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MedSurg II - Hepatitis

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olanjones's version from 2017-04-16 01:41

Viral Hepatitis

Question Answer
HAVResults in mild to acute liver failure (not chronic), Vaccination decreases incidence
HAV transmission-RNA virus through fecal-oral route via contaminated food/water
HBVResults in acute or chronic disease, Vaccination decreases incidence
-At-risk persons: those undergoing hemodialysis, healthcare/public safety workers, household contact w/ infected person
HBV transmission-DNA virus through mucosal exposure to infectious blood or other body fluids (in people w/ HBV, hepatitis B surface antigen has been detected in almost every body fluid)
-HBV can live on a dry surface for at least 7 days (much >infectious than HIV)
-No evidence that urine, feces, breast milk, tears, sweat are infective
HCVResults in acute or chronic disease, Acute is usually asymptomatic; Majority of patients develop chronic
HCV transmissionRNA virus through percutaneous/perinatal exposure; 10% are d/t occupational exposure/hemodialysis/perinatal
Why is chronic Hep C so badMost people are unaware of their infection (15-20 year delay btwn infection & clinical appearance of liver damage)
*Results in a potentially progressive liver disease; 20-30% of infected patients develop cirrhosis
*Most common cause of chronic liver disease/indication for transplant in US
Co-infections*Persons at risk for HCV also at risk for HBV & HIV
*30-40% of HIV-infected pts also have HCV (primarily r/t IV drug use)
*Those w/ HIV & HCV at greater risk for progression to cirrhosis
*Chronic HBV & HCV account for 80% hepatocellular cancer
HDVResults in spectrum of illness ranging from an asymptomatic chronic carrier state to acute liver failure, No vaccine available but vaccination against HBV reduces risk of co-infection
HDV transmissionPercutaneous transmission; Is a defective single-stranded RNA virus that cannot survive on its own, requires hepatitis B to replicate. It can be acquired at the same time as HBV, or a person with HBV can be infected with HDV at a later time
HEVOccurs primarily in developing countries (epidemics in India, Asia, Mexico, Africa), few cases in US - usu related to travel in endemic area
HEV transmissionRNA virus transmitted through fecal-oral route via contaminated water
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Hepatitis Patho & Manis

Question Answer
Acute infection-Liver damage from cytotoxic cytokines & NKC = lysis of infected hepatocytes; Inflammation interrupts bile flow
-After Resolution of infection liver cell can regenerate in normal form
Chronic infectionCauses chronic inflammation & can cause fibrosis (over decades) can → to cirrhosis
PathoAntigen-antibody complexes btwn virus & corresponding antibody may form circulating immune complexes (early phases hepatitis) → activate the complement system
S/S of complement activationRash, angioedema, arthritis, fever, malaise; *Cryoglobulinemia (abn proteins found in blood), glomerulonephritis, & vasculitis have also been found d/t immune complex activation
A large number of pts with _____ hepatitis have _____Acute; No symptoms (as a result infection may not be detected)
What other S/S may be intermittent or ongoingmalaise, fatigue, arthralgias, hepatomegaly
Acute phase-Lasts 1-4 mos; acute phase is the period of maximal infectivity
-S/S: ↓Sense of smell, HA, Low-grade fever, Arthralgias, Skin rash
-PE may reveal hepatomegaly, lymphadenopathy, splenomegaly, jaundice
Incubation period S/SMalaise, Anorexia, Wt loss, Fatigue, N&V, Abd discomfort, Distaste for cigarettes
Cause of jaundiceAlteration in normal bilirubin metabolism/flow of bile into hepatic/biliary duct systems; Urine may darken (excess bilirubin excretion by kidneys); Light/clay colored stools (conjugated bilirubin cannot flow out of liver); Pruritus (accumulation of bile salts under skin)
Convalescent phase-Lasts weeks-months (average 2-4); begins as jaundice disappears
-S/S malaise & easily fatigued; hepatomegaly remains for several wks but splenomegaly subsides
RecoveryMost pts with acute viral hepatitis recover completely (mortality <1%)
*Infection w/ HAV or HBV will provide homologous immunity but pt can still be infected w/ another type of viral hepatitis
*Those infected with HCV can be re-infected w/ another strain of HCV
ComplicationsAcute liver failure, Chronic hepatitis, Cirrhosis, Hepatocellular carcinoma
*RF: male, ETOH, excess iron deposition in liver, ↑lipids, obesity, DM
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Hepatitis Dx & Tx

