hepatic encephalopaty

7/30/2019 Hepatic Encephalopaty

1/23

Biographic Data:

Patient J.P, 65 years old, Male, Filipino, Married, Roman Catholic, Working as a

jeepney driver and presently residing in Caloocan City was admitted at our institution last

February 11, 2012.

Chief Complaint:

Generalized body weakness

History of Present Illness:

Patient was apparently well 1 month PTA patient was noted yellowish discoloration of

the skin and eyes on the patient. He was brought to Ospital ng Maynila, after 4 days of

symptoms wherein he was admitted for 2 nights. Laboratories done were urinalysis, CBC,

HBT-UTZ revealing diffuse parenchymal Liver disease and bile sludge. Patient was sent home

with Silymarin and Lactulose.

3 week PTA, patient sought consult with AP to regression symptoms with associated

generalized body weakness and loss of appetite. Diagnostic were done such as chest X-ray

revealing pneumonitis urinalysis with trace albumin, CBC with low hemoglobin of 10.9

Medications prescribed such as Senokot, Diphenhydramine 25mg/tab, Cefuroxime 500mg/tab,

Polynerve 500mg OD, Iberet FA, Ascorbic Acid and Ciprofloxacin 500mg/tab BID.

1 week PTA with the above symptoms, there was noted edema on both feet,

associated with on and off fever. At this time patient was noted by the relatives to have

increasing sleeping time during the day. Symptoms progress which prompted patient to seek

consult hence this admission.

Past Medical History:

(-) Hypertension

(-) DM

(-) Allergies

(+) previous Hospitalization


2/23

Family History:

(+) DM-Mother

(+) Asthma

Personal and Social history:

Non smoker Chronic alcohol drinker for 30 years, usually hard drinks amounting to 3-

4L/day

Physical Exam upon Admission:

V/S BP= 90/60, HR=78bpm, RR=18BPM, T=36.1 (+) generalized jaundice Yellowish conjunctiva, pallor oral mucosa tongue (+) Spider Angiomata

PHYSICAL EXAMINATION:

Physical examination upon admission:

Globular abdomen, (+) visible veins or peristalsis, fluid wave or bruit, tense andglistering

Dull (+) direct/rebound tenderness abdominal girth=88cm (+) grade 3 bipedal pitting edema.

Physical Assessment:

PHYSICAL

ASSESSMENT

Date Assisted

February 13,2012

NORMAL ACTUAL FINDING INTERPRETATION

Vital Signs

Blood Pressure

Heart Rate

Respiratory Rate

Temperature

120/80mmHg

60-100bpm

16-20cpm

36-37.5C

90/60mmHg

78 beat per minute

18cpm

36.1 C

Decrease BP due to

anemia

Within normal limit

Within normal limit

Within normal limit

Weight

Height

70-83 kgs 63kgs.

56 ft

BMI= 18.86

Underweight


3/23

PHYSICAL

ASSESSMENT

NORMAL ACTUAL FINDING INTERPRETATION

Mouth

Nose

Uniform pink color pale oral mucosa

with foul odor

with NGT

Associated with anemia,

fetor hepaticus may be

associated with liver

disease

For ostorized feeding

Upper Extremities

Skin

Muscles

Hand

Varies from light to

deep brown, from

ruddy pink to light

pink, from yellow over

tones to olive.

Smooth coordinated

movements

Jaundiced and warm

to touch in both

extremities,

Flapping of both

hands,

Yellowish discolorations

signifies liver disease,

Asterexis early sign of

hepatic encephalopathy

Abdomen

Inspection

No visible vascular

pattern

Silver white striae

Noted visible veins,

tense and glistening

Presence of purplishstriae

Abdominal girth

103cm

Visible veins pattern is

associated with liver

disease,tense glistening

may indicate ascites and

edema

Purplish striae or spiderAngiomas associated with

liver disease

Auscultation

Percussion

Audible bowel sound

Dullness is only in

full bladder and at

the liver and spleen

area

high pitch,loud,

rushing sounds

Dullness at the entire

part

Hyperactive sound

associated with the use

of laxatives.

Large dull area

associated with presence

of fluid


4/23

Palpation

Elimination

Urine

No tenderness

Amber or clear and

aromatic, amounting

to 30cc per hour

Reported rebound

tenderness when

palpation

Cola colored,

amounting to 400-

500 drained every 8

hours, with foul odor

Indicate peritoneal

inflammation

Indication of bilirubin

excretion

Lower extremities

Legs

Plantar Reflex

Toenails

No deformities no

swelling

All five toes bend

downward

Prompt return of pinkor usual color general

less than 4 seconds

Noted grade 3

bipedal edema

All five toes spread

outward and the big

toes moves upward

Capillary refill delayedat 6 sec.

