Hey everyone, it's Sarah with RegisteredNurseAriene.com and today we're going to talk about hepatitis, specifically viral hepatitis. And after you get done watching this YouTube video, don't forget to access the free quiz that will test you on this condition. So let's get started.
What is hepatitis? Well, let's break down the word hepatitis. The prefix in this word is hepat, and this means liver.
The suffix is itis, and this means inflammation. When we put that together, we know that the word hepatitis means we have liver inflammation. What is this liver inflammation caused by? What is causing the cells in our liver to become inflamed and it's affecting the way that this liver is working and it can lead to some serious long-term complications like cirrhosis, liver cancer, liver failure?
Hepatitis can be caused by many things. It can be caused by drugs or medications. Excessive use of alcohol but most commonly it is caused by viruses which is what this video is going to concentrate on. So what we're going to be talking about is hepatitis A, B, C, D, and E and we're going to compare all five types of these viruses that cause hepatitis and we're going to go over those highlights of what you need to know on your exams and the nursing education. But before we do that, we really need to talk about the liver's job and what it does for our body.
So, let's do a quick anatomy and physiology review of our liver. Our liver is an amazing organ that really doesn't get a lot of credit considering what it actually does for our body. It acts as the gatekeeper in that it filters, stores, protects, and breaks down substances among other things.
When it can't work properly, eventually the whole body will shut down. So our liver is found in the right upper quadrant of the abdomen just below the diaphragm. And it's made up of two lobes that can be divided into eight segments. Now within these segments are called lobules.
And these are the functional units of the liver and they contain hepatocytes, which are liver sites. And these hepatocytes... do majority of the function of the liver.
Now a cool thing about the liver is that it receives its blood supply from two sources. One source sends blood that is very rich in oxygen and it's called the hepatic artery. It's coming off of the heart where the aorta is and it's feeding all of these cells of the liver oxygen.
Because one thing we learned in our shock series is that cells don't function if they're deprived of oxygen. So that's what this hepatic artery does. Now, the other source is really interesting because it sends blood that is poor in oxygen, but very, very rich in nutrients. So it's coming from the digestive system.
It's just broken down your food, and it's like, hey, we're done. We have all this nutrients. We're going to send it.
to the liver because the liver will deal with it. It's the gatekeeper of the body and it'll decide what we need and make sure we haven't taken in some bacteria or viruses or something and deal with that appropriately. So let's highlight the functions of the liver because when we're talking about complications of these viral types of hepatitis whenever you're having liver enzymes that are increasing, bilirubin, ammonia, it's going to make a lot more sense if you know what I mean. what the liver is doing naturally with ammonia and bilirubin. So the liver filters because again it's receiving all that blood that's rich in nutrients.
It has to filter it. It's going to store some some of those substances. It's going to protect us and one thing the liver does is that it actually produces some proteins that play a role in our immune system.
It's also going to play a role with clotting because whenever we talked about warfarin also called Coumadin we learned that the liver is really involved because vitamin K which plays a role in our clotting. Another thing is that it's going to break down substances so let's stop at this point and talk about this part. Okay one substance that it breaks down is ammonia. Ammonia is a byproduct of protein breakdown in the gut.
So it's going to break down ammonia and turn it into urea and it's going to send it to the kidneys and the kidneys are going to deal with that and you're going to excrete it in your urine. But if it didn't do this, ammonia would build up in your body and your brain and ammonia really don't go together and it's going to affect brain function. which is why when you have someone who has a crazy high ammonia level, they're going to be confused.
Their mental status is going to be not what it should be. So that's one thing I want you to know whenever we're getting into some of these really chronic viral hepatitis, we will have high ammonia levels and that is Guess why? Because normally this liver deals with this and will take care of it for us. Another thing is with red blood cells. The liver will help with breaking down red blood cells.
And whenever we break down red blood cells, a substance is released. release that is like brownish dark brownish yellowish color called bilirubin and the liver will deal with this bilirubin and it will take it and put it into the stool and the person will remove it and that's really what gives our stool that brownish color. Now when the liver's not working appropriately bilirubin will not be released into the bile and go into the stool and the person will excrete it.
