Hepatitis B is a systemic, viral infection in whichnecrosis and inflammation of liver cells producea characteristic cluster of clinical, biochemical,and cellular changes. It is caused by a double-stranded DNA virus called, the hepatitis B virus(HBV).
Most people (more than 90%) who contract HBVinfection develop antibodies and recoverspontaneously in 6 months. The mortality ratefrom hepatitis B has been reported to be as highas 10%. Another 10% of patients who havehepatitis B progress to a carrier state or developchronic hepatitis with persistent HBV infectionand hepatocellular injury and inflammation. Itremains a major worldwide cause of cirrhosis andhepatocellular carcinoma.
EpidemiologyHBV infects more than 350 million peopleworldwide. Studies show that in thePhilippines there is a Hepatitis B carrier rate of9%. This means that out of 10 people at least1 is a carrier of Hepatitis B. It is estimated thatmore than 7.7 million people are chronicallyinfected with Hepatitis B, of whom between1.1 and 1.9 million are expected to dieprematurely of cirrhosis or liver cancer.
• Transmission• The HBV is transmitted primarily through blood (percutaneous and permucosal routes). HBV can be 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 infants.
Risk Factors Frequent exposure to blood, blood products, or other body fluids Health care workers: hemodialysis staff, oncology and chemotherapy nurses, personnel at risk for needlesticks, operating room staff, respiratory therapists, surgeons, dentists Hemodialysis Male homosexual and bisexual activity IV/injection drug use Close contact with carrier of HBV Travel to or residence in area with uncertain sanitary conditions Multiple sexual partners Recent history of sexually transmitted disease Receipt of blood or blood products (eg, clotting factor concentrate)
• Pathogenesis• Shortly after the virus enters a new host, it’s initial response is to infect liver cells, called hepatocytes. The virus main target is the liver because the virus possesses surface antigens specific for receptors found on liver cells only. The binding of these viral antigens to hepatocyte receptors induces viral entry by receptor- mediated endocytosis and uncoats in the cytoplasm. Generally, the liver is responsible for purifying blood and processing nutrients. A healthy liver is essential to the functioning of blood, lymph, and bile production. If the liver fails, all other organs in the body will soon start to fail.
• Clinical Features• PATHOGNOMONIC SIGN• Jaundice, icteric mucous membranes, dark urine and clay-colored stools.• Clinically, the disease closely resembles hepatitis A, but the incubation period is much longer (1 to 6 months). Signs and symptoms may be insidious and variable. Fever and respiratory symptoms are rare; some patients have arthralgias and rashes. The liver may be tender and enlarged to 12 to 14 cm vertically. The spleen is enlarged and palpable in a few patients; the posterior cervical lymph nodes may also be enlarged.
OBJECTIVE SUBJECTIVE PROBLEM IDENTIFIED • Fatigue • FatigueACTIVITY/REST • Weakness • Activity intolerance • General Malaise • Bradycardia (in severe • Impaired skin integrityCIRCULATION hyperbilirubinemia) • Disturbed body image • Jaundiced sclera, skin, mucous membranes • Diarrhea • Dark urine, clay-colored stools • Imbalanced nutrition: less thanELIMINATION • Constipation body requirements • Fluid volume deficit • Loss of appetite, weight loss • Ascites • Imbalanced nutrition: less thanFOOD/FLUID • Weight gain—edema, ascites body requirements • Nausea, vomiting • Fluid volume excess • Ineffective breathing pattern • Disturbed body image • Irritability, drowsiness, lethargy, • High risk for injuryNEUROSENSORY asterixis • Abdominal cramping, RUQ • Muscle guarding, restlessness • Chronic pain and discomfortPAIN/DISCOMFORT tenderness • Joint pain • Headache • Blood transfusions or organ • Fever—usually low grade • HyperthermiaSAFETY transplant received prior to viral • Urticaria, maculopapular lesions, • Pain screening tests irregular patches of erythema • Impaired skin Intergrity • Tattoos (possible equipment • Spider angiomas, palmar • Disturbed Body Image source) erythema, gynecomastia in men • Itching (pruritus) (sometimes present in alcoholic hepatitis) • Splenomegaly, posterior cervical node enlargementSEXUALITY • Lifestyle or behaviors increasing risk of exposure—unprotected sexual intercourse with infected person
DIAGNOSTIC STUDIES• BLOOD TESTS Hepatitis B viral panels (antibody/antigen tests) – Detect antibodies to the various viruses.• Alanine aminotransferase (ALT) – Considered best liver enzyme test for detecting hepatitis. – Elevation usually occurs before other symptoms, such as jaundice, are noted.
