Hepatitis A

Overview

Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. The virus is one of
several types of hepatitis viruses that cause liver inflammation and affect your liver's ability to
function.

You're most likely to get hepatitis A from contaminated food or water or from close contact with a
person or object that's infected. Mild cases of hepatitis A don't require treatment. Most people who
are infected recover completely with no permanent liver damage.

Symptoms

Hepatitis A symptoms typically appear a few weeks after you've had the virus. But not everyone with
hepatitis A develops symptoms. If you do, symptoms can include:

 Unusual tiredness and weakness

 Sudden nausea and vomiting and diarrhea
 Abdominal pain or discomfort, especially on the upper right side beneath your lower ribs,
which is over your liver
 Clay- or gray-colored stool
 Loss of appetite
 Low-grade fever
 Dark urine
 Joint pain
 Yellowing of the skin and the whites of your eyes (jaundice)
 Intense itching

These symptoms may be relatively mild and go away in a few weeks. Sometimes, however, hepatitis
A results in a severe illness that lasts several months.

When to see a doctor

Make an appointment with your health care provider if you have symptoms of hepatitis A.

Getting the hepatitis A vaccine or an injection of an antibody called immunoglobulin within two
weeks of exposure to the hepatitis A virus may protect you from infection.

Ask your health care provider or your local health department about receiving the hepatitis A vaccine
if:

 You traveled recently to areas where the virus is common, particularly Mexico, Central
America and South America or to areas with poor sanitation
 You ate at a restaurant with a hepatitis A outbreak
  You live with someone who has hepatitis A
 You recently had sexual contact with someone who has hepatitis A

Causes

Hepatitis A is caused by a virus that infects liver cells and causes inflammation. The inflammation
can affect how your liver works and cause other symptoms of hepatitis A.

The virus spreads when infected stool, even just tiny amounts, enters the mouth of another person
(fecal-oral transmission). You may get hepatitis A when you eat or drink something contaminated
with infected stool. You may also get the infection through close contact with a person who has
hepatitis A. The virus can live on surfaces for a few months. The virus does not spread through
casual contact or by sneezing or coughing.

Here are some of the specific ways the hepatitis A virus can spread:

 Eating food handled by someone with the virus who doesn't thoroughly wash hands after
using the toilet
 Drinking contaminated water
 Eating food washed in contaminated water
 Eating raw shellfish from water polluted with sewage
 Being in close contact with a person who has the virus — even if that person has no
symptoms
 Having sexual contact with someone who has the virus

Risk factors

You're at increased risk of hepatitis A if you:

 Travel or work in areas of the world where hepatitis A is common

 Live with another person who has hepatitis A
 Are a man who has sexual contact with other men
 Have any type of sexual contact with someone who has hepatitis A
 Are HIV positive
 Are homeless
 Use any type of recreational drugs, not just those that are injected

Complications

Unlike other types of viral hepatitis, hepatitis A does not cause long-term liver damage, and it doesn't
become an ongoing (chronic) infection.

In rare cases, hepatitis A can cause a sudden (acute) loss of liver function, especially in older adults
or people with chronic liver diseases. Acute liver failure requires a stay in the hospital for monitoring
and treatment. Some people with acute liver failure may need a liver transplant.
Prevention

The hepatitis A vaccine can prevent infection with the virus. The vaccine is typically given in two
shots. The first shot is followed by a booster shot six months later. The hepatitis A vaccine can be
given in a combination that includes the hepatitis B vaccine. This vaccine combination is given in
three shots over six months.

