Hepatitis - Lewis 10th Ed (2018) PDF

Summary

This document is a chapter on Hepatitis from the Lewis 10th Edition medical textbook (2018). It includes information on types, causes, and pathophysiology of viral and non-viral hepatitis .

Full Transcript

Hepatitis Chapter 43 Copyright © 2017, Elsevier Inc. All Rights Reserved. Hepatitis Inflammation of the liver Causes Viral (most common) Alcohol Medications Chemicals Autoimmune diseases Metabolic abnormalities Copyright © 2017, Elsevier Inc. All Rig...

Hepatitis Chapter 43 Copyright © 2017, Elsevier Inc. All Rights Reserved. Hepatitis Inflammation of the liver Causes Viral (most common) Alcohol Medications Chemicals Autoimmune diseases Metabolic abnormalities Copyright © 2017, Elsevier Inc. All Rights Reserved. Viral Hepatitis Types of viral hepatitis A B C D E Copyright © 2017, Elsevier Inc. All Rights Reserved. Hepatitis A Virus (HAV) Ranges from mild to acute liver failure Not chronic Incidence decreased with vaccination RNA virus transmitted via fecal-oral route Contaminated food or drinking water Copyright © 2017, Elsevier Inc. All Rights Reserved. Serologic Events in HAV Infection Copyright © 2017, Elsevier Inc. All Rights Reserved. Hepatitis B Virus (HBV) Acute or chronic disease Incidence decreased with vaccination DNA virus transmitted Perinatally Percutaneously Via small cuts on mucosal surfaces and exposure to infectious blood, blood products, or other body fluids Copyright © 2017, Elsevier Inc. All Rights Reserved. Hepatitis B Virus (HBV) At-risk populations Men who have sex with men Household contact of chronically infected Patients undergoing hemodialysis Health care and public safety workers Transplant recipients Copyright © 2017, Elsevier Inc. All Rights Reserved. Serologic Events in HBV Infection Copyright © 2017, Elsevier Inc. All Rights Reserved. Hepatitis C Virus (HCV) Acute: asymptomatic Chronic: liver damage RNA virus transmitted percutaneously IV drug use High-risk sexual behaviors Occupational exposure Dialysis Perinatal exposure Blood transfusions before 1992 Copyright © 2017, Elsevier Inc. All Rights Reserved. Hepatitis D Virus (HDV) Also called delta virus Defective single-stranded RNA virus Cannot survive on its own Requires HBV to replicate Transmitted percutaneously No vaccine Copyright © 2017, Elsevier Inc. All Rights Reserved. Hepatitis E Virus (HEV) RNA virus Transmitted via fecal-oral route Most common mode of transmission: drinking contaminated water Occurs primarily in developing countries Few cases in United States Copyright © 2017, Elsevier Inc. All Rights Reserved. Pathophysiology Acute infection Large numbers of hepatocytes are destroyed Liver cells can regenerate in normal form after resolution of infection Chronic infection can cause fibrosis and progress to cirrhosis Copyright © 2017, Elsevier Inc. All Rights Reserved. Pathophysiology Antigen-antibody complexes activate complement system Systemic manifestations Rash Malaise Angioedema Cryoglobulinemia Arthritis Glomerulonephritis Fever Vasculitis Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Comstock/Thinkstock) A.M. is a 30-year-old man admitted to the hospital with general fatigue, lack of appetite, headaches, and jaundice. Symptoms became progressive during the past few days. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Comstock/Thinkstock) One month ago, he was in Mexico, where he ate a lot of seafood and local food. A.M. also tells you that he had sex with a prostitute while in Mexico. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Comstock/Thinkstock) The health care provider suspects A.M. may have acute hepatitis. For what other clinical manifestation would you assess A.M.? Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Classified as acute and chronic Many patients: asymptomatic Symptoms intermittent or ongoing Malaise Fatigue Myalgias/arthalgias Right upper quadrant tenderness Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Acute phase Maximal infectivity; lasts 1–6 months Symptoms during incubation Anorexia ↓ Sense of smell Lethargy Low-grade fever Weight loss Skin rashes Fatigue Myalgias Nausea/vomiting Arthralgias RUQ tenderness Skin rashes Distaste for cigarettes Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Acute phase Physical examination findings Hepatomegaly Lymphadenopathy Splenomegaly Icteric (jaundice) or anicteric If icteric, patient can also have Dark urine Light or clay-colored stools