A patient with cirrhotic liver is not tolerating proteins. A nurse should think of prescribing which drug should prescribe for the patient?

Appeared in: SCTIMST Staff Nurse - 2016

Explanation

In liver cirrhosis, the liver's ability to convert ammonia (from protein breakdown) to urea is impaired, leading to toxic blood ammonia levels.
Protein intolerance is a clinical sign of this process, known as hepatic encephalopathy (HE).
Lactulose is the primary medication used to treat HE.
It works by acidifying the colon, which converts absorbable ammonia (NH₃) into non-absorbable ammonium (NH₄⁺), trapping it in the gut.
Its laxative effect then expels the trapped ammonium from the body, reducing overall blood ammonia levels.
The therapeutic goal is typically 2-3 soft bowel movements per day.

Option B: Folic acid is a B-vitamin used to treat megaloblastic anemia. It has no role in reducing ammonia levels.
Option C: Thiamine (Vitamin B1) is crucial for carbohydrate metabolism and nerve function but does not affect ammonia levels.
Option D: 5% Dextrose is an intravenous fluid that provides free water and a minimal amount of calories. It does not treat the metabolic cause of hepatic encephalopathy.

Clinical Relevance

Nursing practice connection: Use the key finding related to Pharmacological management of hepatic encephalopathy in liver cirrhosis to guide bedside assessment, documentation, and the next nursing action.
A nurse's primary role is to monitor for signs of hepatic encephalopathy (confusion, lethargy, asterixis) and administer prescribed treatments like lactulose.
Accurate monitoring of bowel movements is critical. Too few stools mean the treatment is ineffective; too many can lead to dehydration and electrolyte imbalances (hypokalemia, hypernatremia).
Patient education is key. The nurse must explain the importance of taking lactulose as prescribed to prevent confusion and other neurological symptoms.

How to Approach the Question

First, identify the key elements in the clinical scenario: 'cirrhotic liver' and 'not tolerating proteins'.
Recognize that this combination points to a specific complication: hepatic encephalopathy (HE), caused by the buildup of ammonia.
The question asks for the appropriate drug. Your goal is to find the option that directly addresses the cause of HE, which is high ammonia.
Evaluate each option based on its mechanism of action.
Lactulose directly lowers ammonia levels in the gut.
Folic acid and Thiamine treat nutritional deficiencies common in alcoholism but do not affect ammonia.

Concept Tested & Keywords

Concept Tested: Pharmacological management of hepatic encephalopathy in liver cirrhosis.
Stem keywords: cirrhotic liver, not tolerating proteins
Lead-in keywords: which drug
Clinical cues: The combination of liver cirrhosis and protein intolerance is a classic indicator for hepatic encephalopathy due to hyperammonemia.

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E6 Nutrition Kumud Khanna 2e pp. 279-281, 277-279

E6 Medicine Harrison 22e Part 2 p. 621-623

Practise the full SCTIMST Staff Nurse - 2016

Attempt every question from this paper in a timed mock, then review the full solution for each one.