Infection and Inflammation (Student) PDF

Infection & Inflammatio n Hepatitis and Cirrhosis About the Liver The liver has 4 main jobs ◤ Storing Glycogen ◤ Drug & Fat Metabolism ◤ Detoxing ammonia ◤ Producing bile, coagulation factors, and albumin Production A Albumin: transports drugs, attracts water, and binds w...

Infection & Inflammatio n Hepatitis and Cirrhosis About the Liver The liver has 4 main jobs ◤ Storing Glycogen ◤ Drug & Fat Metabolism ◤ Detoxing ammonia ◤ Producing bile, coagulation factors, and albumin Production A Albumin: transports drugs, attracts water, and binds with Calcium for bone strength B Bile: scoops up bilirubin and cholesterol and excretes them through the GI system C Clotting factors: regulates PT, PTT, INR Ammonia Byproduct of protein breakdown Normally, the liver converts ammonia into urea where it can eventually be excreted by the kidneys Bilirubin Byproduct of RBC breakdown Normally, the liver converts old RBCs to bilirubin and then excretes it via stool Hepatic Portal Vein Hepatic Artery Pumps blood rich in Pumps fresh oxygenated nutrients from the GI blood to the liver from the system to the aorta hepatocytes which will then store or remove products; it filters the blood  0 1 Hepatitis  Hepat itis Liver Inflammation Hepatitis can take many forms 1 Viral (A,B,C,D,E) 2 Idiopathic 3 Drug Toxicity 4 Autoimmunity 5 Alcohol induced Inflammation Mild Moderate Impairs hepatocyte Severe function May lead to obstruction of blood Contributes to and bile which cirrhosis, impairs overall liver hepatocellular function cancer, and liver failure  Phases of Hepatitis Preicteric (prodromal) Posticteric Vague body symptoms are Icteric present often described as Decrease in flu like (convalescent) flu-like symptoms. Onset of Jaundice and dark urine jaundice and dark urine begin to subside, stool from high bilirubin levels, normalizes, liver enzymes clay stools, hepatomegaly, and bilirubin decrease and and pain eventually normalize Acute Lasting less than 6 months, usually self-limiting Chronic Lasting over 6 months. Liver begins to deteriorate over time leading to cirrhosis, liver cancer, or liver failure Hepatitis – A Brief Overview 0 0 0 0 1 Hepatitis 2 3 4 Targets the Hepatocyte Hepatocyte infection liver s become lysis inflamed 0 0 5 Contents of 6 Increased hepatocytes ALT & AST released into  AcutE Hepatitis A and E are acute only (do not progress to chronic) They are contracted through the oral-fecal route Some Risk Factors Medications Ingestion of contaminated Hep A vaccine (may be food and water (especially used pre or post-exposure) shellfish) Immunoglobulin within 2 Contact with infected stool weeks post-exposure for (poor hand hygiene in food Hep A preparation) Crowded conditions Hep A & E Pathophysiology When ingested (fecal-oral route), Hep A & E travel through the digestive system. Nutrients are (enveloped by the cell membrane and brought inside) absorbed through the hepatic portal venous system and the Hepatitis is absorbed too Once inside the liver, it binds with the receptors on hepatocytes and enters through endocytosis Chronic Hepatitis (B,C,D) Hepatitis B, C, and D have the risk of becoming chronic The are contracted via blood and bodily fluids Some Risk Factors Medications Unprotected sex Interferons Contact with blood Hep C: peginterferon alfa 2-a & Substance use disorder ribavirin combination therapy Birth (Hep B may be during Hep B immunoglobulin therapy pregnancy) within 24 hours * Tattoos Hemodialysis Unscreened blood Carrier State ◤ Hepatitis B and C may exist in a carrier state; the infected person is asymptomatic and may be unaware they have it as they have never had active disease, have a chronic low- grade infection and/or continue to be asymptomatic ◤ This is why universal precautions are so important in health care!  HEP B 10x More infectious than Hep C 100x More infectious than HIV Vaccine Exposure risk now low among persons 18 and younger due to Hep B vaccine Hep B & Birth Hep B + Birthing Parent There is a high risk of transmission of Hep B from mother to baby Babies have 90% chance of developing chronic Hep B. Precaution If the mother is confirmed or suspected of having Hepatitis B, immunoglobulin is given to the infant within 12 hours of birth (this differs from the standard 24 hours post-exposure)  274 Hepatitis C is a growing concern cases In 2021, Nova Scotia reported 274 cases of Hepatitis C. This gives us a rate of 27.6 cases per 100,000 people This puts us well ahead of the national average of 19.7 cases per 100,000 population HEP C IS CURABLE Old treatment was very difficult on the body; now with Direct Acting Antivirals (DAAS) treatment is 8-12 weeks and patients report minimal side effects The issue with treatment, is that 44% of people with Hep C are unaware they have it  bd Hepatitis D cannot occur without Hepatitis B! The best prevention is the Hepatitis B vaccine  FULMINANT HEPATITIS* Rare but life-threatening complication of Hepatitis in which severe liver failure occurs over hours to days  Malaise Flu-like symptoms Nausea, vomiting, diarrhea, Low appetite, Joint pain, Acute Hepatitis low-grade fever Clay stools Lack of bilirubin in stool Dark urine Jaundice RUQ tenderness Hepatomegaly Serology for Viral Hepatitis Hep A Hep B * Anti-HAV IgM (ACTIVE) HBsAg (Hep B surface antigen) – Anti-HAV IgG shows infectious (RECOVERED/IMMUNE) Anti HBs IgG (hep B surface antibody) – patient has recovered and immune or chronic Hep C Hep D Presence of anti-HCV (HCV Presence of HDAg (hepatitis D antibodies) for current or past antigen) and anti-HDV infection HCV RNA present only in active/current infection Hep E Anti-HEV Hep B Serology Table Labs to Watch in Hepatitis H AST H ALT H Bilirubin + Antibodies Liver Biopsy ◤ May be used to test for the extent of damage to the