Nursing Care Plan – Hepatitis

Hepatitis (plural hepatitides) is an inflammation of the liver characterized by the presence of inflammatory cells in the tissue of the organ. The name is from the Greek hepar (ἧπαρ), the root being hepat- (ἡπατ-), meaning liver, and suffix -itis, meaning "inflammation" (c. 1727). The condition can be self-limiting (healing on its own) or can progress to fibrosis (scarring) and cirrhosis.
Hepatitis may occur with limited or no symptoms, but often leads to jaundice, anorexia (poor appetite) and malaise. Hepatitis is acute when it lasts less than six months and chronic when it persists longer. A group of viruses known as the hepatitis viruses cause most cases of hepatitis worldwide, but it can also be due to toxins (notably alcohol, certain medications, some industrial organic solvents and plants), other infections and autoimmune diseases.

Anatomy Liver

Liver of a sheep: (1) right lobe, (2) left lobe, (3) caudate lobe, (4) quadrate lobe, (5) hepatic artery and portal vein, (6) hepatic lymph nodes, (7) gall bladder. The liver is a reddish brown organ with four lobes of unequal size and shape. A human liver normally weighs 1.44–1.66 kg (3.2–3.7 lb), and is a soft, pinkish-brown, triangular organ. It is both the largest internal organ (the skin being the largest organ overall) and the largest gland in the human body. It is located in the right upper quadrant of the abdominal cavity, resting just below the diaphragm. The liver lies to the right of the stomach and overlies the gallbladder. It is connected to two large blood vessels, one called the hepatic artery and one called the portal vein. The hepatic artery carries blood from the aorta, whereas the portal vein carries blood containing digested nutrients from the entire gastrointestinal tract and also from the spleen and pancreas. These blood vessels subdivide into capillaries, which then lead to a lobule. Each lobule is made up of millions of hepatic cells which are the basic metabolic cells.

Types Of Hepatitis

Hepatitis A is caused by eating food and drinking water infected with a virus called HAV. It can also be caused by anal-oral contact during sex. While it can cause swelling and inflammation in the liver, it doesn't lead to chronic, or life long, disease. Almost everyone who gets hepatitis A has a full recovery.

Hepatitis B is caused by the virus HBV. It is spread by contact with an infected person's blood, semen, or other body fluid. And, it is a sexually transmitted disease (STD). You can get hepatitis B by:

• Having unprotected sex (not using a condom) with an infected person.
• Sharing drug needles (for illegal drugs like heroin and cocaine or legal drugs like vitamins and steroids).
• Getting a tattoo or body piercing with dirty (unsterile) needles and tools that were used on someone else.
• Getting pricked with a needle that has infected blood on it (health care workers can get hepatitis B this way).
• Sharing a toothbrush, razor, or other personal items with an infected person.
• An infected woman can give hepatitis B to her baby at birth or through her breast milk.
• Through a bite from another person.

With hepatitis B, the liver also swells. Hepatitis B can be a serious infection that can cause liver damage, which may result in cancer. Some people are not able to get rid of the virus, which makes the infection chronic, or life long. Blood banks test all donated blood for hepatitis B, greatly reducing the risk for getting the virus from blood transfusions or blood products.

Hepatitis C is caused by the virus HCV. It is spread the same way as hepatitis B, through contact with an infected person's blood, semen, or body fluid (see above). Like hepatitis B, hepatitis C causes swelling of the liver and can cause liver damage that can lead to cancer. Most people who have hepatitis C develop a chronic infection. This may lead to a scarring of the liver, called cirrhosis. Blood banks test all donated blood for hepatitis C, greatly reducing the risk for getting the virus from blood transfusions or blood products.

Hepatitis D is caused by the virus HDV. You can only get hepatitis D if you are already infected with hepatitis B. It is spread through contact with infected blood, dirty needles that have HDV on them, and unprotected sex (not using a condom) with a person infected with HDV. Hepatitis D causes swelling of the liver.

Hepatitis E is caused by the virus HEV. You get hepatitis E by drinking water infected with the virus. This type of hepatitis doesn't often occur in the U.S. It causes swelling of the liver, but no long-term damage. It can also be spread through oral-anal contact.

CARE SETTING

Usually at the community level. In toxic states, brief inpatient acute care on a medical unit may be required.

RELATED CONCERNS

1. Alcohol: acute withdrawal
2. Cirrhosis of the liver
3. Psychosocial aspects of care
4. Renal dialysis
5. Substance dependence/abuse rehabilitation
6. Total nutritional support: parenteral/enteral feeding
7. Patient Assessment Database
8. Data depend on the cause and severity of liver involvement/damage.

ACTIVITY/REST

• May report: Fatigue, weakness, general malaise

CIRCULATION

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

ELIMINATION

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

FOOD/FLUID

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

NEUROSENSORY

• May exhibit: Irritability, drowsiness, lethargy, asterixis

PAIN/DISCOMFORT

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

RESPIRATION

• May report: Distaste for/aversion to cigarettes (smokers)
• Recent flulike URI

SAFETY

• 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

SEXUALITY

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

TEACHING/LEARNING

1. 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); prescription drug use (e.g., sulfonamides, phenothiazines, isoniazid)
2. Travel to/immigration from China, Africa, Southeast Asia, Middle East (hepatitis B [HB] is endemic in these areas)
3. Street injection drug or alcohol use
4. Concurrent diabetes, HF, malignancy, or renal disease
5. Discharge plan
6. DRG projected mean length of inpatient stay: 6.1 days
7. May require assistance with homemaker/maintenance tasks
8. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

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

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, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.