Unit 3: Hepatitis Flashcards
The Liver Located
-located under the diaphragm; in RUQ of abdominal cavity
The Functions of the Liver
- blood storage
- blood filtration
- production of bile
- synthesis of clotting factors (prothrombin, factors II, VII, IX, and X)
- removal of clotting factors to prevent clotting
- metabolism of carbohydrates, fats, and proteins
- detoxify the blood
- storage for vitamins A, D, E, and K and Iron
When does hepatic dysfunction occur?
liver is no longer able to perform its usual functions
ex: hepatitis; inflammation of the liver
Risk for developing hepatitis is associated with what?
individual behavior and exposure
Transmission of Hepatitis
- fecal-oral
- directly through blood and body fluid exposures
Risk Factors for Hepatitis
- alcohol abuse
- some prescription or OTC medications
- toxins
- autoimmune disease
Medication Risk Factors for Hepatitis
- Statins
- Anabolic steroid
- Azathioprine
- Methotrexate
- Isoniazid
- Valproic acid
- Tetracyclines
- Phenytoin
- Acetaminophen
Toxin risk factors for Hepatitis
- Industrial chemicals
- Carbon tetrachloride
- Phosphorus
- Mushrooms
Pathophysiology
hepatitis is inflammation of the liver cells most commonly caused by a virus that impairs its ability to function normally
- the inflammation limits the ability of the liver to detoxify substances, limits the production of proteins and clotting factors, and alters the ability to store vitamins, fats, and sugars
- patients w/ hepatitis may experience a mild or severe illness that can be acute or chronic
Hepatitis
inflammation of the liver cells most commonly caused by a virus that impairs its ability to function normally
Modes of Transmission of Viral Hepatitis
- contact w/ blood, blood products, semen, saliva and mucous membranes
- direct contact w/ infected fluids or objects
- fecal-oral route w/ contaminated water or food such as shellfish
Most Common Hepatitis Viruses
A, B, and C
Table 59.1: Hepatitis A
> Route: Fecal-oral, contaminated water or food
Source of virus: Feces, contaminated water or food
Incubation period: 15-50 days
Acute
Vaccine available
Treatment: symptomatic
Table 59.1: Hepatitis B
>Routes: -percutaneous or mucosal -blood, body fluids, needles or sharp instruments >Source of virus: blood, body fluids >Incubation period: 45-60 day >Chronic >Vaccine available >Treatment: interferon and antivirals
Table 59.1: Hepatitis C
>Route of Transmission: -percutaneous or mucosal -blood, body fluids, needles, or sharp instruments >Source of virus: blood, body fluids, needles, or sharp instruments >Incubation period: 2-25 weeks >Chronic >No available vaccine -Treatment: interferon and antivirals
Table 59.1: Hepatitis D
>Routes: -percutaneous or mucosal -in conjunction w/ hepatitis B -blood, body fluids, or sharp instruments >Source of virus: blood, body fluids, needles, or sharp instruments >Incubation period: 2-8 weeks >HBV vaccine >Treatment: interferon and antivirals
Table 59.1: Hepatitis E
>Routes: -fecal-oral -contaminated water or food >Source of virus: feces >Incubation period: 2-8 weeks >Acute >No vaccine >Treatment: symptomatic >develop jaundice
Table 59.1: Hepatitis G
>Route: -infected blood or blood products >Source of virus: infected blood or blood products >Incubation period: unknown >Acute >No vaccine >Treatment: symptomatic
Which types of hepatitis are transmitted by fecal-oral?
- Hep A
- Hep E
Which type of Hepatitis is transmitted through blood or blood products?
> Hep B
Hep C
Hep D
Hep G
Clinical Manifestations of Hepatitis
- abdominal pain
- irritability
- pruritis (itching)
- malaise
- fever
- nausea
- vomiting
- jaundice (icterus)/yellowing of skin or sclera
- clay colored stool
- dark amber urine
- hepatomegaly
- ascites
- flu-like symptoms
Laboratory Analysis: Abnormalities
- Elevated liver enzymes (AST, ALT)
- Elevated Bilirubin (total and direct)
- Elevated serum ammonia
- Decreased albumin
Clinical Manifestations: Clay colored stool
bile acids normally secreted by the liver make stool its brown color
-with an obstruction in the liver, these bile acids are not secreted in the stool, resulting in clay colored stools
Clinical Manifestations: Dark amber urine
d/t increased excretion of conjugated bilirubin in the urine
Obstructive Jaundice is caused by?