The Centers for Disease Control and Prevention recommends the hepatitis A vaccine for the
following people:

 All children at age 1 year, or older children who didn't receive the childhood vaccine
 Anyone age 1 year or older who is homeless
 Infants ages 6 to 11 months traveling to parts of the world where hepatitis A is common
 Family and caregivers of adoptees from countries where hepatitis A is common
 People in direct contact with others who have hepatitis A
 Laboratory workers who may come into contact with hepatitis A
 Men who have sex with men
 People who work or travel in parts of the world where hepatitis A is common
 People who use any type of recreational drugs, not just injected ones
 People with chronic liver disease, including hepatitis B or hepatitis C
 Anyone wishing to obtain protection (immunity)

If you're concerned about your risk of hepatitis A, ask your health care provider if you should be
vaccinated.

Follow safety precautions when traveling

If you're traveling to parts of the world where hepatitis A outbreaks occur, take these steps to prevent
infection:

 Wash all fresh fruits and vegetables in bottled water and peel them yourself. Avoid pre-cut
fruit and vegetables.
 Don't eat raw or undercooked meat and fish.
 Drink bottled water and use it when brushing your teeth.
 Avoid all beverages of unknown purity. The same goes for ice.
 If bottled water isn't available, boil tap water before drinking it or using it to make ice.

Practice good hygiene

Thoroughly wash your hands often, especially after using the toilet or changing a diaper and before
preparing food or eating.

Diagnosis

Blood tests are used to look for signs of the hepatitis A virus in your body. A sample of
blood is taken, usually from a vein in your arm. It's sent to a laboratory for testing.
Treatment

No specific treatment exists for hepatitis A. Your body will clear the hepatitis A virus on
its own. In most cases of hepatitis A, the liver heals within six months with no lasting
damage.

Hepatitis A treatment usually focuses on keeping comfortable and controlling

symptoms. You may need to:

 Rest. Many people with hepatitis A feel tired and sick and have less energy.
 Get adequate food and liquid. Eat a balanced healthy diet. Nausea can make it
difficult to eat. Try snacking throughout the day rather than eating full meals. To get
enough calories, eat more high-calorie foods. For instance, drink fruit juice or milk
rather than water. Drinking plenty of fluids is important to prevent dehydration,
especially if vomiting or diarrhea occurs.
 Avoid alcohol and use medications with care. Your liver may have difficulty
processing medications and alcohol. If you have hepatitis, don't drink alcohol. It
can cause liver damage. Talk to your health care provider about all the medications
you take, including medications available without a prescription.

Lifestyle and home remedies

If you have hepatitis A, you can take steps to reduce the risk of passing the virus to
others.

 Avoid sexual activity. Avoid all sexual activity if you have hepatitis A. Many kinds
of sexual activity can spread the infection to your partner. Condoms don't offer
adequate protection.
 Wash your hands thoroughly after using the toilet and changing
diapers. Scrub vigorously for at least 20 seconds and rinse well. Dry your hands
with a disposable towel.
 Don't prepare food for others while you're actively infected. You can easily
pass the infection to others.

 to school while I have hepatitis A?

 What are the signs and symptoms of serious hepatitis A complications?
 How will I know when I can no longer spread hepatitis A to others?
 Are there brochures or other printed material I can have? What websites do you
recommend?
Don't hesitate to ask other questions you have.

What to expect from your doctor

Your health care provider is likely to ask you a number of questions, including:

 Have you recently traveled or been exposed to someone with hepatitis A?

 When did your symptoms begin?
 Do you have symptoms all the time, or do they come and go?
 How severe are your symptoms?
 What, if anything, seems to improve your symptoms?
 What, if anything, appears to make your symptoms worse?

Preparing and anticipating questions will help you make the most of your appointment.

Nursing Care Plans and Management

Nursing care planning and management for patients with hepatitis includes: reducing
the demands of the liver while promoting physical well-being, preventing complications
of hepatitis, enhance self-concept, acceptance of situation, and providing information
about the disease process, prognosis, and treatment.

Nursing Problem Priorities

The following are the nursing priorities for patients with hepatitis:

 Manage symptoms and provide supportive care.

