Group 6 - Alvarado, Briones, Piñon, Ramos, & Tendero | BSN 3B

CASE STUDY 1: HEPATITIS

Joann S. is a 71-year-old female patient who is a direct admit to the medical-surgical unit after
being sent from her physician’s office for further evaluation with a diagnosis of “weakness and
failure to thrive.” She is accompanied by her spouse of 53 years, Anthony, with whom she
resides. She is a retired office manager with several adult children and prior to this admission
lived at home without medical assistance. She appears confused and cannot stand even though
she moves all extremities.

Her speech is slurred, but Anthony reports, “The doctor said something about her liver. That’s
weird to me because she doesn’t drink
or take any medicine except vitamins. How could there be anything wrong with her liver? I
don’t understand. She stopped being able to walk a few days ago and really isn’t eating or
drinking.”

I. What assessments and initial check-in activities should the nurse perform to best
assist the patient?
○ Assess the patient’s Vital Signs
○ Assess the client’s pain using COLDSPA (Character, Onset, Location, Duration,
Severity, Pattern, and Aggravating Factors). This is to get a better understanding
of the patient’s condition by assessing the kind of pain they are experiencing.
○ After Assessing the vitals and the pain, the nurse could now assess the patient’s
health history which includes: Past Medical History, History of Present Illness,
and History of Family Illness. The nurse could also ask what the patient was
doing or if she ingested anything prior to the onset of symptoms.
○ Next is to perform the Physical Examination. Make sure to use IPPA (inspection,
palpation, percussion, and auscultation).
○ Assess the patient’s neurological and psychological problems.
○ Since the patient experiences confusion, slurred speech, as well as verbalizing that
she could not stand, it is imperative that the nurse assess the patient using
Glasgow coma scale.
○ Ask for a dietitian’s opinion in order to give the best nursing care.
○ Deliver lab results to the physician for consultation.
 II. What physical and/or neurological assessment findings does the nurse anticipate
seeing for this patient? Why?
○ Jaundice - Due to the presence of the liver problem, bilirubin is overproduced
which leads to its high concentration to the blood. This results in the yellowish
pigment in the skin of the patient. The sclerae also becomes yellowish to green in
this instance. This is especially evident when the Bilirubin levels are higher than
20 mg/dl.
○ Weight loss and Loss of Appetite - The patient may suffer from altered sense of
taste which could contribute to the loss of appetite. Since the Patient has a liver
problem, this could cause malabsorption and digestion issues.
○ Confusion - The patient’s confusion could be the result of the elevated ammonia
levels. Since the patient’s liver is not functioning normally, the ammonia will not
be converted to urea thus, there is an elevation of ammonia levels in the
bloodstream.
○ Abdominal Pain - The patient may experience abdominal pain so it is best not to
palpate too much around the upper right quadrant.

III. Are there specific history details the nurse may ask the patient and/or spouse about?
Why?
The nurse may ask questions about the patient's alcohol and drug intake because these are the
most common causes of liver impairment. The patient's physical examination shows that the
patient has yellow tinge, complains of itching and yellow sclera knowing that this is caused by
abnormally high bilirubin or bile pigment in the bloodstream. Also according to the patient
laboratory result that the hepatitis C is reactive meaning the patient has been infected once also
her age is susceptible to hepatitis C.

The nurse obtains vital signs from the patient and performs a focused physical assessment:
BP 90/50 mmHg SpO2 90% on Room Air low
HR 120 bpm and regular - normal
Ht 172.7 cm
Wt 89.6 kg
RR 28 bpm high
Temp 36.6°C normal

The patient is oriented to self only. Her skin appears tan with a yellowish tinge, and she
complains of itching. She has many bruises in various stages of healing on her extremities
and her sclera are bright yellow. The abdomen is distended and tender with palpation.
The physician orders laboratory studies that include blood alcohol content, urine drug screen,
complete blood count, hepatic panel, coagulation studies, Hepatitis C Virus Antibody, and an
abdominal ultrasound.

The labs result with the following values:

BAC: 0.0 percent (No alcohol in the blood)
UDS: Negative for amphetamines, methamphetamines, benzodiazepines, barbiturates, marijuana,
cocaine, PCP, methadone, opioids
WBC 14,000/mm3 (H)
HGB 9.2 g/dL (L)
HCT 27.6% (L)
Platelets 40,000 cells/µL (40 x 109/L) (L)
Albumin 2.6 g/dL (L)
Aspartate Aminotransferase (AST) 701 U/L (H)
Alanine Aminotransferase (ALT) 501 U/L (H)
Ammonia 150 mcg/dL (H)
Bilirubin (total) 5 mg/dL (H)
Partial thromboplastin time 50 seconds (H)
Prothrombin time (PT) 18 seconds (H)
International Normalized Ratio 1.6 (H)
Hepatitis C virus (HCV) Antibody: reactive

The abdominal ultrasound shows an enlarged liver and fluid accumulation in the abdomen
(ascites).