Pruritus Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Convalescent phase Begins as jaundice is disappearing Lasts weeks to months Major complaints Malaise Easy fatigability Hepatomegaly persists Splenomegaly subsides Copyright © 2017, Elsevier Inc. All Rights Reserved. Recovery Most patients recover completely with no complications Most cases of acute hepatitis A resolve Some HBV and majority of HCV result in chronic hepatitis Copyright © 2017, Elsevier Inc. All Rights Reserved. Complications Acute liver failure Chronic hepatitis Some HBV and majority of HCV infections Cirrhosis Portal hypertension Hepatocellular carcinoma Copyright © 2017, Elsevier Inc. All Rights Reserved. Complications Acute liver failure Fulminant hepatic failure Manifestations include Encephalopathy Gastrointestinal bleeding Disseminated intravascular coagulation Liver transplant is usually the cure Copyright © 2017, Elsevier Inc. All Rights Reserved. Complications Chronic hepatitis Chronic HBV is more likely to develop in infants and those under age 5 HCV infection is more likely than HBV to become chronic Manifestations include anemia and coagulation problems, as well as skin manifestations Copyright © 2017, Elsevier Inc. All Rights Reserved. Complications Cirrhosis Risk factors include Male gender Alcohol consumption Concomitant fatty liver disease Excess iron deposition in liver Patients with metabolic syndrome Copyright © 2017, Elsevier Inc. All Rights Reserved. Complications Hepatic encephalopathy Potentially life-threatening spectrum of neurologic, psychiatric, and motor disturbances Results from liver’s inability to remove toxins Copyright © 2017, Elsevier Inc. All Rights Reserved. Complications Ascites Accumulation of excess fluid in peritoneal cavity Due to reduced protein levels in blood, which reduces the plasma oncotic pressure Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Comstock/Thinkstock) Physical assessment of A.M. reveals hepatomegaly and splenomegaly. His urine is also icteric. What diagnostic tests would you expect the health care provider to order? Copyright © 2017, Elsevier Inc. All Rights Reserved. Diagnostic Studies Specific antigen and/or antibody for each type of viral hepatitis Anti-HAV IgM , anti-HAV IgG HBsAg, anti-HBs, HBeAg, anti-Hbe, anti-HBc IgM, anti-HBc IgG, HBV DNA quantitation Anti-HCV, HCV quantitation Anti-HDV, HDV Ag None currently for HEV Copyright © 2017, Elsevier Inc. All Rights Reserved. Diagnostic Studies Liver function tests Viral genotype testing HBV HCV Physical assessment findings Liver biopsy FibroScan FibroSure (FibroTest) Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Comstock/Thinkstock) Laboratory results show Hemoglobin 12 g/dL Bilirubin (direct) 5.6 mg/dL Bilirubin (indirect) 3.4 mg/dL Alkaline phosphatase 600 U/mL AST 1200 U/mL ALT 1510 U/mL Urine positive for bilirubin Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Comstock/Thinkstock) Additional laboratory results show Anti-HAV IgM positive Anti-HAV IgG negative HBsAg negative Anti-HBs negative Anti-HCV negative Anti-HDV negative Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Comstock/Thinkstock) What type of hepatitis does A.M. have? How did he get infected? Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Comstock/Thinkstock) What interventions would you expect the health care provider to order? Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Acute and chronic Adequate nutrition Well balanced diet Vitamin supplements Rest (degree and strictness varies) Avoid alcohol intake and drugs detoxified by liver Notification of possible contacts Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care: Drug Therapy Acute HAV infection: no specific Acute HBV infection: only if severe Acute HCV infection Pegylated interferon or DAAs Supportive drug therapy Antihistamines Antiemetics Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Chronic Hepatitis B To ↓ viral load , liver enzyme levels, and rate of disease progression Prevent cirrhosis, portal hypertension, liver failure, and cancer Copyright © 2017, Elsevier Inc. All Rights Reserved. Drug Therapy Chronic Hepatitis B and C Copyright © 2017, Elsevier Inc. All Rights Reserved. Drug Therapy Chronic Hepatitis B Interferon Naturally occurring immune protein Antiviral, antiproliferative, and immune modulating effects Pegylated interferon (PegIntron, Pegasys) given subcutaneously Side effects Flu-like symptoms, depression Copyright © 2017, Elsevier Inc. All Rights Reserved. Nutritional Therapy