 Prevent further liver damage and promote liver health.
 Monitor liver function and assess disease progression.
 Administer antiviral medications, if applicable.
 Educate patients on lifestyle modifications to minimize liver stress.
 Prevent transmission of hepatitis to others.
 Address complications or comorbidities associated with hepatitis.
Nursing Assessment

Assess for the following subjective and objective data:

 Aversion to eating/lack of interest in food; altered taste sensation

  Abdominal pain/cramping
 Loss of weight; poor muscle tone
Nursing Diagnosis

Following a thorough assessment, a nursing diagnosis is formulated to specifically

address the challenges associated with hepatitis based on the nurse’s clinical judgement
and understanding of the patient’s unique health condition. While nursing diagnoses
serve as a framework for organizing care, their usefulness may vary in different clinical
situations. In real-life clinical settings, it is important to note that the use of specific
nursing diagnostic labels may not be as prominent or commonly utilized as other
components of the care plan. It is ultimately the nurse’s clinical expertise and judgment
that shape the care plan to meet the unique needs of each patient, prioritizing their
health concerns and priorities.

Nursing Goals

Goals and expected outcomes may include:

 The client will maintain adequate hydration, as evidenced by stable

vital signs, good skin turgor, capillary refill, strong peripheral pulses,
and individually appropriate urinary output.
 The client will report an improved sense of energy.
 The client will perform ADLs and participate in desired activities at
the level of ability.
 The client will verbalize understanding of the disease process,
prognosis, and potential complications.
 The client will identify the relationship between signs/symptoms of
the disease and correlate symptoms with causative factors.
 The client will verbalize understanding of therapeutic needs.
 The client will initiate necessary lifestyle changes and participate in
treatment regimen.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with hepatitis may include:

1. Optimizing Nutritional Balance

Encourage mouth care before meals.

Enhances appetite by eliminating unpleasant tastes.
Recommend eating in an upright position.
Reduces the sensation of abdominal fullness and may enhance intake.

Encourage the intake of fruit juices, carbonated beverages, and hard candy throughout the
day.
These supply extra calories and may be more easily digested or tolerated than other foods.

Consult with the dietitian, and nutritional support team to provide a diet according to the
patient’s needs, with fat and protein intake as tolerated.
Useful in formulating a dietary program to meet individual needs. Fat metabolism varies
according to bile production and excretion and may necessitate the restriction of fat intake
if diarrhea develops. If tolerated, a normal or increased protein intake helps with liver
regeneration. Protein restriction may be indicated in severe disease (fulminant hepatitis) because
the accumulation of the end products of protein metabolism can potentiate hepatic
encephalopathy.

Administer medications as indicated:

 Antiemetics: metoclopramide (Reglan), trimethobenzamide (Tigan)

Given 1/2 hr before meals, may reduce nausea and increase food tolerance. Prochlorperazine
(Compazine) is contraindicated in hepatic disease.
 Antacids: Mylanta, Titralac
Counteracts gastric acidity, reducing gastric irritation and risk of bleeding.
 Vitamins: B complex, C, and other dietary supplements as indicated
Corrects deficiencies and aids in the healing process.
 Steroid therapy: prednisone (Deltasone), alone or in combination
with azathioprine (Imuran)
Steroids may be contraindicated because they can increase the risk of relapse and
development of chronic hepatitis in patients with viral hepatitis; however, the anti-
inflammatory effects may be useful in chronic active hepatitis (especially idiopathic) to
reduce nausea and vomiting and enable patients to retain food and fluids. Steroids may
decrease serum aminotransferase and bilirubin levels, but they do not affect liver necrosis or
regeneration. Combination therapy has fewer steroid-related side effects.

Provide supplemental feedings and TPN if needed.

May be necessary to meet caloric requirements if marked deficits are present and symptoms are
prolonged.

