its related to health and medicine.

2. PRESENTED BY: NUSRAT
MSN SEM-1

3. 
 Present a case study;(Demographic Data/ History).
 Define hepatitis and its types
 Enlist clinical manifestation along with etiology of hepatitis
 Describe pathophysiology of hepatitis
 Explain hepatitis screening & diagnostic tests
 Discuss treatment and diet plan for hepatitis patient
OBJECTIVES

4. 
Conti…
Identify risk factors & preventive measurement of
hepatitis
Describe Nursing diagnosis with intervention.
Explain complication of hepatitis.
References

5. 
A 50 years female was admitted in Gastro ward at HMC. She was
a case of Hepatitis C since 2 years. She never got any kind of
treatment for her illness. She didn’t has any major symptoms as
such but, she complained of weakness and tiredness. Now, she
was admitted with HCV+ve along with fever history. Due to high
grade fever and weakness she could not talk properly. She has
also HTN and her younger daughter was taking care of her
mother in hospital as well as at home.
Case Scenario

6. 
According to her daughter statement, her father was passed away
3 years ago and he had also HCV positive.
This patient was under tremendous stress due to her health and
this was additional stress that she had faced at that time. She was
not taking care in diet and she ate everything whatever she likes
to eat if it is available. That’s why, her BP was going to shout up.
This make more worst her health status. Economically, she was
poor. She looks anemic and malnourished.
Conti..

7. 
 Current complaint:
Fever from 3 days
Pain abdomen from 7 days
Excessive weakness and fatigue from 4 days
 Present history:
Known HTN and HCV positive. Patient has fever from
3 days high grade intermittent with slight abdomen
distension.
Conti…

8. 
Past history:
HCV +ve, HTN +ve, appendectomy 3 years ago, jaundice +ve, using
over the counter (OTC) drugs for HTN but off and on not regularly.
Medications were:
Inj. Daytaxime (cefotaxime) 1gm I/V TDS
Inj. Omeprazole 40mg in 100ml N/Saline I/V OD
Syp. Duphalac 2 TSF P/O TDS
Lactose Enema P/R stat then BD
Conti…

9. 
Family History:
• Family history positive for HCV
Personal & Social History:
• She was socially very active specially in taking care of any sick
person even hospitalized. She has personally poor hygiene and
don’t care about her health status.
Conti…

10. 
Conti…
 Assessment:
• Pulse Rate: 106/min
• Fever: 102F
• Cardiac Rhythm: Regular
• BP: 170/90 mmHg
• Heart Sounds: S1+S2+O
• Cardiac Murmurs: No added sound
• Edema: Positive
• Tongue: Dry coated
• Sclera: yellowish

11. 
• Skin and mucous: Yellowish
• Abdomen: tenderness with distention
• Liver: palpable
• Urine: dark color
• Stool: pale color
• Poor personal hygiene
• Lack of knowledge regarding health
 Medical diagnosis:
• HCV+ve
Conti…

12. 
 “Inflammation of the liver, due to
hepatotropic (liver preferring) viruses,
drugs , or associated factors.”
Hepatitis
Netter F.(2008)

13. 
1.HAV (HEPATITIS ‘A’ VIRUS):
• Incubation period : 2-7 weeks (average 28 days)
• Also known as “Infectious Hepatitis “
• Mainly occurs due to unsanitary conditions
 Mode of Transmission :
• Contaminated food and water
• Fecal- oral route
• Sexual route
Types of hepatitis

14. 
2. HBV (hepatitis ‘B’ virus ):
• Incubation period : 30-180 days (average 75 days )
• Also known as ‘Serum Hepatitis’, since it was found that HBV
could be spread only by blood/ serum
 Now, it is found that HBV can also be spread via:
a. Sexual contact
b. Shared needles among drug abusers
c. Blood transfusions
d. Hemodialysis
e. Vertical transmission
f. Tattooing(Body piercing)
Conti…

