Cirrhosis and Hepatic Encephalopathy

Medical-Surgical · Gastrointestinal (GI)·Updated 2026-10-28

What it is

Cirrhosis is end-stage scarring of the liver, most often from alcohol use, chronic hepatitis B or C, or metabolic dysfunction-associated steatotic liver disease. Scar tissue obstructs portal blood flow, causing portal hypertension (ascites, esophageal varices, splenomegaly), and the failing liver cannot make albumin and clotting factors or clear ammonia and drugs. Ammonia produced by gut bacteria from protein reaches the brain and causes hepatic encephalopathy, which is why lactulose and rifaximin are central to care.

What the NCLEX focuses on

Early encephalopathy: reversed sleep-wake pattern, personality change, confusion and poor handwriting; asterixis (flapping tremor of the outstretched hands) and fetor hepaticus; progresses to coma.
Triggers: GI bleeding, infection, constipation, hypokalemia, dehydration from overdiuresis, and sedatives or opioids.
Lactulose traps ammonia in the colon and removes it in stool; titrate to 2 to 3 soft stools a day and watch for diarrhea, dehydration and hypokalemia.
Rifaximin reduces ammonia-producing gut bacteria and is added to lactulose to prevent recurrence; protein is not routinely restricted.
Ascites: 2-g sodium diet, spironolactone with furosemide, daily weight and abdominal girth; before paracentesis have the client void, and afterward monitor for hypotension.
Bleeding risk: prolonged INR and low platelets; varices are prevented with a nonselective beta-blocker and an acute variceal bleed is treated with octreotide, endoscopic band ligation and antibiotics.
Spontaneous bacterial peritonitis: fever, abdominal tenderness and new confusion in a client with ascites.

Priority nursing actions

Protect the airway and keep the client safe: head of bed elevated, aspiration and fall precautions.
Assess level of consciousness, orientation and asterixis, and compare with the baseline.
Give lactulose as prescribed (oral, NG or retention enema) and record every stool.
Look for and report the trigger: melena or hematemesis, fever, low potassium or glucose; hold sedatives and clarify them.
Monitor intake and output, daily weight, potassium, glucose and ammonia trend.

Numbers to know

Value	Normal or target	Why it matters
Ammonia	15 to 45 mcg/dL (11 to 32 micromol/L)	Elevated in hepatic encephalopathy
Albumin	3.5 to 5.0 g/dL (35 to 50 g/L)	Low albumin causes ascites and edema
INR	0.8 to 1.1	Prolonged when the liver cannot make clotting factors
Platelets	150,000 to 400,000/mm3 (150 to 400 x 10^9/L)	Low from splenic sequestration; bleeding risk
Lactulose goal	2 to 3 soft stools a day	Shows ammonia is being removed
Sodium limit with ascites	2 g (2,000 mg) a day	Reduces fluid retention

Common exam traps

Choosing to hold lactulose because the client has 2 to 3 soft stools a day: wrong because that is the therapeutic goal.
Choosing a benzodiazepine for restlessness: wrong because the liver cannot clear it and it deepens encephalopathy.
Choosing a very low-protein diet: wrong because malnutrition worsens outcomes; protein is not routinely restricted.
Choosing daily potassium supplements with spironolactone without a prescription: wrong because spironolactone retains potassium and causes hyperkalemia.
Choosing ibuprofen for pain: wrong because NSAIDs cause GI bleeding and kidney injury in cirrhosis; acetaminophen is limited to 2 g a day.

What to teach

Avoid all alcohol, and take no over-the-counter drugs or herbal products without asking the provider.
Take lactulose every day even when alert; aim for 2 to 3 soft stools and report diarrhea, sleepiness or confusion.
Follow the sodium limit, weigh daily, and report rapid weight gain, increasing girth, fever or abdominal pain.
Use a soft toothbrush and electric razor, avoid straining, and report black stools or vomiting blood.

Client handout: Living With Cirrhosis (nurse guide and printable patient handout).

Try 2 NCLEX-style questions on this topic

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Question 1 · QID 88FB3316

A client with cirrhosis and hepatic encephalopathy is prescribed lactulose. Which statement indicates correct understanding?

Select the best answer.

A. I can reduce the dose when my mental status returns to its usual baseline.
B. I should adjust the dose to produce one formed bowel movement each day.
C. This medication decreases ammonia production by improving hepatic metabolism.
D. This medication helps reduce ammonia through the bowel.

Question 2 · QID 112CA18D

The nurse teaches a client with cirrhosis, ascites, and a new prescription for spironolactone. For each statement, indicate whether it shows correct understanding or requires correction.

Select all that apply.

	Correct understanding	Requires correction
I will take potassium supplements every day without asking my prescriber.
I will follow the sodium limit in my meal plan.
I will keep follow-up appointments for electrolyte and kidney-function monitoring.
I should report increasing shortness of breath or rapid weight gain.
I should stop the medication once my abdomen feels less tight.

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Sources

Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Liver, Biliary Tract, and Pancreas Problems.
Vilstrup H, Amodio P, Bajaj J, et al. Hepatic Encephalopathy in Chronic Liver Disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60(2):715-735.
Biggins SW, et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74(2):1014-1048.

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