IV. Prioritize the top nursing interventions/considerations based on the diagnostic data.
● Bleeding Risk and Confusion due to Elevated Ammonia Intervention/Considerations
○ Educate the patient and family members about signs of bleeding that need to be
reported to a health care provider.
○ Inform the patient to check the color and consistency of stools.
○ Tell the patient to observe skin and mucous membranes for oozing of blood.
○ Orient the client to surroundings, staff, and necessary activities as needed. Present
reality concisely and briefly.
○ Modulate sensory exposure. Provide a calm environment; eliminate extraneous
noise and stimuli.
○ Encourage family/caregivers to participate in reorientation as well as provide
ongoing input (e.g., current news and family happenings).
 ● Risk for Skin Breakdown Interventions/Considerations:
○ Encourage the patient to change position every 15 minutes and change
chair-bound positions every hour.
○ Use pillows or foam wedges to keep bony prominences from direct contact with
each other. Keep pillows under the heels to raise off the bed.

● General Interventions/Considerations:
○ Administer medications as indicated.
○ Standard precautions should always be initiated but infection control (hep C).
○ The nurse must be especially vigilant because of all findings/factors.
○ There should be no further abdominal palpation due to findings.
○ Respiratory status should be monitored due to the ascites fluid occupying space in
the thoracic cavity.
○ Frequent turning and assistance with repositioning are important.
○ Encourage mouth care before meals.
○ Recommend eating in an upright position.
○ Encourage the intake of fruit juices, carbonated beverages, and hard candy
throughout the day.
○ Provide supplemental feedings and TPN if needed.
○ Provide IV fluids (usually glucose), and electrolytes. Protein hydrolysates.

V. The nurse questions alcohol and drug use labs. Why are they important? What
about the other abnormal lab values? What is their significance?
● It is important to check the presence of substances such as alcohol and drugs because
hepatotoxic substances and excessive alcohol intake can damage the cells in the liver and
cause liver disease which results in the impairment of the liver's normal function.
● Blood alcohol content or BAC refers to the percent of alcohol in a person’s bloodstream
● The (HCV) indicates that the patient has been infected with the hepatitis C virus. This
may have been caused by Injectable medication sharing, needlestick injuries,
contaminated tools, contact with infected blood products or through unprotected
intercourse.
● Having a high amount of WBC usually means there is an infection or inflammation in the
body. It may also be a reaction to some medicines and may indicate other health
problems.
● Having low levels of hemoglobin (HGB) and hematocrit (HCT) means that red blood
cells are lost due to bleeding or that there are not enough red blood cells being produced.
● Having a low platelet count indicates that it will be difficult for the patient to stop
bleeding. This can be serious if left untreated.
 ● The AST/ALT values and ratio indicates liver failure.
● The high bilirubin count indicates that the liver isn't clearing bilirubin properly. It also
explains the presence of jaundice and itching.
● Having a Low level of albumin is also associated with liver disease.
● Liver disease is the most common cause of having high levels of ammonia. The abnormal
level of ammonia is also what causes her confusion.
● The abnormal levels of Partial thromboplastin time (PTT), Prothrombin time (PT) and
international normalized ratio (INR) indicates that the process for clotting time is longer
than normal.

VI. What is the best way to explain the patient’s decreased level of consciousness and
appearance to her family?
The best way of explaining to the patient is to use layman’s terms for them to understand it in
simpler terms. Because of increased ammonia it causes confusion to the patient. Since the patient
is confused the patient's safety must constantly be taken into account because she is at a great
risk for fall and getting hurt. The liver is the one who is responsible for managing ammonia as
waste which we excrete during urination. But due to build up of ammonia which means her liver
is not functioning properly it causes her to be increasingly confused.

VII. The nurse works to retrieve the medication and notes that the concentration is 10
mg/15 mL. How many milliliters of lactulose should the nurse give? What is the
rationale for this medication? What are some nursing considerations for this
medication?

𝐷
= 𝐻
×𝑄

20 𝑚𝑔
= 10 𝑚𝑔
× 15 𝑚𝐿 = 30 𝑚𝐿 𝑜𝑓 𝐿𝑎𝑐𝑡𝑢𝑙𝑜𝑠𝑒

Rationale: Lactulose is synthetic sugar that acts as a laxative and is given to help with lowering
ammonia levels. It is thick and sweet tasting. Due to its mechanism of action, it causes frequent
loose stools; therefore, the nurse should be prepared for bedpans / skin protection measures.