liver ◤ A small piece of tissue is removed an examined in the lab ◤ Teach client to lay on RIGHT SIDE to prevent bleeding post-procedure  High Carb High Calorie Diet Low protein Low fat Handwashing Eat low fat/protein and high carbs/cals Personal hygiene products Activity restriction Patient Teaching Toxins are avoided Individual bathroom Testing Interferon Small frequent meals A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1. Malaise 2. Left upper quadrant discomfort 3. Dark stools 4. Weight gain The nurse is teaching a client diagnosed with hepatitis B infection about how the virus is transmitted. Which of the following are possible methods of transmission of hepatitis B? Select all A. that apply. Intravenous drug use B. Sharing a razor with someone who has hepatitis b infection C. Through unprotected sexual contact with someone infected with hepatitis B D. Receiving a blood transfusion from a donor who received the hepatitis B immunization E. Through directly touching a surface contaminated with feces from someone who has hepatitis B and then unknowingly touching the eyes, nose, or mouth.  0 2 Cirrhosis What causes cirrhosis? Cirrhosis can come from many sources, including chronic hepatitis (specifically B and C) Normal liver tissue is replaced with fibrotic tissue that lacks function; the liver becomes rigid. The end-stage of this fibrosis is called cirrhosis Portal Hypertension ◤ The portal vein narrows due to scar tissue in the liver, restricting blood flow and increasing pressure in the portal vein. ◤ The increased pressure means that fluid is more likely pushed out into peritoneal spaces ◤ This in turn increases pressure to the organs connected to the vein including the spleen and vessels to GI structures resulting in varices. ◤ Fluid backs up into spleen (splenomegaly) Esophageal Varices ◤ Severe pressure from portal HTN causes enlarged, thinned, esophageal veins. ◤ Once they are too large or too thin, they risk rupturing, which can be fatal (shock/airway obstruction) ◤ Risk for hemorrhage! Rupture can occur from straining, coughing, sneezing, or NG tube insertion Ascites ◤ Venous congestion occurs due to portal hypertension and coupled with low albumin levels, fluid shifts to peritoneal cavity ◤ Monitor intake and output and abdominal girth ◤ Daily weight Hepatic Encephalopathy ◤ The liver cannot detoxify and ammonia builds up in the bloodstream ◤ Remember, ammonia is created when protein breaks down. The liver converts it to urea then it is excreted. ◤ When the liver is not doing its job, ammonia accumulates in the blood ◤ Ammonia is able to cross the blood-brain barrier which leads to altered LOC ◤ Key finding is asterixis (involuntary hand-flapping) Examination for Asterixis Liver and Estrogen The liver produces small amounts of estrogen, but more importantly, estrogen is fat-soluble. As the liver is responsible for fat breakdown, when it is impaired there can be an influx of circulating estrogen. High levels of estrogen can cause gynecomastia, spider angiomas, and palmer erythema Hepatorenal Syndrome ◤ Progressive renal failure associated with hepatic failure ◤ Sudden decrease in urine output, elevated BUN and Creatinine (think AKI) Late Stage Cirrhosis Symptoms “The Liver Is Scarred” Tremor of hands (asterixis) Itchy skin Hepatic Foetor (late sign, musty Spider angiomas breath) Eye and skin yellowing Splenomegaly & Stool Clay Coloured Confusion/coma Loss of appetite Ascites Increased bilirubin Redness of palms Varices Renal failure Edema Enlarged breasts in men Reduced platelets Deficient in vitamins Monitor Diet Same as hepatitis Vitamin and mineral diet (low protein, supplementation Low sodium to help low fat, high carb, (multivits, folate, with edema high calorie) thiamine) Monitor glucose Oral care prior to levels closely and meals may help NO ALCOHOL. assess for hyper wake up tastebuds and hypoglycemia. Labs to Watch in Cirrhosis H AST H ALT H Bilirubin L Albumin & Calcium L Platelets (Thrombocytopenia) H PT/PTT/INR Treatment Options Endoscopic Shunting Surgery variceal ligation Transjugular Intrahepatic Varices are sclerosed or Portosystemic Shunt banded (TIPS) is minimally Small rubber bands are invasive. placed around varices to prevent bleeding and A shunt creates a new shrink/strangulate the channel and allow some varix blood to bypass the liver and reduce pressure Liver Transplant Very strict protocols Can be received from living or deceased donor Not a candidate if severe cardiac and respiratory disease, metastatic malignant liver Ca, or ETOH/drug disorder Acute graft rejection post liver transplant within 4-10 days post surgery. Paracentesis Drain for ascites Prior to procedure, ensure bladder is empty to avoid risk of perforation Take vital signs. Take note of BP as pressure will drop as fluid drains Measure abdominal circumference and take weight Drain according to order (usually no more than 1L/day) Keep HOB up to help drain flow and help with breathing Pharmacology Beta blockers and nitrates Portal HTN and varices Vitamin K Clotting Lactulose* Decrease ammonia level through stool (monitor for hypokalemia) Diuretics Decrease fluid buildup Albumin Help with ascites and edema  Lactulose Laxitive Ammonia decreases C ognition improves A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction? A. “I will obtain adequate rest” B. “I will take acetaminophen if I get a headache” C. “I need to monitor my weight on a regular basis” D. “I need to include sufficient amounts of carbohydrates in my diet” The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions would be included in the care plan for this client? Select all that apply. A. Monitor daily weight B. Measure abdominal girth C. Monitor respiratory status D. Place the client in a supine position E. Assist the client with care as needed