- scarring
- edema
- stone formation
- any obstruction that interferes w/ normal process of bile flow through the bile ducts
Fulminant viral Hepatitis
- severe, rapidly progressive, life-threatening form of acute liver failure
- Neurological decline (encephalopathy, insomnia, somnolence, and impaired mentation)
- GI bleeding
- Coagulation disorders
- Thrombocytopenia (low platelet count of less than 150000)
- Fever
- Oliguria
- Edema
- Ascites
Hepatic Encephalopathy
-impaired mentation, altered LOC, confusion, somnolence, insomnia; d/t the accumulation of toxins in the bloodstream that are normally cleared by a healthy liver
Scarring of the Liver
d/t scarring, blood bypasses the liver and is not detoxified
-waste products accumulate (ammonia), causing changes in mental status
Complications of Liver Failure
-inability of the liver to produce clotting factors
>results in coagulation disorders and thrombocytopenia (low platelet count)
Complications of Liver Failure
-inability of the liver to produce clotting factors
>results in coagulation disorders and thrombocytopenia (low platelet count)
Hepatitis A: Phases
>First phase: -last for about a week -abrupt onset of fever w/ anorexia, nausea, vomiting, malaise, abdominal pain, myalgia, diarrhea, urticaria (pale red, raised bumps on the skin), cough, and hepatosplenomegaly (enlarged liver and/or spleen) >Manifestation of later phases: -clay-colored stools -elevated bilirubin levels -jaundice (4 to 30 days after infection)
Hepatitis C is the leading cause of what?
liver cirrhosis and hepatocellular cancer
Definitive Diagnosis of Hepatitis A
anti-hepatitis A immunoglobulin M (IgM anti-HAV)
-can be elevated for as long as 6 months
Hepatitis B Diagnosis
- detectable serum HBV DNA levels
- persistent elevation of ALT and AST
High-risk patients w/ hepatitis B should do what?
- screened every 6 to 12 months for HCC
- screening includes an ultrasound and a serum alpha-fetoprotein (protein produced by the liver) level as a marker for liver cancer
Non-Viral Forms of Hepatitis are caused by?
ingested, inhaled, or injected toxins or medications
-if it is determined that the patient has been exposed to a liver toxin and the toxin is removed, recovery can be rapid
Clinical Manifestations of non-viral forms of hepatitis
- anorexia
- N/V
- jaundice
- hepatomegaly (enlarged liver)
Diagnostic Testing for liver disorders
- ALT
- AST
- Alkaline phosphate (total)
- GGT (Gamma Glutamyl Transferase)
- LDH (Lactate Dehydrogenase)
- Bilirubin (total, indirect, direct)
- Albumin
- Ammonia
- Coagulation Tests (prothrombin time, activated partial thromboplastin time (aPTT)
- Platelets
ALT
Males: 13 to 40 units/L
Females: 24-36 units/L
>levels can be elevated for 1 to 2 months; can take as long as 3 to 6 months to return back to normal
AST
Males: 20 to 40 units/L
Females: 15 to 35 units/L
>remain elevated for 1 to 2 months; take as long as 3 to 6 months to return to normal
Alkaline Phosphate (total)
Males: 35-142 units/L
Females: 24-125 units/L
>enzyme found in bone, intestine, liver, and bile ducts
>elevated = a blockage of bile flow that can be caused by gallstones or scarring in biliary tree
Alkaline Phosphate (Liver Fraction)
0-93 units/L
Gamma Glutamyl Transferase (GGT)
Males: 0-30 units/L
Females: 0-24 units/L
>indicate abnormalities of bile flow
>a protein found in the liver and bile ducts
>high levels can indicate inflammation, injury, or blockage of bile ducts (cholestasis)
Lactate Dehydrogenase (LDH)
90-176 units/L
>is a test for an enzyme that is produced by many organs in the blood as the result of tissue damage
>used as a conjunction w/ other tests to determine presence and severity of liver dysfunction
Bilirubin (total)
- 3 to 1 mg/dL
- by-product of the breakdown of RBCs that is filtered through the liver
Bilirubin (indirect)
- 2 to 0.8 mg/dL
- “unconjugated bilirubin”
- measures the serum level of bilirubin before it gets to the liver
Bilirubin (Direct)
- 1 to 0.3 mg/dL
- once in the liver, indirect bilirubin is changed to direct bilirubin while it binds to certain sugars
- direct bilirubin is released into the bile and stored in the gallbladder
- when the liver is unable to conjugate the bilirubin b/c of dysfunction, levels are elevated, and pts develop jaundice
Serum Albumin
- 4 to 5.1 g/dL
- measures the amount of protein that is made by the liver
- low serum albumin may be an indicator of liver damage and malnutrition
Serum Ammonia
15 to 60 mcg/dL
Prothrombin time (PT)
10 to 13 seconds
Activated partial thromboplastin time (aPTT)
25 to 35 seconds
Platelets
150,000 to 450,000 mm3
Medications
- oral antiviral agents for viral suppression
- use of immune globulin is recommended if exposure to the source of hepatitis A was less than 2 weeks
- hepatitis A vaccine
- pegylated interferon injections
- hepatitis B vaccine
