Hepatitis and Cirrhosis

Question 1

hepatitis

Answer 1

• Inflammation of liver cells
• Can be caused by a viral or toxic agent, or as a secondary infection in conjunction w/ another virus
• Classified as acute/chronic
• Viral hepatitis is the most common type
• Toxic and drug induced hepatitis: occurs secondary to an exposure to a chemical or medication agent such as alcohol, industrial toxins, ephedra, or acetaminophen
• Can occur in conjunction w/ varicella-zoster, cytomegalovirus, or herpes simplex
• After exposure to a virus or toxin, the liver becomes enlarged from the inflammatory process
  
  • As the dz progresses, there is an inc in inflammation and necrosis, interfering with blood flow to the liver
• Individuals can be infected with hepatitis and remain free of manifestations, and therefore are unaware that they could be contagious
• Viral hepatitis includes: A, B, C, D, and E

Question 2

hepatitis: health promotion and dz prevention

Answer 2

• Provide community health education interventions on transmission and exposure
• Follow vaccine recommendations
• Follow isolation
• Reinforce safe injection practices:
  
  • Aseptic technique for prep and administration of parenteral meds
  • Sterile, single use, disposable needle and syringe for each injection
  • Single dose vials
  • Needleless systems or safety caps
• Use PPE:
  
  • Hep A: clients who are incontinent of stool
  • Hep B or C: exposure to blood
• Proper hand hygiene
• When traveling to underdeveloped countries, drink purified water and avoid sharing utensils and bed linens

Question 3

hepatitis A: route of transmission and risk factors

Answer 3

• Route of Transmission: fecal oral
• Risk factors:
  
  • Ingestion of contaminated food or water, esp shellfish
  • Close personal contact w/ an infected individual

Question 4

hepatitis B: route of transmission and risk factors

Answer 4

• Route of transmission: blood
• Risk factors:
  
  • Unprotected sex w/ infected individual
  • Infants born to infected mothers
  • Contact w/ infected blood
  • Substance use disorder: injectable substances

Question 5

hepatitis C: route of transmission and risk factors

Answer 5

• Route of transmission: blood
• Risk factors:
  
  • Substance use disorder: injectable substances
  • Blood, blood products, or organ transplants
  • Contaminated needle sticks, unsanitary tattoo equipment
  • Sexual contact

Question 6

hepatitis: additional risk factors

Answer 6

• Unscreened blood transfusions: prior to 1992
• Hemodialysis
• Percutaneous exposure: dirty needles, sharp instruments, body piercing, tattooing, use of another person’s substance use paraphernalia or personal hygiene tools
• Unprotected sex w/ a hepatitis infected person, sex w/ multiple partners, anal sex
• Ingestion of food prepared by a hepatitis infected person who does not practice proper sanitation precautions
• Travel and residence in underdeveloped country: contaminated water
• Eating or living in crowded environments: correctional facilities, dormitories, universities, long term care facilities, military base housing

Question 7

hepatitis: expected findings

Answer 7

• Failure to take personal precautions w/ blood and body fluid
• Influenza like manifestations:
• Fatigue
  
  • Dec appetite w/ nausea
  • Abdominal pain
  • Joint pain
  • Fever
• Vomiting
• Dark colored urine
• Clay colored stool
• Jaundice

Question 8

hep A: lab findings

Answer 8

• ALT: elevated
• AST: elevated
• ALP: normal or elevated
• Total bilirubin: elevated (normal is 0.3-1.0)
• Hepatitis A virus Abs (anti-HAV): presence indicates presence of hepatitis A
• Immunoglobulin M Abs (IgM): presence indicates inflammation of liver
• Immunoglobulin G Abs (IgG): presence indicates permanent immunity to hep A

Question 9

hep B: lab findings

Answer 9

• ALT: elevated
• AST: elevated
• ALP: normal or elevated
• Total bilirubin: elevated
• Hep B surface Ag: presence indicates individual is infectious
  
  • However, a client who is vaccinated against HBV will have a positive Hep B Ag, indicating immunity to the dz
• Hep B surface Ab: presence indicates recovery and immunity from HBV infection
• Hep B core antibody: presence indicates previous or ongoing infection
• IgM Ab to Hep B core Ag: presence indicates acute infection
• Hep B e Ag: presence indicates virus is replicating
• Hep B e Ab: presence is a predictor of long term clearance of the virus
• Ab to HBsAb: presence indicates recovery and immunity to hep B

Question 10

hep C: lab findings

Answer 10

• ALT: elevated
• AST: elevated
• ALP: normal or elevated
• Total bilirubin: elevated
• Hep C virus Ab: detects presence of Ab to hep C infection
• Enzyme immunoassay (EIA): detects presence of Ag or Ab to hep C infection
• Enhanced chemiluminescence immunoassay (CIA): detects presence of Ab to hep C infection
• Recombinant immunoblot assay (RIBA): detects presence of Ab to hep C infection
• HCV RNA PCR: qualitative test to detect the presence and amount of HCV

Question 11

hepatitis: liver biopsy

Answer 11

• Most definitive diagnostic approach
• Used to identify intensity of the infection, and the degree of liver damage
• Pre procedure:
  
  • Explain procedure
  • Informed consent
  • Ensure the client fasts starting at midnight on the day of the procedure in case surgery is needed due to a complication
  • Administer meds
• Intraprocedure:
  
  • Put client in supine w/ RUQ of abdomen exposed
  • Relaxation techniques
  • exhale and hold for at least 10 sec while needle is inserted
  • Resume breathing once needle is withdrawn
  • Apply pressure to puncture site
• Postprocedure:
  
  • Right side lying position and maintain for several hours
  • Monitor V/S
  • Assess abdominal pain
  • Assess for bleeding from puncture site
  • Assess for manifestations of pneumothorax (dyspnea, cyanosis, restlessness) due to accidental puncture if the pleura or lung

Question 12

hepatitis: nursing care

Answer 12

• Care for in home unless acutely ill
• Enforce contact precautions if indicated
• High carb, high calorie, low to moderate fat, and low to moderate protein diet
  
  • Small, frequent meals to promote nutrition and healing
• Promote hepatic rest and regeneration of tissue:
  
  • Administer only needed medications
  • Avoid OTC meds for herbal supplements
  • Avoid alcohol
  • Limit physical activity
• Teach how to prevent transmission of dz at home
  
  • Avoid sexual intervourse until hepatitis Ab testing is negative
  • Use proper hand hygiene
• Provide culturally sensitive care

Question 13

hep A meds

Answer 13

• Immunization for post exposure protection
• Ig: for post exposure protection for clients over 40 yo, younger than 12 mos, who have chronic liver dz, who are immunosuppressed, or who are allergic to vaccine

Question 14

hep B meds

Answer 14

• Acute infection: no meds, supportive care
• Chronic infection:
  
  • antiviral meds: adefovir dipivoxil, IFN alfa 2b, pegIFN alfa 2a, lamivudine, entecavir, telbivudine

Question 15

hep C meds:

Answer 15

• Combo therapy with peg IFN alfa 2a and ribivirin: preferred tx

Question 16

hepatitis: list complications

Answer 16

• chronic hepatitis
• fulminating hepatitis
• cirrhosis of liver
• liver cancer liver failure

Question 17

hepatitis: complication of chronic hepatitis

Answer 17

• Ongoing inflammation of liver cells
• Results from hep B, C, or D
• Inc risk for liver cancer

Question 18

hepatitis: complication of fulminating hepatitis

Answer 18

• Extremely severe and potentially fatal form of viral hepatitis
• Clients develop manifestations of viral hepatitis, then w/in hour or days develop severe liver failure
• No meds, supportive care

Question 19

hepatitis: complication of cirrhosis of liver

Answer 19

permanent scarring of liver that is caused by chronic inflammation

Question 20

hepatitis: complication of liver failure

Answer 20

irreversible damage to liver cells, w/ dec ability to function adequately to meet the body’s needs

Question 21

cirrhosis

Answer 21

• Permanent scarring of the liver that is usually caused by chronic inflammation or necrotic injury over a prolonged period of time
  
