Hepatology Review: What is Hepatic Encephalopathy?

Continuing from a series of lectures on the liver, we have indicated the importance of remembering the PDSM Recycling Company. This recycling company is the liver and PDSM suggests the liver’s primary functions – Produce, Detox, Storage, and Metabolize.

When it comes to hepatic encephalopathy, the liver’s metabolic properties are compromised.

Focusing on Metabolism

What does metabolism have to do with hepatic encephalopathy? The liver metabolizes ammonia into urea. Ammonium, on the other hand, is the waste product of protein. In our previous lectures, we have discussed that ammonium can be considered as the wrapper of a protein bar.

The Wrapper

Normally, if there’s waste inside the body, it will be filtered by the liver and is metabolized into something that can be excreted. This is what happens with ammonia.

Ammonia goes into the liver to be metabolized as urea and is then excreted through the kidneys and into the potty. So, what happens if the liver is broken due to scarring or other injuries? Aside from the other functions being compromised, metabolism cannot happen. Therefore, converting ammonia into urea will be difficult for the liver.

The ammonia (wrapper) will now stay inside the bloodstream and will travel around the body and affect the vital organs like the brain. The wrapper is now wreaking havoc inside the body, and one of the primary manifestations that ammonia has reached the brain is altered level of consciousness (LOC).

Decreasing Ammonia

As a medical professional, what are the things that you can do to make sure that protein is no longer broken down to prevent wrappers circulating in the bloodstream?

What are the ways to combat ammonia?

1. Protein must be withheld.

This is to prevent the small intestine from breaking down protein and causing the release of more ammonia going into the compromised liver. Advising the client to have a low protein diet is also a must.

2. Give lactulose.

Lactulose acts like a small garbage bin that scoops up ammonia from the blood and into the potty. Therefore, if you give your client lactulose, expect that they will have severe diarrhea. Make sure that the restroom or commode is accessible to your client.

3. Give neomycin.

Neomycin is a type of antibiotic that kills all of the bacteria in the gut that causes the breaking down of the protein. One thing you have to take note of is that neomycin will kill off not only the bad but also the good bacteria in the stomach. It’s like having a SWAT team go inside a bank, killing off not just the hostage-takers but the bank tellers, managers, and clients as well.

For this reason, neomycin is given on a short-term basis just to decrease the presence of ammonia inside the body.

Nursing Considerations

When taking care of clients with hepatic encephalopathy, there are a couple of nursing considerations that must be made.

1. Safety.

Since the client has altered level of consciousness, medical professionals must make sure that the client’s safety is the main priority. Therefore, padding the side rails of the bed is necessary. Restraining the client is no longer allowed which is why it is essential to ask the family members to sit with the client or have a CNA to sit at the bedside and watch over the client to promote safety and prevent any liabilities.

2. Give drugs like lactulose and neomycin.
3. Promote low protein diet, usually depending on the doctor’s order and the severity of the ammonia level.
4. Maintain skin integrity.

The liver produces albumin, bile, and coagulation factors. If a client that is at risk for bleeding, due to the absence of coagulation factors, is on bed rest for the entirety of your shift, he or she is also at risk for the following:

• Bedsores
• Open wounds
• Bleeding
• Bruises
• Pruritus – happens due to the increased amount of ammonia that causes skin inflammation leading to irritation.

When dealing with skin integrity, you have to do the following:

• Cool compress
• Anti-itch lotion

Summary

One of the main considerations with clients who have hepatic encephalopathy is their safety due to altered LOC. Always include drugs like lactulose and neomycin. Low protein diet must be emphasized. Finally, you have to watch out for skin irritation like pruritus and bleeding.

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