Hepatitis Nursing management

Hepatitis is an umbrella term for a variety of viral, bacterial, and noninfectious causes of widespread inflammation that results in necrosis and scaring of liver cells. Inflammation of the liver can be due to viral or bacterial invasion. Noninfectious causes include physical or toxic chemical agents (e.g., drugs, alcohol, industrial chemicals) and nonalcoholic or autoimmune hepatitis.

Viral infections can be transmitted by blood and body fluids and/or food. These viruses are designated by letters of the alphabet, (A, B, C, D, E, G) and variously used (e.g., B is known as HBV, or HepB). HCV is responsible for about 30% of viral hepatitis cases. Other causes of hepatitis include cytomegalovirus (CMV), Epstein-Barr virus (EBV), Mycobacterium avium complex (MAC), toxoplasmosis, and histoplasmosis. Studies have shown that almost 25% of persons with human immunodeficiency virus (HIV) infection also have hepatitis. 
Hepatitis can be acute or chronic. Although most cases of hepatitis are self-limiting, approximately 5%–10% of clients with hepatitis B and 80%–85% of clients with hepatitis C progress to a chronic state. Chronic inflammation can lead to fibrotic scarring (cirrhosis) and can be fatal.

Client Assessment Database
   Data depend on the cause (type of hepatitis) and severity of liver involvement/damage.
May report: Fatigue, weakness, general malaise, muscle aches

May exhibit: Bradycardia (severe hyperbilirubinemia)
Jaundiced sclera, skin, mucous membranes

May report: Dark urine
Diarrhea/constipation, clay-colored stools
Current/recent hemodialysis

May report: Loss of appetite (anorexia), weight loss or gain (edema)
May exhibit: Ascites

May exhibit: Irritability, drowsiness, lethargy, asterixis, headache

May report: Abdominal cramping, right upper quadrant (RUQ) tenderness
Myalgias, arthralgias; headache
Itching (pruritus)
May exhibit: Muscle guarding, restlessness

May report: Distaste for/aversion to cigarettes (smokers)
Recent flu-like URI signs and symptoms

May report: Transfusion of blood/blood products in the past
May exhibit: Fever
Urticaria, maculopapular lesions, irregular patches of erythema
Exacerbation of acne
Spider angiomas, palmar erythema, gynecomastia in men (sometimes present in alcoholic hepatitis)
Splenomegaly, posterior cervical node enlargement

May report: Lifestyle/behaviors increasing risk of exposure (e.g., sexual promiscuity, sexually active homosexual/bisexual male)

May report: History of known/possible exposure to virus, bacteria, or toxins (contaminated food, water, needles, surgical equipment or blood), carriers (symptomatic or asymptomatic), recent surgical procedure with halothane anesthesia, exposure to toxic chemicals (e.g., carbon tetrachloride, vinyl chloride)
History of known/possible exposure to hepatotoxic prescription (e.g., sulfonamides, phenothiazines, isoniazid) or OTC drug use (e.g., acetaminophen)
Use of herbal supplements associated with heptotoxicity, (e.g., chaparral, JinBuHuan, germander, comfrey, mistletoe, skullcap, margosa oil, pennyroral)
Use of street injection drugs or alcohol
Travel to/immigration from China, Africa, Southeast Asia, Middle East (hepatitis B [HBV] and C (HVC) are endemic in these areas)
Concurrent diabetes, HF, malignancy, or renal disease

Discharge plan
considerations: May require assistance at home with maintenance tasks
Refer to section at end of plan for postdischarge considerations.

Diagnostic Studies
Liver enzymes/isoenzymes: Abnormal (4–10 times normal values). However, of limited value in differentiating viral from nonviral hepatitis.
AST/ALT: Initially elevated. May rise 1–2 weeks before jaundice is apparent, then decline.
Alkaline phosphatase (ALP): Slight elevation (unless severe cholestasis present).
Hepatitis A, B, C, D, E panels (antibody/antigen tests): Specify type and stage of disease and determine possible carriers.
CBC: Red blood cells (RBCs) decreased because of shortened lifespan of RBCs (liver enzyme alterations) or hemorrhage.
WBC count and differential: Leukopenia, leukocytosis, monocytosis, atypical lymphocytes, and plasma cells may be present.
Serum albumin: Decreased.
Blood glucose: Transient hyperglycemia/hypoglycemia (altered liver function).
Prothrombin time: May be prolonged (liver dysfunction).
Serum bilirubin: Above 2.5 mg/100 mL. (If above 200 mg/100 mL, poor prognosis is probable because of increased cellular necrosis.)
Stools: Clay-colored, steatorrhea (decreased hepatic function).
Bromsulphalein (BSP) excretion test: Blood level elevated.
Liver biopsy: Usually not needed, but should be considered if diagnosis is uncertain, or if clinical course is atypical or unduly prolonged.
Liver scan: Aids in estimation of severity of parenchymal damage.
Urinalysis: Elevated bilirubin levels; protein/hematuria may occur.
Nursing Care
Nursing Priorities

1. Reduce demands on liver while promoting physical well-being.
2. Prevent complications.
3. Enhance self-concept, acceptance of situation.
4. Provide information about disease process, prognosis, and treatment needs.

