Download Hepatitis B Vaccine

Assessment and
Management of Patients
With Hepatic Disorders
Part 1
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Serum Aminotransferase or
Transaminase Studies
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AST (SGOT)
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ALT (SGPT)
GGT, GGTP
LDH
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10–40 units (4.8–19
U/L)
5–35 units (2.4–17 U/L)
10–48 IU/L
100–200 units (100–225
U/L)
The studies are based on release of enzymes from damaged liver
cells. These enzymes are elevated in liver cell damage. Elevated in
alcohol abuse.
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Definition
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Hepatitis is an inflammation of the liver. Viral
hepatitis can be acute or chronic.
There are five major categories of viral hepatitis
(hepatitis F and G have been identified but are
uncommon).
Hepatitis A virus (HAV)
Hepatitis B virus (HBV)
Hepatitis C virus (HCV)
Hepatitis D virus (HDV)
Hepatitis E virus (HEV)
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There are a lot of carriers and not infected
persons
People with hepatitis should never donate
blood, body organs, or other body tissue.
Every healthcare worker should take the series
of hepatitis B vaccines.
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High Risk Behaviors
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Failure to follow Universal Precautions
Percutaneous exposure (dirty needles, sharp
instruments, body piercing, tattooing,……)
Unprotected sexual intercourse with a
hepatitis-infected person; sex with multiple
partners)
Unscreened blood transfusions
Hemodialysis
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High Risk Behaviors
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Ingestion of food prepared by a hepatitisinfected person
Using tap water to clean food products and
drinking contaminated water)
Eating and/or living in crowded environments
(correctional facilities, dormitories,
universities, long-term care facilities, military
base housing)
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Diagnostic Assessments and Nursing
Interventions
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Albumin: Decreased (normal – 3 to 5 g/dL)
Serologic Markers: Identify presence of virus (HAV,
HBsAg and Anti HBc IgM, HCV, HDV, HEV).
Serum presence of HBsAg for longer than 6 months
indicates chronic hepatitis and/or hepatitis carrier status.
Hepatitis antibody serum testing: Identify exposure to
anti-HAV, HBsAb, anti-HCV, anti-HDV, anti-HEV.
Serum presence of HBsAb indicates immunity to HBV
either following recovery from hepatitis B or successful
vaccination.
Stool analysis for hepatitis A antigen
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Diagnostic Assessments and Nursing
Interventions
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Serum liver enzymes: Elevated
 ALT: Elevated (normal – 8 to 20 units/L; 3 to 35 IU/L); most
definitive for assessment of liver tissue damage.
 AST: Elevated (normal – 5 to 40 units/L)
 Alkaline phosphatase (ALP): Elevated (normal – 42 to 128 units/L;
30 to 85 IU/L)
Serum bilirubin: Elevated
 Bilirubin – direct (conjugated): Elevated (normal – 0.1 to 0.3
mg/dL)
 Bilirubin – indirect (unconjugated): Elevated (normal – 0.2 to 0.8
mg/dL)
 Bilirubin – total: Elevated (normal – 0.1 to 1.0 mg/dL)
either following recovery from hepatitis B or successful
vaccination.
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Diagnostic Assessments and Nursing
Interventions
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Abdominal films to visualize possible
hepatomegaly, ascites, spleen enlargement.
Liver biopsy: Most definitive. Identifies
intensity of infection and degree of tissue
damage.
Nursing interventions include: pre & post
procedural responsibilities)
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Assessments
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Influenza symptoms (headache, fatigue, low grade fever, RUQ
abdominal pain, N&V).
HBV presents with additional symptoms: hepatomegaly, signs of
obstruction (light colored stools, dark urine, jaundice, elevated
bilirubin and liver enzyme levels).
Assess for alterations in physical assessment related to hepatitis:
 Inspect overall color of skin, eyes, and mucus membranes for
presence of jaundice and skin irritations probably due to pruritus.
 Pain in muscles, joints, and abdomen.
 Fever, malaise, increased fatigue, and N&V.
 Change in color of stool (clay colored) or dark urine.
 Palpate RUQ for swelling and complaints of tenderness. Have
the client take deep breath to feel border of liver under ribs and
measure/ record abdominal distention.
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Assessments
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Pertinent Client History
 Take an inventory of recent travel, work
history, and onset and intensity of symptoms.
 Identify measures the client has already taken
such as pain medicine, fluids, and diet changes.
 Identify exposure agents.
 When interviewing the client, use a
nonjudgmental manner. Behaviors that may
have caused this disease occurred years before
the present illness and can be embarrassing to
the client to express comfortably.
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A. HEPATITIS A VIRUS (HAV)
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HAV accounts for 20% to 25% of cases of
clinical hepatitis in the developed world.
Hepatitis A, formerly called infectious
hepatitis
The mode of transmission of this disease is the
fecal–oral route, primarily through the
ingestion of food or liquids infected by the
virus. The virus has been found in the stool of
infected patients before the onset of symptoms
and during the first few days of illness.
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Clinical Manifestations
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Many patients are anicteric (without jaundice) and
symptomless.
If symptoms appear, they are of a mild, flu-like
upper respiratory tract infection, with low-grade
fever.
Anorexia, an early symptom, is often severe.
Later, jaundice and dark urine may become
apparent.
Indigestion is present in varying degrees, marked
by vague epigastric distress, nausea, heartburn, &
flatulence.
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Medical Management
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Bed rest during the acute stage and a diet that
is both acceptable to the patient and nutritious
are part of the treatment and nursing care.
During the period of anorexia, the patient
should receive frequent small feedings,
supplemented, if necessary, by IV fluids with
glucose.
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Nursing Management
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The patient is usually managed at home unless
symptoms are severe.
