Hepatitis



Hepatic and Biliary System

Learning Objectives:

Upon completion of this unit the learners will be able to:

1. Identify the metabolic function of the liver and the alterations in these functions that occur with the liver disease.

2. Explain the liver function tests and the clinical manifestations of liver dysfunction in relation to the pathophysiologic alterations of the liver.

3. Differentiate among the types of viral hepatitis, including etiology, Pathophysiology, clinical manifestations, complications, and collaborative care.

4. Describe the nursing management of the patient with viral hepatitis.

5. Explain the etiology, pathophysiology, clinical manifestation, complications and collaborative care of the patient with cirrhosis of the liver.

6. Describe the nursing management of the patient with cirrhosis of the liver.

7. Explain the etiology, Pathophysiology, clinical manifestation, complications and collaborative care of acute and chronic pancreatitis.

8. Describe the nursing management of the patient with acute and chronic pancreatitis.

9. Explain the etiology, Pathophysiology, clinical manifestation, complications and collaborative care including surgical therapy of gallbladder disorders.

10. Describe the nursing management of the patient undergoing conservative or surgical treatment of cholecytitis and cholelithiasis.

Assessment and Management of Patients with Hepatic Disorders

1 Liver is the largest gland in the body, can be considered a chemical factory that manufactures, stores, alters, and excretes a large number of substances involved in metabolism.

▪ The liver is located behind the ribs in the right upper portion of the abdominal cavity

2 The liver is especially important in the regulation of glucose and protein metabolism.

▪ The liver manufactures and secretes bile, which has a major role in the digestion and absorption of fat in the GI tract.

▪ It removes the waste products from the blood stream and secretes them into the bile.

▪ The bile produced by the liver is stored temporarily in the gall bladder until it is needed for digestion, at which time the gall bladder empties and bile enters the intestine.

Functions of the liver

| | |

|Function |Actions |

| | |

|Digestion |Bile salts for digestion/emulsification of fats |

| |Processing and storage of fats, carbohydrates and proteins absorbed by the intestine and sent to the liver |

| |via the portal circulation |

| |Processing and storage of vitamins and minerals |

| |Vitamin B 12, A, D, E ,K |

| | |

|Endocrine |Metabolism of glucocorticoids, mineralocorticoids and sex hormones |

| |Regulation of fat, carbohydrate and protein metabolism |

| |Glucose stored as glycogen |

| |Main source of body heat |

| | |

|Hematologic |Temporary storage of blood |

| |Synthesis of bilirubin from breakdown of RBCs |

| |Hematopoiesis in certain disease states |

| |Synthesis of blood clotting factors (fibrinogen, thrombin, prothrombin) |

| |synthesis of albumin, prealbumin, |

| | |

|Excretion |Excretion of bile pigment |

| |Excretion of cholesterol via bile |

| |Urea synthesis as the final step in the excretion of ammonia (protein breakdown) |

| |Detoxification of drugs, poisons and other foreign substances |

Laboratory Assessment of Liver and Pancreatic Function

| | |

|Lab test |Significance |

| | |

|Direct bilirubin |Increased with biliary obstruction |

| | |

|Indirect bilirubin |Increased with destruction of RBCs |

| | |

|Serum amylase |Pancreatic digestive enzymes, increased with acinar cells are destroyed. This test also measures salivary |

| |amylase (enzyme which converts starches into sugar), so pancreatic isoamylase more accurate |

| | |

|Serum lipase |Pancreatic digestive enzyme, increased with acute pancreatitis |

| | |

|Ammonia |By-product of protein metabolism. Reduced synthesis of urea from body stores of ammonia, elevations seen |

| |in severe hepatic failure/injury and lead to encephalopathy (central nervous system dysfunction resulting |

| |from liver disease)and coma |

| | |

|Enzymes: |Cellular enzymes are released from hypoxic or damaged cells. |

|AST |AST, ALT, and LDH are increased from damaged liver, heart, kidney and muscle cells. |

|ALT |ALP is increased with biliary obstruction |

|LDH |LDH 5 is an isoenzyme from the liver and striated muscle |

|ALP |GGT is more specific to liver disease |

|GGT | |

• AST: Aspartate Amino Transferase, formerly SGOT

• ALT: Alanine Amino Transferase, formerly SGPT

• LDH: Lactic Dehydrogenase

• ALP: Alkaline Phosphate

• GGT: Gamma Glutamyl Transpeptide

Assessing People with Hepatic Disorders:

Common Hepatic Manifestations:

1. Abdominal pain or discomfort.

2. Nausea& vomiting.

3. Anorexia.

4. Weight loss.

5. Fluid and electrolytes imbalance.

6. Jaundice: Appear when the liver cannot able to metabolize bilirubin.

7. Altered mental or neurological status (Encephalopathy).

This symptom has been attributed to: increase level of ammonia and other protein by product in the blood because of the inability of the liver to metabolize them into urea.