• Alkaline phosphatase (ALP) – Usually only slightly elevated unless severe biliary obstruction is present.• Complete Blood Count – RBCs are decreased because of shortened life span of RBCs - liver enzyme alterations or hemorrhage. – WBCs may be abnormally low (leukopenia) or high (leukocytosis); monocytes may be increased (monocytosis), and lymphocytes may be increased and atypical in appearance.• Serum AlbuminMeasures the main body protein manufactured by the liver.Level is decreased.
• Prothrombin time (PT) Evaluates the body’s ability to produce a clot in a reasonable amount of time. May be prolonged - liver dysfunction.• Serum Bilirubin High level indicates the liver is incapable of adequately removing bilirubin in a timely manner due to blockage of bile ducts or liver disease, such as acute hepatitis.
• LIVER SCAN May be indicated for differential diagnosis, to identify underlying chronic liver disease, or for evaluating organ function. Helps estimate the severity of parenchymal damage.• LIVER BIOPSY Considered if diagnosis is uncertain or if clinical course is atypical or unduly prolonged. Provides initial assessment of disease severity in client• URINALYSIS Checks the urine for bilirubin for the nonjaundiced client. Elevated bilirubin levels and proteinuria and hematuria may occur.• STOOL ANALYISIS Clay-colored stools indicate lack of normal bile excretion into the intestine.
MEDICAL MANAGEMENTPharmacology• Alpha-interferon-is the single modality of therapy that offers the most promise of all agents that has been used to treat chronic hepatitis B.-a regimen of 5 million units daily or 10 million units three times weekly for 16 to 24 weeks results in remission of disease in approximately one third of patients.-a prolonged course of treatment may also have additional benefits and is currently under study.-it must be administered by injection and has significant side effects, including fever, chills, anorexia, nausea, myalgias, and fatigue. Delayed side effects are more serious and may necessitate dosage reduction or discontinuation. These include bone marrow suppression, thyroid dysfunction, alopecia, and bacterial infections.
• Lamivudine (Epivir)-an antiviral agent.-have revealed improved seroconversion rates, loss of detectable virus, improved liver function, and reduced progression to cirrhosis-it can be used for patients with decompensated cirrhosis who are awaiting liver transplantation• Adefovir (Hepsera)-an antival agent.-may be effective in people who are resistant to lamivudine.• Antacids and Antiemetics-measures to control the dyspeptic symptoms and general malaise.
NURSING MANAGEMENT Convalescence may be prolonged, with complete symptomatic recovery sometimes requiring 3 to 4 months or longer. During this stage, gradual resumption of physical activity is encouraged after the jaundice has resolved. The nurse identifies psychosocial issues and concerns, particularly the effects of separation from family and friends if the patient is hospitalized during the acute and infective stages. Even if not hospitalized, the patient will be unable to work and must avoid sexual contact. Planning is required to minimize social isolation. Planning that includes the family helps to reduce their fears and anxieties about the spread of the disease. Bed rest may be recommended, regardless of other treatment, until the symptoms of hepatitis have subsided. Activities are restricted until the hepatic enlargement and levels of serum bilirubin and liver enzymes have decreased. Gradually increased activity is then allowed. Adequate nutrition should be maintained. Proteins are restricted if symptoms indicate that the liver’s ability to metabolize protein byproducts is impaired.
