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Chapter 55

Hepatitis and Cirrhosis

What is hepatitis? (Pg. 610) Inflammation of the liver cells
What causes hepatitis? Classified as? Viral, toxic agent, or 2ndary infection. Acute or chronic
What is cirrhosis? Permanent scarring of the liver that is usually caused by chronic inflammation
What is the most common type of hepatitis? Viral
What do toxic and drug induced hepatitis occur secondary to? Exposure of a chemical or med. Ex. alcohol, industrial toxins, ephedra or acetaminophen
Can hep occur in conjunction with other virus's? Yes. Ex. varicella-zoster, cytomegalovirus, or herpes
5 major categories of viral hep? Hep A (HAV), Hep B (HBV), Hep C (HCV), Hep D (HDV), Hep E (HEV)
What happens when exposed to a virus or toxin? Liver becomes enlarged from inflammation & w progression of disease= increase in inflammation & necrosis, interfering with blood flow to the liver
Is hepatitis symptomatic? Depends. Some can be infected and not no & be contagious
Personal protective equipment with Hep A and Hep B/C? Hep A: incontinent clients. Hep B/C: exposure to blood
1. Hep A (HAV): Route of transmission & Risk factors Fecal-oral route. Ingestion of contaminated food/water, close personal contact w/ infected person
2. Hep B (HBV): Route & Risks Blood. Unprotected sex, birth canal, contact w/ blood, injection drug users
3. Hep C (HCV): Route & Risks Blood. Drug abuse & sexual contact
4. Hep D (HDV): Route & Risks Coinfection w/ HBV (need B to get D). Injection drug users & unprotected sex
5. Hep E (HEV): Route & Risks Fecal-oral route. Ingestion of contaminated food or water
High-risk behaviors: (Pg. 612) Blood transfusions (unscreened back in the day), hemodialysis, percutaneous exposure (dirty needle), unprotected sex, food, traveling to countries, crowded env't
S/S: Influenza like symptoms: Fatigue, low appetite w/ nausea, abdominal pain, joint pain. Also--> Fever, vomit, dark-colored urine, clay-colored stool, jaundice
ALT expected range: 3-35 IU/L or 8-20U/L
AST expected range: 5-40U/L
ALP expected range: 30-120U/L
Total bilirubin level: 0.1 to 1.0 mg/dl
What does the presence of IgM antibodies indicate? Inflammation of the liver
What does presence of IgG antibodies indicate? Permanent immunity to Hep A
Hep A lab results: ^ ALT, ^ AST, normal or ^ ALP, ^ total bilirubin, presence of Hep A virus antibodies (anti-HAV)
Hep B lab results: ^ ALT, ^ AST, normal or ^ ALP, ^ total bilirubin, Hep B surface antigen (HBSaG) = infectious,
What does the presence of Hep B surface antibody (anti-hsb) indicate? Recovery & immunity from HBV infection
What does the presence of Hep Bc ore antibody (anti-hcb) indicate? Previous or ongoing infection
What does the presence of Hep B e antigen (hbeag) indicate? Virus is replicating
What does the presence of Hep B e antibody (anti-hbe) indicate? Predictor of long-term clearance of the virus
Hep C lab results? ^ ALT, ^ AST, normal or ^ ALP, ^ total bilirubin, presence of hep C virus antibodies (anti-HCV) = hep C infection & presence of enzyme immunoassay (EIA) = HEP C.
What else indicates a Hep C infection? CIA, RIBA. and HCV RNA polymerase chain reaction (PRC) is a qualitative test to detect the presence and amount of Hep C virus
Hep D lab results? Identification of intrahepatic delta antigen, presence of Hep D virus antibodies (anti-HDV) indicates it.
Hep E lab results? Hep E virus antibodies (anti-HEV) indicates the presence of the virus
Dx procedures for hepatitis: 1. liver biopsy Most definitive dx! -intensity of infection & degree of liver damage
Liver biospy preprocedure nursing: Explain, witness informed consent, client fasts for at lest 2hr, administer prescribed meds
Liver biospy intra: Supine w/ upper right quadrant of the abdomen exposed. Relax. Exhale breath & hold for at least 10 seconds while needle is inserted. Resume breathing once needle is withdrawn. Pressure to site.