No special diet required Emphasis on well-balanced diet that patient can tolerate Adequate calories are important during acute phase Fat content may need to be reduced Vitamins B-complex and K IV glucose or enteral nutrition Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Assessment Subjective Data Past health history Hemophilia Exposure to infected persons Ingestion of contaminated food or water Ingestion of toxins Past blood transfusion (before 1992) Other risk factors Medications Acetaminophen, OTC, or herbal medications Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Assessment Subjective Data: Functional Health Patterns IV drug and alcohol abuse Distaste for cigarettes (in smokers) High-risk sexual behaviors Weight loss, anorexia, nausea/vomiting RUQ abdominal discomfort Urine and stool color Fatigue/arthralgias/myalgia Exposure to high-risk groups Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Assessment Objective Data Low-grade fever Jaundice Rash Hepatomegaly Splenomegaly Abnormal laboratory values Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Comstock/Thinkstock) Identify appropriate nursing diagnoses for A.M. Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Diagnoses Imbalanced nutrition: less than body requirements Activity intolerance Risk for impaired liver function Copyright © 2017, Elsevier Inc. All Rights Reserved. Planning Patient will Have relief of discomfort Be able to resume normal activities Return to normal liver function without complications Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Comstock/Thinkstock) What is the priority care for A.M.? How would A.M.’s family members and close contacts be treated? Copyright © 2017, Elsevier Inc. All Rights Reserved. interprofessional Care Health Promotion: Hepatitis A General measures Active immunization: HAV vaccine Children at 1 year of age Adults at risk Post-exposure prophylaxis with HAV vaccine and immune globulin (IG) Special precautions for health care personnel Copyright © 2017, Elsevier Inc. All Rights Reserved. interprofessional Care Health Promotion: Hepatitis B General measures Immunization Recombivax HB, Engerix-B Series of three IM injections All children and at-risk adults Postexposure prophylaxis: vaccine and hepatitis B immune globulin (HBIG) Copyright © 2017, Elsevier Inc. All Rights Reserved. interprofessional Care Health Promotion: Hepatitis C No vaccine to prevent HCV General measures to prevent HCV transmission Screen all persons born between 1945 and 1965 No postexposure prophylaxis; baseline and follow-up testing Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation Acute Care Assess for jaundice Comfort measures Adequate nutrition Small, frequent meals Measures to stimulate appetite Carbonated beverages Adequate fluid intake Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation Acute Care Physical rest Psychologic and emotional rest Diversion activities Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation Ambulatory Care Dietary teaching Plan activities after periods of rest Teach how to prevent transmission What to report Assessment for complications Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation Ambulatory Care Regular follow-ups for at least 1 year after diagnosis No alcohol Medication education How to administer interferon Side effects No blood donation by HBsAg- or HCV- positive patients Copyright © 2017, Elsevier Inc. All Rights Reserved. Evaluation Expected Outcomes Maintain food and fluid intake adequate to meet nutritional needs Avoid alcohol and other hepatotoxic agents Demonstrate gradual increase in activity tolerance Perform daily activities with scheduled rest periods Copyright © 2017, Elsevier Inc. All Rights Reserved. Evaluation Expected Outcomes Ability to explain methods of transmission and methods of preventing transmission Copyright © 2017, Elsevier Inc. All Rights Reserved. Hepatitis A Dr. Sibi Peter,PhD,RN,CCRN What is Hepatitis? Inflammation of the liver Viral hepatitis (Most common cause) Etiology RNA Virus Transmitted fecal-oral route (fecal contamination and oral ingestion) Frequently occurs in small outbreaks Caused by contamination of food or drinking water Pathophysiology Widespread inflammation of liver tissue Liver damage is caused by cytotoxic cytokines and natural killer cells Hepatic cell necrosis Inflammation may interrupt bile flow (cholestasis) Mode of Transmission Hep A found in feces: 2 weeks before onset of symptoms (most infectious) Up