UNKLAB NURSING PORTAL

Viral Hepatitis

Description

  • Is a viral infection of the liver associated with a broad spectrum of clinical manifestations from asymptomatic infection through icteric hepatitis to hepatic necrosis.

Five forms of viral hepatits

Type A Hepatitis (HAV), (infectious hepatitis)

  • Is caused by an RNA virus of the enterovirus family.
  • It spreads primarily by fecal-oral route, usually through the ingestion of infected food or liquids.
  • It may also spread from person-to-person contact and, rarely, by blood transfusion.
  • Type A hepatitis occurs worldwide, especially in areas with overcrowding and poor sanitation.

Type B Hepatitis (HBW), (serum hepatitis) 

  • Is caused by a double-shelled virus containing DNA.
  • It spreads primarily through blood (percutaneous and permucosal route).
  • It can also spread by way of saliva, breast feeding, or sexual activity (blood, semen, saliva, or vaginal secretions.
  • Male homosexuals are at high risk for infection.
  • After acute infection, 10% of patients progress on to carrier status or develop chronic hepatitis.
  • HBV is the main cause of cirrhosis and hepatocellular carcinoma.

Type C Hepatitis (HCV),( non-A, non-B hepatitis or posttransfusion hepatitis) 

  • Formerly called non-A, non-B hepatitis, usually spreads through blood or blood product transfusion, usually from asymptomatic blood donors.
  • It may also be transmitted through unsterile piercing or tattooing tools or dyes.
  • It commonly affects I.V. drug users and renal dialysis patients and personnel.
  • HCV is the most common form of postransfusion hepatitis.

Type D Hepatitis (HDV),(delta agent hepatitis)

  • Also known as Delta hepatitis.
  • Is caused by a defective RNA virus that requires the presence of hepatitis B-specifically, hepatitis B surface antigen (HBsAg) – to replicate.
  • HDV occurs along with HBV or may superinfect a chronic HBV carrier, and cannot outlast a hepatitis B infection.
  • It occurs primarily in I.V. drug abusers or those who have had multiple blood transfusions, but the highest incidence is in the Mediterranean, Middle East, and South America.

Type E Hepatitis (HEV),(enterically transmitted or epidemic non-A, non-B)

  • Is caused by a nonenveloped, single-strand RNA virus.
  • It transmitted by the fecal-oral route but is hard to detect because it is inconsistently shed in the feces.
  • Its occurence is primarily in India, Africa, Asia, or Central America.

Fulminant Hepatitis

  • Is a rare but severe complication of hepatitis, which may require liver transplantation.

Stages of Viral Hepatitis

  1. Preicteric Stage- The first stage of hepatitis preceding the apperance of jaundice.
  2. Icteric Stage– The second stage of Hepatitis, which includes the apperance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools
  3. Posticteric Stage- The convalescent stage in which the jaundice decreases and the color of the urine and stool return to normal.

Causes/ Risk Factors

  • Hepatitis can be caused by bacteria,by hepatotoxic agents (drugs,alcohol,industrial chemicals), or most commonly,by a virus.

Pathophysiology

Assessment 

Type A hepatitis

  • Incubation period, 3 to 5 weeks.
  • Prodromal symptoms: fatigue, anorexia, malaise, headache, low-grade fever, nausea, vomiting. Highly contagious at this time, usually 2 weeks before onset of jaundice.
  • Icteric phase: jaundice, tea-colored urine, clay0colored stools, right upper quadrant pain and tenderness.
  • Symptoms often milder in children.

Type B hepatitis

  • Incubation period, 2 to 3 months.
  • Prodronal symptoms (insidious onset): fatigue, anorexia, transient fever, abdominal discomfort, nausea, vomiting, headache.
  • May also have myalgias, photophobia, arthritis, angioedema, urticaria, maculopapular rash, vasculitis.
  • Icteric phase occurs 1 week to 2 months after onset of symptoms.

Type C hepatitis

  • Incubation period, 6 weeks to several months.
  • Similar to HBV but less severe.

Type D hepatitis

  • Unclear incubation period.
  • Similar to HBV but more severe.

Applicable to all type:

  • Obtain a patient history. Ask about I.V. drug use, blood transfusions, contact with infected persons (including sexual activity), travel to endemic areas, and ingestion of possible contaminated food or water to help determine cause of hepatitis.

