About
A result of cirrhosis or liver failure, major neurological changes occur including changes in level of consciousness, impaired thinking and memory, and even coma. This can be reversible if caught in the earlier stages.
Assess
- Elevated ammonia, confusion, lethargy, changes in level of consciousness, coma, twitching, asterixis, fetor hepaticus, muscle rigidity, seizures
Complications
- End stage liver disease, coma, death
Diagnosis
Chronic confusion related to increased ammonia retention
Risk for injury related to altered mental state
Goals
- The client will be free from injury.
- The client will exhibit signs of improved cognition and orientation.
Interventions
- Monitor vitals, liver enzymes, electrolytes, ammonia levels.
- Monitor neurological checks every two hours.
- Monitor for hypokalemia as a result of medication therapy.
- Assess for signs and symptoms of worsening ( asterixis, fetor hepaticus, decline in neuro status).
- Maintain a safe environment; monitor for cognitive changes or weakness associated with imbalance.
- Administer medications ( lactulose, etc.) as ordered.
- Teach client about continuing medications at home to maintain two to three stools daily.
- Include family members in care and teaching if client unable to remember instructions.
- Teach to avoid alcohol and over the counter medications.
- Monitor for signs/ symptoms of complications.
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