Medical Surgical Nursing

gastrointestinal bleeding.

Collaborative Problem: Hepatic encephalopathy

Goal: Absence of changes in cognitive status and of injury

1. Assess cognitive status every

4 – 8 h:

a. Assess patient's

orientation to person,

place, and time.

b. Monitor patient's

level of activity,

restlessness, and

agitation. Assess for

presence of flapping

hand tremors

(asterixis).

c. Obtain and record

daily sample of

patient's handwriting

or ability to construct

a simple figure (eg,

star).

d. Assess neurologic

signs (deep tendon

reflexes, ability to

follow instructions).

2. Monitor medications to

prevent administration of

those that may precipitate

hepatic encephalopathy

(sedatives, hypnotics,

analgesics).

3. Monitor laboratory data,

especially serum ammonia

level.

4. Notify physician of even

subtle changes in patient's

neurologic status and

1. Data will provide baseline of

patient's cognitive status and

enable detection of changes.

2. Medications are a common

precipitating factor in

development of hepatic

encephalopathy in patients at

risk.

3. Increases in serum ammonia

level are associated with

hepatic encephalopathy and

coma.

4. Allows early initiation of

treatment of hepatic

encephalopathy and

prevention of hepatic coma

5. Reduces breakdown and

conversion of protein to

ammonia

6. Reduces serum ammonia

level

7. The patient who develops

hepatic coma is at risk for

respiratory complications (ie,

pneumonia, atelectasis,

infection).

8. The patient in coma is at risk

for skin breakdown and

pressure ulcer formation.

 Remains awake, alert, and

aware of surroundings

 Is oriented to time, place,

and person

 Exhibits no restlessness or

agitation

 Record of handwriting

demonstrates no

deterioration in cognitive

function

 States rationale for

treatment used to prevent

or treat hepatic

encephalopathy

 Demonstrates stable serum

ammonia level within

acceptable limits

 Consumes adequate

caloric intake and adheres

to protein restriction

 Takes medications as

prescribed

 Breath sounds are normal

without adventitious

sounds

 Skin and tissue intact

without evidence of

pressure or breaks in

integrity