Case Scenario:

Patient A is a 50 year old college professor who presented himself to the emergency department with the chief complaint of yellowing of skin. LEGEND

The patient reports being in good health until a week before, at which time he began having progressive flu-like symptoms of headache,
low-grade fever, nausea and vomiting, loss of appetite, and malaise. He self-treated the fever with acetaminophen. The symptoms persisted. PATHOPHYSIOLOGY
Upon awakening this morning, he noticed that his eyes were yellow. He also indicated that his urine has been darker than usual and stools
have been light in color. He reports being immunized with Hepatitis B vaccine in 1986 and denied any previous surgeries. Family history is RISK FACTORS
positive for cardiovascular disease (father) and diabetes (mother). He did not recall any peculiar food exposures during the prior week. He
denied ever having experienced symptoms like this in the past but he admitted that he went on a field trip and took a swim in the river where CLINICAL
locals usually take a bath and wash their clothes 2 weeks ago. MANIFESTATIONS Presented by: Salvador, Sederiosa, Templado & Tolibas
Subjective Data:
COMPLICATIONS
- Pt. verbalized, ?Grabe kaayo akong pagka-kapoy ug sakit sa akong kaunuran. Wala pud kaayo koy gana mu kaon ug kabati ko na sige kog
kasukaon.?
- Experiences joint pain and always feeling tired
- Experiences fever and diarrhea
ASSESSMENT &
DIAGNOSTICS CARE OF PATIENTS WITH HEPATITIS
- Reported having dark urine and clay-colored stools
- Complains of pain in the upper right part of the belly NURSING DIAGNOSES
- Complains of intense itching
- Rated pain as 7/10, 10 as the highest and 0 with no pain
NURSING MANAGEMENT
- Self-treated the fever with acetaminophen
- Immunized with Hepatitis B vaccine in 1986
- Went on a field trip and took a swim in the river where locals usually take a bath and wash their clothes MEDICAL MANANGEMENT

Objective Data:
- Vital Signs: BP=135/98 mmHg, T=37.9°C, RR=19 cpm, PR= 86 bpm Medical Management
for Hepatitis B
- Facial grimacing and adbominal guarding noted
- Appears restless during the interview
- Skin and eye jaundice
- Loss of apetite
- Vomiting
- Pale colored stool
Medical Management
- Dark colored urine for Hepatitis C

