Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? Select all that apply.
A. Assessing the client's neurologic status every 2 hours
B. Monitoring the client's hemoglobin and hematocrit levels
C. Evaluating the client's serum ammonia level
D. Monitoring the client's handwriting daily
E. Preparing to insert an esophageal tamponade tube
F. Making sure the client's fingernails are short
Correct Answers: A, C, & D
Hepatic encephalopathy results from an increased ammonia level due to the liver’s inability to convert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. Hepatic encephalopathy (HE) is a reversible syndrome observed in patients with advanced liver dysfunction. The syndrome is characterized by a spectrum of neuropsychiatric abnormalities resulting from the accumulation of neurotoxic substances in the bloodstream (and ultimately in the brain).
Option A: The nurse should monitor the client’s neurologic status. Symptoms typically include confusion, personality changes, disorientation, and a depressed level of consciousness. The earliest stage is often characterized by an inverted sleep-wake pattern wherein patients are found to be sleeping during the day and awake throughout the night.
Option B: Monitoring the client’s hemoglobin and hematocrit levels address esophageal bleeding. A diagnosis of HE should involve a thorough evaluation of the patient’s vital signs and airway followed by classification of the symptoms according to the West-Haven Criteria.
Option C: The nurse should monitor the client’s serum ammonia level. Elevated blood ammonia levels are often seen in patients with hepatic encephalopathy. It is more useful, however, to assess the clinical improvement or deterioration of a patient undergoing treatment rather than monitor serial arterial blood ammonia measurements.
Option D: The nurse should monitor the client’s handwriting. During the intermediate stages of HE, a characteristic jerking movement of the limbs is often observed (e.g., asterixis) when the patient attempts to hold arms outstretched with hands bent upward at the wrist.
Option E: Insertion of an esophageal tamponade tube addresses esophageal bleeding. Treatment for HE involves proper identification and treatment of the underlying cause. Antibiotics (e.g., rifaximin) neomycin/paromomycin/metronidazole, or vancomycin) are often given empirically due to the frequency of infection as an underlying cause.
Option F: Keeping fingernails short addresses jaundice. Protein restriction is only of use in patients with acute flare-ups and is not justified in chronic cases. These patients need nutrition as they have a high catabolic rate and severe wasting.
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