ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION
Risk Factors: Risk for Acute Confusion After the shift family
- inability of liver to members or SO verbalize
detoxify understanding of disease
- High ammonia level ( 186 process and prognosis and
umol/L ) the patient’s needs ,
- Low sodium level recognize and engage in
( EASYLYTE ) ( 129.5 interventions to deal
mmol/L ) completely with the
situation , and provide for
maximal independence
while meeting safety needs
of the patient.
- Observe for changes in
behavior and mentation:
lethargy , confusion ,
drowsiness, slowing or
slurring of speech , and
irritability.Arouse client at
intervals as indicated.
- Review current medication
regimen.
- Note development or
presence of asterixis, fetor
hepaticus , and seizure
activity.
- Consult with SO about
client’s usual behavior and
mentation.
- Reorient to
time,place,person,and
situation,as needed.
- Provide continuity of care .
If possible , assign same
RATIONALE EVALUATION
- Ongoing assessment of After the shift family members
behavior and mental status or SO verbalized understanding
is important because of the disease process and
fluctuating nature of prognosis and the patient’s
hepatic encephalopathy or needs , recognized ad engaged
impending hepatic coma. in interventions to deal
completely with the situation ,
and provide for maximal
- Adverse drug reactions or independence while meeting
interactions may potentiate safety needs of the patient.
or exacerbate confusion.
- Suggests elevating serum
ammonia levels and
increased risk of
progression to
encephalopathy.
- Provides baseline for
comparison of current
status.
- Assists in maintaining
reality orientation ,
reducing cofusion and
anxiety.
- Familiarity provides
reassurance , aids in
nurse over a period of time. reducing anxiety ad
provides a more accurte
documentation of subtle
changes.

- Discuss current situation - Client and SO may be

and future expectations. reassured that intellectual
as well as nemotional
function may improve as
liver involvement resolves.