Lamivudine (Epivir-HBV)
Adefovir dipivoxil (Hepsera)
Laboratory Findings Pharmacologic class: Nucleoside reverse transcriptase inhibitor Telbivudine (Tyzeka)
Pharmacologic class: Nucleotide reverse transcriptase Interferon Tenofovir or entecavir (Baraclude)
Therapeutic class: Antiretroviral Pharmacologic class: Nucleoside reverse transcriptase inhibitor
inhibitor Therapeutic Class: Antiviral Interferon
- Liver Function Studies Dosage: Therapeutic class: Antiretroviral
Therapeutic class: Antiviral
Therapeutic Class: Antineoplastic, antiviral
Pharmacologic Class: Biological response modifier Pharmacologic Class: Guanosine nucleoside Therapeutic Class: Antineoplastic, antiviral
? Chronic HBV Adults: 100 mg (Epivir-HBV) P.O. once daily
- Alanine aminotransferase (ALT): 358 Units/L (Normal Values 5?35 Units/L)
- Aspartate aminotransferase (AST) : 323 Units/L (Normal Values 5?40 Units/L
Children ages 2 to 17: 3 mg/kg (Epivir-HBV) P.O. once daily, to a
maximum of 100 mg P.O. daily
Adverse reactions:
Action: Inhibits replication of HBV DNA polymerase, which inhibits HBV replication
Uses: Treatment of chronic hepatitis B
Contraindications: Hypersensitivity, breastfeeding
Dosage: ? Chronic HBV with active viral replication
plus persistent elevations in alanine aminotransferase
(ALT) or aspartate aminotransferase (AST) or
Dosage: ? Chronic hepatitis B
Adults: 30 to 35 million international units
subcutaneously or I.M. weekly for 16 weeks, given as
analogue
Dosage: Oral solution: 0.05 mg/ml Tablets: 0.5 mg, 1
mg
Hepat it is Pharmacologic Class: Biological response modifier
Dosage: ? Chronic hepatitis B
Adults: 30 to 35 million international units
Renal dose: Adverse effects: CNS: headache, dizziness, fatigue subcutaneously or I.M. weekly for 16 weeks, given as
histologically active disease Adults: 10 mg P.O. daily 5 million international units daily or 10 million
- Serum Total Bilirubin: 3.7 mg/dL (Normal Value 0.2?1.6 mg/dL) CNS: fatigue, headache, insomnia, malaise, asthenia, depression, Adult: PO CCr 30-49 ml/min 600 mg tab q48hr or 400 mg oral sol/day; CCr ,30 ml/min (not
Adverse reactions: international units three times weekly GI: nausea, diarrhea, dyspepsia, increased GI 5 million international units daily or 10 million
dizziness, paresthesia, peripheral neuropathy, seizures requiring dialysis) 600 mg tab q72hr or 200 mg oral sol/day enzymes international units three times weekly
- Alkaline phosphatase (ALP): 85 Units/mL (Normal Values 30?115 Units/mL) GI: nausea, vomiting, diarrhea, anorexia, abdominal discomfort, Available forms: Tabs 600 mg
CNS: headache Adverse effects: swelling or other reactions at the
Hematologic: hematuria Adverse effects: swelling or other reactions at the
ribavirin (Copegus, Rebetol)
GI: nausea, vomiting, diarrhea, abdominal pain, injection site flu-like symptoms such as Pharmacologic class: Synthetic nucleoside analog
dyspepsia, splenomegaly, pancreatitis
- Anti- HAV IgM: Positive Hematologic: anemia, neutropenia
Adverse Effects: flatulence, dyspepsia, anorexia, pancreatitis
headache, tiredness, and weakness, chills,
Hepatic: HBV exacerbation, severe hepatomegaly injection site flu-like symptoms such as Therapeutic class: Antiviral
CNS: Fever, headache, malaise, weakness, dizziness, insomnia GU: renal dysfunction Metabolic: glycosuria, lactic acidosis
headache, tiredness, and weakness, chills, Dosage:
- HBsAb: Positive Hepatic: hepatomegaly with steatosis EENT: Taste change, hearing loss, photopho-bia Hepatic: severe hepatomegaly with steatosis, hepatitis
fever, trouble sleeping, nausea, vomiting, Patient monitoring: ? Monitor renal function before
fever, trouble sleeping, nausea, vomiting, ? Chronic hepatitis C infection
Metabolic: hyperglycemia, lactic acidosis GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, hepatomegaly diarrhea,irritability or other mood changes, boceprevir (Victrelis)
exacerbation (if therapy is withdrawn) and during therapy, especially in liver transplant
- HBsAg: Negative Musculoskeletal: muscle, joint, or bone pain; muscle weakness; INTEG: Rash Metabolic: lactic acidosis muscle pain, low levels of white blood cells, loss recipients who are receiving or have received
