Report worsening confusion, lethargy, or asterixis indicating rising ammonia.
Before you read
Test yourself first: 3 questions
Question 1 of 3
A client with hepatic encephalopathy from alcohol-related liver disease is prescribed lactulose. Which outcome indicates the medication is effective?
Answer: A. Lactulose treats hepatic encephalopathy by acidifying the colon and trapping ammonia for elimination, producing two to three soft stools per day and lowering the serum ammonia level. Improved mental status and a decreasing ammonia level indicate effectiveness. Constipation, a rising ammonia level, and worsening confusion would indicate the drug is not working or is underdosed.
Question 2 of 3
Lactulose is prescribed for a client with hepatic encephalopathy. Which outcome indicates the medication is effective?
Answer: A. Lactulose lowers serum ammonia by acidifying the colon and trapping ammonia for excretion in stool; producing two to three soft stools daily and improved mental status indicate effectiveness. Constipation would signal underdosing.
Question 3 of 3
A client with hepatic encephalopathy is prescribed lactulose. Which outcome indicates the medication is achieving its therapeutic goal?
Answer: B. Lactulose lowers blood ammonia by acidifying the colon (trapping ammonia as ammonium) and by its laxative effect, which expels ammonia in the stool. The therapeutic endpoint is two to three soft stools per day and improved mentation. Constipation would indicate the dose is too low. The drug is not given to relieve pain or lower potassium.
Keep the streak going with more questions like these, each with a full rationale.
What is lactulose?
Memory aid: in liver failure, lactulose 'cleans out the ammonia' through the gut. It is titrated to produce 2 to 3 soft stools per day.
Key points to remember
- Acts as an osmotic laxative and, in hepatic encephalopathy, converts ammonia to ammonium that is excreted in feces.
- Dose is titrated to achieve 2 to 3 soft stools daily, the key marker of effectiveness in encephalopathy.
- Improving mental status (orientation, asterixis) indicates therapeutic effect in liver patients.
- Excessive doses cause diarrhea leading to dehydration and hypokalemia.
- Onset is typically 24 to 48 hours for the laxative effect.
- Can cause bloating, flatulence, and abdominal cramping.
Signs & symptoms
- Bloating, flatulence, cramps
- Improving LOC = working
Nursing priorities
- Titrate dose to 2 to 3 soft stools per day in hepatic encephalopathy.
- Monitor serum ammonia and neurologic/mental status for improvement.
- Monitor potassium and fluid balance for losses from excessive stooling.
- Assess level of consciousness and check for asterixis (flapping tremor).
- Do not stop abruptly in liver patients, as ammonia and confusion can rise.
Labs & values
Patient teaching
- Aim for 2 to 3 soft stools a day; report fewer or excessive diarrhea.
- Do not stop suddenly if you have liver disease.
- May be mixed in juice, water, or milk to improve the sweet taste.
- Report increasing confusion or sleepiness to your provider.
Red flags: report now
- Report worsening confusion, lethargy, or asterixis indicating rising ammonia.
- Report severe watery diarrhea with signs of dehydration or hypokalemia.
- Report fewer than 2 stools per day in an encephalopathy patient (subtherapeutic).
References
Clinical references for this topic