to 1 week after onset of jaundice Characteristics of Hepatitis A Incubation Period 15-50 days (average 28) Fecal/oral route-Primarily fecal contamination and oral ingestion Infectivity Most infectious 2 weeks before onset of symptoms Infectious until 1-2 weeks after start of symptoms, including jaundice Greatest risk of transmission occurs before symptoms Sources of Infection Poor hygiene Improper food handling/Infected food handlers Crowded situations Poor sanitary conditions Contaminated food Present in blood briefly Found in feces 2 or more weeks before the onset of symptoms and up to 1 week after the onset of jaundice. Detection of Hep A Antibodies to HAV-Immunoglobulin M (IgM) appear in serum: Once stool becomes negative for virus Detection of hepatitis A IgM-acute hepatitis IgG indicator of past infection Systemic Effects-Acute Hepatitis Antigen-Antibody complexes during acute phase cause complications: Rash Angioedema Arthritis Fever Malaise Glomerulonephritis Cryoglobulinemia Vasculitis Cryoglobulinemia Clinical Manifestations Many patients are asymptomatic Acute onset Mild, flulike symptoms Malaise Anorexia Weight loss Fatigue Nausea Occasional vomiting Right upper quadrant discomfort Jaundice Convalescent phase begins as jaundice disappears (lasts for wks to months with an average of 2-4 months) Major complaint is malaise Diagnostic Studies Acute Infection Anti-HAV immunoglobulin M Previous Infection/ Long-term immunity or immunization Anti-HAV immunoglobulin G Nursing Assessment Nursing Assessment- Subjective Past health history Exposure to infected persons Ingestion of contaminated food or water Unsanitary living conditions Transfusion before 1992 Use of liver toxic drugs (Acetaminophen, Phenytoin, Halothane) Functional Health Patterns Health Perception, Health Management- IV drug and alcohol use, risky sexual behaviors Nutritional Metabolic- weight loss, anorexia, nausea, vomiting Activity/Exercise: Fatigue, arthralgias, myalgias Cognitive/Perception: Right upper quadrant pain, liver tenderness Role Relationship: Exposure as health care worker, homeless, incarceration Nursing Assessment Objective General-low grade fever, lethargy Integumentary–rash skin changes, jaundice GI-hepatomegaly,splenomegaly Diagnostic Findings Elevated liver enzymes Hypoalbuminemia Increased serum total bilirubin, urobilnogen Diagnosis Imbalanced nutrition: less than body requirements related to anorexia, nausea & reduced metabolism of nutrients Activity intolerance related to fatigue and weakness Risk for impaired liver function related to viral infection Prevention Wash your hands with soap and warm water – Every time you use the bathroom – Every time you change a diaper Don’t eat raw or undercooked seafood or shellfish Travelers to developing countries should not drink untreated water or beverages with ice Fruits and vegetables should not be eaten unless cooked or peeled Contaminated surfaces should be cleaned with household bleach to kill the virus Heat food or water to 185 deg F or 85 deg C to kill the virus Vaccines Havrix and VAQTA Contains no live virus Series of 2 shots!! – Second shot is given 6-18 months after first Protection starts 2 to 4 weeks after first shot – Second shot offers long term protection Estimated protection at least 20 years Must be given before exposure to virus Medical Treatment No specific medicines to cure infections with hepatitis A Immune globulin given to people who are likely to be exposed to someone infected with HAV. Dietary Management No special diet is required for the treatment of viral infections Recommend small, frequent, well-balanced meals Intake 2000 – 3000 calories Restrict fat intake Question #1 To prevent the spread of hepatitis A virus (HAV) infection the nurse is especially careful when? A. Disposing of food trays B. Emptying the bed pan C. Taking an oral temperature D. Changing IV tubing Rationale Answer is B HAV is transmitted primarily person to person by the fecal-oral route. Food can be a method of transmission but needs to be contaminated by fecal contents. Since the transmission of hepatitis A is fecal-oral and not saliva or blood like hepatitis B, taking a temperature and changing IV tubing would not spread hepatitis A. Question #2 A female client who has just been diagnosed with hepatitis A asks, “How could I have gotten this disease?” What is the nurse’s best response? A. “You may have eaten contaminated restaurant food.” B. “You could have gotten it by using IV