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T3: Hepatitis

QuestionAnswer
Inflammation of the liver. hepatitis
Causes of hepatitis viruses (common); drugs (alcohol); chemicals; autoimmune diseases; metabolic abnormalities
Type of viral hepatitis A, B, C, D, E
Mild to acute liver failure, not chronic, incidence dec. w/vaccination, RNA virust transmitted by fecal-oral rte or by contaminated foor or drinking water. Hepatitis A Virus (HAV)
Cause acute or chronic disease, incidence dec. w/vaccination, DNA virus transmitted: perinatally, percutaneously, mucosal exposure to infectious blood, or body fluids. Hepatitis B Virus (HBV)
Who is at risk for HBV? Men who have sex w/men; household contact of chronically infected; pts undergoing hemodialysis; health care & public safety workers; transplant recipients
How long can HBV live on a dry surface? For at least 7 days, HBV is much more infectious than HIV.
Can be acute (asymptomatic) or chronic (liver damage), RNA virus transmitted percutaneously: IV drug use, high risk sexual behaviors, occupational exposure, dialysis, perinatal exposure blood transfusions before 1992. Hepatitis C Virus (HCV)
Also know as delta virus, is a defective single-stranded RNA virus that can't survive on its own; requires HBV to replicate; transmitted percutaneously; no vaccine. Hepatitis D Virus (HDV)
An RNA virus, transmitted by fecal oral rte, most common mode of transmission: drinking contaminated water; occurs primarily in developing countries; few cases in US. Hepatitis E Virus (HEV)
Liver damage by cytotoxic cytokines & natural killer cells that cause lysis of infected hepatocytes. Inflammation can interrupt bile flow (cholestasis). After resolution liver cells can regenerate back to normal function & appearance. acute hepatitis infection
Can cause fibrosis and progress to cirrhosis. chronic hepatitis infection
CM of viral hepatitis Can be acute and chronic. Acute usually no symptoms but may have intermittent or ongoing malaise, fatigue, myalgias, arthralgias, and hepatomegaly.
CM during the incubation period of the acute phase of hepatitis Malaise, anorexia, wt loss, fatigue, N/V, abdominal discomfort, distaste for cigarettes (smokers), dec. sense of smell, headache, low-grade fever, arthralgias, skin rashes
Physical examination may reveal what? Hepatomegaly, lymphadenopathy, splenomegaly; may be icteric (jaundice) or anicteric; if icteric pt can have dark urine, light or clay colored stools, pruritus.
A yellowish discoloration of body tissues, results from an alteration in normal bilirubin metabolism or flow of bile into the hepatic or biliary duct systems. jaundice
Why would the urine darken with jaundice? B/c of excess bilirubin being excreted by the kidneys.
Why are the stools light or clay colored with jaundice? B/c conjugated bilirubin cannot flow out of the liver b/c of obstruction or inflammation of the bile ducts.
Intense chronic itching. pruritus
Why does pruritus occur with jaundice? B/c of the accumulation of bile salts beneath teh skin.
The convalescent phase follows the acute phase and begins when? Jaundice disappears and lasts for weeks to months, with an average of 2 to 4 months.
What is the patient's major complaints during the convalescent phase? Malaise and easy fatigability. Hepatomegaly remains for several weeks, but splenomegaly subsides during this period.
Complications of hepatitis acute liver failure, chronic hepatitis, cirrhosis, hepatocellular carcinoma
What is the only definitive way to distinguish among the various forms of viral hepatitis? By testing the patient's blood for the specific antigen and/or antibody.
Many liver function tests show abnormalities in what? AST, ALT, GGT (liver enzymes) & alkaline phosphatase levels all elevated. Serum proteins: y-globulin level normal or inc. Albumin normal or dec. Bilirubin (total) & urinary levels inc. PT prolonged.
Diagnostic studies for hepatitis liver function tests, viral genotype test: HBV, HCV; physical assessment findings; liver biopsy; FibroScan; FibroSure (FibroTest)
When caring for patients with hepatitis what measures would you emphasize? To rest the body and assist the liver in regenerating. Adequate nutrition & rest seem to be most beneficial for healing and liver cell regeneration. If anorexia, N/V are severe, IV sol. of glucose or supple. enteral nut. therapy. Maintain F&E balance.
Why is rest so important with hepatitis? It reduces the metabolic demands on the liver and promotes cell regeneration.
What should you teach the pt with hepatitis to avoid? Alcohol intake and drugs detoxified by the liver.
What drug therapies are used for HAV? no specific drug therapy
What drug therapy is used for HCV? Pegylated interferon within the first 12-24 wks of infections markedly reduces the development of chronic hep C
Supportive drug therapy for hepatitis antiemetics for nausea such as prohlorperazine (Compazine), promethazine (Phenergan), or ondansetron (Zofran)
Drug therapy for chronic HBV infection is focused on what? Decreasing the viral load and liver enzyme levels, and slowing the rate of disease progression.
What are the long term goals for chronic HBV? Prevention of cirrhosis, hepatic failure, and hepatocellular cancer.
What are the drug therapies for chronic HBV and how do they work? First line therapy are peglyated interferon and nucleoside and nucleotide analogs. They don't eradicate the virus but work well to suppress viral replication and prevent complications of Hep B.
Functions of interferons on viral replication. After binding to receptors on host cell membranes, the drug blocks viral entry into cells, synthesis of viral proteins, and viral assembly and release.