diarrhea,irritability or other mood changes, Note: Dosage calculated solely on basis Pharmacologic class: Hepatitis C NS3/4A protease inhibitor
Therapeutic class: Antiviral agent ribavirin (Copegus, Rebetol)
of patient?s weight.
myalgia; rhabdomyolysis MISC: Lactic acidosis immunosuppressants that may affect renal function. muscle pain, low levels of white blood cells, loss telaprevir (Incivek)
- IgM antibodies: Positive Respiratory: cough, abnormal breath sounds, wheezing MS: Myalgia, arthralgia, muscle cramps
Respiratory: pneumonia of appetite
of appetite
Adults and children weighing 75 kg
Pharmacologic Class: NS3/4A protease inhibitor
Dosage: ? Chronic hepatitis C genotype 1 in patients with compensated hepatic Pharmacologic class: Synthetic nucleoside analog
Other: fever, infection, pain, antiretroviral resistance in itchy skin Patient monitoring: >Monitor liver function closely for evidence of HBV (165 lb) or more: 600 mg P.O. q morning and evening, given with interferon disease (including cirrhosis) who are previously untreated or who have failed previous Therapeutic class: Antiviral
Skin: alopecia, rash, urticaria, erythema multiforme,
- Prothrombin time (PT): 11.6 seconds (Normal Values: Control 10.4 seconds (normal is ±2.0 seconds from control) RESP: Cough patients with unrecognized HIV o Before therapy and monthly during therapy, assess
exacerbation for at least several months after drug itchy skin Patient monitoring: alfa-2b
Therapeutic Class: Antiviral, antihepatitis agent interferon and ribavirin therapy Dosage:
Stevens-Johnson syndrome Patient Monitoring: discontinuation. Uses: Chronic hepatitis C
Patient monitoring CBC with white cell differential, bone marrow hairy o Before therapy and monthly during therapy, assess Adults weighing less than 75 kg (165 lb) and children weighing more Adults age 18 and older: 800 mg P.O. t.i.d. (q 7 to 9 hours) in combination with ? Chronic hepatitis C infection
- Albumin: 3.8 mg/dL (Normal Values: 3.5?5.5 mg/dL) Other: lymphadenopathy, body fat redistribution, hypersensitivity · Monitor signs of hepatitis (jaundice, fatigue, anorexia, pruritus) during therapy.
? Monitor fluid intake and output. cells, glucose and electrolyte levels, and liver and
>Monitor for lactic acidosis (associated with CBC with white cell differential, bone marrow hairy than 61 kg (134 lb): 400 mg P.O. q morning and 600 mg P.O. q evening, given
Dosage:Adults: PO 750 mg tid (q7-9hr) peginterferon alfa and ribavirin; in patients with compensated cirrhosis, give Note: Dosage calculated solely on basis
reactions including anaphylaxis; immune reconstitution syndrome · Assess for signs of myopathy (diffuse myalgias, muscle tenderness or muscle nucleoside analogues). Adult: PO 750 mg tid (q7-9hr)
cells, glucose and electrolyte levels, and liver and
- Hematocrit (Hct): 40% (Normal Values: 37% to 47%) Patient monitoring weakness with increases in creatine kinase). Interrupt therapy if myopathy is suspected
? Watch for hematuria. kidney function tests. with interferon alfa-2b
Available forms: Tab 375 mg
peginterferon alfa and ribavirin for 4 weeks followed by 44 weeks boceprevir 800 mg of patient?s weight.
? Assess for signs and symptoms of lactic acidosis, o Monitor for mental status changes, depression, and kidney function tests. Children weighing 50 to 61 kg (110 to 134 lb): 400 mg P.O. b.i.d., given with t.i.d. (q 7 to 9 hours) in combination with peginterferon alfa and ribavirin Adults and children weighing 75 kg
? Check vital signs regularly. Adverse Effects:
- Hemoglobin (Hgb): 13.3 mg/dL (Normal Values: 12.0?16.0 mg/dL) ? Monitor CBC and platelet count frequently. Watch for evidence of
and discontinue therapy if myopathy is diagnosed. especially in women and overweight patients. suicidal ideation. o Monitor for mental status changes, depression, and interferon alfa-2b ? Chronic hepatitis C genotype 1 in patients with compensated hepatic disease (165 lb) or more: 600 mg P.O. q morning and evening, given with interferon