drugs.” C. “You must have received an infected blood transfusion.” D. “You probably got bit by a spider.” Rationale Answer is A Hepatitis A is transmitted through fecal-oral route. Eating contaminated restaurant food is the easiest way to get Hepatitis A. Question #3 Which priority teaching information should the nurse discuss with the client to help prevent contracting Hepatitis A? A) Explain the importance of good hand washing. B) Tell the client to take the hepatitis B vaccine in three (3) doses. C) Tell the client not to ingest unsanitary food or water. D) Discuss how to implement standard precautions. Rationale Answer is A All the answers are important but the most important teaching to prevent Hep A is through good hand washing, especially after defecation. Question #4 "A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following? A) Malaise B) Dark stools C) Weight gain D) Left upper quadrant discomfort Rationale Answer is A Hepatitis causes GI symptoms such as anorexia, nausea, right upper quadrant discomfort and weight loss. Fatigue and malaise are common. Stools will be light or clay colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts. HEPATITIS B Dr. Sibi Peter, PhD, RN, CCRN HEPATITIS Hepatitis is defined as inflammation of the liver Hepatitis can be caused by: drugs (including alcohol), chemicals, autoimmune diseases and metabolic abnormalities. Rarely it is cause by bacteria such as streptococci, salmonellae or e. coli Viral hepatitis is the most common The types are: A, B, C, D, E, G , you are only responsible for types A, B & C HEPATITIS B Worldwide nearly 2 billion people are infected with the hepatitis B virus (HBV) Nearly 45,000 new cases of Hepatitis B annually in the United States The incidence of hepatitis B has decreased overall because of the widespread use of the HBV vaccine Over a million Americans are chronically infected with HBV Chronic HBV and HCV account for 80% of hepatocellular cancer cases today Etiology & Pathophysiology HBV is a deoxyribonucleic acid (DNA) virus Transmitted perinatally, percutaneously, mucosal exposure to infectious blood, blood products or other body fluids HBV can live on dry surface for at least 7 days, much more infectious than HIV HBV has three distinct antigens: Surface antigen (HBsAg), Core antigen (HBcAg), e antigen (HBeAg) Etiology & Pathophysiology HDV requires HBV to replicate. Though you are not responsible for Hepatitis D, know that Hepatitis D requires Hepatitis B for its replication. Hepatitis involves widespread inflammation of liver tissue Liver damage results from hepatic cell necrosis Inflammation of the periportal areas may interrupt bile flow (cholestasis) Clinical Manifestations Viral hepatitis can be classified into ACUTE and CHRONIC PHASES 30% pts of acute HBV are asymptomatic The acute phase is the period of maximal infectivity Physical examination may reveal hepatomegaly, lymphadenopathy, splenomegaly Acute HBV infection can result in chronic viral infection Complications Fulminant hepatic failure Chronic Hepatitis Cirrhosis of the liver Hepatocellular carcinoma Diagnostic Studies Many liver function tests show significant abnormalities There are at least 8 different genotypes (A to H) of HBV Genotyping is useful in predicting disease and treatment outcomes Physical assessment may reveal hepatic tenderness, hepatomegaly, and splenomegaly Sonograms (Fibroscans)-Provide information about the degree of liver scarring Collaborative Care Well-balanced diet Vitamin supplements Rest Avoid alcohol intake and drugs detoxified by the liver Drug Therapy Therapy is focused on decreasing: First line therapies Viral load Pegylated α-interferon Liver enzyme levels Entecavir Rate of disease progression Tenofovir Rate of drug-resistant HBV Nursing Assessment subjective data Important Health Information Functional health patterns Hemophilia Health perception-health management: IV drug and alcohol abuse, malaise, distaste for cigarettes Exposure to infected persons (in smokers), high risk sexual behaviors. Exposure to contaminated needles Nutritional-metabolic: weight loss, anorexia, nausea, vomiting, feeling of fullness in RUQ Organ transplant recipient Activity-exercise: fatigue, arthralgia, myalgia Hemodialysis Cognitive-perceptual: RUQ pain and liver tenderness, headache, pruritus Transfusion of blood or blood products Role-relationship: exposure as health care worker, HIV status long-term care institution resident, homeless. Nursing Assessment