مريض تليف كبد يأخذ لاكتولوز، يخرج مرة واحدة يومياً براز صلب، وصار أكثر تشوشاً وظهرت عنده رجفة الرفرفة في اليدين. ما التصرف الصحيح؟

A client with cirrhosis on lactulose passes one hard stool a day, has become more confused and now has asterixis. What is the correct action?

1. Increase dietary protein to build strength and reduce confusion
2. Give an antidiarrhoeal to reduce fluid and electrolyte loss
3. Hold the lactulose, because confusion is a known side effect
4. Notify the provider, as the lactulose dose may need increasing

Answer: D) Notify the provider, as the lactulose dose may need increasing. Lactulose removes ammonia in the stool, with a target of 2–3 soft stools daily. One hard stool with rising confusion and asterixis means ammonia is climbing and the dose is inadequate. Holding it or giving an antidiarrhoeal makes things worse.