2. Promoting Adequate Fluid Balance

Monitor I&O, and compare with periodic weight. Note enteric losses: vomiting
and diarrhea.
Provides information about replacement needs and effects of therapy. Diarrhea may be due to the
transient flu-like response to viral infection or may represent a more serious problem of
obstructed portal blood flow with vascular congestion in the GI tract, or it may be the intended
result of medication use (neomycin, lactulose) to decrease serum ammonia levels in the presence
of hepatic encephalopathy.
Assess vital signs, peripheral pulses, capillary refill, skin turgor, and mucous membranes.
Indicators of circulating volume and perfusion.

Check for ascites or edema formation. Measure abdominal girth as indicated.

Useful in monitoring the progression and resolution of fluid shifts.

Observe for signs of bleeding: hematuria, melena, ecchymosis, oozing from gums, puncture
sites
Prothrombin levels are reduced and coagulation times prolonged when vitamin K absorption is
altered in the GI tract and synthesis of prothrombin is decreased in the affected liver.

Monitor periodic laboratory values: Hb/Hct, Na, albumin, and clotting times.
Reflects hydration and identifies sodium retention/protein deficits, which may lead to edema
formation. Deficits in clotting potentiate the risk of bleeding and hemorrhage.

Use small-gauge needles for injections, applying pressure for longer than usual after
venipuncture.
Reduces the possibility of bleeding into tissues.

Have the patient use cotton or sponge swabs and mouthwash instead of a toothbrush or use
a soft-bristled toothbrush.
Avoids trauma and bleeding of the gums.

Provide IV fluids (usually glucose), and electrolytes. Protein hydrolysates.

Provides fluid and electrolyte replacement in an acute toxic state.

Administer medications as indicated:

 Vitamin K
Correction of albumin and protein deficits can aid in the return of fluid from tissues to
the circulatory system. Because the absorption is altered, supplementation may prevent
coagulation problems, which may occur if clotting factors and prothrombin time (PT) is
depressed.
 Antacids or H2-receptor antagonists: cimetidine (Tagamet)
Neutralize and reduce gastric secretions to lower the risk of gastric irritation and bleeding.

Diphenoxylate with atropine (Lomotil)

Reduces fluid and electrolyte loss from the GI tract.

Infuse fresh frozen plasma, as indicated.

May be required to replace clotting factors in the presence of coagulation defects.

3. Promoting Gradual Ambulation and Managing Fatigue

Monitor for recurrence of anorexia and liver tenderness or enlargement.

Indicates a lack of resolution and exacerbation of the disease, requiring further rest, and a change
in the therapeutic regimen.
Monitor serial liver enzyme levels.
Aids in determining appropriate levels of activity because the premature increase in activity
potentiates the risk of relapse.

Institute bed red or chair rest during the toxic state. Provide a quiet environment; limit
visitors as needed.
Promotes rest and relaxation. Available energy is used for healing. Activity and an upright
position are believed to decrease hepatic blood flow, which prevents optimal circulation to the
liver cells.

Recommend changing position frequently. Provide and instruct caregiver in good skin
care.
Promotes optimal respiratory function and minimizes pressure areas to reduce the risk of tissue
breakdown.

Do necessary tasks quickly and at one time as tolerated.

Allows for extended periods of uninterrupted rest.

Determine and prioritize role responsibilities and alternative providers and possible
community resources available
Promotes problem-solving of the most pressing needs of individuals and families.

Identify energy-conserving techniques: sitting to shower and brush teeth, planning steps of
activity so that all needed materials are at hand, and scheduling rest periods.
Helps minimize fatigue, allowing the patient to accomplish more and feel better about self.

Increase activity as tolerated, and demonstrate passive or active ROM exercises.

Prolonged bed rest can be debilitating. This can be offset by limited activity alternating with rest
periods.

Encourage the use of stress management techniques: progressive relaxation, visualization,

and guided imagery. Discuss appropriate diversional activities: radio, TV, reading
Promotes relaxation and conserves energy, redirects attention, and may enhance coping.