objective data General Gastrointestinal Low-grade fever Hepatomegaly Lethargy Splenomegaly Lymphadenopathy Possible diagnostic findings Integumentary Elevated liver enzymes, elevated serum total bilirubin, positive HBcAG, Rash/skin changes HBeAG, HBsAG, Jaundice Abnormal liver scan Icteric sclera Abnormal results on liver biopsy Injection site irritation and redness Planning The overall goal for a patient with Hepatitis B are: Patient will have relief of discomfort Patient will be resume normal activities Patient will return to normal liver function without complications Nursing Diagnosis Imbalanced nutrition: less than body requirements related to anorexia and nausea Activity intolerance related to fatigue and weakness Risk for impaired liver function related to viral infection Nursing Implementation Preventive measures for Hepatitis B Percutaneous transmission General measures Screening of donated blood Hand washing Use of disposable needles and syringes Avoid sharing toothbrushes and razors Sexual transmission HBIG administration for one-time HBIG administration to sexual partner of exposure (needle stick, contact with HBs AG + person mucous membranes with infectious HBV vaccine series administered to material uninfected sexual partners HBV vaccine Condoms used for sexual intercourse Nursing Implementation Preventative measures for Hepatitis B Use infection control precautions Reduce contact with blood and blood containing secretions Handle the blood of all patients as potentially infectious Dispose of needles properly Use needleless IV access devices when available HBV Vaccine Best means of prevention Recombivax, HB and Engerix-B Contains HBsAG Promotes synthesis of specific antibodies directed against HBV Given n a series of three IM injections in the deltoid muscle. Second dose should be administered within one month of the first Third dose is administer six months after the second dose Effective in 95% of the cases For post-exposure prophylaxis, the HBV vaccine and hepatitis B immune globulin (HBIG) are used. Acute Intervention Assess for presence and degree of jaundice Provide relieve measures for pruritus, headache, and arthralgia Small, frequent meals are preferable to ensure adequate nutrition and prevent nausea. Adequate fluid intake (2500-3000 mL/day) is important Assess patient response to rest and activity and modify accordingly Ambulatory and Home Care Most patients with viral hepatitis are cared for at home. Patient should rest and follow physician’s advice to avoid complications. Patient should be educated about how to prevent spreading the virus to family members and to identify signs of relapse. Patients with chronic HBV should avoid alcohol consumption, since it can speed disease progression. Evaluation Expected outcomes are: Patient will maintain food and fluid intake adequate to maintain nutritional needs Demonstrate gradual increase in activity tolerance Perform daily activities with scheduled rest periods NCLEX ?????? The nurse is preparing discharge instructions for a client with hepatitis B. The discharge plan should include which of the following instructions for the client? 1. Use a condom during sexual intercourse 2. Avoid all alcohol consumption for one month 3. Eat a low protein, high carbohydrate diet 4. Have all family members vaccinated for hepatitis Rationale 1 The hepatitis B virus is spread through contact with infected blood and body fluids and is considered a sexually transmitted disease. The consumption of alcohol should be kept to a minimum but absolute avoidance is not necessary. A well balanced diet is preferable. Vaccination is not necessary for family members NCLEX ?????? Which of the following will the nurse include in the care plan for a client hospitalized with viral hepatitis? 1. Bland diet 2. Administer antibiotics as ordered 3. Increase fluid intake to 3000 ml per day 4. Adequate bed rest Rationale 4 Treatment of hepatitis consists of bed rest during the acute phase to reduce metabolic demands on the liver, thus increasing blood supply and cell regeneration. Forcing fluids, antibiotics, and bland diets are not part of the treatment plan for viral hepatitis NCLEX ?????? A college student is required to be inoculated for hepatitis before beginning college. The nurse realizes the client will be inoculated to prevent the development of : 1. Hepatitis C 2. Hepatitis D 3. Hepatitis B 4. Hepatitis E Rationale 3 Hepatitis is considered a significant sexually transmitted