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Chapter 55
Hepatitis and Cirrhosis
| Term | Definition |
|---|---|
| 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:
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