Chart — Gastrointestinal
Hepatic Encephalopathy Staging
West Haven Criteria for grading hepatic encephalopathy severity — mental status findings, neurological signs, and stage-specific nursing priorities for Grades 0 through 4.
Educational use only. This content is intended for nursing students and exam preparation. Clinical decisions require licensed professional judgment and institutional protocols. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
| Grade | Consciousness | Mental Status & Behavior | Neurological Signs |
|---|---|---|---|
| Grade 0 Minimal / Covert HE | Normal — fully alert and oriented | Subtle impairment detectable ONLY by psychometric testing (number connection test, digit symbol test). No clinically apparent deficits. | No clinically apparent neurological signs. Mild psychomotor slowing on formal testing only. |
| Grade 1 Mild HE (Overt) | Mildly reduced awareness; intact orientation | Shortened attention span; mild forgetfulness; sleep-wake cycle inversion (sleeping during day, awake at night); mild personality changes (irritability, apathy) | Subtle asterixis (positive flapping tremor on formal testing); impaired handwriting; mild tremor |
| Grade 2 Moderate HE | Lethargy; moderate reduction in alertness but arousable to verbal stimulation | Obvious disorientation to time and place; inappropriate behavior; moderate personality change; confusion, poor judgment | Obvious asterixis (flopping hands when wrists dorsiflexed); dysarthria (slurred speech); ataxia; fetor hepaticus (musty/sweet breath from mercaptans) |
| Grade 3 Severe HE | Somnolent but arousable with vigorous stimulation; confused and disoriented when awake | Profound disorientation; bizarre behavior; inability to perform simple commands reliably; agitation possible | Asterixis often absent (patient too obtunded to cooperate); clonus; hyperreflexia; muscle rigidity; positive Babinski reflex in some cases |
| Grade 4 Hepatic Coma | Unresponsive — no purposeful response to pain or verbal stimuli | Cannot be assessed — coma | Absent asterixis; decerebrate or decorticate posturing; possible pupillary changes; cerebral edema risk (especially in acute liver failure); loss of brainstem reflexes in severe cases |
Nursing Priorities by Stage
- ✦Assess for subtle changes: driving ability, work performance, complex task management
- ✦Screen with validated psychometric tests (Stroop test, number connection) if suspected
- ✦Ensure medications are taken as prescribed — lactulose prophylaxis in high-risk patients
- ✦Educate patient and family on early warning signs to report
- ✦Avoid alcohol, benzodiazepines, and CNS depressants
- ✦Administer lactulose as ordered — titrate to 2–4 soft stools per day
- ✦Assess orientation and document behavioral changes at each encounter
- ✦Safety precautions: avoid driving, operating machinery
- ✦Identify and treat precipitating cause (infection, constipation, bleeding)
- ✦Sleep hygiene education — gradual restoration of normal sleep-wake cycle
- ✦Family education: behavioral changes are disease-related, not volitional
- ✦Implement fall precautions: bed in lowest position, side rails up, non-slip footwear, call bell within reach
- ✦Assess gag reflex — consider aspiration risk before oral intake
- ✦Administer lactulose via NG tube if unable to take PO reliably
- ✦Monitor neurological status every 2–4 hours; document asterixis
- ✦Restrict activity; assist with all ADLs
- ✦Notify provider of any worsening — transition from Grade 2 to 3 is rapid
- ✦Avoid benzodiazepines (worsens CNS depression synergistically with ammonia)
- ✦Continuous cardiorespiratory monitoring — ICU or step-down level of care
- ✦Airway protection: semi-Fowler's or HOB ≥30°, suction at bedside, NPO except medications
- ✦Assess Glasgow Coma Scale (GCS) and neurological status hourly
- ✦Lactulose via NG tube or rectal enema (300 mL + 700 mL water) if oral route unreliable
- ✦Strict I&O — Foley catheter for accurate monitoring
- ✦Restraint-free interventions for agitation (minimize stimulation, reorientation, family presence)
- ✦Anticipate possible intubation for airway protection if declining
- ✦ICU admission — mechanical ventilation for airway protection and oxygenation
- ✦Neurological monitoring: pupillary response, GCS, ICP monitoring if acute liver failure with cerebral edema
- ✦Lactulose via NG tube — continue to prevent further ammonia accumulation
- ✦Strict aseptic technique: infection prevention (pneumonia, CAUTI, CLABSI)
- ✦Nutritional support: enteral feeding if hemodynamically stable
- ✦Liver transplant evaluation if appropriate — Grade 4 HE is a poor prognostic indicator
- ✦Family communication and goals of care discussion
Key Pharmacology: Lactulose
Mechanism
Acidifies colon → converts NH₃ (absorbable) to NH₄⁺ (trapped) → excreted in stool. Also osmotic cathartic.
Goal
2–4 soft bowel movements per day. NOT diarrhea — excessive diarrhea causes dehydration and worsens HE.
Adjunct: Rifaximin
Non-absorbable antibiotic — reduces ammonia-producing gut bacteria. Used with lactulose for secondary prevention.
Source: West Haven Criteria (Conn et al.); AASLD/EASL HE Practice Guidelines 2014; ISHEN Consensus
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with West Haven Criteria (Conn et al.); AASLD/EASL HE Practice Guidelines 2014; ISHEN Consensus. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →