Hepatitis and Cirrhosis Flashcards
1
Q
hepatitis
A
- 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
2
Q
hepatitis: health promotion and dz prevention
A
- 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
3
Q
hepatitis A: route of transmission and risk factors
A
- Route of Transmission: fecal oral
- Risk factors:
- Ingestion of contaminated food or water, esp shellfish
- Close personal contact w/ an infected individual
4
Q
hepatitis B: route of transmission and risk factors
A
- 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
5
Q
hepatitis C: route of transmission and risk factors
A
- 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
6
Q
hepatitis: additional risk factors
A
- 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
7
Q
hepatitis: expected findings
A
- 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
8
Q
hep A: lab findings
A
- 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
9
Q
hep B: lab findings
A
- 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
10
Q
hep C: lab findings
A
- 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
11
Q
hepatitis: liver biopsy
A
- 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
12
Q
hepatitis: nursing care
A
- 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
13
Q
hep A meds
A
- 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
14
Q
hep B meds
A
- Acute infection: no meds, supportive care
- Chronic infection:
- antiviral meds: adefovir dipivoxil, IFN alfa 2b, pegIFN alfa 2a, lamivudine, entecavir, telbivudine
15
Q
hep C meds:
A
- Combo therapy with peg IFN alfa 2a and ribivirin: preferred tx
16
Q
hepatitis: list complications
A
- chronic hepatitis
- fulminating hepatitis
- cirrhosis of liver
- liver cancer liver failure
17
Q
hepatitis: complication of chronic hepatitis
A
- Ongoing inflammation of liver cells
- Results from hep B, C, or D
- Inc risk for liver cancer
18
Q
hepatitis: complication of fulminating hepatitis
A
- 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
19
Q
hepatitis: complication of cirrhosis of liver
A
permanent scarring of liver that is caused by chronic inflammation
20
Q
hepatitis: complication of liver failure
A
irreversible damage to liver cells, w/ dec ability to function adequately to meet the body’s needs
21
Q
cirrhosis
A
- 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
22
Q
cirrhosis: health promotion and dz prevention
A
- Stay current on immunizations
- Encourage client to avoid drinking alcohol and to engage in an alcohol recovery program
23
Q
types of cirrhosis
A
- 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
24
Q
cirrhosis: risk factors
A
- 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
25
Q
cirrhosis: expected findings
A
- 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
26
Q
cirrhosis: lab tests
A
- 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
27
Q
cirrhosis: diagnostic tests
A
- 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
28
Q
cirrhosis: liver biopsy
A
- 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
29
Q
cirrhosis: nursing care of respiratory status
A
- 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
30
Q
cirrhosis: nursing care of skin integrity
A
- Watch for skin breakdown
- Implement measures to prevent pressure ulcers
- Pruritus is common
- Encourage washing with cold water and apply lotion to dec itching
31
Q
cirrhosis: nursing care of fluid balance
A
- Monitor for fluid vol excess
- Strict I&O
- Daily weights
- Assess for ascites and peripheral edema
- Restrict fluids/sodium if prescribed
32
Q
cirrhosis: nursing care of neuro status
A
- 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
33
Q
cirrhosis: nursing care of nutritional status
A
- High carb, high protein, moderate fat, and low sodium diet
- Vitamin supplements: thiamine, folate, and multivitamins
34
Q
cirrhosis: nursing care of GI status
A
- 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
35
Q
cirrhosis: nursing care of pain
A
Assess and administer analgesics/GI antispasmodics
36
Q
cirrhosis: medications
A
- 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
37
Q
cirrhosis: list the therapeutic procedures
A
- paracentesis
- endoscopic variceal ligation/endoscopic sclerotherapy
- transjugular intrahepatic portosystemic shunt
- surgical bypass shunting procedures
- liver transplant
38
Q
cirrhosis: paracentesis
A
- 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
39
Q
cirrhosis: endoscopic variceal ligation/endoscopic sclerotherapy
A
- Varices can be sclerosed or banded endoscopically
- Dec risk of hemorrhage w/ banding
40
Q
cirrhosis: tranjugular intrahepatic portosystemic shunt
A
Performed in interventional radiology for clients who require further intervention w/ ascites or hemorrhage
41
Q
cirrhosis: surgical bypass shunting procedures
A
- Last resort for clients who have portal HTN and esophageal varices
- Ascites is shunted from abdominal cavity to SVC
42
Q
cirrhosis: liver transplant
A
- 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
43
Q
cirrhosis: liver transplant post procedure care
A
- 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
44
Q
cirrhosis: client edu
A
- 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
45
Q
cirrhosis: list possible complications
A
- portal systemic encephalopathy
- esophageal varices
- acute graft rejection post liver transplant
46
Q
cirrhosis: complication of portal systemic encephalopathy
A
- 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
47
Q
cirrhosis: portal systemic encephalopathy nursing actions and client edu
A
- 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
48
Q
cirrhosis: complication of esophageal varices–>causes
A
- 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
49
Q
cirrhosis: esophageal varices–>nursing actions
A
- 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
50
Q
cirrhosis: acute graft rejection post liver transplant–>indications of infection and causes
A
- 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
51
Q
cirrhosis: acute graft rejection post liver transplant–>nursing actions and client edu
A
- 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