Liver biospy post: Maintain a right side lying position for several hours. VS, abd pain, bleeding at site.
Nursing care: diet & exercise & meds. Limit activity to allow liver to heal. High-carb, high-calorie, low-mod fat, low-mod protein. Small, frequent meals. Administer only necessary meds.
Meds Hep A: vaccine? Vaccine for post exposure protection. Immunoglobulin for post exposure protection for people >40yr, kids <12 months & people w chronic liver disease, immunocomprmised or people allergic to the vaccine
Meds Hep B: Acute vs. chronic Acute: no meds, supportive. Chronic: antiviral meds
Antiviral meds: Adefovir dipivoxil (hersera), interferon alpha 2b (Intron A), peginterferon alfa-2a (pegasys), lamivudine (epivr-HBV), antecavir (baraclude), and telbivudine (tyzeka)
Hep C meds: Combination therapy w/ peginterferon & ribavirin (Virazole)
Hep D meds: Same as for Hep. B
Hep E meds: No meds, supportive care
Complications of Hepatitis: 1. chronic Ongoing inflame of liver cells, from B, C, D, ^ risks for liver cancer
Complications of Hepatitis: 2. Fulminating Extremely progressive form of viral hep. S/S of viral then days later severe liver failure, prevention of viral hep, no meds, supportive care.
Complications of Hepatitis: 3. Cirrhosis. Other; liver cancer & failure Permanent scarring of the liver that is usually caused by chronic inflx
Cirrhosis (Pg. 616) Extensive scarring of the liver caused by necrotic injury or a chronic reaction to inflmx over a prolonged period of time. Normal liver tissue is replaced w fibrotic tissue that lacks function
What areas of the liver become involved w cirrhosis? Portal & periportal areas; affects flow of bile. New bile channels = over growth of tissue & liver scarring/enlargment. = JAUNDICE
3 types of cirrhosis? Postnecrotic, laennec's, biliary
What is post necrotic cirrhosis? Caused by viral hepatitis or certain meds/toxins
What is laennec's? Caused by chronic alcoholism
What is biliary? Caused by chronic biliary obstruction or autoimmune disease
Risks to cirrhosis? Alcohol, chronic viral hep B,C,D, autoimmune hep, steatohepatitis, liver damage, chronic biliary cirrhosis, cardiac cirrhosis
S/S cirrhosis? Fatigue, wt loss, abd pain/distention, pruritis, confusion or difficulty, personality/mental changes, emotional lability, euphoria, depression
S/S con't: -cognitive, sleep, emotions Changes, altered sleep wake, depression lability, euphoria
S/S con't: GI bleeding; varices burst (vomit/BMs), ascites (bloating in abdomen/legs from fluid build up), jaundice, icterus (yellowing of eyes), petechiae, ecchymoses, nosebleeds, hematemesis, melena
What petechiae? Round, pinpoint, red-purple lesions
Ecchymoses? Large yellow & purple bruises
S/S con't: Palmar erythema, spider angiomas, dependent edema, asterixis, fetor hepaticus
What are spider angiomas? red lesions, vascular in nature w branches radiating on the nose, cheeks, upper thorax, shoulders
Asterixis Liver flapping tremor; course tremor characterized by rapid, nonrhythmic extension and flexion of the wrists and fingers
Fetor hepaticus Liver breath; fruity or musty odor
Lab tests with cirrhosis -Serum liver enzymes Elevated initially ALT, AST, ALP. ALT & AST ^ initially d/t inflammation & return to normal when liver is no longer to create an inflx response. ALP ^ d/t intrahepatic biliary obstruction
Lab tests with cirrhosis -Serum bilirubin Elevated d/t liver's inability to excrete bilirubin
Bilirubin indirect unconjugated (0.2 to 0.8 mg/dl)
Bilirubin total 0.1 to 1.0
Lab tests with cirrhosis -Serum protein Decreased d/t lack of hepatic synthesis
Normal serum protein levels 6-8
Lab tests with cirrhosis -Serum albumin Decreased d/t lack of hepatic synthesis
Normal albumin levels: 3.5-5
