1. 1 Treatment of Hepatitis Acute and Chronic Well-balanced diet Vitamin supplements Rest (degree of strictness varies) Avoidance of alcohol intake and drugs detoxified by the liver

2. 2 Nursing Implementation Acute interventions Rest Jaundice/ pruritus Small, frequent meals Ambulatory and home care Dietary teaching (avoid ETOH) (low fat, high CHO) Assessment for complications Regular follow-up for 1 year after diagnosis Medication teaching

3. 3 Collaborative Care: Drug therapy No specific drug therapies ( acute hepatitis ) Supportive therapy Antiemetics Watch for drugs metabolized by liver Vitamins Milk Thistle (Silymarin)

4. 4 Drug therapies: Chronic HBV & HCV Anti-virals: Interferon ↓ viral load ↓ liver enzyme levels ↓ rate of disease progression Side effects Flu-like SX Anemia, anorexia Depression, insomnia

5. 5 Hepatitis A Hand washing! Food Washing Proper personal hygiene Immunization: HAV vaccine (2 shots, immunity in 30 days) Immune Globulin 1-2 weeks post exposure Hepatitis B and C Screen donated blood Use disposable needles Hand washing Safe sex Avoid sharing toothbrushes/razors Immunization: HBV vaccine (3 doses, 1 st @ birth/complete by 18m/o) Prevention/Health Promotion Table 44-8: preventative measures for Hepatitis

6. 6 Evaluation: Expected outcomes Adequate nutritional intake Increased tolerance for activity Verbalization of understanding of follow-up care Able to explain to others methods of transmission and methods of preventing transmission

7. 7 Major Functions (pg 870/Table 39-4) Review Metabolic CHO, Protein, and Fat metabolism Albumin, clotting factors Detoxification – Ammonia (NH3) to Urea Management of Bilirubin (Production/Excretion) Liver cells destroyed – scar tissue forms – alters blood flow in liver – BP in GI system elevates

8. 8 Liver dysfunction Early S/SX of liver DX Pain, Fever, Anorexia (N/V) Fatigue Physical exam may reveal hepatomegaly, lymphadenopathy, and splenomegaly. Progressive S/SX Jaundice Ascites, anasarca Skin Lesions/bruising refer to Patho Map – figure 44-5 pg 1018/Text Complications: -Fulminant/acute hepatic failure -Chronic hepatitis -Cirrhosis -carcinomas

9. 9 Liver Dysfunction Bleeding Inability to make clotting factors Development of collateral circulation r/t portal hypertension Increased serum Ammonia Inability to convert NH 3, from metabolism of protein,to urea Third spacing – ascites Inability make plasma protein (albumin) Other: altered drug metabolism, electrolyte imbalances, etc

10. 10 Nursing Assessment (table 44-14) Past health history  Chronic alcoholism  Viral hepatitis  Chronic biliary disease Medications Physical examination Weight loss Jaundice Abdominal distention Nausea/vomiting Altered mentation/asterixis RUQ pain Abnormal laboratory values

11. 11 Complications of liver failure Portal hypertension Esophageal and gastric varices Peripheral edema and ascites (table 44-9) Portal HTN, Hypoalbuminemia, hyperaldosteronism Hepatic encephalopathy (table 44-10) Protein metabolism dysfunction produces elevated ammonia levels (conversion of ammonia to urea) Hepatorenal syndrome Kidney failure related poor circulating blood volume

12. 12 Esophageal Varices No special assessment findings – obvious GI bleed, low H & H, occult blood Goal: Avoid bleeding/hemorrhage Avoid alcohol, aspirin, irritating foods, straining. Supportive measures for acute bleeds Next slide Treatment Measures Endoscopic sclerotherapy, Endoscopic ligation Balloon tamponade (Blakemore tube) – old TX Shunting procedures (TIPS) (portacaval shunt) Sengstaken-Blakemore Tube

13. 13 Treatment for acute UGI bleed Support ABCs, fluid resuscitation Drug therapy may include Octreotide (Sandostatin) Vasopressin (VP, Terlipressin) Fresh frozen plasma, Packed RBCs Vitamin K Histamine blockers, Proton pump inhibitors Lactulose & Neomycin – prevents hepatic encephalopathy from increased RBC breakdown/ammonia

14. 14 Treatment of Ascites High-carbohydrate, low-Na + diet (2 g/day) Diuretics, albumin infusion Paracentesis Peritoneovenous shunt Continuous reinfusion of ascitic fluid from abdomen to vena cava Complications : Thrombosis, infection, fluid overload

15. 15 Paracentesis Patient Positioning – sitting upright, HOB ↑ Empty bladder Complications: Persistent leak from the puncture site, bruising Hypotension after a large-volume paracentesis Perforation of bowel, infection, Major blood vessel laceration Post procedure Position on right side to splint puncture site

16. 16 Hepatic encephalopathy S/SX: altered mentation, asterixis (liver flap), fetor hepaticus, NH3 (ammonia) Goal: Decrease ammonia formation May reduce protein in diet Sterilization of GI tract with antibiotics (e.g., neomycin) Lactulose (Cephulac) traps NH3 in gut. Cathartics/enemas Treatment of precipitating cause

17. 17 Generalized Collaborative Care Rest, avoid further liver damage Avoidance of alcohol, aspirin, acetaminophen, and NSAIDs Monitor LFTs, electrolytes Management of ascites Accurate I/O, Daily weights, Abdominal girth, extremities measurement Nursing care r/t paracentesis Prevention and management of esophageal variceal bleeding Management of encephalopathy

18. 18 Nutritional Treatment High in calories (3000 kcal/day)  ↑ carbohydrate  Moderate to low fat  Protein restriction depends on degree of hepatic encephalopathy Low-sodium diet for patient with ascites and edema Between-meal nourishment, Explanation of dietary restrictions Administration of B-complex vitamins, vitamin K

19. 19 Nursing Evaluation Maintenance of food/fluid intake to meet needs Maintenance of muscle tone and energy Maintenance of skin integrity Normalization of fluid balance Maintenance of blood pressure and urinary output Reports increased ease of breathing Experiences normal respiratory rate/rhythm