Administer medications as indicated: sedatives, and antianxiety agents: diazepam

(Valium), and lorazepam (Ativan).
Assists in managing required rest. The use of barbiturates and antianxiety agents, such as
prochlorperazine (Compazine) and chlorpromazine (Thorazine), is contraindicated because of
hepatotoxic effects.

Administer antidote or assist with inpatient procedures as indicated (lavage, catharsis,

hyperventilation) depending on the route of exposure.
Removal of the causative agents in toxic hepatitis may limit the degree of tissue involvement and
damage.
4. Preventing Skin Breakdown and Maintaining Skin Integrity

Observe skin for areas of redness, and breakdown.

Early detection of problem areas allows for additional intervention to prevent
complications/promote healing.

Encourage the use of cool showers and baking soda or starch baths. Avoid the use of
alkaline soaps. Apply calamine lotion as indicated.
Prevents excessive dryness of the skin. Provides relief from itching.

Provide diversional activities.

Aids in refocusing attention, reducing the tendency to scratch.

Suggest the use of knuckles if the desire to scratch is uncontrollable. Keep fingernails cut
short, and apply gloves on the comatose patient or during hours of sleep. Recommend
loose-fitting clothing. Provide soft cotton linens.
Reduces potential for dermal injury.

Provide a soothing massage at bedtime.

May be helpful in promoting sleep by reducing skin irritation.

Avoid comments regarding the patient’s appearance.

Minimizes psychological stress associated with skin changes.

Administer medications as indicated:

6.1. Antihistamines: diphenhydramine (Benadryl), azatadine (optimine)

Relieves itching. Use cautiously in severe hepatic disease.

6.2 Antilipemics: cholestyramine (Questran)

May be used to bind bile acids in the intestine and prevent their absorption. Note side effects of
nausea and constipation.

Establish isolation techniques for enteric and respiratory infections according to infection
guidelines and policy. Encourage or model effective handwashing.
Prevents transmission of viral disease to others. Thorough handwashing is effective in preventing
virus transmission. Types A and E are transmitted by oral-fecal route, contaminated water, milk,
and food (especially inadequately cooked shellfish). Types A, B, C, and D are transmitted by
contaminated blood/blood products; needle punctures; open wounds; and contact with
saliva, urine, stool, and semen. Incidence of both hepatitis B virus (HBV) and hepatitis C virus
(HCV) has increased among healthcare providers and high-risk patients. Toxic and alcoholic
hepatitis are not communicable and do not require special measures and isolation.

Stress need to monitor and restrict visitors as indicated.

Patient exposure to infectious processes (especially respiratory) potentiates risk of secondary
complications.
Explain isolation procedures to patient and SO.
Understanding reasons for safeguarding themselves and others can lessen feelings of isolation
and stigmatization. Isolation may last 2–3 wk from onset of illness, depending on type or
duration of symptoms.

Give information regarding availability of gamma globulin, ISG, H-BIG, HB vaccine

(Recombivax HB, Engerix-B) through health department or family physician.
Immunoglobulins may be effective in preventing viral hepatitis in those who have been exposed,
depending on type of hepatitis and period of incubation.

Administer medications as indicated:

 Antiviral drugs: vidarabine (Vira-A), acyclovir (Zovirax)

Useful in treating chronic active hepatitis.
 Interferon alfa-2b (Intron A)
Treats the symptoms of hepatitis C and may lead to a temporary improvement in liver
function.
 Ribavirin
Used in conjunction with interferon to improve the effectiveness of that drug. Note: These
treatments lead to improvement, not cure of the disease.

Antibiotics appropriate to causative agents (Gram-negative, anaerobic bacteria) or

secondary process.
Used to treat bacterial hepatitis or to prevent/limit secondary infections.

5. Providing Emotional Support

Assess effect of illness on economic factors of patient and SO.

Financial problems may exist because of loss of patient’s role functioning in the family and
prolonged recovery.

