NURSING DIAGNOSIS: Confusion, risk for acute
Risk factors may include
- Alcohol abuse
- Inability of liver to detoxify certain enzymes/drugs
- Maintain usual level of mentation/reality orientation.
- Initiate behaviors/lifestyle changes to prevent or minimize recurrence of problem.
Nursing Interventions & Rationale
|Observe for changes in behavior and mentation, e.g., lethargy, confusion, drowsiness, slowing/slurring of speech, and irritability (may be intermittent). Arouse patient at intervals as indicated.||Ongoing assessment of behavior and mental status is important because of fluctuating nature of impending hepatic coma.|
|Review current medication regimen/schedules.||Adverse drug reactions or interactions (e.g., cimetidine plus antacids) may potentiate/exacerbate confusion.|
|Evaluate sleep/rest schedule.||Difficulty falling/staying asleep leads to sleep deprivation, resulting in diminished cognition and lethargy.|
|Note development/presence of asterixis, fetor hepaticus, seizure activity.||Suggests elevating serum ammonia levels; increased risk of progression to encephalopathy.|
|Consult with SO about patient’s usual behavior and mentation.||Provides baseline for comparison of current status.|
|Have patient write name periodically and keep this record for comparison. Report deterioration of ability. Have patient do simple arithmetic computations.||Easy test of neurological status and muscle coordination.|
|Reorient to time, place, person as needed.||Assists in maintaining reality orientation, reducing confusion/anxiety.|
|Maintain a pleasant, quiet environment and approach in a slow, calm manner. Encourage uninterrupted rest periods.||Reduces excessive stimulation/sensory overload, promotes relaxation, and may enhance coping.|
|Provide continuity of care. If possible, assign same nurse over a period of time.||Familiarity provides reassurance, aids in reducing anxiety, and provides a more accurate documentation of subtle changes.|
|Reduce provocative stimuli, confrontation. Refrain from forcing activities. Assess potential for violent behavior.||Avoids triggering agitated, violent responses; promotes patient safety.|
|Discuss current situation, future expectation.||Patient/SO may be reassured that intellectual (as well as emotional) function may improve as liver involvement resolves.|
|Maintain bedrest, assist with self-care activities.||Reduces metabolic demands on liver, prevents fatigue, and promotes healing, lowering risk of ammonia buildup.|
|Identify/provide safety needs, e.g., supervision during smoking, bed in low position, side rails up and pad if necessary. Provide close supervision.||Reduces risk of injury when confusion, seizures, or violent behavior occurs.|
|Investigate temperature elevations. Monitor for signs of infection.||Infection may precipitate hepatic encephalopathy caused by tissue catabolism and release of nitrogen.|
|Recommend avoidance of narcotics or sedatives, antianxiety agents, and limiting/restricting use of medications metabolized by the liver.||Certain drugs are toxic to the liver, whereas other drugs may not be metabolized because of cirrhosis, causing cumulative effects that affect mentation, mask signs of developing encephalopathy, or precipitate coma.|
|Eliminate or restrict protein in diet. Provide glucose supplements, adequate hydration.||Ammonia (product of the breakdown of protein in the GI tract) is responsible for mental changes in hepatic encephalopathy. Dietary changes may result in constipation,which also increases bacterial action and formation of ammonia. Glucose provides a source of energy, reducing need for protein catabolism. Note: Vegetable protein may be better tolerated than meat protein.|
|Assist with procedures as indicated, e.g., dialysis, plasmapheresis, or extracorporeal liver perfusion.||May be used to reduce serum ammonia levels if encephalopathy develops/other measures are not successful.