Risk for Acute Confusion | Nursing Care Plan for Liver Cirrhosis

Nursing diagnosis: risk for acute Confusion

Risk factors may include
Alcohol abuse
Inability of liver to detoxify certain enzymes and drugs

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Cognition
Maintain usual level of mentation and reality orientation.
Initiate behaviors or lifestyle changes to prevent or minimize recurrence of problem.

Nursing intervention with rationale:
1. Observe for changes in behavior and mentation: lethargy, confusion, drowsiness, slowing or slurring of speech, and irritability. Arouse client at intervals, as indicated.
Rationale: Ongoing assessment of behavior and mental status is important because of fluctuating nature of hepatic encephalopathy or impending hepatic coma.

2. Review current medication regimen.
Rationale: Adverse drug reactions or interactions may potentiate or exacerbate confusion.

3. Note development or presence of asterixis, fetor hepaticus, and seizure activity.
Rationale: Suggests elevating serum ammonia levels and increased risk of progression to encephalopathy.

4. Consult with SO about client’s usual behavior and mentation.
Rationale: Provides baseline for comparison of current status.

5. Have client write name periodically and keep this record for comparison. Report deterioration of ability. Have client do simple arithmetic computations.
Rationale: Easy test of neurological status and muscle coordination.

6. Reorient to time, place, person, and situation, as needed.
Rationale: Assists in maintaining reality orientation, reducing confusion and anxiety.

7. Maintain a pleasant, quiet environment and approach in a slow, calm manner. Encourage uninterrupted rest periods.
Rationale: Reduces excessive stimulation and sensory overload, promotes relaxation, and may enhance coping.

8. Provide continuity of care. If possible, assign same nurse over a period of time.
Rationale: Familiarity provides reassurance, aids in reducing anxiety, and provides a more accurate documentation of subtle changes.

9. Reduce provocative stimuli and confrontation. Refrain from forcing activities. Assess potential for violent behavior.
Rationale: Avoids triggering agitated, violent responses; promotes client safety.

10. Discuss current situation and future expectations.
Rationale: Client and SO may be reassured that intellectual as well as nemotional function may improve as liver involvement resolves.