Hematological tests: RBC, H&H & plts decreased
Normal RBC count: Female: 4..2-5.4 million, Male: 4.7 to 6.1 million
Normal Hemoglobin: F: 12 to 16. M: 14 to 18
Normal Hematocrit: F: 37-47. M: 42-52
Normal plt count: 150,000 to 400,000
PT/INR: Prolonged d/t decreased synthesis of prothrombin
PT range: 11 to 12.5
INR range: 0.7 to 1.8
Ammonia levels: rise w cirrhosis; prevents conversion of ammonia to urea for excretion (toxic)
Normal ammonia levels? 11 to 32
Serum creatinine levels? increase d/t deteriorating kidney function w/ advanced liver disease
Normal serum creatinine? F: 0.5 to 1.1 and M: 0.6 to 1.2
DX for cirrhosis: US, X-rays & CTs, MRI, liver biopsy, EGD, ERCP (see more pg. 618)
Nursing: Resp, skin, fluid, VS, neuro, nutrition, GI status, pain -Sit up, 30 degrees for breathing at least. Minimize pressure ulcers, cold water & lotion for itching. Strict I&O, hepatic encephalopathy; (lactulose & ammonia), measure abdominal girth daily (ascites)
Nutrition for cirrhosis? High-carb, high-protein, mod-fat, low-sodium w/ vitamins; thiamine, folate
Meds: Metabolism = liver.. so use sparingly especially opioids, sedatives and barbiturates
Meds: Diuretics Rid of excess fluid volume
Meds: BB used w/ varices to prevent bleeding
Meds: Lactulose (Cephulac) excretes ammonia through the stool
Meds: Nonabsorpable antibiotic: can be used in place of lactulose
Procedures: 1. Paracentesis.. pre care Explain, witness informed consent, VS & wt, assist client to void
1. Paracentesis.. during Supine w/ HOB elevated, relax, dressing over puncture site
1. Paracentesis.. after VS, bed rest, measure fluid TACO, send specimen to lab, assess dressing for drainage, WT
2. EVL/EST Endoscopic variceal ligation/Endoscopic sclerotherapy: varices sclerosed or banded endoscopically. Decreased risk for hemorrhage with banding
3. Transjugular intrahepatic portosystemic shunt TIPS; Performed in interventional radiology for clients who require more w ascites
Surgical interventions (Pg. 620) 1. Surgical bypass shunting LAST resort for portal htn & varices. Ascites are shunted from abdominal cavity to the SVC
Surgical interventions (Pg. 620) 2. Liver transplant Portions can be used from trauma or healthy livers. Part will regenerate & grow w body. Need transport criteria
Who are not candidates? Cardiac & respiratory disease, metastatic malignant liver cancer, alcohol/substance con't hx. See pg. 620 for after surgery actions
Low protein diet if..? Encephalopathy, high ammonia
Complications: PSE Portal systemic encephalopathy: waste products liver can't covert are carried to the brain; reduce dietary protein & give lactulose for high ammonia
What lab value should be monitored on lactulose d/t s/e? Potassium, can be low
Worsening s/s of encephalopathy? Asterixis and hepaticus
Complications: Esophageal varices Portal htn, ^ BP in veins that carry blood from intestines to the liver. Caused by impaired circulation of blood through the liver. Collaterals are developed; upper stomach & esophagus. Fragile & can bleed easily. Don't bear down!
Esophageal varices; nursing actions Saline lavage (vasoconstriction), esophagogastric balloon tamponade, blood transfusions, ligation & sclerotherapy & shunts to stop bleeding & reduce risk for hypovolemic shock. Monitor H&H, and bleeding.
Complications: Acute graft rejection post liver transplantation -When does it occur? S/S 4-10 days after surgery usually occurs. S/S: tachycardia, upper right flank pain, jaundice, lab values indicate failure.
Causes of acute graft rejection: GVHD (graft versus host disease); recipients bone marrow cells creates T-cells to attack the new organ
What do you give if this happens? Immunosuppresants & monitor WBC
Created by: mary.scott260!