15. 
 Cause high risk of chronic liver conditions, like :
• Liver cirrhosis
• Liver cancer (Hepatocellular carcinoma )
• Liver failure
Conti…

16. 
3. HCV (HEPATITIS ‘C’ VIRUS ):
• Incubation period : 50-150 days
 Mode of transmission include :
• Shared needles among drug abusers
• Hemodialysis
• Sexual route (rare)
• Also associated with chronic liver conditions.
Conti…

17. 
4. HDV (hepatitis ‘D’ virus ):
• Incubation period : 5 weeks
• Also known as “Delta Virus”
• Small virus, that requires related infection with HBV in order
to survive
• HBV Provides surface antigen (envelope protein) required
by HDV for survival
 Mode of Transmission : Same as that of HBV
• (HBV+ HDV) combined infection
• difficult to treat.
Conti…

18. 
5. HEV (HEPATITIS ‘E’ VIRUS):
• Incubation period : 2-9 weeks (approximately 45 days)
• Similar to HAV in terms of disease
 Transmitted by:
• contaminated water
• Most common in Asia
6. HGV (hepatitis ‘G’ virus):
 Resembles to HCV
 Not much common
Conti…

19. 
Can be divided into 3 stages:
1.Prodromal phase:
Observed 1-2 weeks after viral exposure
Anorexia - Nausea - Vomiting
Fatigue - Arthralgia - Myalgia
Headache - Photophobia - Pharyngitis
- Fever - Cough - Taste alterations
Clinical manifestation of
hepatitis

20. 
 2. Icteric phase:
• Observed 1-2 weeks after prodromal phase
• Continues for 2-6 weeks - Clay colored stools
• Yellowish color of skin, sclera and urine
• - Hepatomegaly (liver enlargement)
• Weight loss
• General itching-( pruritus)
Conti…

21. 
 3. Convalescence phase (recovery phase ):
• Resolving of symptoms
• Liver enzyme levels comes to normal
• Hepatomegaly condition still persists
• Lasts for 6-12 weeks
Conti…

22. 
Etiology of hepatitis

23. 
E- INFECTIOUS AGENTS:
1. Bacteria
2. Viruses:
a. Hepatitis Viruses (HAV, HBV, HCV, HDV, HEV , HGV)
b. Miscellaneous Viruses:
- Adenovirus
- CMV (Cytomegalovirus)
- EBV (Epstein-Barr Virus)
- Herpes Simplex Virus
F- I.V DRUG ABUSE
Conti…

24. 
 Here, we will discuss pathophysiology of :
 Hepatitis ‘A’
 Hepatitis ‘B’
 Hepatitis ‘C’
 Hepatitis ‘D’
 Hepatitis ‘E’
 Hepatitis ‘G’
Pathophysiology of hepatitis

25. 
 Parenteral/ oral inoculation of HAV into body causes accumulation of
infective virus HAV enters hepatocytes (Liver cells) HAV replicates
inside Hepatocytes Leads to 2 conditions
 Viral antigen gets shed into bile and through feces (a condition, known as
‘infectivity’)
 Initiation of host immune response (T-cell activity, monocytes) release
cytokines cause hepatocellular injury
1. Pathophysiology of
hepatitis ’A’

26. 
 In some cases Jaundice occurs Significant liver
dysfunction is observed(along with hepatocellular
damage ) improvement occurs by subsequent
therapeutically measures recovery
 In most cases ‘Acute icteric phase’ is observed mild
symptoms, along with minimum hepatocellular damage
improvement occurs by subsequent therapeutically
measures recovery
Conti…

27. 
 HBV enters body (through any mode of transmission routes
explained earlier ) HBV enters hepatocytes HBV
replicates inside liver cells Release 3 types of antigens :
 a. Hbc Antigen b. Hbs Antigen c. HbVe Antigen
 The above antigens expressed on hepatocellular surface
triggers host immune response leads to 2 types of immune
activities:
2. Pathophysiology of
hepatitis ‘B’