Indication of fluid

retention

Associated with neurologic

function

May indicate circulatoryimpairment

Glasgow Coma Scale 14-15 normal GCS =12-13 Near normal, with

disoriented to time and

date


5/23

GORDONS FUNCTIONAL HEALTH PATTERNS

HEALTH PATTERN PATIENT PARAMETERS PATIENT DATA

NUTRITIONAL PATTERN Parameters:

Eating habits, appraisal of

appetite, weight loss or gain

change in skin, hair or nails.Observation:

Tone,texture,coloring of skin

and mucus membrane,

proportion of height and

weight texture of hair,

condition of scalp, nails gums

and teeth.


6/23

ANATOMY


7/23

GI Tract ProducesAMMONIA

Ammonia Enters Portal Circulation

Unable to Metabolized by Liver

Enters the Brain

Excites Peripheral Benzodiazepine Type Receptors

Neuro Steroid Synthesis

Stimulates GABA Neurotransmitters

Depression of CNS

Ammonia Inhibits Transmission & Synaptic Regulation

S/Sx:

Mental Changes

Motor Disturbance

Alteration in Mood & Sleep

Restlessness & Insomnia @ Night

Progress

Difficulty to Awaken at Day

Disoriented to Time & Date

Generalized Jaundice

Ascites

Peripheral Edema

Plantar Reflex- Abnormal

Asterixis

Fetor Hepaticus (breathe)

PATHOPHYSIOLOGY OF HEPATIC ENCEPHALOPATHY

Complication:

DEATH

IncreaseAMMONIA


8/23

Risk Factor:

Modifiable:

*Alcohol consumption *chemicals

* Malnutrition * Bacterial Dse.

Non-modifiable

*Gender: Men>Women

*Age: 40-60 to 63 y/o

Destroy Liver Cells

Replace by Scar Tissue

Liver is contracting

Hobnail Liver Appearance

Obstruction of Hepatic Portal Vessel Occurs because Blood Not Allow Circulation Freely

Glucoromide Pressure of Hepatic

Portal Vessel

Accumulation of Fluid in

Peritoneal Cavit

No Conversion of

B2 B1

Venous Congestion

AscitesB2 Edema

COMPLICATION: Hepatic Encephalopathy

PATHOPHYSIOLOGY OF LIVER CIRRHOSIS

Damming of blood in GIT

S/sx:

Weakness,

Fatigue


9/23

MEDICATION

Drugs Action Indication Side Effect Nursing Implication

Brand Name:

aminoleban

Generic

Name

Classification:

parenteral

nutrition

An enteral

formula

containing

amino acids,

carbohydrates,

fats, vitamins

and minerals as

a dietary

supplement

especially for

patients with

liver impairment.

Nutritional

supplement for

patient with

chronic liver

impairment.

Contraindication:

severe renal

disorder,

abnormal amino

acid metabolism

and other than

hepatic disorder.

occasional

nausea and

vomiting,

hypersensitivity

reactions,

occasional

fever, chills,

headache and

vascular pain

>Assess patients

condition before starting

the therapy.

>Be alert to adverse

reactions.

>Monitor patient

temperature.

>If GI reaction occur

monitor patient hydration.


10/23


Brand Name:

kalium Durule

Generic Name:

Potassium

Chloride

Classification:

electrolyte

Replacement of

potassium and

maintain

potassium level.

Prevention and

correction of

potassium

deficiency

Contraindication

:

patient with

oliguria, GI

disorders,

hyperkalemia,

heat cramps

Rash, vomiting,

diarrhea,

hyperkalemia

>Take drugs with meals

or with food and a full

glass of water to

decrease GI upset.

>Do not chew or crush

tablets, swallow tablets

whole

>You may find wax

matrix capsules in the

stool. It is not absorbed

in the GI tract.

>Report tingling of the

hands and feet, unusual

tiredness or weakness,feeling of heaviness in

the legs, severe nausea,

vomiting, abdominal pain,

black or tarry stools, pain

at IV injection site.


11/23


Brand Name:

ursofalk

Generic Name:Ursodeoxycholic acid

Classification:

Naturally occurring

bile acid.

Bile salt replinisher

Alters composition

of bile, increasing

concentrations of

itself anddecreasing amounts

of toxic bile acids.

It also increases

bile flow

Used in the treatment

of chronic liver

disease in which the

flow of the bile hasstopped for some

reason

Contraindication

Acute inflammation of

the gall bladder or

biliary tract.

Hypersensitivity to bile

acids or any excipient

of the formulation

Diarrhea,

allergic

reactions,

nausea andvomiting, sleep

disturbance

>Administer with food

increase drug dissolutio

>If patient inadvertentltakes too much,

diarrhea will most like

result and may warran

systemic treatment.


