Hepatitis – H6 PDF

LWBK720-Part-II-H_p140-163.qxd 9/23/10 1:31 PM Page 150 Aptara Inc 150 Hepatitis ▼ C ONTACT PRECAUTIONS ◗ Type G is a newly discovered form of hepatitis. Transmission is by the...

LWBK720-Part-II-H_p140-163.qxd 9/23/10 1:31 PM Page 150 Aptara Inc 150 Hepatitis ▼ C ONTACT PRECAUTIONS ◗ Type G is a newly discovered form of hepatitis. Transmission is by the bloodborne H6- Hepatitis route, and it occurs more commonly in those who receive blood transfusions. Viral hepatitis is a fairly common systemic CAUSES disease. It is marked by hepatic cell destruc- The six major forms of viral hepatitis—A, B, tion, necrosis, and autolysis leading to C, D, E, and G—result from infection with anorexia, jaundice, and hepatomegaly. In causative viruses. most patients, hepatic cells eventually regen- Type A hepatitis is highly contagious and erate with little or no residual damage, allow- is usually transmitted by the fecal-oral route, ing complete recovery. However, old age and commonly within institutions or families. serious underlying disorders make complica- However, it may also be transmitted par- tions more likely. The prognosis is poor if enterally. Hepatitis A usually results from in- edema and hepatic encephalopathy develop. gestion of contaminated food, milk, or water. Today, six types of viral hepatitis are rec- Outbreaks of this type are often traced to in- ognized: gestion of seafood from polluted water. ◗ Type A (infectious or short-incubation Type B hepatitis is transmitted by the di- hepatitis) is on the rise in homosexuals and rect exchange of contaminated blood as well in people with immunosuppression related as by contact with contaminated human se- to human immunodeficiency virus (HIV) cretions and stools. Transmission of hepatitis infection. It’s usually self-limiting and with- B also occurs during intimate sexual contact out a chronic form. and through perinatal transmission. ◗ Type B (serum or long-incubation hepati- Type C hepatitis is a blood-borne illness tis) is also increasing among HIV-positive transmitted primarily via sharing of needles individuals. Hepatitis B is considered a sex- by I.V. drug users, through unsanitary tat- ually transmitted infection because of the tooing, and through blood transfusions. high incidence and rate of transmission by People with chronic hepatitis C are consid- this route. Routine screening of donor blood ered infectious. for hepatitis B surface antigen (HBsAg) has Type D hepatitis is found only in patients decreased the incidence of posttransfusion- with an acute or a chronic episode of hepati- related cases, but transmission via needles tis B. Type D infection requires the presence shared by drug abusers remains a major of HBsAg; the type D virus depends on the problem. double-shelled type B virus to replicate. For ◗ Type C hepatitis accounts for about 20% this reason, type D infection can’t outlast a of all viral hepatitis cases and is transmitted type B infection. primarily through blood and body fluids or Type E hepatitis is transmitted enterically during tattooing. and is usually waterborne, much like type A. ◗ Type D (delta hepatitis) is confined to Because this virus is inconsistently shed in people who are frequently exposed to stools, detection is difficult. Outbreaks of blood and blood products, such as I.V. drug type E hepatitis have occurred in developing users and hemophiliacs. It’s transmitted countries. Hepatitis G is thought to be parenterally and, less commonly, sexually. blood-borne, with transmission similar to It occurs only in those who have hepatitis B that of hepatitis C. virus. ◗ Types C and E hepatitis occur primarily in COMPLICATIONS people who have recently returned from an Life-threatening fulminant hepatitis—the endemic area (such as India, Africa, Asia, or most feared complication—develops in Central America). about 1% of patients. Fulminant hepatitis LWBK720-Part-II-H_p140-163.qxd 9/23/10 1:31 PM Page 151 Aptara Inc Hepatitis 151 causes unremitting liver failure with en- weakness, arthralgia, myalgia, photophobia, cephalopathy, progresses to coma, and com- and nausea with vomiting may also be re- monly leads to death within 2 weeks. ported. The