Contract with patient regarding time for listening. Encourage discussion of

feelings/concerns.
Establishing time enhances trusting relationship. Providing opportunity to express feelings
allows patient to feel more in control of the situation. Verbalization can
decrease anxiety and depression and facilitate positive coping behaviors. Patient may need to
express feelings about being ill, length and cost of illness, possibility of infecting others, and (in
severe illness) fear of death. May have concerns regarding the stigma of the disease.

Avoid making moral judgments regarding lifestyle.

Patient may already feel upset and angry and condemn self; judgments from others will further
damage self-esteem. Can also start distrust issues with care worker.

Discuss recovery expectations.

Recovery period may be prolonged (up to 6 mo), potentiating family and/or situational stress and
necessitating need for planning, support, and follow-up.
Offer diversional activities based on energy level.
Enables patient to use time and energy in constructive ways that enhance self-esteem and
minimize anxiety and depression.

Suggest patient wear bright reds or blues and blacks instead of yellows or greens.
Enhances appearance, because yellow skin tones are intensified by yellow/green colors. Jaundice
usually peaks within 1–2 wk, then gradually resolves over 2–4 wk.

Make appropriate referrals for help as needed: case manager, discharge planner, social
services, and/or other community agencies.
Can facilitate problem solving and help involved individuals cope more effectively with
situation.

6. Initiating Patient Education and Health Teachings

Assess level of understanding of the disease process, expectations and prognosis, possible
treatment options.
Identifies areas of lack of knowledge or misinformation and provides opportunity to give
additional information as necessary. Liver transplantation may be needed in the presence of
fulminating disease with liver failure.

Provide specific information regarding prevention and transmission of disease: contacts

may require gamma-globulin; personal items should not be shared; observe strict
handwashing and sanitizing of clothes, dishes, and toilet facilities while liver enzymes are
elevated. Avoid intimate contact, such as kissing and sexual contact, and exposure to
infections, especially URI.
Needs and recommendations vary with type of hepatitis (causative agent) and individual
situation.

Plan resumption of activity as tolerated with adequate periods of rest. Discuss restriction of
heavy lifting, strenuous exercise and/or contact sport.
It is not necessary to wait until serum bilirubin levels return to normal to resume activity (may
take as long as 2 mo), but strenuous activity needs to be limited until the liver returns to normal
size. When patient begins to feel better, he or she needs to understand the importance of
continued adequate rest in preventing relapse or recurrence (Relapse occurs in 5%–25% of
adults). Energy level may take up to 3–6 mo to return to normal.

Help patient identify appropriate diversional activities.

Enjoyable activities promote rest and help patient avoid focusing on prolonged convalescence.

Encourage continuation of balanced diet.

Promotes general well-being and enhances energy for healing process and tissue regeneration.

Identify ways to maintain usual bowel function: adequate intake of fluids and dietary
roughage, moderate activity and exercise to tolerance.
Decreased level of activity, changes in food and fluid intake, and slowed bowel motility may
result in constipation.

Discuss the side effects and dangers of taking OTC and prescribed drugs
(acetaminophen, aspirin, sulfonamides, some anesthetics) and necessity of notifying future
healthcare providers of diagnosis.
Some drugs are toxic to the liver; many others are metabolized by the liver and should be
avoided in severe liver diseases because they may cause cumulative toxic effects and chronic
hepatitis.

Discuss restrictions on donating blood.

Prevents spread of infectious disease. Most state laws prevent accepting as donors those who
have a history of any type of hepatitis.

Emphasize importance of follow-up physical examination and laboratory evaluation.

Disease process may take several months to resolve. If symptoms persist longer than 6 mo,
liver biopsy may be required to verify presence of chronic hepatitis.

Review necessity of avoidance of alcohol for a minimum of 6–12 mo or longer based on

individual tolerance.
Increases hepatic irritation and may interfere with recovery.

Refer to community resources, drug/alcohol treatment program as indicated.

May need additional assistance to withdraw from substance and maintain abstinence to avoid
further liver damage.