8. Increased susceptibility to infection.

This symptom has been attributed to: the decreased ability of the liver to perform phagocytes may result in increased susceptibility to infection.

9. Altered bleeding tendencies. This symptom has been attributed to: The liver becomes unable to manufacture clotting factors or clear fibrinolysins result in increase the risk for bleeding.

10. Fatty food intolerance manifested by pain on ingestion of

fat.

11. Dark, tea-colored urine or clay colored stools.

12. Altered bowel habit.

Hepatitis

Definition:

Hepatitis is inflammation of the liver caused by viral infection or exposure to toxic chemicals

Clinical Manifestation of the Phases of Hepatitis:

|Preicteric |Icteric |Post Icteric |

|It lasts 1-21 days |It lasts 2-4 weeks |It persist several months |

|Anorexia. |Jaundice. |Malaise. |

|Nausea, vomiting. |Pruritus due to accumulation of bile salts under |Easy fatigability. |

|Right upper quadrant discomfort. |skin. |Hepatomegaly. |

|Decrease sense of taste and smell. |Dark urine. | |

|Malaise. |Bilirubinuria. | |

|Headache. |Light or clay colored stool. | |

|Fever. |Fatigue. | |

|Arthralgias. |Continued hepatomegaly with tenderness. | |

|Urticaria, rash. |Weight loss. | |

|Hepatomegaly & tenderness of the liver. | | |

|Splenomegaly. | | |

|Weight loss. | | |

• Jaundice: A condition characterized by raised bilirubin level in the blood.

• Bilirubin: The pigment gives bile its oranges color; it is a waste product from the break down of hemoglobin.

Characteristics of Viral Hepatitis

|Source of infection and spread of disease |Mode of transmission |Incubation Period |Virus Name |

|Contaminated food, milk, water and selfish; person's with sub clinical infections infected food|Fecal-oral route; poor sanitation, person to person contact.|15-50 days |Hepatitis A virus ( HAV) |

|handler, poor personal hygiene, poor sanitation. |Waterborne; food borne. |( average 30 days) | |

|Contaminated needles, syringes, and blood products. |Percutaneous (parenteral)/ permucosal exposure to blood or |28-160 days |Hepatitis B virus |

|Sexual activity with infected partners. |blood products |(average 70-80 days) |( HBV) |

|Oral-oral contact. |Sexual contact. | | |

|Tattoo / body piercing, bites. |Perinatal transmission | | |

|Occupational hazards for health care personnel, hemodialysis staff, chemotherapy nurses, | | | |

|operating room nurses, dentists, persons at risk needle sticks. | | | |

|Blood and blood products, needles and syringes. |Transfusion of blood and blood products |15-160 days |Hepatitis C virus |

|Sexual activity with infected partners. Increased with sexual transmitted disease. |Exposure to contaminated blood or blood products through |(average 50 days) |( HCV) |

|Chronic treatment with hemodialysis. |equipment | |(non A –non-B) |

| |High risk sexual contact. | |Called post transfusion H. |

| |Perinatal contact. | | |

|Same as HBV. |Can cause infection only together with HBV. |21-140 days |Hepatitis D virus ( HDV) |

| |Rotes of transmission same as for HBV. |(average 35days) | |

| |HBV surface antigen necessary for replication. |HBV must precede HDV; | |

| | |Chronic carriers of HBV are always at risk. | |

|Contaminated water; poor sanitation |Fecal-oral. |15-65days |Hepatitis E virus |

| |Outbreaks associated with contaminated water supply in |( average 42 days) |( HEV) |

| |developing countries | |Similar to HAV |

Nursing Care for a Patient with Hepatitis:

A-) Nursing Assessment:

Subjective Data: Important Health Information:

1. Past health history:

▪ Previous liver disease, hepatitis immunization.

▪ Hemophilia.(An inherited bleeding disease)

▪ Exposure to infected persons.

▪ Ingestion of contaminated food and water.

▪ Sexual promiscuity.

▪ Exposure to toxins.

▪ Exposure to contaminated needles.

▪ Recent travel.

▪ Organ transplant recipient.

▪ Exposure to new drug regimen.

2- Present illness:

▪ Fatigue.

▪ Weight loss.

▪ Weight changes.

▪ Digestive disturbance.

▪ Skin changes.

▪ Feeling of fullness in right upper quadrant.

3- Functional assessment:

▪ Diet,.

▪ Alcohol intake.

▪ Occupation.

▪ Exposure to toxins.

▪ Interpersonal relationship.

Objective Data:

Vital signs: Hypertension, tachypnea, low grade fever.

Skin: Dryness, scratches, jaundice, bruises, angioedema. (Sever form of urticaria which involve skin, face, hands and genital organ)

Eyes: Icteric sclera.