  • Normal liver tissue replaced by fibrotic tissue that lacks function
• Portal and periportal areas of the liver are primarily involved
  
  • Affects the liver’s ability to handle the flow of bile by nodules blocking the bile ducts and normal blood flow thru the liver
  • Development of new bile channels causes an overgrowth of tissue and liver scarring/enlargement
  • Jaundice often results

Question 22

cirrhosis: health promotion and dz prevention

Answer 22

• Stay current on immunizations
• Encourage client to avoid drinking alcohol and to engage in an alcohol recovery program

Question 23

types of cirrhosis

Answer 23

• Postnecrotic: caused by viral hepatitis or some meds/toxins
• Laennec’s: caused by chronic alcohol use disorder
• Biliary: caused by chronic biliary obstruction or autoimmune dz

Question 24

cirrhosis: risk factors

Answer 24

• Alcohol use disorder
• Chronic viral hepatitis (B, C, or D)
• Autoimmune hepatitis: destruction of the liver cells by the immune system
• Steatohepatitis: fatty liver dz causing chronic inflammation
• Damage to the liver from meds, toxins, infections
• Chronic biliary cirrhosis: bile duct obstruction, bile stasis, hepatic fibrosis
• Cardiac cirrhosis from severe RHF inducing necrosis and fibrosis due to lack of blood flow

Question 25

cirrhosis: expected findings

Answer 25

• Fatigue
• Weight loss, abdominal pain, distention
• Pruritis
• Confusion or difficult thinking: due to the buildup of waste products in the blood and brain that the liver is unable to get rid of
• Personality and mentation changes, emotional lability, euphoria, depression
• Cognitive changes
• Altered sleep/wake pattern
• GI bleed:
  
  • esophageal varices develop and burst–>causes vomiting and passing of blood in BM
  • Portal HTN gastropathy: bleeding of gastric mucosa
• Splenomegaly: from backup of blood from the spleen
  
  • Can cause thrombocytopenia and platelet destruction
• Ascites
• Jaundice and icterus (yellowing of eyes) from dec excretion of bilirubin
• Petechiae, ecchymoses, nosebleeds, hematemesis, melena
• Palmar erythema
• Spider angiomas: on the nose, cheeks, upper thorax, shoulders
• Dependent peripheral edema of extremities and sacrum
• Asterixis (liver flapping tremor): coarse tremor characterized by rapid, nonrhythmic extension and flexion of wrists and fingers
• Fetor hepaticus (liver breath): fruity or musty

Question 26

cirrhosis: lab tests

Answer 26

• Serum liver enzymes: elevated initially (LDH, ALT, AST) due to hepatic inflammation
  
  • AST and ALT return to normal when liver cells are no longer able to create inflammatory response
  • ALP inc in cirrhosis due to intrahepatic biliary obstruction
• Bilirubin: elevated
  
  • Due to inability to excrete bilirubin
  • unconjugated/indirect bilirubin: elevated
  • Total bilirubin: elevated
• Serum protein: dec due to lack of hepatic synthesis
• Serum albumin: dec due to lack of hepatic synthesis
• RBC: dec
• H&H: dec
• Platelet count: dec
• PT/INR: prolonged due to dec synthesis of prothrombin
• Ammonia levels:
  
  • Inc when hepatocellular injury (cirrhosis) prevents the conversion of ammonia to urea for excretion
• Serum creatinine levels: can inc due to deteriorating kidney fcn which can occur as a result of advanced liver dz

Question 27

cirrhosis: diagnostic tests

Answer 27

• U/S: detect ascites, hepatomegaly, splenomegaly, biliary stones, or biliary obstruction
• Abdominal x-rays or CT scan: visualize possible hepatomegaly, ascites, splenomegaly
• MRI: visualize mass lesions and determine if liver is malignant or benign
• Liver biopsy: most definitive
• EGD: performed under moderate (conscious) sedation to detect presence of esophageal varices, ulcerations in stomach, or duodenal ulcers and bleeding
• Endoscopic retrograde cholangiopancreatography: used to view biliary tract to assist in removing stones, to collect specimens to biopsy, and for stent placement

Question 28

cirrhosis: liver biopsy

Answer 28

• most definitive
• Identifies progress and extent of cirrhosis
• To minimize risk of hemorrhage, radiologist may perform the biopsy thru the jugular vein, which is threaded to the hepatic vein to obtain tissue for microscopic eval
• Done under fluoroscopy for safety b/c this procedure can be problematic for cirrhosis clients due to an inc risk for bleeding complications

Question 29

cirrhosis: nursing care of respiratory status

Answer 29

• Monitor O2 sats and distress
• Provide comfort measures by positioning the client to ease respiratory effort
  
  • Can be compromised by plasma volume excess and ascites
• Have the client sit in a char or elevate the HOB to 30 deg with feet elevated

Question 30

cirrhosis: nursing care of skin integrity

Answer 30

• Watch for skin breakdown
• Implement measures to prevent pressure ulcers
• Pruritus is common
  
  • Encourage washing with cold water and apply lotion to dec itching

Question 31

cirrhosis: nursing care of fluid balance

Answer 31

• Monitor for fluid vol excess
• Strict I&O
• Daily weights
• Assess for ascites and peripheral edema
• Restrict fluids/sodium if prescribed

Question 32

cirrhosis: nursing care of neuro status

Answer 32

• Monitor for deteriorating mental status and dementia consistent w/ hepatic encephalopathy
• Monitor for asterixis (coarse tremor of wrists & fingers) and fetor hepaticus (fruity odor of breath)
• Administer lactulose to aid in excretion of ammonia

Question 33

cirrhosis: nursing care of nutritional status

Answer 33

• High carb, high protein, moderate fat, and low sodium diet
• Vitamin supplements: thiamine, folate, and multivitamins

Question 34

cirrhosis: nursing care of GI status

Answer 34

• In the presence of ascites, measure abdominal girth daily over the largest part of the abdomen
  
  • Mark location of tape for consistency
• Observe for potential bleeding

Question 35

cirrhosis: nursing care of pain

Answer 35

Assess and administer analgesics/GI antispasmodics

Question 36

cirrhosis: medications

Answer 36

• b/c metabolism of meds is dependent upon a functioning liver, general meds are administered sparingly, especially opioids, sedatives, and barbiturates
  
  • Diuretics: dec excessive fluid in the body
  • Beta blocking agent: used for clients who have varices to prevent bleeding
  • Lactulose: used to promote excretion of ammonia from body thru the stool
  • Nonabsorbable abx: can be used in place of lactulose

Question 37

cirrhosis: list the therapeutic procedures

Answer 37

• paracentesis
• endoscopic variceal ligation/endoscopic sclerotherapy
• transjugular intrahepatic portosystemic shunt
• surgical bypass shunting procedures
• liver transplant

Question 38

cirrhosis: paracentesis

Answer 38

• to relieve ascites
• Preprocedure:
  
  • Explain and witness informed consent
  • Obtain V/S and weight
  • Have client void to reduce risk of injury to bladder
• Intraprocedure:
  
  • Position client in supine with HOB elevated
  • Assist with relaxation
  • Apply dressing over puncture site
• Postprocedure:
  
  • Monitor V/S and maintain bedrest
  • Measure fluid and document amount/color
  • Send to lab
  • Assess puncture site for drainage
  • weigh client

Question 39

cirrhosis: endoscopic variceal ligation/endoscopic sclerotherapy

Answer 39

• Varices can be sclerosed or banded endoscopically
• Dec risk of hemorrhage w/ banding

Question 40

cirrhosis: tranjugular intrahepatic portosystemic shunt

Answer 40

Performed in interventional radiology for clients who require further intervention w/ ascites or hemorrhage

Question 41

cirrhosis: surgical bypass shunting procedures

Answer 41

• Last resort for clients who have portal HTN and esophageal varices
• Ascites is shunted from abdominal cavity to SVC

Question 42

cirrhosis: liver transplant

Answer 42

• Portions of healthy livers from deceased or living donors can be used
• Transplanted liver portion will regenerate and grow in size based on the needs of the body
• Client must meet transplant criteria
• Client is not a candidate if: severe cardiac and respiratory dz, metastatic malignant liver cancer, or alcohol/substance use disorder