Discharge Goals

1. Meeting basic self-care needs.
2. Complications prevented/minimized.
3. Dealing with reality of current situation.
4. Disease process, prognosis, transmission, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

May be related to

Decreased metabolic energy production
States of discomfort
Altered body chemistry (e.g., changes in liver function, effect on target organs)
Possibly evidenced by

Reports of lack of energy/inability to maintain usual routines
Decreased performance
Increase in physical complaints
Endurance (NOC)

Report improved sense of energy.
Perform ADLs and participate in desired activities at level of ability.

NURSING DIAGNOSIS: imbalanced Nutrition: less than body requirements
May be related to

Insufficient intake to meet metabolic demands: anorexia, nausea/vomiting
Altered absorption and metabolism of ingested foods: reduced peristalsis (visceral reflexes), bile stasis
Increased caloric needs/hypermetabolic state
Possibly evidenced by

Aversion to eating/lack of interest in food; altered taste sensation
Abdominal pain/cramping
Loss of weight; poor muscle tone
Treatment Behavior: Illness or Injury (NOC)
Initiate behaviors, lifestyle changes to regain/maintain appropriate weight.
Nutritional Status (NOC)
Demonstrate progressive weight gain toward goal with normalization of laboratory values and no signs of malnutrition.
NURSING DIAGNOSIS: risk for deficient Fluid Volume
Risk factors may include

Excessive losses through vomiting and diarrhea, third-space shift
Altered clotting process
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Hydration (NOC)

Maintain adequate hydration, as evidenced by stable vital signs, good skin turgor, capillary refill, strong peripheral pulses, and individually appropriate urinary output.
Coagulation Status (NOC)
Be free of signs of hemorrhage with clotting times WNL.
NURSING DIAGNOSIS: situational low Self-Esteem
May be related to
Annoying/debilitating symptoms, confinement/isolation, length of illness/recovery period
Possibly evidenced by

Verbalization of change in lifestyle, fear of rejection/reaction of others, negative feelings about body, feelings of helplessness
Depression, lack of follow-through, self-destructive behavior
Self-Esteem (NOC)

Verbalize feelings.
Identify methods for coping with negative perception of self.
Verbalize acceptance of self in situation, including length of recovery/need for isolation.
Acknowledge self as worthwhile; be responsible for self
NURSING DIAGNOSIS: risk for Infection
Risk factors may include

Inadequate secondary defenses (e.g., leukopenia, suppressed inflammatory response) and immunosuppression
Insufficient knowledge to avoid exposure to pathogens
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Risk Control (NOC)

Verbalize understanding of individual causative/risk factor(s).
Demonstrate techniques; initiate lifestyle changes to avoid reinfection/transmission to others.
NURSING DIAGNOSIS: risk for impaired Skin/Tissue Integrity
Risk factors may include
Chemical substance: bile salt accumulation in the tissues
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Tissue Integrity: Skin and Mucous Membranes (NOC)

Display intact skin/tissues free of excoriation.
Report absence/decrease of pruritus/scratching.
NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May be related to

Lack of exposure/recall; information misinterpretation
Unfamiliarity with resources
Possibly evidenced by

Questions or statements of misconception, request for information
Inaccurate follow-through of instructions, development of preventable complications
Knowledge: Illness Care (NOC)

Verbalize understanding of disease process, prognosis, and potential complications.
Identify relationship of signs/symptoms to the disease and correlate symptoms with causative factors.
Verbalize understanding of therapeutic needs.
Initiate necessary lifestyle changes and participate in treatment regimen.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition/presence of complications, personal resources, and life responsibilities)

Fatigue—generalized weakness, decreased strength/endurance, pain, imposed activity restrictions, depression.
impaired Home Maintenance—prolonged recovery/chronic condition, insufficient finances, inadequate support systems, unfamiliarity with neighborhood resources.
imbalanced Nutrition: less than body requirements—insufficient intake to meet metabolic demands: anorexia, nausea/vomiting; altered absorption and metabolism of ingested foods; increased calorie needs/hypermetabolic state.
risk for Infection—inadequate secondary defenses; malnutrition; insufficient knowledge to avoid exposure to pathogens.

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