Question Answer
Dx-Antibody tests for A, B, C, D (none for E)
-Anti-HAV IgM = acute infection, Anti-HAV IgG = previous infection or immunization
-HBsAg = acute/chronic infection or chronic carrier, AntiHBs = previous infection or immunization
-Anti-HCV = acute/chronic infection, HCV RNA quant = active ongoing viral replication
-Anti-HDV = past/current infection, HDV Ag = present w/in a few days after infection
Lab tests↑AST, ALT, GGT, alk phos; nl/↑serum protiens & bilirubin; ↑urinary urobilinogen; prolonged PT
Viral genotype testingDone in patients undergoing drug therapy for HBV or HCV infection; one of the strongest predictors of response to drug therapy (in HCV done prior to tx)
Physical assessPalpable liver, hepatic tenderness, hepatomegaly, splenomegaly
Liver bxExam of liver cells & degree of inflammation, fibrosis, or cirrhosis that may be present (not indicated in acute hepatitis unless dx is in doubt)
FibroScannon-invasive, ultrasound transducer is used to determine liver fibrosis
FibroSure/FibroTestBiomarker - results of serum tests (e.g. liver enzymes) are used to assess degree of hepatic fibrosis
Acute CC –all typesWell-balanced diet (↑calorie, low-fat), Vit supplements, Rest, Avoid ETOH/drugs dtx by liver; NOTIFY possible contacts
*no specific tx for acute viral hepatitis- manage at home
Drug tx-Acute Hep A: no specific
-Acute Hep B: only w/ severe hepatitis & liver failure
-Acute Hep C: pegylated interferon within the first 12 to 24 weeks of infection
*Supportive tx: antiemetics
CC chronic Hep BGoals: ↓viral load , liver enzyme levels, rate of progression, prevent cirrhosis, hepatic failure, cancer
*Drug tx do not eradicate virus but suppress viral replication/prevent complications
Dx tx chronic Hep B1stline: pegylated interferon & nucleoside/nucleotide analogs, sub-q inj
-Response is varied, pt should have blood counts & LFTs q 4-6 wks
-SE are dose-related & tend to ↓w/ cont. tx
Dx tx chronic Hep CIndividualized based on genotype, severity, SE, co-morbities, oral and/or injectable
*Drug tx directed at eradicating virus & prevent complications
What is significant about Ribavirin (Hep C tx)is teratogenic, pregnancy must be avoided, both by women taking the drug and by women whose male partners are taking the drug
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Hepatitis Nursing

Question Answer
Subjective- Past HHhemophilia; exposure to infected persons; ingestion of contaminated food or water; exposure to benzene, carbon tetrachloride, or other hepatotoxic agents; crowded, unsanitary living conditions; exposure to contaminated needles; recent travel; organ transplantation; exposure to new drug regimens, hemodialysis, transfusion of blood or blood products before 1992, HIV status
Subjective- Medsuse/misuse of acetaminophen, new Rx, OTC, or herbal med/supplements
Subjective- Health patternsIV/ETOH use, distaste for cigarettes, high-risk sexual behavior, wt loss/anorexia/N&V, RUQ pain, Urine/stool color, Fatigue/arthralgia/myalgia
ObjectiveLow-grade fever, Jaudice, Rash, Hepatomegaly, Splenomegaly, Abn labs
NDImbalanced nutrition r/t anorexia, N&V; Activity intolerance r/t fatigue, weakness; Risk for impaired liver function r/t viral infection
Health Promo Hep A-Personal/environmental hygiene & health education to promote good sanitation
-Vaccination; post-exposure prophy: vaccination & immune globulin w/in 2 wks
-Isolation not required for HAV infection, use infection control precautions
Health Promo Hep B-Good hygienic practices, use condom w/ sex, use gloves when expecting contact w/ blood
-Vaccination (3 doses); post-exposure: vaccination & HBIG w/in 24 hrs
Health Promo Hep C-Infection control, modification of high-risk behaviors; no vaccine avail
-No post-exposure prophy; base-line anti-HCV & ALTs, f/u at 4-6 mos (test for HCV RNA at 4-6 wks)
-CDC recommends all persons born btwn 1945-65 be tested
NI acute care*Assess for jaundice, Comfort measures (pruritus, HA, arthralgia)
*Adequate nutrition (small, frequent meals; stimulate appetite w/ mouth care, antiemtics, attractive presentation; carbonated beverages; adequate fluid intake = 2500-3000 mL)
*Physical, psychological, emotional rest; diversional activities
NI ambulatory & homeDietary teaching, Activity restrictions, Transmission prevention, What symptoms should be reported to PCP, Assess for complications (bleeding, encephalopathy, ↑LFTs)
Pt should f/uat least 1 year after dx or if relapses occur (w/ Hep B & C)
Interferon teachingAdmin sub-q (teach how), SE - flu-like symptoms (e.g., fever, malaise, fatigue) make adherence to therapy challenging for some patients
Can carriers donate bloodNO, positive for HBsAg or HCV antibody should not be blood donors
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