Question 43

cirrhosis: liver transplant post procedure care

Answer 43

• Close monitoring
• Monitor V/S and neuro status frequently
• Monitor for acute graft rejection: tachycardia, fever, RUQ pain, change in bile color or inc jaundice, inc ALT/AST levels
• Monitor for infection: fever or excessive, foul smelling drainage
• Monitor for clotting problems: blood in drainage tubes, petechiae
• Monitor for hepatic complications: dec bile drainage, inc RUQ pain with distention, n/v, inc jaundice
• Monitor for acute kidney injury: change in urine output, inc BUN and Cr levels and electrolyte imbalance
• Administer immunosuppressant agents and abx prophylaxis
• Obtain blood cultures
• Keep T tube in dependent position and empty frequently, documenting amount and description

Question 44

cirrhosis: client edu

Answer 44

• Help client abstain from alcohol and engage in alcohol recovery
  
  • Helps prevent further scarring and fibrosis of liver
  • Allows healing/regeneration of liver
  • Prevents irritation of stomach and esophagus lining
  • Dec risk of bleeding
• Consult provider if need OTC meds
• Follow diet:
  
  • High calorie, moderate fat
  • Low sodium (if client has excessive fluid in peritoneal cavity)
  • Low protein (if encephalopathy, elevated ammonia)
  • Small, frequent, well balanced meals
  • Supplement vitamin enriched liquids
  • Replace and administer vitamins due to inability of liver to store them
  • Fluid intake restrictions if sodium is low

Question 45

cirrhosis: list possible complications

Answer 45

• portal systemic encephalopathy
• esophageal varices
• acute graft rejection post liver transplant

Question 46

cirrhosis: complication of portal systemic encephalopathy

Answer 46

• If a pt has a poorly functioning liver, then they are unable to convert ammonia and other waste products to a less toxic form
  
  • These are carried to brain–>neuro manifestations
• Pt is treated with meds such as lactulose to reduce ammonia levels in the body via intestinal excretion
• Reductions in dietary protein are indicated as ammonia is formed when protein is broken down by intestinal flora

Question 47

cirrhosis: portal systemic encephalopathy nursing actions and client edu

Answer 47

• Nursing actions:
  
  • Administer lactulose
  • Monitor labs findings
    
    • Esp potassium: hypokalemia b/c of inc stools from lactulose therapy
  • Assess for changes in LOC and orientation
  • Report asterixis (flapping of hands) and fetor hepaticus (fruity breath odor)
  • Indicate that encephalopathy is worsening
• Client edu: teach about diet

Question 48

cirrhosis: complication of esophageal varices–>causes

Answer 48

• Portal HTN: elevated BP in veins that carry blood from intestines to liver
  
  • Caused by impaired circulation of blood thru liver
  • Collateral circulation is developed which creates varices in upper stomach and esophagus
  • Varices are fragile and can bleed easily

Question 49

cirrhosis: esophageal varices–>nursing actions

Answer 49

• Assist w/ saline lavage (vasoconstriction), esophagogastric balloon tamponade, blood transfusions, ligation and sclerotherapy, and shunts to stop bleeding and reduce risk for hypovolemic shock
• Monitor Hgb and V/S
• Monitor for bleeding

Question 50

cirrhosis: acute graft rejection post liver transplant–>indications of infection and causes

Answer 50

• Occurs b/w 4-10 days after surgery
• Indications of infection:
  
  • Tachycardia
  • Upper right flank pain
  • Jaundice
  • Lab findings indicative of liver failure
• Causes: GVHD–>recipient’s bone marrow creates T cells to attack the new organ

Question 51

cirrhosis: acute graft rejection post liver transplant–>nursing actions and client edu

Answer 51

• Nursing Actions:
  
  • Early diagnosis is necessary to successfully prevent total rejection by liver
  • Administer immunosuppressants
  • Monitor lab findings
• Client edu:
  
  • Inform client of importance of taking immunosuppressants and monitoring WBC count
  • Report indications of rejection to provider immediately