CLINICAL EXEMPLAR 1

Clinical Exemplar

Jazmine Robertte J. Mejia

University of South Florida

CLINICAL EXEMPLAR 2

Clinical Experience

The patient has returned back to the ER today due to confusion. The patient was recently

hospitalized 2 weeks ago for hepatic encephalopathy and confusion. The patients wife states that he

was doing extremely well 4 days ago and was alert and oriented and talking in full sentences. However,

over the weekend, she states that she is unsure if the patient was receiving his daily lactulose and unsure

about how many bowel movements he was having and is concerned about the care he is receiving at the

nursing facility. She had no report of any shortness of breath, and coughs, fevers, chills or abdominal

pain. The patient is now completely encephalopathic as evidence by deterioration in mental status,

psychomotor dysfunction, impaired memory, increased reaction time, sensory abnormalities, poor

concentration, and disorientation. The patient has a history of hepatic encephalopathy, liver cirrhosis,

chronic alcohol abuse, hypertension, hyperlipidemia, neuropathy, emphysema, abdominal ascites,

protein-calories malnutrition, thrombocytopenia and anemia. The patient notes with hemoglobin of 8.4,

hematocrit of 24.3, platelets of 71, creatinine 1.41, BUN 28, bilirubin of 6.3, AST 118, ALT 78, and

ammonia level 124. All these as an indicator of end-stage liver disease.

An abnormal presentation during this shift is the patient was presenting foaming of the mouth. I had

never seen foaming of the mouth and was unsure o the cause; however, I knew that this is not a normal

finding. With that the nurse and I further investigated his condition and assessment as well as called the

Rapid Response team immediately. The health care team had not seen this episode occur prior to shift.

This patient was being monitored by me and the nurse. After the Rapid Response Team reported

with no further intervention at this time. We asked them if the patient should be transferred to ICU or if

anything needs to be done for the patient. The team concluded that many of these symptoms are

expected from the severity of his case and we need to continue palliative care and monitor for increasing

changes. The patient remained stable throughout the day. We tried to give Lactulose via enema,
CLINICAL EXEMPLAR 3

however, the patient was unable to tolerate and keep the medication in. It was important for me and the

nurse to know the patients baseline and most current lab values. The attending hospitalist, rapid

response team, PCT, and nursing team would need to be involved and notified in the care of the patient.

Seizure activity or a coma presentation would make this situation critical and in need to complete

intervention.

Conclusion

It was important for me and the nurse to know the patients baseline. Although the patient was

already very sick, we knew that foaming of the mouth was a new abnormal presentation which was the

beginning of us treating the patient more aggressively. Further monitoring and evaluation will be

continued as ordered by the attending physician and rapid response team. I can delegate care, such as

bed baths and hygiene, to the PCT as well as taking vital signs and monitoring the patient as I care for

other patients. The patients ammonia level was extremely high. Due to his end-stage liver disease, his

condition is worsened because the ammonia cannot be converted to urea. Recent research has been

done in regards to the use of Lactulose plus Rafiximin. According to Sharma (2013), Rifaximin reduced

the risk of a breakthrough episode of hepatic encephalopathy a combination of both is much more

effective that using lactulose alone in the treatment of hepatic encephalopathy.

By the end of my shift caring the patient had two bowel movement and stable vital signs. I was

checking in on him as often as possible, as his LOC would go in and out throughout the day. The patient

was in end-stage liver disease, so at this point we were giving him palliative care as requested by his

family. The use of lactulose and Rifaximin increases function caused by hepatic encephalopathy. We did

all tests and treatments in a timely fashion and were able to stabilize the patients status.
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References
Sharma, B.C., Sharma, P., Kunia, M.K., Srivastava, S., Goyal, R., & Sarin, S.K. (2013). A
Randomized, Double Blind, Controlled Trial Comparing Rifaximin Plus Lactulose with Lactulose

Alone In Treatement of Overt Hepatic Encepalopathy. TheAmerican Journal of

Gastronterology,108(1458-1463). doi: 10.1038/ajg.2013.21