Pegylated Interferon Injection
- work toward viral suppression
- can be given weekly or multiple times a week for 6 to 12 months
Diet and Activity
- low in fat
- high in fruits, vegetables, and whole grains
- adequate oral intake to ensure hydration
- eat small frequent meals
- avoid alcohol
- avoid medications toxic to liver (acetaminophen)
- vitamin supplements of A, D, E, and K
- walking, resistance training, and low-impact aerobics help maintain strength and minimize fatigue
- balance of rest and exercise
Connection Check: In reviewing diagnostic results of a patient w/ suspected hepatitis, the nurse correlates which result as consistent with hepatitis A? A. Prolonged prothrombin time (PT) B. Decreased WBC count C. Presence of IgM anti-HAV D. Detectable serum HBV DNA
C. Presence of IgM anti-HAV
Surgical Management: Liver Transplant
- Hepatitis C-related cirrhosis is most common reason for liver transplant
- orthotopic liver transplant
Orthotopic Liver Transplant
-the native diseased liver is removed, and a cadaver donor liver is transplanted in it space
Major Complications after liver transplant
- organ rejection
- infection
Complication: Organ rejection
- presents between days 4 and 10 post-op
- fever, RUQ pain, tachycardia, changes in bile, jaundice
How to reduce the risk of rejection after liver transplantation?
- placed on immunosuppression medications (cyclosporine and tacrolimus)
- these meds may increase risk of infection
Nursing Management: Assessment and Analysis
clinical manifestations in a patient w/ hepatitis are directly associated w/ the inability of the liver to perform its normal functions b/c of inflammation
- Elevated temperature r/t inflammation
- Elevated liver enzymes (AST, ALT)
- Jaundice
- Fatigue
- Decreased appetite
Nursing Diagnoses
- Activity intolerance associated w/ fatigue, fever, flu-like symptoms
- Acute pain associated w/ edema of the liver
- Altered nutrition (less than body requirements) associated w/ decreased liver metabolic function secondary to loss of appetite, nausea, and vomiting
- Altered thought processes associated w/ elevated serum ammonia levels secondary to liver dysfunction
- Knowledge deficit associated w/ the disease process
Nursing Assessment for Hepatitis
- Vital signs
- Serum Liver Enzymes
- Serum Bilirubin
- Color of skin, sclera
- Nutritional intake
- Daily weight
- Intake and Output
- Signs of organ rejection in the patient after liver transplantation
Assessments: Vital Signs
elevation in temperature and pulse (tachycardia) associated w/ infectious process
Assessment: Serum Liver Enzymes
Elevated levels of liver enzymes indicate that liver injury is present and liver enzymes have entered the blood stream
Assessment: Serum Bilirubin
- Bilirubin is a by-product of red blood cell breakdown
- The Liver is responsible for removing bilirubin in the blood
- Total bilirubin and direct, or conjugated, bilirubin levels are elevated b/c of inflammation and obstruction of the liver by hepatitis; it cannot remove the bilirubin in the blood
Assessment: Color of skin, sclera
- Yellow pigmentation of the eyes and skin occurs b/c of increased bilirubin levels in the blood
- Deep jaundice may result in a greenish tint to the skin d/t by-products of bilirubin conversion
Assessment: Nutritional Intake
- loss of appetite occurs b/c of abdominal fullness or the lack of desire to eat foods the patient previously enjoyed as a result of indigestion
- occurs frequently w/ fatty foods and alcohol
Assessment: Daily Weight
- monitors nutritional intake and evaluates weight loss associated w/ decreased nutritional intake
- anorexia may develop secondary to abdominal distention and obstruction
- increase in body weight may be secondary to ascites
Assessment: Intake and Output
- fluid volume status, either overload or depletion, may occur
- fluid overload associated w/ ascites that develops secondary to damage to the liver by the inflammatory and infectious processes seen w/ hepatitis
Assessment: Signs of organ rejection in patient after liver transplantation
in patients who undergo transplantation for cirrhosis, organ rejection may occur within the first 10 days after procedure
-include RUQ pain, changes in bile drainage, fever, tachycardia, and jaundice
Nursing Actions for Hepatitis
- Administer medications as ordered
- Provide small, frequent meals and supplements (PRN)
- Administer antiemetics
- Promote balance between physical activity and rest
- Encourage rest periods between walking and physical activity; maintains strength/conditioning
Actions: Provide small, frequent meals and supplements (as needed)
b/c of decreased appetite and feelings of fullness, small frequent meals and nutritional supplements are encouraged to promote adequate nutrition
Actions: Administer antiemetics
- decrease symptoms of N/V associated w/ the virus, which may occur for a prolonged period of time