The bilirubin will start to build up and it will leak into the skin and the whites of the eyes, the sclera, and the patient will have jaundice, that yellow pumpkin hue to their body. So that's why that bilirubin isn't going where it's supposed to and their stool will look different. It won't be that nice brown color that bilirubin naturally gave it.
It will be clay grayish color from where that is not in the system. And another thing. that our liver does is that it produces bile and bile is going to help us digest fats and it's stored in the gallbladder it'll just drain down in there and the gallbladder will store it and then it'll be released into the small intestines which will help break down our fats whenever the person has ingested them now let's do a comparison of those five types of viral hepatitis and as I do this make sure you pay attention to how each type is transmitted if it causes an acute or chronic infection or both acute and chronic diagnostic testing like when the patient gets blood work and they have these certain results in their blood how do you interpret that as a nurse to provide education to them meaning are they still infectious or are they now immune along with the treatment and prevention measures like for instance does this type of hepatitis have a vaccine that they can receive to prevent it if in case they're exposed to it in the future?
Or does it have like a post-exposure plan with it where the patient can get immune globulin to provide themselves with temporary passive immunity? So we're going to start with hepatitis A. It's most commonly transmitted via the fecal-oral route and it's most likely to be transmitted in food and water.
So a person who is infectious with hepatitis A, let's say... They go to the bathroom, they don't perform proper hand hygiene, and they go and they prepare food for someone. They can easily transmit it to someone who is consuming that food. So that person would eat the food that has that hepatitis A in it and they can become infected.
And that has actually happened here in the US. And if you get online, you can read stories about where people who went to restaurants, one of the workers had it and they had to go and get it. get the post exposure of the immune globulin to help prevent becoming infected with hepatitis A.
Hepatitis A tends to only cause acute infections. So that means the person gets it, their immune system attacks it and gets rid of it. It doesn't cause chronic, it's only acute. The signs and symptoms of hepatitis A go along with the typical signs and symptoms of hepatitis. Some patients may be asymptomatic.
They don't have any symptoms at all, but the typical signs and symptoms of hepatitis include GI symptoms like nausea, vomiting, stomach pain, loss of appetite, jaundice where they have yellowing of the skin and the whites of the eyes, fever, feeling tired, fatigue. They may have dark urine from where the bilirubin has leaked into the urine, clay colored stool where there's no bilirubin in the stool so the stool looks abnormal, and they can have joint. pain.
Now in regards to the signs and symptoms of hepatitis A, a patient can be contagious two weeks before those signs and symptoms presented and one to three weeks from when those signs and symptoms presented. Now diagnostic testing, they can look at the blood work and they can see if there's antibodies for that hepatitis A virus. So the patient will have that.
But another thing they can also look at with that is IgM. and IgG. So you want to remember this if a patient has the antibodies of the hepatitis A virus and they're positive for IgM that means that they have an active infection of hepatitis A Now if they're positive for IgG that means that they have recovered from a past infection of hepatitis A and they're immune or if they received the vaccine and they had the positive of IgG. They are the vaccine work and they're immune to hepatitis A. So remember the difference.
How I remember it is the M, I think that mean virus is in there and the G, it's gone. They've recovered. So maybe that'll help you keep it straight.
Okay, treatment for hep A is really, there's no medications. Patients tend to recover on their own because it's like an acute infection. It's just rest, supportive therapy, preventative. There is a vaccine for hepatitis A it's part of the pediatric childhood vaccination schedule and hand-washing of course meticulous hand-washing to prevent exposing others to this if they have it or getting it yourself so you don't infect yourself and the post exposure let's talk about that for a second a patient can get what's called immune globulin and they can get this you they want to get this within about two weeks exposure and this will help provide temporary passive immunity in case they were that person who ate at that restaurant and the person did have hepatitis A who prepared their food.
Now let's talk about hepatitis B. It is spread through blood and body fluids like saliva, semen, vaginal fluids, amniotic fluids and it's most commonly spread here in the US through sexual intercourse and IV drug use. So we're talking about the percutaneous... mucosal route.