Nursing Considerations:
● Assess patient for abdominal distention, presence of bowel sounds, and normal pattern of
bowel function.
○ Assess color, consistency, and amount of stool produced.
 ● PSE: Assess mental status (orientation, level of consciousness) before and periodically
throughout the course of therapy.
● Lab Test Considerations:
○ ↓ blood ammonia concentrations by 25–50%.
● Explain the purpose of lactulose to patient. Instruct the patient to take lactulose as
directed.
● Caution patient that this medication may cause belching, flatulence, or abdominal
cramping. Healthcare professional should be notified if this becomes bothersome or if
diarrhea occurs.

VIII. What patient education topics would need to be covered?

Hepatitis C Transmission
The hepatitis C virus is usually spread when someone comes into contact with blood from an
infected person. This can happen through:
● Sharing drug-injection equipment.
○ Today, most people become infected with hepatitis C by sharing needles, syringes,
or any other equipment used to prepare and inject drugs.
● Health care exposures.
○ Although uncommon, people can become infected when health-care professionals
do not follow the proper steps needed to prevent the spread of bloodborne
infections.
● Sex with an infected person.
○ While uncommon, hepatitis C can spread during sex, though it has been reported
more often among men who have sex with men.
● Unregulated tattoos or body piercings.
○ Hepatitis C can spread when getting tattoos or body piercings in unlicensed
facilities, informal settings, or with non-sterile instruments.
● Sharing personal items.
○ People can get infected from sharing glucose monitors, razors, nail clippers,
toothbrushes, and other items that may have come into contact with infected
blood, even in amounts too small to see.
● Blood transfusions and organ transplants.
○ Before widespread screening of the blood supply in 1992, hepatitis C was also
spread through blood transfusions and organ transplants. Now, the risk of
transmission to recipients of blood or blood products is extremely low.
● Hepatitis C is not spread by sharing eating utensils, breastfeeding, hugging, kissing,
holding hands, coughing, or sneezing. It is also not spread through food or water.
Risk Factors
Because of her age (Baby Boomer who was born between 1945-1965), she is at higher risk for
hepatitis C due to potentially risky behavior when she was younger:
● Had a blood transfusion before 1992. A screening test for HCV went into use that year.
Before then, this was the main cause of most new cases in the U.S. With routine blood
screening for HCV and improvements in the test in mid-1992, transfusion-related
hepatitis C has virtually disappeared.

How it’s Treated

The patient should rest in the early stages of the illness and combat anorexia by eating small
meals high in calories and protein. (Protein intake should be reduced if signs of precoma —
lethargy, confusion, mental changes — develop.) Large meals are usually better tolerated in the
morning.

In acute viral hepatitis, hospitalization is usually required only if severe symptoms or

complications occur. Parenteral nutrition may be needed if the patient can’t eat because of
persistent vomiting.

Other measures include the following:

● Current therapy for hepatitis C includes interferon or a combined interferon and ribavirin
therapy. The decision on how to treat the individual is made after laboratory tests and
liver biopsy confirm hepatic inflammation or early cirrhosis. Treatment lasts from 6 to 18
months, based on the outcome and genotype of the virus. The patient needs instruction on
self-injection and adverse effects.
● Laboratory tests — including CBC with differential, thyroid studies, liver function tests,
and hepatitis quantitative studies — help determine the effectiveness of therapy and
prevent complications during treatment.
● Drug dosages may be reduced if WBC count, hemoglobin level, or hematocrit drop
below normal.
● Adverse effects of medication include depression, flu-like syndrome, fatigue, malaise,
and GI disturbance.

Teaching Tips
● Before discharge, emphasize the importance of having regular medical checkups for at
least 1 year. Warn the patient not to drink any alcohol during this period, and teach her
how to recognize signs of recurrence. Refer the patient for follow-up care as needed.
● Advise a hepatitis carrier to prevent exchange of body fluids during sexual relations.
 ● Drink plenty of fluids (at least 4,000 ml/day). Encourage the anorexic patient to drink
fruit juices. Also, offer chipped ice and effervescent soft drinks to promote adequate
hydration without inducing vomiting.
● Record weight daily, and keep accurate intake and output records.
● Observe stool for color, consistency, frequency, and amount.
● Watch for signs of hepatic coma, dehydration, pneumonia, vascular problems, and
pressure ulcers.
● Should be able to maintain adequate hydration and nutrition, follow appropriate isolation
precautions, modify her diet and lifestyle as needed, and obtain appropriate follow-up
care. Her close contacts also should seek evaluation and possible vaccination.

If unable to rebound from this condition, may suggest hospice care to the family
Many of us are unaware of liver disease hospice criteria and how to access these services.
Fortunately, with a greater understanding of the signs and symptoms associated with liver
disease, it is possible to get a better handle on hospice eligibility. Knowing when and how to start
the conversation about hospice is essential for ensuring that patients receive the support and care
they need during their transition.