28. 
 T-Cell activation:
T-Cell activation releases cytokines and activates
cytotoxic T-cells Cytokines cause direct liver cell
injury
 B- Cell activation:
B-Cell activation produces 3 antibodies ( Anti-Hbs,
Anti-HbVeAg, Anti-Hbc) cause liver injury by
damaging the liver cell in an attempt to destroy virus.
Conti…

29. 
 The cause of hepatitis C is a spherical enveloped single-
stranded RNA virus belonging to the Flaviviridae family and
Flavivirus genus. The natural targets of HCV are hepatocytes
and possibly B lymphocytes. Viral clearance is associated with
the development and persistence of strong virus-specific
responses by cytotoxic T lymphocytes and helper T cells.
3. Pathophysiology of
hepatitis ‘C’

30. 
 In most infected people, viremia persists and is
accompanied by variable degrees of hepatic
inflammation and fibrosis. Findings from studies
suggest that at least 50% of hepatocytes may be
infected with HCV in patients with chronic
hepatitis C
Conti…

31. 
 Hepatitis D virus (HDV) is an RNA virus that is structurally
unrelated to hepatitis A (HAV), hepatitis B (HBV), or hepatitis
C virus (HCV). It was discovered in 1977. HDV causes a unique
infection that requires the assistance of viral particles from
HBV to replicate and infect other hepatocytes.
Pathophysiology of hepatitis ‘D’

32. 
 Hepatitis E results from HEV infection and is spread by fecal
contaminated water within endemic areas. However, in non-
endemic areas, the major mode of the spread of HEV is
foodborne, especially consumption of undercooked pork, raw
liver, and sausages.
5. Pathophysiology of
hepatitis ‘E’

33. 
 Blood Tests:
• Liver function panel: A liver function panel
checks how well the liver is working and
consists of many different blood tests.
• ALT (Alanine Aminotransferase): An elevated ALT helps
identify liver disease or damage from any number of causes,
including hepatitis.
• AST (Aspartate Aminotransferase): Along with an elevated ALT,
the AST checks for liver damage.
• Alkaline phosphatase: Alkaline phosphatase is present in bile-
secreting cells in the liver; it's also in bones. High levels often
mean bile flow out of the liver is blocked.
Lab & diagnostic test

34. 
• Bilirubin: High bilirubin levels suggest a problem with the
liver.
• Albumin: As part of total protein levels, albumin helps
determine how well the liver is working.
• Ammonia: Ammonia levels in the blood rise when the liver is
not functioning properly.
• Hepatitis A tests: If hepatitis A is suspected, the doctor will
test liver function as well as antibodies to detect the hepatitis
A virus.
Conti…

35. 
• Hepatitis B tests: Your doctor can test antibody levels to determine
if you have been infected with the hepatitis B virus.
• Hepatitis C tests: In addition to
checking liver function, blood tests
can determine if you have been
infected with the hepatitis C virus.
• Prothrombin Time (PT): A prothrombin time, or PT, is commonly
done to see if someone is taking the correct dose of the blood
thinner warfarin (Coumadin). It also checks for blood clotting
problems.
• Partial Thromboplastin Time (PTT): A PTT is done to check for
blood clotting problems.
Conti…

36. 
 Imaging Tests:
• Ultrasound:
An abdominal ultrasound can
test for many liver conditions, including
cancer, cirrhosis, or problems from gallstones.
• CT scan (computed tomography):
A CT scan of the abdomen gives
detailed pictures of the liver and other abdominal organs.
Conti…

37. 
 Liver biopsy:
A liver biopsy is most commonly done after another
test, such as a blood test or ultrasound, indicates a
possible liver problem.
 Liver and spleen scan:
This nuclear scan uses radioactive material
to help diagnose a number of conditions, including
abscesses, tumors, and other liver function problems.
Conti…