Diagnostic Evaluation

  1. All forms of hepatitis; elevated serum transferase levels (aspartate aminotransferase, lanine aminotransferase); may have abnormal clotting tests.
  2. HAV: radioimmunoassay detects immunoglobulin M (IgM) antibodies to hepatitis A virus in the acute phase.
  3. HBV: radioimmunoassays detect hepatitis B surface antigen (HBsAg), antibody to hepatitis B core antigen (anti-HBc), anti-HBsAg in various stages of hepatitis B infection.
  4. HCV: hepatitis C antibody may not be detected for 3 to 6 months after onset of illness (used for screening); polymerase chain reaction testing evaluates viral activity.
  5. HDV: anti-delta antibodies in the presence of HBsAg, or detection of IgM in acute disease and IgG in chronic disease.
  6. Hepatitis E antigen (with HCV ruled out).
  7. If indicated, prepare the patient for liver biopsy to detect chronic active disease, track progression, and evaluate response to therapy.

Primary Nursing Diagnosis

  • Altered nutrition:Less than body requirements related to decreased oral intake, nausea, vomiting,and anorexia

Pharmacologic Intervention

  • Vitamin K injected subcutaneously (S.C.) if prothrombin time is prolonged.
  • I.V. fluid and electrolyte replacements as indicated.
  • Antiemetic for nausea.
  • Long-term interferon therapy in combination with oral ribavirin may produce remission inHCV patients. Peginterferon alfa-2b is a long-acting preparation given S.C., once per week, and ribavirin is taken twice daily.
  • Antiviral treatment is being investigated for HBV.

Nursing Intervention

  1. Monitor hydration through intake and output.
  2. Monitor prothrombin time and for signs of bleeding.
  3. Encourage the patient to eat meals in a sitting position to reduce pressure on the liver.
  4. Encourage pleasing meals in an environment with minimal noxious stimuli (odors, noise, and interruptions).
  5. Teach self-administration of antiemetics as prescribed.
  6. Encourage rest during symptomatic phase, according to level of fatigue.
  7. Encourage diversional activities when recovery and convalescence are prolonged.
  8. Encourage gradual resumption of activities and mild exercise during convalescent period.
  9. Stress importance of proper public and home sanitation and proper preparation and dispensation of foods.
  10. Encourage specific protection for close contacts.
  11. Explain precautions about transmission and prevention of transmission to others to the patient and family.
  12. Warn the patient to avoid trauma that may cause bruising.
  13. Stress the need to follow precautions with blood and secretions until the patient is deemed free of HBsAg.
  14. Emphasize that most hepatitis is self-limiting, but follow up is needed for liver function tests.

Documentation Guidelines

  • Findings of physical exam and ongoing assessments: Nausea, vomiting, anorexia, diarrhea, color of stools and urine, daily weights, vital signs, jaundice, pruritus, edema, ascites, pain, level of consciousness
  • Response to medical and nursing interventions:Medications,comfort measures,diet,hydration
  • Pain:Location, duration,precipitating factors,response to interventions

Discharge and Home Healthcare Guidelines

  • Provide instruction on the prevention of the spread of hepatitis to others. With hepatitis A, do the following for 1 to 2 weeks after the onset of jaundice. Use strict hand washing after bowel movements and before meals. Have separate toilet facilities if possible (if not,clean the seat with bleach after each use). Wash linens,towels,and undergarments separately from other items in hot,soapy water. Do not donate blood or work in food services until such work is cleared by a physician.
  • With hepatitis B,C,or D,do the following,as directed by a physician,until antigen-antibody tests are negative. Maintain strict hand washing after urination and defecation. Do not share personal items (toothbrush, razor,washcloth). Use disposable eating utensils or wash utensils separately in hot, soapy water. Do not share food or eating utensils. Do not share needles, and dispose of them properly after a single use. Avoid intimate sexual contact; when sex can be resumed, use a condom and avoid intercourse during menstruation. Do not donate blood. Instruct the patient to inform household members and sexual partners of the fact that she or he has developed hepatitis and to encourage them to notify a primary healthcare provider immediately to assess the risk of the disease.
  • To prevent complications, teach the patient to avoid alcohol for 6 months to 1 year, avoid illicit drugs and toxic chemicals, and take acetaminophen only when necessary and not beyond the recommended dosage. Note that in viral hepatitis, the patient has immunity only to the type of hepatitis he or she has had.

Ref: 
Image at: http://www.epidemic.org/…/ hepatitisC/transmission
Nursingcrib.com
Saunders, Comprehensive Review for the NCLEX_RN Exam , 2005 ed
Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing Therapeutics Manual, 2007 3rd ed 

Source:

http://www.rnpedia.com/home/notes/medical-surgical-nursing-notes/viral-hepatitis

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