Dietary Management of Viral HepatitisRecommend small, frequent meals.Provide intake of 2000 to 3000 kcal/d during acute illness.Although early studies indicate that a high- protein, highcalorie diet may be beneficial, advise patient not to force food and to restrict fat intake.Carefully monitor fluid balance.
If anorexia and nausea and vomiting persist, enteral feedings may be necessary.Instruct patient to abstain from alcohol during acute illness and for at least 6 mo after recovery.Advise patient to avoid substances (medications, herbs, illicit drugs, and toxins) that may affect liver function.
Teaching Patients Self-Care• Because of the prolonged period of convalescence, the patient and family must be prepared for home care. Provision for adequate rest and nutrition must be ensured. The nurse informs family members and friends who have had intimate contact with the patient about the risks of contracting hepatitis B and makes arrangements for them to receive hepatitis B vaccine or hepatitis B immune globulin as prescribed. Those at risk must be made aware of the early signs of hepatitis B and of ways to reduce risk by avoiding all modes of transmission. Patients with all forms of hepatitis should avoid drinking alcohol and eating raw shellfish.
Continuing Care• Follow-up visits by a home care nurse may be needed to assess the patient’s progress and answer family members’ questions about disease transmission. During a home visit, the nurse assesses the patient’s physical and psychological status and confirms that the patient and family understand the importance of adequate rest and nutrition. The nurse also reinforces previous instructions. Because of the risk of transmission through sexual intercourse, strategies to prevent exchange of body fluids are recommended, such as abstinence or the use of condoms. The nurse emphasizes the importance of keeping follow-up appointments and participating in other health promotion activities and recommended health screenings
PREVENTION• Active Immunization: Hepatitis B Vaccine• Hepatitis B vaccine provides long-term protection against HBV infection. Hepatitis immune globulin may be effective for unvaccinated persons who are exposed to the infection if given within 7 days of exposure. Hepatitis vaccination is recommended for preexposure and postexposure prophylaxis.• The vaccine also is recommended for all persons who are at high risk for exposure to the virus. The vaccines are administered intramuscularly in three doses; the second and third doses are given 1 and 6 months, respectively, after the first dose. The third dose is very important in producing prolonged immunity. Hepatitis B vaccination should be administered to adults in the deltoid muscle.
GUIDE ON HEPATITIS B IMMUNIZATIONRoute IntramuscularSite Outer portion of the left thighNumber of Dose 3 dosesAge at First Dose Within 24 hours after birthDosage 2 dropsStorage Temperature 2 to 8 °C
Prevention of HepatitisEncourage proper community and home sanitation.Encourage conscientious individual hygiene.Instruct patients regarding safe practices for preparing and dispensing food.Support effective health supervision of schools, dormitories, extended care facilities, barracks, and camps.Promote community health education programs.
Facilitate mandatory reporting of viral hepatitis to local health departments. Recommend vaccination for all children 1 year of age and older. Recommend vaccination for travelers to developing countries, illegal drug users (injection and noninjection. drug users), men who have sex with men, and people with chronic liver disease, and recipients (eg, hemophiliacs) of pooled plasma products. Promote vaccination to interrupt community-wide outbreaks.
EVALUATION• PROGNOSIS• Some people rapidly improve after acute hepatitis B. Others have a more prolonged disease course with very slow improvement over several months, or with periods of improvement followed by worsening of symptoms.• A small group of people (about 1% of infected people) suffer rapid progression of their illness during the acute stage and develop severe liver damage (fulminate hepatitis). This may occur over days to weeks and may be fatal.• Other complications of HBV include development of a chronic HBV infection. People with chronic HBV infection are at further risk for liver damage (cirrhosis), liver cancer, liver failure, and death.