· Monitor liver function tests, hepatitis B serology, creatine kinase, periodically; monitor suicidal ideation. CNS: Fatigue (without cirrhosis) who are previously untreated or are partial responders or relapsers
? Check for liver enlargement. Children weighing 37 to 49 kg (81 to 108 lb): 200 mg P.O. every morning alfa-2b
- White blood cell count: 6200 cell/microliter (Normal Values: 4300?10,800 cells/microliter) bone marrow toxicity. HBV DNA after 24 wk, if viral suppression is incomplete start alternate therapy, monitor ? Monitor liver and kidney function test results. and 400 mg P.O. every evening, given with interferon alfa-2b
GI: Anorectal discomfort, diarrhea, dysgeusia, hemorrhoids, hyperbilirubinemia, nausea, to interferon and ribavirin therapy Adults weighing less than 75 kg (165 lb) and children weighing more
? Monitor blood glucose level and kidney and liver function test HBV DNA q6mo. pruritus ani, rectal burning, vomiting Adults age 18 and older: Initiate therapy with peginterferon alfa and ribavirin for 4
- Platelet count: 200,000/microliter of blood results.
? After therapy ends, monitor patient for evidence of Children weighing 25 to 36 kg (55 to 79 lb) : 200 mg P.O. b.i.d., given with
HEMA: Anemia, decreased Hgb, leukopenia, lymphopenia, neutropenia, thrombocytopenia
than 61 kg (134 lb): 400 mg P.O. q morning and 600 mg P.O. q evening, given
serious hepatitis exacerbation. Engerix B (Hepatitis B Vaccine) interferon alfa-2b weeks (treatment weeks 1 to 4). Add boceprevir 800 mg P.O. t.i.d. (q 7 to 9 hours) to with interferon alfa-2b
? Assess neurologic and mental status. Report signs or symptoms INTEG: Drug reaction with eosinophilia and systemic symptoms (DRESS), pruritus, rash,
Mechanism of Action: Adverse reactions Nausea, diarrhea, stomach upset,headache, peginterferon alfa and ribavirin regimen after 4 weeks of treatment. Based on patient?s Children weighing 50 to 61 kg (110 to 134 lb): 400 mg P.O. b.i.d., given with
of depression. Stevens-Johnson Syndrome (SJS); severe rashes (bullous rash, skin ulcerations, and
Induces specific humoral antibodies against dizziness, blurred vision, trouble sleeping, cough, low appetite, weight HCV-RNA levels at treatment week 8, treatment week 12, and treatment week 24, use interferon alfa-2b
? Closely monitor obese patients, women, and patients with a vesicular rash)
HBsAg (anti-HBs antibodies). loss or gain, dry skin, or changes in taste/hearing may occur
the following response-guided therapy guidelines below to determine duration of Children weighing 37 to 49 kg (81 to 108 lb): 200 mg P.O. every morning
history of hepatic disease; they?re at increased risk for lactic META: Increased uric acid
Dosage: treatment. and 400 mg P.O. every evening, given with interferon alfa-2b
acidosis and severe hepatomegaly with steatosis. Patient monitoring Patient Monitoring:
- Children and adolescents: 3 doses of 0.5 mL at Adverse reactions: fatigue, headache, asthenia, dizziness, insomnia, irritability, Children weighing 25 to 36 kg (55 to 79 lb) : 200 mg P.O. b.i.d., given with
>Carefully monitor patient?s respiratory status. Check ventilator often to ensure · Pregnancy (X) combination therapy; obtain a pregnancy test prior to, monthly during, and
birth, 1-4, 6-18 months for infants or 0, 1-2, 4-6 nausea, vomiting, diarrhea, dry mouth, anemia, neutropenia, interferon alfa-2b
months for older children that drug precipitates don?t impede function. for 6 months after treat-ment is completed; those who are not willing to practice strict
>Monitor ECG and vital signs. Watch for hypotension, bradycardia, and other Patient monitoring Adverse reactions Nausea, diarrhea, stomach upset,headache,
- Adults: 3 doses of 1 mL at 0, 1, 4-6 months contraception should not receive treatment with these products
signs of impending cardiac arrest or worsening respiratory condition. ? Continue to monitor CBC with WBC differential at treatment weeks 4, 8, and 12; dizziness, blurred vision, trouble sleeping, cough, low appetite, weight
Side Effects: · Monitor hemoglobin prior to, at treatment wks 4, 8, and 12, and as needed. If Hgb is