Therefore, the nurse assists the patient and family in
coping with the temporary disability and fatigue that
are common in hepatitis and instructs them to seek
additional health care if the symptoms persist or
worsen.
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B. HEPATITIS B VIRUS (HBV)
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Transmitted primarily through blood (percutaneous
and permucosal routes). HBV has been found in
blood, saliva, semen, and vaginal secretions and can
be transmitted through mucous membranes and
breaks in the skin.
HBV is also transferred from carrier mothers to their
babies, especially in areas with a high incidence (ie,
Southeast Asia). The infection is usually not via the
umbilical vein, but from the mother at the time of
birth and during close contact afterward.
HBV has a long incubation period. It replicates in the
liver and remains in the serum for relatively long
periods, allowing transmission of the virus.
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B. HEPATITIS B VIRUS (HBV)
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transmitted primarily through blood (percutaneous and
permucosal routes). HBV has been found in blood, saliva,
semen, and vaginal secretions and can be transmitted through
mucous membranes and breaks in the skin.
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HBV is also transferred from carrier mothers to their babies,
especially in areas with a high incidence (ie, Southeast Asia).
The infection is usually not via the umbilical vein, but from
the mother at the time of birth and during close contact
afterward.
Those at risk for developing hepatitis B include surgeons,
clinical laboratory workers, dentists, nurses, and respiratory
therapists. Staff and patients in hemodialysis and oncology
units and sexually active homosexual
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Clinical Manifestations
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Clinically, the disease closely resembles hepatitis A,
but the incubation period is much longer (1 to 6
months). Signs and symptoms of hepatitis B may be
insidious and variable. Fever and respiratory
symptoms are rare; some patients have arthralgias and
rashes.
Prevention
The goals of prevention are to interrupt the chain of
transmission, to protect people at high risk with active
immunization through the use of hepatitis B vaccine,
and to use passive immunization for unprotected
people exposed to HBV
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A. PREVENTING TRANSMISSION
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Continued screening of blood donors for the presence of
hepatitis B antigens
The use of disposable syringes, needles, and lancets and the
introduction of needleless IV
Good personal hygiene is fundamental to infection control. In
the clinical laboratory, work areas should be disinfected daily.
Gloves are worn when handling all blood and body fluids as
well as HBAg positive specimens.
Eating and smoking are prohibited in the laboratory and in
other areas exposed to secretions, blood products.
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B. Active Immunization: Hepatitis B Vaccine
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Active immunization is recommended for individuals at
high risk for hepatitis B (eg, health care personnel and
hemodialysis patients). In addition, individuals with
hepatitis C and other chronic liver diseases should receive
the vaccine.
Administered IM (in the deltoid muscle in adults) in three
doses, the second and third doses 1 & 6 months after the
first dose. The third dose is very important in producing
prolonged immunity.
Antibody response may be measured by anti-HBs levels 1
to 3 months after completing the basic course of vaccine
Universal vaccination of all infants.
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C.
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PASSIVE IMMUNITY: HEPATITIS B
IMMUNE GLOBULIN
Hepatitis B immune globulin (HBIG) provides passive
immunity to hepatitis B and is indicated for people
exposed to HBV who have never had hepatitis B and have
never received hepatitis B vaccine. Specific indications
for postexposure vaccine with HBIG include:
(1) inadvertent exposure to HBAg-positive blood through
percutaneous (needlestick) or transmucosal (splashes in
contact with mucous membrane) routes,
(2) sexual contact with people positive for HBAg, and
(3) perinatal exposure (babies born to HBV-infected
mothers should receive HBIG within 12 hours of
delivery).
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NANDA Nursing Diagnoses
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Fatigue
Nausea
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Nursing Interventions
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Implement contact isolation precautions (universal precautions).
Limit client activity (bedrest) in order to promote hepatic
healing.
Provide dietary education: high-carbohydrate, high-calorie, lowto moderate-fat, and low- to moderate-protein diet and small,
frequent meals to promote nutrition and healing.
Medications are used sparingly for hepatic rest and regeneration
of tissue.
Administer interferon (for HBV and HCV). Monitor clients
receiving interferon for side effects of flu-like symptoms,
alopecia, and bone marrow suppression. Monitor CBC and
administer antiemetics as needed during interferon therapy.
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Nursing Interventions
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Educate the client and family regarding measures to
prevent transmission of disease with others at home
Provide comfort measures.
Encourage hepatitis prevention activities:
Community health educational interventions on
transmission and exposure.
Hepatitis B vaccination prophylaxis for all healthcare
workers.
Proper use of Universal Precautions.
Use of a needleless system when delivering
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medications
Nursing Interventions
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Frequent handwashing
If traveling in underdeveloped countries, drink
bottled water, and limit sharing of bed linens and
eating utensils.
Report hepatitis outbreaks to health authorities.
Instruct clients to avoid alcohol and all OTC
Consider administration of immunoglobin (Ig) to
clients exposed to hepatitis A or hepatitis B.
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Complications and Nursing Implications
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Chronic hepatitis – results from hepatitis B, C, or D.
Increases the client’s risk for liver cancer.
Fulminating hepatitis (fatal); due to the inability of
the liver cells to regenerate with increased
progression of the necrotic process.
This disease results in hepatic encephalopathy and
death.
Cirrhosis of the liver – continued episodes of chronic
hepatitis result in scarring and permanent injury to the
liver and also is a risk factor for liver cancer.
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Complications and Nursing Im
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Liver cancer – chief report is abdominal
discomfort. Diagnosis is made by
US, CT, elevated liver enzymes, and liver
biopsy for confirmation of cancer.
Liver failure – chronic hepatitis, liver
abscesses, and fatty liver infiltration all result
in changes within the healthy liver and cause
irreversible damage
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