Nursing 272: Final Semester > Unit 3: Hepatitis > Flashcards

Unit 3: Hepatitis Flashcards

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1
Q

The Liver Located

A

-located under the diaphragm; in RUQ of abdominal cavity

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2
Q

The Functions of the Liver

A
  • 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
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3
Q

When does hepatic dysfunction occur?

A

liver is no longer able to perform its usual functions

ex: hepatitis; inflammation of the liver

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4
Q

Risk for developing hepatitis is associated with what?

A

individual behavior and exposure

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5
Q

Transmission of Hepatitis

A
  • fecal-oral

- directly through blood and body fluid exposures

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6
Q

Risk Factors for Hepatitis

A
  • alcohol abuse
  • some prescription or OTC medications
  • toxins
  • autoimmune disease
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7
Q

Medication Risk Factors for Hepatitis

A
  • Statins
  • Anabolic steroid
  • Azathioprine
  • Methotrexate
  • Isoniazid
  • Valproic acid
  • Tetracyclines
  • Phenytoin
  • Acetaminophen
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8
Q

Toxin risk factors for Hepatitis

A
  • Industrial chemicals
  • Carbon tetrachloride
  • Phosphorus
  • Mushrooms
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9
Q

Pathophysiology

A

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
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10
Q

Hepatitis

A

inflammation of the liver cells most commonly caused by a virus that impairs its ability to function normally

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11
Q

Modes of Transmission of Viral Hepatitis

A
  • 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
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12
Q

Most Common Hepatitis Viruses

A

A, B, and C

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13
Q

Table 59.1: Hepatitis A

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

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14
Q

Table 59.1: Hepatitis B

A 
>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
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15
Q

Table 59.1: Hepatitis C

A 
>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
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16
Q

Table 59.1: Hepatitis D

A 
>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
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17
Q

Table 59.1: Hepatitis E

A 
>Routes: 
-fecal-oral
-contaminated water or food
>Source of virus: feces
>Incubation period: 2-8 weeks
>Acute
>No vaccine
>Treatment: symptomatic
>develop jaundice
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18
Q

Table 59.1: Hepatitis G

A 
>Route:
-infected blood or blood products
>Source of virus: infected blood or blood products
>Incubation period: unknown
>Acute
>No vaccine
>Treatment: symptomatic
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19
Q

Which types of hepatitis are transmitted by fecal-oral?

A
  • Hep A

- Hep E

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20
Q

Which type of Hepatitis is transmitted through blood or blood products?

A

> Hep B
Hep C
Hep D
Hep G

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21
Q

Clinical Manifestations of Hepatitis

A
  • 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
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22
Q

Laboratory Analysis: Abnormalities

A
  • Elevated liver enzymes (AST, ALT)
  • Elevated Bilirubin (total and direct)
  • Elevated serum ammonia
  • Decreased albumin
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23
Q

Clinical Manifestations: Clay colored stool

A

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

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24
Q

Clinical Manifestations: Dark amber urine

A

d/t increased excretion of conjugated bilirubin in the urine

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25
Obstructive Jaundice is caused by?
- scarring - edema - stone formation - any obstruction that interferes w/ normal process of bile flow through the bile ducts
26
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
27
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
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Scarring of the Liver
d/t scarring, blood bypasses the liver and is not detoxified | -waste products accumulate (ammonia), causing changes in mental status
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Complications of Liver Failure
-inability of the liver to produce clotting factors | >results in coagulation disorders and thrombocytopenia (low platelet count)
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Complications of Liver Failure
-inability of the liver to produce clotting factors | >results in coagulation disorders and thrombocytopenia (low platelet count)
31
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) ```
32
Hepatitis C is the leading cause of what?
liver cirrhosis and hepatocellular cancer
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Definitive Diagnosis of Hepatitis A
anti-hepatitis A immunoglobulin M (IgM anti-HAV) | -can be elevated for as long as 6 months
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Hepatitis B Diagnosis
- detectable serum HBV DNA levels | - persistent elevation of ALT and AST
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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
36
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
37
Clinical Manifestations of non-viral forms of hepatitis
- anorexia - N/V - jaundice - hepatomegaly (enlarged liver)
38
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
39
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
40
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
41
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
42
Alkaline Phosphate (Liver Fraction)
0-93 units/L
43
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)
44
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
45
Bilirubin (total)
0. 3 to 1 mg/dL | - by-product of the breakdown of RBCs that is filtered through the liver
46
Bilirubin (indirect)
0. 2 to 0.8 mg/dL - "unconjugated bilirubin" - measures the serum level of bilirubin before it gets to the liver
47
Bilirubin (Direct)
0. 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
48
Serum Albumin
3. 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
49
Serum Ammonia
15 to 60 mcg/dL
50
Prothrombin time (PT)
10 to 13 seconds
51
Activated partial thromboplastin time (aPTT)
25 to 35 seconds
52
Platelets
150,000 to 450,000 mm3
53
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
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Pegylated Interferon Injection
- work toward viral suppression | - can be given weekly or multiple times a week for 6 to 12 months
55
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
56
``` 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
57
Surgical Management: Liver Transplant
- Hepatitis C-related cirrhosis is most common reason for liver transplant - orthotopic liver transplant
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Orthotopic Liver Transplant
-the native diseased liver is removed, and a cadaver donor liver is transplanted in it space
59
Major Complications after liver transplant
- organ rejection | - infection
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Complication: Organ rejection
- presents between days 4 and 10 post-op | - fever, RUQ pain, tachycardia, changes in bile, jaundice
61
How to reduce the risk of rejection after liver transplantation?
- placed on immunosuppression medications (cyclosporine and tacrolimus) - these meds may increase risk of infection
62
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
63
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
64
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
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Assessments: Vital Signs
elevation in temperature and pulse (tachycardia) associated w/ infectious process
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Assessment: Serum Liver Enzymes
Elevated levels of liver enzymes indicate that liver injury is present and liver enzymes have entered the blood stream
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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
68
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
69
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
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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
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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
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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
73
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
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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
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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
76
Actions: Promote balance between physical activity and rest
rest decreases metabolic demands on the liver
77
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
78
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
79
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
80
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
81
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
82
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
83
Hepatitis B Vaccine
- Recommended for everyone, including newborns - Series of 3 injections over 6 to 12 months - Effective for 15 years or longer
84
Approved Agents for Hepatitis A
None | -Hep A vaccine
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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
86
Approved Injection Agent for Hepatitis B
- Interferon-alpha | - Pegylated interferon
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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
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Injection: Pegylated interferon
- for hep B - weekly injection (6-12 months) - Action: Viral Suppression - Side Effect: flu-like symptoms, depression, fatigue, headaches, thyroid problems
89
Approved Agents for Hepatitis C
- Pegylated Interferons - Ribavirin - Combination therapy; peginterferon w/ ribavirin, interferon w/ ribavirin - Harvoni (sofosbuvir + ledipasvir); polymerase inhibitor
90
Interferon Therapy for Hepatitis C
- lasts 12- 8 months - Action: viral suppression - Treatment response: serum test for presence of Hep C
91
Ribavirin Therapy for Hep C
- lasts 48 weeks - action: viral suppression - treatment response: serum test for presence for Hep C
92
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
Nursing 272: Final Semester
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