- Use caution; some antiemetics (phenothiazines) are metabolized by the liver and should not be used
Actions: Promote balance between physical activity and rest
rest decreases metabolic demands on the liver
Nursing Patient Teachings
- Nutritional teaching
- Good hand hygiene before and after meals and use of the bathroom to decrease transmission from fecal-oral route
- Avoid behaviors (needle sharing, unprotected sex) that contribute to transmission
- Importance of Vaccinations to prevent hepatitis A and B
- Safe public water supply, sewage
Nutritional Teachings
- importance of balanced nutrition to promote energy
- small, frequent meals to increase nutritional intake while minimizing the negative effects of eating
- patients w/ N/V tend to limit food intake
- stress calorie intake
- proteins in moderate doses b/c the liver processes protein
- vitamins and minerals w/ balanced diet or supplements
- limit fat intake b/c the liver may not be able to make enough bile to process fats
- small, frequent meals are indicated b/c the liver cannot store glycogen for energy b/c of inflammation
- hydration to manage symptoms; dizziness, fatigue, skin and mucus membrane dryness and side effects of any medications
- alcohol and caffeine avoided b/c they cause dehydration
Importance of Vaccinations to prevent Hepatitis A and B
- Hepatitis A vaccine can prevent hepatitis A
- Recommended for healthcare workers, food handlers, child-care workers, and travelers to endemic hepatitis A areas
- Series of two injections (initial and booster 6-12 months later)
- Vaccine effective for as long as 20 years
- Hepatitis B vaccine can prevent hepatitis B and the serious consequences of HBV infection including liver cancer and cirrhosis
- given as a series of several injections
- gives long-term protection from HBV
- recommended for everyone
Teachings: Safe water supply, sewage
- consider the water source and whether the public water supply is safe from sewage
- infected fecal matter can transmit hepatitis A
Evaluating Care Outcomes
- Hepatitis is a manageable disease process when patients have a clear understanding of the disease and are compliant w/ interventions and therapies
- Expected outcomes = stable vital signs, stable weight, and comprehensive understanding of risk factors, transmission, and treatment of hepatitis
- Additional outcomes = decrease in liver function test values while the infection is resolving
- Lifestyle activities that contribute to liver disease should be altered or eliminated to slow the progression of the disease
- Knowledge of diet, nutritional intake, activity tolerance, and compliance w/ medical interventions
- Require serial follow-up and monitoring of symptoms
- Should take a proactive role in their self-care
Hepatitis A Vaccine
> Recommended for:
-healthcare workers, restaurant workers, food handlers, persons traveling to areas w/ endemic hepatitis A. children and workers in child care, those w/ risky behaviors (illegal injected drug users), and persons with chronic liver disease
One injection followed by a booster dose 6-12 months later
Vaccine effective for 15-20 years
Protection from vaccine occurs 2-4 weeks after vaccination
Hepatitis B Vaccine
- Recommended for everyone, including newborns
- Series of 3 injections over 6 to 12 months
- Effective for 15 years or longer
Approved Agents for Hepatitis A
None
-Hep A vaccine
Approved Oral Agents for Hepatitis B
> tenofovir, entecavir, lamivudine, telbivudine
- all oral agents are given once a day for 1 year or longer
- Action: viral suppression and remission
- Side effects: limited
- Treatment response: based on serial monitoring of liver enzymes
Approved Injection Agent for Hepatitis B
- Interferon-alpha
- Pegylated interferon
Injection: Interferon-alpha
- for hepatitis B
- injection several times a week (6-12 months)
- Action: viral suppression
- Side effects: flu-like symptoms, depression, fatigue, headaches, thyroid problems
Injection: Pegylated interferon
- for hep B
- weekly injection (6-12 months)
- Action: Viral Suppression
- Side Effect: flu-like symptoms, depression, fatigue, headaches, thyroid problems
Approved Agents for Hepatitis C
- Pegylated Interferons
- Ribavirin
- Combination therapy; peginterferon w/ ribavirin, interferon w/ ribavirin
- Harvoni (sofosbuvir + ledipasvir); polymerase inhibitor
Interferon Therapy for Hepatitis C
- lasts 12- 8 months
- Action: viral suppression
- Treatment response: serum test for presence of Hep C
Ribavirin Therapy for Hep C
- lasts 48 weeks
- action: viral suppression
- treatment response: serum test for presence for Hep C
Polymerase Inhibitor: Harvoni
- for Hep C
- 8-12 weeks of treatment
- Action: direct acting antiviral
- Side Effects: severe forms of anemia, fatigue, headache, nausea, diarrhea, insomnia, weakness