12/23


Brand Name:

tazidime

Generic Name:

ceftazidime

Classification:

Antibiotic

3rd

gen

cephalosphorin

Use to treat

against a broad

range of gram

(- ,+) bacteria

It inhibits

synthesis of

bacterial cell

wall, causing

cell death

Cns infection

Contraindica

tion:

Contraindicated to

patient with

allergies to

penicillins,

cephalosphorin

Urticaria, kidney

damage, loss of

liver function

>Assess for liver and

renal dysfunction

>Culture infection

>Have vit. K available

in hypoprothrombinemia

occurs

>Discontinue if

hypersensitivity occurs


13/23


Brand Name:

Duphalac

Generic Name:

lactulose

Classification:

Gastrointestinal

agent

Hyperosmotic

laxative

Inhibits bacterial

DNA gyrase

thus preventing

replication in

susceptible

bacteria.

Used to reduce

the amount of

ammonia in the

blood of patient

with liver disease.

It works by

drawing ammonia

form the blood

into the colon

where it is

removed from the

body

Contraindication:

Patient who require

a low lactose diet

Diarrhea, gas,

nausea

Stop and

report: stomach

pain or cramps

and vomiting

>Assess condition

before therapy and

reassess regularly

thereafter to monitor

drug effectiveness

>Monitor pt. for any

adverse reactions

>Regularly assess

mental condition

>Monitor I&O


14/23


Brand Name:

Acifre, omepron

Generic Name:

omeprazole

Classifigastic:

Gastric acid

pump inhibitor

It inhibits

transport of

hydrogen ions

into gastric

lumen also it

increases the

gastric ph and

reduces gastric

acid formation

Treatment of

gastric ulcer

In combination

with appropriate

antibiotics

Contraindication:

Known

hypersensitivity

with omeprazole

Headache,

dizziness,

diarrhea,

abdominal pain,

nausea and

vomiting, URI

infection, back

pain, rash,

cough

>Give before meals

>Do not crush or

chew tablet,

swallow whole

>Evaluate for

therapeutic response

like relief of GI

symptoms

>Report headache


15/23

LABORATORY

February 12,2012

Result Remarks Normal Values Interpretation

Leukocytes 16.88 High 5.0-10.0 Infection

Erythrocyte 3.35 Low M-4.6-6.2 Abnormal loss of RBC

Hemoglobin 9.9 Low M-12.0-17.0 Anemia

Hematocrit 29.00 Low 40.0-54.0 Anemia

Thrombocyte 227 Low M-150-450

Neutrophil 87.800 High 50.00-70.00 Infection

Lymphocyte 4.500 Low 20.0-40.0 Use of corticosteroid

and other

immunosuppressivedrugs.

Monocyte 5.800 0.0-7.0

Eosinophil 1.400 0.00-5.000


Basophil 0.500 0.000-1.000

PT patient 27.2 High 11-14 Liver disease; damage,

Vitamin k deficiency,

obstruction of bile

duct.


16/23

PT control 12.5 High 11-14

BUN 95 mg/dl High 9-20 Renal impairment is

detected by an

increase in both BUN

and cretinine

Creatinine 8.04 mg/dl High 0.66-1.25

SGOT(AST) 776. U/L High 17-59 Liver cell damge

SGPT(ALT) 199. U/L High 21-72


Total Bilirubin 42 mg/dl High 0.2-1.3 Jaundice

Direct Bilirubin 41.5 mg/dl High 0-0.4 Jaundice

Indirect Bilirubin 0.5 mg/dl 0-1.1

ammonia 62 Umol/L high 9-30 Liver disease

Alkalinephosphatase

418.00 High 100.00-290.00IU/L

Liver disease

HBSAg Non-reactive

Albumin 2.6 mg/dl low 1.5-2.5 Edema


PT INR 2.68 Low 11-14

PT Activity 20 Low 70-130



17/23

sodium 129 mmol/L Low 137-145 Hyponatremia

Potassium 3.3 mmol/L Low 3.5-1.5 Hypokalemia

ABG RESULTS


Ph 7.34 Low 7.35-7.45 Acidosis

PCO2 26 mmhg High 22-26 Normal

PO2 100 mmhg High 80-100 normal

HCO3 15 mmol/L low 35-35 Acidosis

***Metabolic Acidosis.


18/23

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIO

Subjective:

pumapayat na

ako as verbalized

by the patient.

Objective:

Weight on

admission = 63kg.

Weight upon

assessment =

59kg.

Imbalanced

nutrition: Less

body

requirements

r/t inability to

absorb nutrients

as manifested

by loss of

weight

Short Term:

After 24 hours of

nursing intervention,

the patient will

display

normalization of

laboratory values.

Long Term:

After 4 days of

nursing intervention,the patient will be

free from signs of

malnutrition .

Auscultate bowel

sounds.

No characteristics

of stool (color,

amount, &

frequency).

Independent:

Discuss eating

habit, including

food preferences

and intolerances.