As a side note, it can also be spread through the birthing process. If mom has hepatitis B, the infant can get it. So that's where they would want to follow those post-exposure regimens like with the hepatitis B immune globulin. Typically, the protocol for that is give that to the baby within 12 hours of exposure. Hepatitis B can cause both acute and chronic infections.
Acute, patient clears it on their own, doesn't cause any problems. cause any issues, no complications. Chronic, however, the patient's body is overwhelmed by the virus.
They can't get rid of it. So there's going to be issues with the liver where the liver can become scarred with cirrhosis, liver failure, liver cancer. So remember that with chronic, they're high risk for complications.
And patients who are at most risk for developing chronic hepatitis are patients who are the infants and young children. So they're the most at risk. Signs and symptoms of Hep B are those typical signs and symptoms of hepatitis that I just went over. So that really covers all the signs and symptoms if a patient does have signs and symptoms of hepatitis for all these types.
Diagnostic wise, you want to be looking at some things. If a patient has a positive hepatitis B surface antigen, an HBSAG, that means that they are infectious. They have an active infection going on.
So you want to educate them. about measures to prevent spreading this to others easily like avoiding sexual intercourse if they have the antibodies for the hepatitis B virus that would mean that they are immune so let's say they had vaccine series they have this vaccine worked or maybe if they had an acute infection cleared it and they have that that means that they've had hepatitis B before treatment for the acute cases just supportive and rest, the body will take care of it and get rid of it out of the body. For chronic infections, the body can't, so they may be prescribed antivirals, interferon, like PEG interferon alpha-2.
This is given sub-Q, so remember that as the nurse. Some preventative measures for Hep B would be vaccine. There's a vaccine series.
It's part of the pediatric scheduled vaccinations. And for people who haven't received the vaccine, but they're at risk for it, like healthcare. workers so if you're in nursing school or going to work in a health care facility you have to have the hep b series because this can be received through like needle sticks or something like that and testing that's another preventative measure they will do especially with pregnant women if she has hep b they will know that they will need to look out for that once that birthing process takes place because it can be spread to the infant the immune globulin the hepatitis B immune globulin for that for the infant remember they want to give that within 12 hours of exposure but for other cases they generally want to give it within 24 hours of exposure so here the post exposure can throw that into every category here that's one of the big things of how to prevent hepatitis is washing those hands.
Now let's look at hepatitis C. This is very similar to hepatitis B in that it's spread through blood and body fluids. The most common way to spread in the US is IV drug use. So it's most common way. Now it can also of course be spread through sexual intercourse.
If a patient received blood or blood products before 1992, sharps, injuries, or or they're receiving long-term dialysis. So it's also the percutaneous and mucosal route as well. Hep C can cause acute and chronic infections just like Hep B. However, most cases of Hep C do turn chronic. The signs and symptoms are the same.
Diagnostic testing, looking at those antibodies against the hepatitis C virus, that's in the chronic cases. Treatment for Hep C would be anti- and they have a new thing of antivirals the direct acting antivirals that they can give patients preventative one thing with hep C you want to remember there is no vaccine for preventing hepatitis C post-exposure immune globulin there is none of that there's no post-exposure immune globulin they can get hand hygiene of course sharp precautions because the way it's spread and strict blood and org donation screening. Now let's talk about hepatitis D. It is spread through blood and body fluids just like B and C and one thing to remember about hepatitis D that's really going to help you is that it cannot occur unless that patient also has hepatitis B.
So if a patient doesn't have hepatitis B they can't have hepatitis D. Hepatitis D is not that common. common in the U.S. as of right now.
It's more common in the southern and eastern parts of Europe, the Mediterranean, and the Middle East. It can cause both acute and chronic infections. The signs and symptoms are the same that we just went over.