What are the 2 forms of interferons? standard and pegylated
This interferon has a short half-life, necessitating frequent subcutaneous administrations (3x/wk). standard (conventional) interferon (Intron A)
This interferon are long acting preparations that are administered subq once per week, making them more convenient plus the blood levels remain high b./t doses so clinical responses are better. pegylated interferons
How are the long acting interferons made? By conjugation of a standard interferon with polyethylene glyco (PEG), in a process known as pegylation.
What is the function of the PEG component? To delay elimination of the drug.
Why are pegylated interferons preferred over standard interferons in the treatment of HBV and HCV? They are more convenient and have superior efficacy.
Patients receiving interferon should have what performed every 4-6 weeks? blood counts and liver function tests
What are the side effects of interferon? flu-like symptoms, depression, irritability, insomnia, neutropenia, thrombocytopenia
How does the Hepatitis B virus reproduce? By making copies of its viral DNA nucleosides and nucleotides.
What is the function of nucleoside/nucleotide analog drugs? Masquerade as normal building blocks for DNA thereby "fooling" the Hep B virus. Thus the virus is unable to reproduce.
T/F: Nucleoside/nucleotide analogs prevent all viral reproduction. False. They do not prevent all viral reproduction but they can substantially lower the amount of virus in the body.
Examples of nucleoside/nucleotide analogs lamivudine (Epivir), adefovir (Hepsera), entecavir (Baraclude), telbivudine (Tyzeka), and tenofovir (Viread)
When are nucleoside/nucleotide analogs used? Long term treatment of chronic HBV when there is evidence of active viral replication.
What are the beneficial effects of nucleoside/nucleotide analogs? reduce viral load, decrease liver damage, and decrease liver enzymes
Treatment of chronic hepatitis C is individualized by what? Based on the genotype, the severity of liver disease, potential side effects, presence of co-morbid conditions, patient's readiness for treatment, and presence of other health problems (HIV).
Drug therapy for chronic Hepatitis C is directed at what? Eradicating the virus and preventing HCV related complications.
What is the treatment for HCV? Includes pegylated interferon (PEG-Intron, Pegasys) given with ribavirin (Rebetol, Copegus). PEG interferon is injected once a week & ribavirin is taken orally twice daily. This has a synergistic effect & reduces relapse after Hep C treatment.
What should be warned about taking Ribavirin? It is teratogenic so pregnancy must be avoided, both by women taking the drug and by women whose male partners are taking the drug.
What protease inhibitors can be taken for patients who have HCV genotype 1? telaprevir (Incivek), boceprevir (Victrelis)
What past health history is important to obtain when diagnosing hepatitis? History of hemophilia, exposure to infected persons, ingestion of contaiminated food or water, ingestion of toxins, past blood transfusion (before 1992), and other risk factors. Also use/misuse of acetaminophen, OTC or herbal meds
What objective data would you note upon assessment of hepatitis? low-grade fever, lethargy, lymphadenopathy, rash or other skin changes, jaundice, icteric sclera; hepatomegaly, splenomegaly, abnormal labs
What are some preventive measures for HAV? Personal & environmental hygiene & health education promote good sanitation. Hand washing important precaution esp after BM & before eating. Control & screening (S/S) of food handlers. Vaccination prophylaxis & immune globulin postexposure prophylaxis.
What is the best protection against HAV? vaccination
Should a person with HAV be put in isolation? No use infection control measures but isolation is not required.
Immune globulin (IG) provides what type of immunity for HAV and when should it be given? Temporary (1-2 mths) passive immunity and is effective if given w/i 2 wks after exposures.
When is IG recommended? For people who do not have anti-HAV antibodies & are exposed as a result of close (household, day care center) contact w/persons who have HAV or foodborne exposure.
Patients with HAV are most infectious when? Just before the onset of symptoms (the preicteric phase).
What is Twinrix? a combined HAV and HBV vaccine
What individuals should be given Twinrix? People who are at high risk, including pts w/chronic liver disease, users of ilicit IV drugs, pts on hemodialysis, men who have sex w/men, & persons w/clotting factor disorders who receive therapeutic blood products.
What are some preventive measures for HBV? Identify those at risk, screen for HBV, & vaccinate. Good hygienic practices (handwashing & use gloves when contact w./blood), don't share razors toothbrushes, etc; use condoms & vaccinate.
What is used as postexposure prophylaxis for HBV? HBV vaccine & hepatitis B immune globulin (HBIG)
When is HBIG recommended? For postexposure prophylaxis in cases of needle stick, mucous membrane contact, or sexual exposure & for infants born to mothers who are HBsAg-positive.
What are the primary measures to prevent HCV? Screen blood, organ, & tissue donors; use infection control precautions; modify high-risk behavior.
What does the CDC recommend for postexposure prophylaxis for HCV? Following acute exposure (needle stick) the person should ahve anti-HCV testing done, baseline anti-HCV & ALT levels should be measured. F/u testing for anti-HCV & ALT done at 4-6 mths. Test for HCV RNA performed at 4-6 wks.
What should be assessed for in patients with hepatitis? Assess for jaundice (usu observed first in sclera of eyes & later in skin); for dark skin people observe jaundice in hard palate of mouth & inner canthus of eyes; urine may be dark brown or brownish red color.
Nursing interventions for hepatitis. Comfort measures to relieve pruritus (if present), headache, & arthralgias. Ensure pt receives adeq. fluid & nutrition (small, freq meals), stimulate appetite (mouth care, antiemetics); carbonated drinks or avoid very hot/cold foods helps w/anorexia.
What is essential & an important factor in promoting hepatocyte regeneration? rest (physical, psychologic, & emotional);
Created by: eblanc1