disease and is seen in all age groups. A vaccine is available for this type of hepatitis Dr. Sibi Peter, PhD,RN,CCRN What is Hepatitis? Inflammation of the liver 6 Major types of hepatitis viruses: – A, B, C, D,E, & G Caused by – Drugs – Chemicals – Autoimmune Diseases – Metabolic Abnormalities Faces of the Disease 3 to 4 million are newly infected each year. – World wide, approximately 170 million people are chronically infected with hepatitis C virus (HCV) In the united states approximately 4 million people have the antibodies for HCV. – While most are unaware they have the infection. Etiology RNA virus that primarily transmitted percutaneously Mode of transmission – Sharing contaminated needles and equipment – Blood transfusion – Sexual activities with infected partners – Perinatal contact Pathophysiology Liver Systemic Effect Widespread inflammation of Virus + antibody = the liver tissue circulating immune Acute Infection: complex – Liver damage is mediated by cytotoxic cytokines & Clinical signs of activation natural killer cells – Rash – Liver damage results from – Angioedema hepatic cell necrosis – Arthritis – Inflammation of the – Fever periportal areas may – Malaise interrupt bile flow – No complications; should resume their normal appearance and function Clinical Manifestation Classified into acute and chronic phases Acute hepatitis: – May be icteric or anicteric Large number of patients have no symptoms – Last about 1-4 months (incubation period) – Maximal infectivity – Symptoms: Malaise Anorexia Fatigue Nausea Occasional vomiting Abdominal (right quadrant) discomfort Decreased sense of smell (associated with interferon use) Clinical Manifestation Cont’d Physical Examination may reveal: – Hepatomegaly – Lymphadenopathy – Splenomegaly (sometimes) Jaundice – Results when bilirubin diffuses into the tissues – Darkened urine – Stool will be light or clay colored – Pruritus may occur – Fever usually subsides at this stage – Liver is enlarged and tender Convalescent phase – Begins as jaundice disappears – Weeks to months (average 2-4 months) – Major complaint is malaise and easy fatigability – Hepatomegaly remains for several weeks while splenomegaly subsides Complications Acute hepatitis 75%-85% who acquire usually recovers HCV will develop chronic infection completely with few 60%-70% with chronic complications. HCV will develop liver Mortality rate is less disease than 1% 5%-50% will develop Possible cirrhosis over 20-30 Complications: years – fulminant hepatic 1%-5% will die of failure, chronic cirrhosis or hepatitis, cirrhosis, hepatocellular cancer liver cancer Diagnostic Studies Hepatitis C There are several tests available for the different types of viral hepatitis In viral hepatitis, many of the liver function tests show significant abnormalities Antibodies to HCV are not protective and may be an indicator of chronic disease Diagnostic Studies Hepatitis C cont. Initial testing for HCV includes HCV antibody testing. If antibody positive, HCV RNA testing should be obtained to assess for chronic infection. A small number of patients may have a false-positive HCV antibody test. Diagnostic Studies Hepatitis C cont. Anti-HCV antibody test by immunoassay -If positive, confirmatory testing is required To detect active disease, HCV RNA quantitation is performed. -This may be helpful in the immunocompromised patient whose antibody production is very low -This test may be helpful in identifying the presence of the virus in exposed individuals before the development of antibodies. Diagnostic Studies Hepatitis C cont. There are 6 genotypes and 50 subtypes of HCV Genotyping has an important role in managing infection: - It is one of the strongest predictors of response to therapy and influences in the duration of treatment Therefore for those patients who test positive for HCV, genotyping of the virus should be determined before drug therapy is started. Diagnostic Studies History Physical assessment findings -hepatic tenderness -hepatomegaly -splenomegaly -palpable liver Collaborative Care There is no specific treatment or therapy for acute viral hepatitis. Most patients can be managed at home. Emphasis on resting the body and receiving adequate nutrients Bed rest may be indicated while the patient is symptomatic. Counseling Drug and Nutritional Therapy Drug Therapy No specific drug therapies for the treatment of acute viral hepatitis With acute HCV, treatment with pegylated interferon within the first 12 to 24 weeks