Diagnostic testing, the patient can have the hepatitis D antigen or the antibodies against the hepatitis D virus. Treatment, same antivirals interfere on. prevention hand hygiene and also one way to prevent it is of course preventing hepatitis B how do we prevent hepatitis B one of the ways is vaccine so it would be very advantageous for the patient to also get the hepatitis B vaccine and lastly let's talk about hepatitis E it is spread through the fecal oral route just like hepatitis A it's most commonly spread through food and water that's being contaminated with this virus It tends to occur in developing countries rather than in the US. You can get it in the US, but it's going to be a lot more common here. You can also get it in pork that's undercooked or wild game.
It only causes acute infections, not chronic. That's another thing that Hep A and Hep E share. Complication though, if the patient is in their third trimester of pregnancy, it can really cause harm. That's one thing. thing you want to remember is your patient pregnant how far along are they because if they're in the third trimester they can definitely develop complications signs and symptoms same they tend to be mild diagnostic testing is those antibodies against the hepatitis e virus treatment no treatment really patient will clear this on their own supportive therapy and rest prevention hand hygiene and there's no vaccine currently here in the u.s for this And if you travel abroad to these developing countries, you want to use bottled water, wash your fruits and everything in bottled water.
You don't want to consume the water because it can be transmitted through that. And cook meat thoroughly. Now let's do a quick recap. So you can sort of group these together to recall this information for exams. So think of HEP A and HEP E together because they're very similar in how they're spread with the fecal oral via contaminated food and water.
This is more... more common in developing countries. They're the only ones up here on this board that cause only acute infections. Other types do both acute and chronic. The treatment for both of these because they're acute infections only, patient can clear it.
themselves is just supportive therapy and rest there is a vaccine for hep a and that post-exposure immune globulin that needs to be given within two weeks over here on hep e there is not a vaccine here in the the US and there's no post exposure immune globulin. Now keep Hep B, C, and D together because they're very similar. They're spread through the blood and the body fluids. It's just a little bit different on the most common way that they're spread here in the US. Like B, it's through sexual intercourse and IV drug use.
C, it's mainly IV drug use. And remember D cannot occur without B. They go together. So how can you really prevent D?
Hep B vaccine. So treatment for B, C, and D would be the antivirals and interferon because they tend to cause the chronic and the patient needs help with that. Their body can't clear it, so they have to have these medications on board.
And Hep B is, of those three types, is the only one with the vaccine. So only Hep A and Hep B have preventative vaccines. And Hep B also has that post-exposure hepatitis B immunoglobulin. globulin that can be given within 24 hours of an exposure to provide passive temporary immunity.
Now let's talk about the patient education that the nurse needs to provide for the patient who has any type of viral hepatitis. And here I've created this mnemonic, it's hepatitis, and it's going to highlight those main concepts of what you need to include in your teaching and that what really can be on an exam. So H is for hand washing.
You want to teach the patient to follow strict meticulous... meticulous hand hygiene to prevent spreading this to anyone else. E for eat a low fat and high carb diet.
This is going to help because patient doesn't want to consume high amount of fat because the liver is really not adequately producing this bile and remember bile help break down fats. So they need to watch that and high carbs is going to help provide them with the nutrition and energy the body needs to help the liver rebuild itself. itself regenerate. So having that adequate calories is very important. P for personal hygiene products are not to be shared.
So go over with the patient those personal products they do not want to share because a lot of patients may not think of it like toothbrushes, razors, drinking cups, utensils, towels, anything that could spread this virus to anyone else. A for activity conservation. It's very important that all patients with hepatitis they rest because this is going to help the liver rebuild so they need to plan for periods of rest and activity t for toxic substances avoided you want to teach your patient about really watching those over-the-counter medications that they may not think of that are considered toxic to their liver like alcohol absolutely drinking no alcohol because it's hard in the liver sedatives aspirins acetaminophen which is tylenol i for individual individual bathrooms. They do not want to share bathrooms with other family members so it's best that they have their own bathroom. T4 testing results.