Assess disease

effects and use of

laxatives.

Determine

psychologicalfactors/perform

psychological

assessment.

To appeal to

clients likes

and dislikes.

That may be

affecting

appetite, food

intake or

absorption.

To assessbody image

and

congruency

with reality.

Short Term:

After 24 ho

of nursing

intervention,

goal was

partially met

the patient

display

laboratory

results closewithin the

normal value

Long Term:

After 4 days

of nursing

intervention,

the goal wa

partially met

patient is no

totally free

from signs o

malnutrition.

Review indicativelaboratory data

including liver

functions and

electrolytes.

Note age, body

Helps determinenutritional needs


19/23

build, strength,

activity/rest level.

>Promote pleasant

and relaxing

environment.

>Develop stress

reduction teaching.

>Weigh regularly.

Dependent:

>Administer drug

as ordered

(amminoleban)

>Assist in treating

underlying

causative factors

includingmalabsorption.

Collaborative:

>Consult dietician

To enhance

intake.

To monitor

effectiveness of

efforts.

Implement

interdisciplinary

team

management.


20/23

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective:

-Peripheral

Edema

-(+3)

BipedalEdema

-ascites

-Takes 2

3 L/day of

liquids (Prior

to admission)

Fluid

Volume

Excess

related to

excessivefluid intake

as

evidenced

by (+3)

bipedal

edema and

ascites

ShortTerm Goal:

>After 2 hours of

nursing

interventions, the

patient will beable to verbalize

or at least

understand the

dietary and fluid

restrictions

INDEPENDENT:

>Record intake

and output every

1 to 8 hours

depending onres-ponse to

interventions and

on patient acuity

>Indicates

effectiveness

of treatment

and adequacy

of fluid

ShortTerm Goal:

After 2 hours of

nursing

interventions, the

patient was ableto verbalized and

understand the

dietary and fluid

restrictions. The

goal was met.

LongTerm Goal:

After 8 hours ofnursing

interventions, the

client will be able

to have a

balanced I & O,

stable weight and

free signs of

edema

>Measure and

record abdominalgirth and weight

daily

>Elevate

edematous

extremities,

change position

frequently

>Place in semi

fowlers

position, asappropriate

>Monitors

change inascites

formation and

accumulation

>To reduce

tissue

pressure and

risk of skin

breakdown

>To facilitate

movement ofdiaphragm,

thus improving

respiratory

effort

LongTerm goal:

After 8 hours ofnursing

interventions the

client was able to

had a balanced I &

O, stable weight

and free signs of

edema. The goal

was partially met.

>Explain rationale

for sodium and

fluid restrictions

DEPENDENT:

>Restrict sodium

and fluid intake if

prescribed

>Administer

diuretics,

potassium and

protein

>Promotes

patients

understanding of

restriction and

cooperation with

it.

>Minimizes

formation of

ascites and

edema

>Promotes


21/23

supplements as

prescribed.

excretion of fluid

through the

kidneys

COLLABORATIVE:

>Assist with

possible

procedures, if

indicated.

>Consult a

dietician, as

needed

and maintenance

of normal fluid

and electrolyte

balance

DISCHARGE PLAN

Medicine:

Advise patient to take his medicine religiously.

>Lactulose 30 cc, once a day.

>Omeprazole 20mg/tab once a day and take this 30 minutes before meal.

>Ceftazidime 500mg/tab twice a day (8am - 8pm)

>Amminozelam 50g (1sachet) once a day.

Exercise:

>Encourage alternating periods of rest and ambulation.

*Have at least 1 hr. ambulation in AM and 1 hr. in PM with specific time of 15-20 mins.

Interval every ambulation and gradually increasing of hours every 3 days.

>Maintain some periods of bed rest with legs elevated to mobilize edema and ascites.


22/23

Treatment:

>Ensure follow up and self-care.

>Advise patient and family to monitor sign and symptoms and to follow the treatment regimen.

>Ensure dietary restriction especially in food with high in protein and alcohol.

> Provide written instruction

Health teaching /Hygiene:

>Stress the necessity of giving up alcohol completely.

>Provide written dietary instruction.

>Emphasize the importance of rest, a sensible lifestyle and adequate well balanced diet.

>Encourage frequent skin care, bathing, and massage with emollient lotions.

>Advice patient to keep fingernails short.

>Encourage oral hygiene before meals.

Others Patient referral:

>Emphasize importance of follow-up check-up after 1 week.

Diet:

>Encourage patient to eat high calorie, moderate protein meals and to have supplementary

feedings.

>Suggest small frequent feedings and attractive meals in an aesthetically pleasing setting at

meal time.

Spiritual:

>Emphasize the importance of having a strong faith with God.

>Advise relatives or significant others to provide a moral support.

>Emphasize the positive effect of prayer.


23/23

hepatic encephalopaty

Documents