Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take?
Reference Range:
Ammonia [10 to 80 μg/dL (6 to 47 μmol/L)]
A.
Hold the next dose of lactulose.
B.
Continue the prescribed dose of lactulose.
C.
Replace total volume voided with oral or IV fluids.
D.
Report the number of diarrhea stools to the healthcare provider (HCP).
The correct answer and Explanation is :
Correct Answer: B. Continue the prescribed dose of lactulose.
Explanation:
Hepatic encephalopathy occurs due to the accumulation of toxins, primarily ammonia, in the bloodstream due to liver dysfunction. Elevated ammonia levels, such as the client’s current level of 220 μg/dL (well above the reference range of 10 to 80 μg/dL), can lead to altered mental status and confusion, which are typical signs of hepatic encephalopathy.
Lactulose is a non-absorbable sugar used to treat this condition. It works by decreasing the absorption of ammonia in the intestines and promoting its excretion via the stool. The drug acidifies the colon, converting ammonia (NH₃) into ammonium (NH₄⁺), which cannot be reabsorbed, effectively reducing serum ammonia levels.
Despite the frequent loose stools and confusion, the elevated ammonia level indicates that the hepatic encephalopathy is not yet controlled, and discontinuing or holding lactulose could worsen the condition. The nurse should therefore continue administering lactulose to promote ammonia excretion. Stopping or holding the drug could lead to further accumulation of ammonia and exacerbate neurological symptoms.
While the diarrhea may be a concern, it is actually a sign that lactulose is working as intended to facilitate ammonia clearance. Generally, the therapeutic goal is to maintain 2-3 soft stools per day to ensure the effectiveness of the treatment. Therefore, loose stools are not necessarily a reason to stop the medication unless they become severe, resulting in dehydration or electrolyte imbalances.
Monitoring the patient’s hydration status is important, so fluid replacement (oral or IV) may be necessary depending on the client’s volume status. However, the priority action remains continuing lactulose therapy to manage the high ammonia levels. Reporting frequent stools is advisable but secondary to maintaining ammonia control.