Just remember all those testing results I was going over especially with hep A with the antibodies for the hepatitis A virus with the IgM. Remember what did that mean? That mean virus is in there so they have an active infection. If they have the antibodies of the hepatitis A virus with the IgE that means it's gone they've recovered or they're immune if they've had the vaccine and hepatitis B the hepatitis B surface antigen if they had that that meant that they were infectious so provide education on how to prevent it from being spread like avoiding sexual contact with others and the antibodies against the hepatitis B virus would show that either they've had it in the past and they're recovered or they're immune due to the vaccine then I for the interferon remember this was with most of the chronic cases of hepatitis and this is administered sub-Q. So educate the patient how to do this, watch them do that.
And for the post-exposure immunoglobulin, that is the hepatitis A needs to be two weeks within being exposed and the hepatitis B, which would be about 24 hours after exposure with that hepatitis B immunoglobulin. And then S for small but frequent meals. A lot of going to have issues with Nausea so eating small but frequent meals can help with that nausea. They need to make sure that they're drinking plenty of fluids and that they're not cooking for other people why they are infectious because they could easily transmit this to other people.
So educate them about that as well. Now let's quickly go over some lab results that can be elevated in patients and what you should be looking out for as the nurse in a patient who has active hepatitis and their liver is starting to be affected. So we can look at liver enzymes.
This is usually on the CMP. that comprehensive metabolic panel where it looks at the liver function. So we can look at the ALT, the aniline transaminase, and a normal is 7 to 56 units per liter, and it will be elevated in these patients. Or an AST, which is an aspartate transaminase, and a normal is 10 to 40 units per liter, and of course it would be elevated. And we want to look at their bilirubin level.
We've talked a lot about that. normal bilirubin level is less than one milligrams per deciliter but in a patient with hepatitis if your patient has jaundice their bilirubin level is going to be high so if it'll be greater than the one milligrams per deciliter and then another result we can look at is the ammonia level and a normal depending on the lab is like 15 to 45 micrograms per deciliter and it's going to be elevated in some patients who are having some severe hepatitis like hepatic encephalopathy. And this will lead to mental status changes. And I've had patients who have had this and they're before they used to be alert and oriented, but their ammonia level went crazy high. And they just literally their mental status changed, confused, even not even responding to you.
And this is because the ammonia affects the way that the brain works. So you can see that. So if you see a mental status change in your patient, They have liver problems. Look at their ammonia level.
Now, how can we get that ammonia level down? Well, if you've worked any time with any patients who've had this, you will have to give a medication called lactulose. And lactulose will help bring the ammonia level down. Side effect of it, it's going to cause diarrhea, but it will lower the ammonia level.
Now let's wrap up this lecture and let's talk about the phases of viral hepatitis. There's three phases that we're going to go over. And while you...
you want to remember is just like the differences in the signs and symptoms that are really going to present in each phase because that's what a test will ask you. Be like, oh, the patient's having these signs and symptoms. Based on these signs and symptoms, what phase may this patient be in a viral hepatitis?
So the first phase we're going to talk about is the pre-ictaric, also called the prodromal phase. And this is where the patient mainly just has body symptoms. So they're not going to attribute it to, hey, I think I have viral hepatitis. viral hepatitis because it's something that when you get sick, you may have this and it's not necessarily unique to viral hepatitis like joint pain, fatigue, nausea, vomiting, GI pain, or changes in taste.
Some patients have reported that. And if their liver enzymes were looked at, they would be increasing along with their bilirubin. Now the next phase, which is the icteric, this is where we're active. This is where the patient is actually going to have a decrease in... these body symptoms that they just had in the previous phase but they will have jaundice and dark urine and clay colored stool because they've had the built up of the bilirubin also their liver is going to be enlarged and swollen and they can have pain so big thing with icteric they are having the jaundice that yellowing pumpkin hue of their skin and the yellowing of the eyes and they're going to see this dark urine and they're stool is going to look different.
And then the last phase, the post-ictaric, also called the convalescent, this is where they're starting to recover. They're getting better. So the jaundice and the dark urine is going to start going away.
Their stool is going to start looking normal where that bilirubin level is normalizing along with their liver enzymes. Okay, so that wraps up this review over hepatitis. Thank you so much for watching.
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