38. 
 Liver Treatments
• Hepatitis A treatment: Hepatitis A usually
goes away with time.
• Hepatitis B treatment: Chronic hepatitis
often requires treatment with antiviral medication.
• Hepatitis C treatment: Treatment for hepatitis C depends on
several factors.
• Liver transplant: A liver transplant is needed when the liver no
longer functions adequately, whatever the cause.
Treatment of hepatitis

39. 
 Liver cancer treatment: While liver cancer is usually difficult to
cure, treatment consists of chemotherapy and radiation. In
some cases, surgical resection or liver transplantation is
performed.
 Paracentesis: When severe ascites –
swelling in the belly from liver
failure -- causes discomfort, a needle
can be inserted through the skin to
drain fluid from the abdomen.
Conti…

40. 
 ERCP (Endoscopic retrograde cholangio-
pancreatography):
Using a long, flexible tube with a
camera and tools on the end, doctors
can diagnose and even treat some
liver problems.
Conti…

41. 
 FOODS TO INCLUDE:
• Steamed green leafy vegetable
• Fish
• Fresh fruits
• Fresh vegetable juices
• Organic chicken
• Plenty of dirking water
• Whole grains
Diet plan of hepatitis

42. 
Conti…
 FOOD TO AVOID:
• Alcohol
• Smoking
• Non veg, packaged food
• Frozen food, artificial food
• Junk food, high protein diet
• Soft drink
• Pain killers
• Citrus food and yogurt and heavy
• Greasy cheesy diet

43. Hygiene
Practicing good hygiene is one key way to avoid contracting hepatitis.
We have to avoid:
• Contaminated drinking water
• Ice
• Rotten Sea food
• Unhygienic fruit and vegetable
Hepatitis contracted through contaminated
blood can be prevented by:
• Not sharing drug needles
• Not sharing razors
• Not using someone’s tooth brush
• Not touching spilled blood
Prevention of hepatitis

44. 
Vaccines
The utilization of vaccines is a second key to preventing hepatitis.
Vaccination are available to prevent the development of A and B.
Experts are currently developing vaccines against hepatitis C, D
and E.
Conti…

45. 
 During June 2010−March 2011, a total of 712 cases of viral hepatitis
were reported by the five sentinel sites. Newly reported hepatitis C
was the most common cause of viral hepatitis, accounting for 53.2%
of cases, followed by acute hepatitis A (19.8%), acute hepatitis E
(12.2%), and newly reported hepatitis B (10.8%). In addition, among
patients, 28 (3.9%) had evidence of HBV and HCV co-infection, and
11 (14.3%) of those with HBV infection had evidence of co-infection
with hepatitis D.
 It is estimated that approximately
ten million people in Pakistan
(6% of the population) have been
living with HCV infection.
Epidemiology

46. 
 . The prevalence rate is high among middle-aged persons and
patients receiving hemodialysis or who received blood
transfusion before the advent of HCV diagnostic tools.
 Since 2000, a significant increase in injection drug use also has
been reported in Pakistan (60%--93%).
 70% of health-care services in Pakistan and provide services
for high-risk groups .
Conti…

47.  Nursing Diagnosis
Acute Pain abdominal related to tender enlarged liver
 Expected Outcome
Report a decrease or absence of abdominal pain and tenderness restrict
activities if pain occurs; participates in planned activities when free of pain;
take prescribed analgesic if necessary.
 Nursing Intervention for Hepatitis
 Asses and record presence or absence of abdominal pain or tenderness,
hepatomegaly and splenomegaly.
 Encourage the patient to maintain bed rest or restrict activities if abdominal
pain or tenderness is present.
 Administer analgesic as prescribed.
 Notify sudden occurrence or increase in pain or tenderness.
Nursing Diagnosis and
Intervention

48.  Nursing Diagnosis
Activity Intolerance related to fatigue generalized malaise.
 Expected outcome
Exhibits increased ability to carry out desired activities and allow
sufficient periods for rest and relaxation.
 Nursing Intervention for Hepatitis
• Encourage the patient to limit activity when fatigue
• Assist the patient in planning periods of rest and activity when
symptoms begin to subside.
• Encourage gradual resumption of activities and mild exercises
during recovery.
Conti…