pain, severe itching, reddening of the skin, >Assess neurologic status. Stay alert for depression and suicidal ideation. closely monitor at other times as clinically appropriate. loss or gain, dry skin, or changes in taste/hearing may occur
Havrix (Hepatitis A Vaccine) less than 10 g/dl, decrease ribavirin dos-age; if Hgb is less than 8.5 g/dl, discontinuation of
weakness, malaise, nausea, vomiting, abdominal ? Monitor HCV-RNA levels at treatment weeks 4, 8, 12, and 24, at the end of Patient monitoring
Mechanism of Action: therapy is recommended;telaprevir dosage should not be altered based on adverse
pain, difficult or labored breathing, diminished treatment, during treatment followup, and at other times as clinically indicated. Be >Carefully monitor patient?s respiratory status. Check ventilator often to ensure
Produces antibodies that confer protection against reac-tions; Anemia may be managed through ribavirin dose modifications; never alter the
appetite, stuffy nose, sore throat aware that discontinuation of therapy is recommended in all patients with HCV-RNA that drug precipitates don?t impede function.
hepatitis A infection. Stimulation of specific antibodies dose of tela-previr. If anemia persists despite a reduction in ribavirin dose, consider
takes place without producing any disease symptoms. level of 100 international units/ml or greater at treatment week 12 or confirmed >Monitor ECG and vital signs. Watch for hypotension, bradycardia, and other
discontinuing telaprevir.
Dosage: detectable HCV-RNA level at treatment week 24. signs of impending cardiac arrest or worsening respiratory condition.
· Assess for toxic epidermal necrolysis, Stevens- Johnson syndrome, eosinophilia, fever,
- Children and adolescents: A single 0.5-mL dose ? If patient is also receiving antiarrhythmics, bosentan, calcium channel blockers, >Assess neurologic status. Stay alert for depression and suicidal ideation.
mucosal skin erosion, mucosal ulceration, target lesions; if serious skin reaction occurs,
and a 0.5-mL booster dose administered between immediately discontinue all components of the three-drug regimen and refer the patient for
digoxin, immunosuppressants, or opioid analgesics, monitor therapeutic levels of
6 to 12 months later. these drugs.
urgent medical care
- Adults: A single 1-mL dose and a 1-mL booster ? Monitor INR closely if patient is receiving warfarin while taking this three-drug
· Thyroid function tests, LFTs, serum bilirubin/ creatinine, BUN, bilirubin, serum
dose administered between 6 to 12 months later. combination.
Side Effects:Swelling, tenderness, redness, electrolytes, serum uric acid, baseline and periodically dur-ing treatment
? Closely watch for adverse reactions in patients taking erectile dysfunction drugs
warmth, or a hard lump where the shot was given, while also taking this three-drug combination.
Low fever, General ill feeling, nausea, loss of ? Closely watch for respiratory depression or prolonged sedation in patients also
appetite, headache - History and physical examination taking sedatives or hypnotics with this three-drug combination.
- Liver function studies
- Alanine aminotransferase (ALT)
- Aspartate aminotransferase (AST)
Hepatitis testing: - Serum bilirubin
- Hepatitis A: Anti-HAV - Prothrombin time (PT) and INR
IgM - Alkaline phosphatase
Hepatitis A Hepatitis B Hepatitis C Hepatitis E - ?-Glutamyl transpeptidase
Hepatitis D
- - FibroScan
- FibroSure (FibroTest)
Predisposing Factors:
-Environment
-Poor sanitation Hepatitis testing:
- Hepatitis B: HBsAg, anti-HBs, Hepatitis testing:
-Geography HBeAg, anti-HBe, anti-HBc IgM Hepatitis testing:
-Close contact with carrier of the virus - Hepatitis C: Anti-HCV, HCV RNA
and IgG, HBV DNA quantitation, quantitation, HCV genotyping - Hepatitis D: Anti-HDV, HDV Ag
-Sexual activity (oral to anal sex) HBV genotyping
-Multiple sexual partners
-Exposure to blood, blood products or other body fluids
-Mother to child transmission
-Drinking alcohol
-Use of recreational drugs
-Healthcare workers
-Tattoo or body piercing Exposure to Risk
-Traveling to areas of high endemicity without being Factors
immunized