patient may describe changes in Other complications may be specific to the senses of taste and smell. the type of hepatitis: Assessment of vital signs may reveal fever, ◗ Chronic active hepatitis may occur as a with a temperature of 100 to 102 F (37.8 late complication of hepatitis B. to 38.9 C). As the prodromal stage draws to ◗ During the prodromal stage of acute hepa- a close, usually 1 to 5 days before the onset of titis B, a syndrome resembling serum sick- the clinical jaundice stage, inspection of ness, characterized by arthralgia or arthritis, urine and stool specimens may reveal dark rash, and angioedema, may occur. This syn- urine and clay-colored stools. drome can lead to misdiagnosis of hepatitis If the patient has progressed to the clini- B as rheumatoid arthritis or lupus erythe- cal jaundice stage, he or she may report pru- matosus. ritus, abdominal pain or tenderness, and in- ◗ Primary liver cancer may develop after in- digestion. Early in this stage, the patient may fection with hepatitis B or C. complain of anorexia; later, the appetite may ◗ Type D hepatitis can cause a mild or return. Inspection of the sclerae, mucous asymptomatic form of hepatitis B to flare membranes, and skin may show jaundice, into severe, progressive, chronic active hepa- which can last for 1 to 2 weeks. Jaundice in- titis and cirrhosis. dicates that the damaged liver can’t remove ◗ Weeks to months after apparent recovery bilirubin from the blood; it doesn’t indicate from acute hepatitis A, relapsing hepatitis disease severity. Occasionally, hepatitis oc- may develop. curs without jaundice. Hepatitis may also lead to pancreatitis, cir- During the clinical jaundice stage, skin rhosis, myocarditis, pneumonia, aplastic inspection may reveal rashes, erythematous anemia, transverse myelitis, or peripheral patches, or hives, especially if the patient has neuropathy. hepatitis B or C. Palpation may disclose ab- dominal tenderness in the right upper quad- ASSESSMENT FINDINGS rant, an enlarged and tender liver and, in The patient’s history may reveal the source of some cases, splenomegaly and cervical transmission (for example, recent ear pierc- adenopathy. ing or tattooing, travel to a foreign country Patient assessment during the recovery or where hepatitis is endemic, or living condi- posticteric stage will reveal that most symp- tions that are, or were, overcrowded). The toms are decreasing or have subsided. On patient’s employment history—such as work palpation, a decrease in liver enlargement in a hospital or laboratory where the risk of may be noted. The recovery phase generally viral exposure from contaminated instru- lasts from 2 to 12 weeks, sometimes longer ments or waste could be high—may indicate in patients with hepatitis B, C, or E. occupational exposure. Also, the patient’s background may show possible exposure to DIAGNOSTIC TESTS toxic chemicals, such as carbon tetrachlo- ◗ In suspected viral hepatitis, a hepatitis ride, which can cause nonviral hepatitis. profile is routinely performed. This study Assessment findings are similar for the identifies antibodies specific to the causative different types of hepatitis. Typically, signs virus, establishing the type of hepatitis: and symptoms progress in several stages. In - Type A: Detection of an antibody to hep- the prodromal (preictal) stage, the patient atitis A virus confirms the diagnosis. generally complains of easy fatigue and - Type B: The presence of HBsAg and hep- anorexia, possibly with mild weight loss. atitis B antibodies confirms the diagnosis. Generalized malaise, depression, headache, LWBK720-Part-II-H_p140-163.qxd 9/23/10 1:31 PM Page 152 Aptara Inc 152 Hepatitis - Type C: Diagnosis depends on serologic With acute viral hepatitis, hospitalization testing for the specific antibody 1 or more usually is required only for patients with se- months after the onset of acute illness. Un- vere symptoms or complications. Parenteral til then, the diagnosis is principally estab- nutrition may be required if the patient has lished by obtaining negative test results for persistent vomiting and is unable to main- hepatitis A, B, and D. tain oral intake. Antiemetics (trimethoben- - Type