49. 
 Fibrosis
 Cirrhosis of the Liver
 Cancer of the Liver
 Liver Failure
 Glomerulonephritis
 Hepatic Encephalopathy
 Portal Hypertension
 Viral Co-Infection
Complication

50. 
 To the almighty ALLAH, for blessing me to make this ppt , and share
it to all of you
 To my respected parents, the prays of without whom I am nothing
 To my highly intellectual mam. Anis Fatima , for her constant backing
and support
 To my professional colleagues, who helping
me in my case study
 To my friends, well-wishers and loved ones,
for their presence, guidance and emotional care
 Last, but not the least, to all of my class-fellows for their endless up
keeping and holding me as back bone of mine !!!!!!!!!!!!!
Acknowledgment

51. 

52. 

53. 
 National Institute of Diabetes and Digestive and Kidney Diseases web site:
"Liver.“
 Netter F. Atlas of Human Anatomy, 4th edition, Saunders, 2008..
 Young B, Wheater's Functional Histology, 5th edition, Churchill Livingstone, 2011.
 Muhammad N, Jan MA. Frequency of hepatitis “C” in Buner, NWFP. J Coll
Physicians Surg Pak. 2005;15:11-4. .
 Hamid S, et all. Pakistan Society of Gastroenterology. PSG consensus statement
on management of hepatitis C virus infection-- 2003. J Pak Med Assoc. 2004.
 Aslam M, et all. Association between smallpox vaccination and hepatitis C
antibody positive serology in Pakistani volunteers. J Clin Gastroenterol.
2005;39:243-6.
 Khokhar N, at all. Risk factors for hepatitis C virus infection in patients on long-
term hemodialysis. J Coll Physicians Surg Pak. 2005;15:326-8.
 Ali SA, at all. Hepatitis B and hepatitis C in Pakistan: prevalence and risk
factors. Int J Infect Dis 2009.
References

54.  Maticic M. Lichen planus in hepatitis C virus infection: an early marker that may save lives. Acta
Dermatovenerol Alp Panonica Adriat. 2007 Mar. 16(1):3-6. [Medline].
 Frank C, Mohamed MK, Strickland GT, et al. The role of parenteral antischistosomal therapy in the
spread of hepatitis C virus in Egypt. Lancet. 2000 Mar 11. 355(9207):887-91. [Medline].
 Ly KN, Xing J, Klevens RM, Jiles RB, Ward JW, Holmberg SD. The increasing burden of mortality
from viral hepatitis in the United States between 1999 and 2007. Ann Intern Med. 2012 Feb 21.
156(4):271-8. [Medline].
 Davis GL, Balart LA, Schiff ER, et al. Treatment of chronic hepatitis C with recombinant interferon
alfa. A multicenter randomized, controlled trial. Hepatitis Interventional Therapy Group. N Engl J
Med. 1989 Nov 30. 321(22):1501-6. [Medline].
 Sterling RK, Bralow S. Extrahepatic manifestations of hepatitis C virus. Curr Gastroenterol Rep. 2006
Feb. 8(1):53-9. [Medline].
 Bonkovsky HL, Mehta S. Hepatitis C: a review and update. J Am Acad Dermatol. 2001 Feb. 44(2):159-
82. [Medline].
 Stramer SL, Glynn SA, Kleinman SH, et al. Detection of HIV-1 and HCV infections among antibody-
negative blood donors by nucleic acid-amplification testing. N Engl J Med. 2004 Aug 19. 351(8):760-8.
[Medline].
 Rischitelli G, Harris J, McCauley L, Gershon R, Guidotti T. The risk of acquiring hepatitis B or C
among public safety workers: a systematic review. Am J Prev Med. 2001 May. 20(4):299-306.
[Medline].
Conti…