Precipitating Factors:
-Chronic Liver Disease
For HBV
-Obesity Virus enters liver
Uncoats and releases its Releases Uses RNA
Transcribed to Makes Undergoes
Produces Converted
-Diabetes cells through make viral Pregenomic Reverse
envelope and proteins into dsDNA Polymerase DNA into dsDNA
endocytosis mRNA RNA (pgRNA) Transcriptase
-Cardiovascular Disease the nucleus
-HIV/AIDS
Releases ssRNA to
the host's
ribosomes

If CD8+ doesn't recognize Cytotoxic T-cells Proteins such as antigens

Induces Activates Body responds Viral Proteins Ribosomes
abnormal viral proteins, it produces specific will be shuttled onto MHC-I,
macrophages and by releasing produces an synthesizes
apoptosis secretes perforins and proteins such as CD8+ to an enzyme on the cell
cytotoxic T-cells interferons infection proteins
grandzymes interact with MHC-I membrane

Encodes RNA Increase in the

DNA RNA Able to make Releases viruses out
Capsomeres Antigens Dependent-RNA production of
Polymerase Polymerase viruses of the hepatocytes
Polymerase RNA

These proteins will be

sent to the Endoplasmic Releases viruses
Able to make
Reticulum (ER) out of the
viruses
hepatocytes

Produces vesicles
containing proteins

Lysis of
Hepatocytes

Apoptosis

Liver cells are damaged

Accumulation of Inability to convert

Produces IL-2, IL-6 and Decrease in bile or Liver is inflamed
hepatotoxins unconjugated bilirubin
TNF? Kidneys excrete biliary production
properly Infection
conjugated bilirubin

Decreased
Gets into the circulation Leaks into the
concentration of
and goes to the CNS bloodstream
bilirubin
Increase in Increase in Increase in bile salts in Decrease in clotting Plasma cells
Increases in size
unconjugated conjugated Bile acid blood proteins produces
bilirubin bilirubin antibodies

Triggers the prostaglandin

process in the brain: PGE2 Goes to the CNS and Decreased
and PGF2 production to an area in the brain urobilinogen Complication:
stem Combines with Thrombocytopenia
More conjugated Clinical Manifestation:
RUQ abdominal pain the virus
bilirubin will be filtered
Nursing Management and will go into the
Starts to deposit into
- Assess V/S q 4 hours certain tissues
kidneys
Complication:
Changes the hypothalamic Decreased
- Assess patient?s level of mobility thermostat stercobilin Hemolytic Anemia
- Observe and monitor the patient?s sleep pattern and the Chemoreceptor
Trigger Zone (CTZ) Creates an Binds with
amount of sleep
immune platelets and
- Assess the need for ambulation complex blood vessels
- Assess emotional response to limitations in physical Acute pain r/t inflamed liver
Activity intolerance r/t Clinical Sclera of the Tissues of the Clinical Manifestion: Complication:
activity. eyes skin Neutropenia
decreased metabolic Manifestations: Darker Urine Clinical Manifestation:
- Observe and document response to activity Fever and Malaise Clay-colored or
- Provide bedside commode as indicated energy production Stimulates emetic
Acholic Stool
- Encourage verbalization of feelings regarding limitations. center
- Support coping and manage anxiety to minimize energy
expenditure Clinical Manifestation: Clinical Manifestation:
- Teach energy conservation techniques Clinical Manifestation: Nursing Management
Icterus (Yellow Sclera) Jaundice specifically on
Pruritus
- Encourage diaphragmatic breathing HEPATITIS A and E the palms of the hand - Assess V/S q 4 hours
- Encourage proper rest periods - Bed rest Activates nerves and soles of the feet - Pain scale and characteristic assessment Deposited into the Deposited into the
Deposited in the Deposited in the
- Provide safe room environment to preven injury - Manage nausea that goes to the GI - Provide accurate information and explain the Deposited to tissues synovial joints blood vessel walls pericardium and glomerular basement
- Position patient for comfort tract myocardium of the heart membrane of the kidney
- Avoid alcohol and use cause of the pain
medications with care - provide quiet room environment
- encourage verbalization of feelings
- Assist in positioning and ambulation
- Teach and encourage deep breathing Complication:
Clinical Manifestations Clinical Manifestations Complication: Complication:
Clinical Complications: -Position bed for maximal respiratory ef?ciency Vasculitis
Myocarditis and
Glomerulonephritis
Inflammation Arthritis Pericarditis
Clinical Manifestations: Dehydration, Decreased Blood - Administer analgesic that does not contain
Complication:
Manifestation: Retroperistalsis Nausea and Volume, Electrolyte Changes
Altered GI motility
Diarrhea and Weight Loss hepatotoxic effects as indicated
Vomiting

Imbalanced Nutrition, Less

Than Body Requirementsr/t
impaired absorption and
digestion of food

Nursing Management
- Monitor intake and output
- Collaborate with the nutritionist about patient?s caloric intake daily
for each meal and snacks.
- Assist in mouth care before meals
- Provide small frequent meals
- Monitor weight and record daily
- Monitor laboratory values and report significant changes to
physician
- Hydration
- Monitor and record the amount and characteristics of the emesis
- Administration of Antiemetics and Antacids as indicated
- Monitor V/S q 4 hours