D: Detection of intrahepatic delta zamide [Tigan] or benzquinamide) may be antigens or immunoglobulin (Ig) M anti- given to relieve nausea and prevent vomit- delta antigens in acute disease (or IgM and ing. For severe pruritus, the cholestyramine IgG in chronic disease) establishes the di- resin (Questran), which sequesters bile salts, agnosis. may be given. - Type E: Detection of hepatitis E antigens supports the diagnosis; however, the diag- NURSING CONSIDERATIONS nosis may also consist of ruling out hepati- ◗ Observe standard precautions to prevent tis C. transmission of the disease. - Type G: Detection of hepatitis G ribonu- ▼ Maintain contact precautions with dia- cleic acid supports the diagnosis. Serologic pered or incontinent patients. assays are being developed. ◗ Provide rest periods throughout the day. ◗ Liver biopsy is performed if chronic hepa- ◗ If symptoms are severe and the patient titis is suspected. (This study is performed can’t tolerate oral intake, provide I.V. therapy for acute hepatitis only if the diagnosis is and parenteral nutrition as ordered. questionable.) ◗ Provide adequate fluid intake. The patient should consume at least 4 L of liquid per day TREATMENT to maintain adequate hydration. Persons believed to have been exposed to ◗ Administer antiemetics as ordered. Ob- hepatitis A virus and the household contacts serve the patient for the desired effects, and of patients with confirmed cases should be note any adverse reactions. treated with standard immunoglobulin. ◗ Record the patient’s weight daily, and keep Travelers planning to visit areas known to accurate intake and output records. Observe harbor such viruses should receive hepatitis the stools for color, consistency, and amount. A vaccine. ◗ Monitor for signs of complications. Hepatitis B immunoglobulin and hepatitis ◗ Report all cases of hepatitis to the state B vaccine are given to individuals exposed to health department or the Centers for Disease blood or body secretions of infected individ- Control and Prevention. uals. The immunoglobulin is effective but very expensive. In addition to its administra- Patient teaching tion as part of the routine childhood immu- ◗ Teach the patient about viral hepatitis, nization schedule, hepatitis B vaccine is now including its signs and symptoms, diagnostic recommended for everyone. There is no vac- tests, and recommended treatments. cine against hepatitis C, but it is usually treat- ◗ Explain that the liver takes 3 weeks to re- ed with interferon alpha-2b (Intron A) and generate and up to 4 months to return to the more recently Food and Drug Adminis- normal functioning. Advise the patient to tration–approved peginterferon alpha-2a avoid contact sports until the liver returns to (Pegasys). In the early stages of the disease, its normal size. Instruct the patient to check the patient is advised to rest and combat with the physician before performing any anorexia by eating small, high-calorie, high- strenuous activity. protein meals. (Protein intake should be reduced if signs of precoma—lethargy, confu- sion, mental changes—develop.) LWBK720-Part-II-H_p140-163.qxd 9/23/10 1:31 PM Page 153 Aptara Inc Hepatitis 153 ◗ Instruct the patient to eat high-calorie, high-protein foods in small meals. Also stress the need for adequate fluid intake and abstinence from alcohol. ◗ Explain to the patient and family that any- one exposed to the disease through contact with the patient should receive prophylaxis as soon as possible after exposure. ◗ Stress the need for continued medical care. PREVENTION Instructing patients about the following measures can help prevent the spread of viral hepatitis: - Stress the importance of thorough and frequent handwashing. - Tell infected patients not to share food, eating utensils, or toothbrushes. - Warn patients with hepatitis A or E not to contaminate food or water with fecal matter because these forms of the disease are transmitted by the fecal-oral route. - Explain to patients with hepatitis B, C, D, or G that transmission occurs through ex- change of blood or body fluids that con- tain blood. While infected, patients shouldn’t donate blood or have unprotected sexual relations.