the long-term goals of a nursing care plan for hepatic encephalopathy? - The long-term goals of a nursing care plan for hepatic encephalopathy are to decrease confusion, decrease risk for injury, and improve urine output.