Thorax: Spider angiomas.

Abdomen: Distention, prominent veins, hepatomegaly, Splenomegaly.

Activity-exercise: Fatigue, Arthralgias (pain in joints), myalgias.

Possible findings:

▪ Abnormal liver enzyme studies.

▪ Elevated serum bilirubin.

▪ Hypoalbuminemia.

▪ Anemia.

▪ Bilirubin in urine and increased urobilinogen.

▪ Prolonged prothrombin time.

▪ Serologic test positive for hepatitis, including anti-HAV IgM, anti-HBc IgM, anti-HCV, anti-HDV.

▪ Abnormal liver scan.

▪ Positive liver biopsy.

Management:

All types of hepatitis:

1. Rest according to patient's level of fatigue.

2. Therapeutic measures to control dyspeptic symptoms and malaise.

3. Hospitalization for protracted nausea and vomiting or life-threatening complications.

4. Small, frequent feedings of a high-caloric, low –fat diet; proteins are restricted when the liver cannot metabolize protein by-products, as demonstrated by the symptoms.

5. Vitamin K injected subcutaneously if prothrombin time is prolonged.

6. Intravenous fluid and electrolyte replacement as indicated.

7. Administration of antiemetic for nausea.

8. After jaundice has cleared gradual increase in physical activity. This may require many months.

For HCV Patients:

Long-term interferon (Betaseron) therapy may produce at least temporary remission.

Complications:

1. Dehydration, Hypokalemia.

2. Chronic "carrier" hepatitis or chronic active hepatitis.

3. Diminution or arrest of flow of bile.

4. Fulminant hepatitis (sudden, sever onset of acute liver failure that occurs within 8 weeks of the first symptoms of jaundice).

5. HBV carriers have a higher risk of developing Hepatocellular carcinoma.

Preventive Measures of Viral Hepatitis

|Hepatitis A |Hepatitis B and C |

|General Measures: |Percutaneous Transmission: |

|Hand washing. |Screening of donated blood. |

|Proper personal hygiene. |Use of disposable needles and syringes |

|Environmental sanitation. |Sexual Transmission: |

|Safe practice for preparing and dispensing food |Acute exposure: HBIG administration to sexual partner of HbsAg-positive person. |

|Control and screening (signs and symptoms of food handlers). |Use condom for sexual intercourse. |

|Serologic screening while carrying virus. |General Measures: |

|Active immunization. |Hand washing. |

|Community health education program. |Avoid sharing tooth brushes and razors |

|Use of immune globulin: |HBIG administration for one-time exposure (needle stick, contact of mucous |

|Early administration (1-2 weeks after exposure to those exposed). |membranes with infectious material). |

|Use of prophylaxis for travelers to areas where hepatitis A is common. |Active immunization: HBV vaccine. |

Measures to Prevent Transmission of Hepatitis Viruses From Patients to health Care Personnel:

|Hepatitis A |Hepatitis B |Hepatitis C |

|Always maintain good personal hygiene. |Use infection control precautions. |Use infection control precaution. |

|Wash hands after contact with a patient or |Wash hands. |Wash hands. |

|removal of gloves. |Reduce contact with blood or blood-containing secretions. |Reduce contact with blood or blood contaminated |

|Use infection control precautions. |Handle the blood of patients as potentially infective. |secretions. |

| |Dispose of needles properly. |Handle the blood of patient as potentially infective.|

| |Administer HBV vaccine to all health care personnel. |Dispose needles properly. |

| |Use needles IV access devices when available. |Use needlesless IV access devices when available. |

|Nursing Diagnosis |Goals |Nursing Intervention |

|Altered Nutrition: Less Than Body |Maintaining Adequate Nutrition |Assess patient’s appetite and adequacy of intake. |

|Requirements related to anorexia and altered | |Provide oral care before meals to enhance patient dietary intake |

|metabolism of nutrient by the liver as | |Encourage frequent small feedings of high-calorie, low-fat diet. Avoid large quantities of protein during acute phase of illness. |

|manifested by inadequate food intake , | |Allow patient to choose food items ; serve high-carbohydrate and high protein foods at time of day patient feels most like eating |

|aversion to eating . | |to increase likllihood of adequate intake |

| | |Encourage eating meals in a sitting position to decrease pressure on the liver. |

| | |Encourage pleasing meals in an environment with minimal noxious stimuli (odors, noise, interruptions(. |

| | |Take weight daily in on same scale , at same time, with same clothes to monitor weight loss secondary to poor appetite. |

| | |Administer or teach self-administration of antiemetics as prescribed. Avoid phenothiazines, such as chlorpromazine (Thorazine), |

| | |which have a cholestatic effect and may cause or worsen jaundice |

|Fluid Volume Deficit related to nausea and/or| | |

|vomiting | | |

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