of infection has shown a reduction in the development of chronic hepatitis C. Drug and Nutritional Therapy Supportive drug therapy Anti-emetics -dimenhydrinate (Dramamine) -trimethobenzamide (Tigan) Phenothiazines should not be used because of their possible cholestatic and hepatotoxic effects. If sedative or hypnotic drug is required, diphenhydramine (Benadryl) or chloral hydrate may be used. Drug and Nutritional Therapy Treatment for HCV includes: pegylated α-interferon (injected once a week) with ribavirin (taken orally twice daily) ribavirin has side effects: anemia, anorexia, cough, rash, pruritus, dyspnea, insomnia, teratogenicity Drug and Nutritional Therapy Treatment of chronic Hepatitis C: individualized based on the severity of liver disease potential for side effects considered presence of co-morbid conditions patients readiness for treatment presence of other health problems (e.g., HIV) Drug and Nutritional Therapy Nutritional Therapy Adequate nutrition is important in assisting hepatocytes to regenerate. No special diet is required in the treatment of viral hepatitis. Adequate calories are important because the patient usually looses weight Drug and Nutritional Therapy Nutritional Therapy cont. Vitamin supplements, particularly B-complex vitamins and vitamin K, are frequently used. If anorexia, nausea, and vomiting are severe, IV solutions of glucose or supplemental enteral nutrition therapy may be used Fluid and electrolyte balance must be maintained. Nursing Management Prevention No vaccine to prevent HCV. CDC does not recommend IG or antiviral agents for post exposure prophylaxis Nursing Management Primary measures to prevent HCV transmission include: Screening of blood, organ, and tissue donors Use of infection control precautions Modification of high-risk behavior Nursing Management Individuals at risk include: IV drug users (or have ever used them, even once many years earlier) patients who received blood (including blood products) or organ and tissue donation before 1992 patients who are or have been on hemodialysis workers in hemodialysis units and laboratories in which blood is handled persons with multiple sexual partners prisoners persons with nonprofessional tattoos and piercings sexual partners of individuals with HCV Control of HCV in Health Care Personnel Transmission is usually due to percutaneous needle exposure or other blood exposure and undetected parenteral transmission. Control of HCV in Health Care Personnel Measures to prevent transmission of the viruses from patients to health care personnel are: use gloves with contact of blood use condoms for sexual intercourse with an individual with HCV do not share razors, toothbrushes, and other personal items Reduce contact with blood or blood-containing secretions Handle the blood of patients as potentially infective Use of disposable needles and syringes Hand washing Use infection control precautions Screening of donated blood Dispose of needles properly Use needleless IV access devices when available 1. Which of the following is not a specific element of Hepatitis C? A. Lifetime carrier B. May be transmitted with sexual contact C. Inflammation of the liver D. Vaccine available Answer: D. Vaccine available Rationale: Unfortunately there is no vaccine available for Hepatitis C. It does cause inflammation of the liver and can be transmitted sexually. Once you get it, you usually have it for life. 2. A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this? A. A history of hepatitis C five years previously. B. Cholecystitis requiring cholecystectomy one year previously. C. Asymptomatic diverticulosis. D. Crohn's disease in remission. Answer: A. A history of Hep C five years previously. Rationale: Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to high risk of infection in the recipient. Cholecystitis (gallbladder disease), diverticulosis, and history of Crohn’s disease do not preclude blood donation. 3. Which places the healthcare worker at greatest risk for acquiring hepatitis C? A. Recapping a used needle B. Administering blood products C. Performing peritoneal dialysis D. Not wearing gloves while bathing a client Answer: A. Recapping a used needle Rationale: It is extremely dangerous to hold a needle in one hand and attempt to cover it with a small cap held in the other hand because the needle could miss the cap and stab the hand holding it. Which then can transmit the virus via bodily fluids.

Use Quizgecko on...
Browser
Browser