6 Hepatitis Nursing Care Plans

Hepatitis is widespread inflammation of the liver with degeneration and necrosis of liver cells. It comes from bacterial invasion, physical or toxic chemical injury (drugs, alcohol, industrial chemicals), viral infection (hepatitis A, B, C, D, E, G), or an autoimmune response. Most cases are self-limiting, but about 20% of acute hepatitis B and 50% of hepatitis C cases progress to chronic disease or cirrhosis and can be fatal. On the floor the work is resting the liver while keeping the patient nourished and hydrated, watching for bleeding, preventing transmission, and teaching a recovery that runs in months, not days.

Nursing Care Plans and Management

Care centers on reducing the demands on the liver, preventing complications, supporting self-concept and acceptance, and teaching the disease process, prognosis, and treatment.

Nursing Problem Priorities

• Manage symptoms and provide supportive care.
• Prevent further liver damage and protect liver health.
• Monitor liver function and disease progression.
• Give antiviral medications if applicable.
• Teach lifestyle changes that lower liver stress.
• Prevent transmission to others.
• Address complications and comorbidities.

Nursing Assessment

Assess for the following subjective and objective data:

• Aversion to eating, lack of interest in food, altered taste
• Abdominal pain or cramping
• Weight loss, poor muscle tone

Nursing Goals

Goals and expected outcomes may include:

• The patient maintains hydration, shown by stable vital signs, good skin turgor, brisk capillary refill, strong peripheral pulses, and appropriate urine output.
• The patient reports improved energy.
• The patient performs ADLs and desired activities at their level of ability.
• The patient explains the disease process, prognosis, and potential complications.
• The patient connects signs and symptoms to causative factors.
• The patient describes therapeutic needs and starts the necessary lifestyle changes.

Nursing Interventions and Actions

1. Optimizing Nutritional Balance

Anorexia and altered taste make intake the daily battle. Encourage mouth care before meals to clear unpleasant tastes, and have the patient eat upright to reduce the sense of fullness. Offer fruit juices, carbonated drinks, and hard candy through the day for easy extra calories.

Consult the dietitian for a plan with fat and protein as tolerated. Fat may need restriction if diarrhea develops, since fat metabolism depends on bile. Normal or increased protein helps liver regeneration, but protein is restricted in severe (fulminant) disease, since end products of protein metabolism can potentiate hepatic encephalopathy. Provide supplemental feedings or TPN if deficits are marked and symptoms prolonged.

Give medications as indicated:

• Antiemetics: metoclopramide (Reglan), trimethobenzamide (Tigan), given 1/2 hr before meals, reduce nausea and improve tolerance. Prochlorperazine (Compazine) is contraindicated in hepatic disease.
• Antacids: Mylanta, Titralac counteract gastric acidity and lower bleeding risk.
• Vitamins: B complex, C, and other supplements correct deficiencies and aid healing.
• Steroid therapy: prednisone (Deltasone), alone or with azathioprine (Imuran). Steroids may be contraindicated in viral hepatitis because they raise the risk of relapse and chronic disease, but their anti-inflammatory effect can help chronic active hepatitis (especially idiopathic). They may lower serum aminotransferase and bilirubin but do not affect liver necrosis or regeneration. Combination therapy has fewer steroid side effects.

2. Promoting Adequate Fluid Balance

Monitor I&O against periodic weight and note enteric losses from vomiting and diarrhea. Diarrhea may be a flu-like viral response, a sign of obstructed portal flow with GI congestion, or the intended effect of neomycin or lactulose used to lower serum ammonia in hepatic encephalopathy.

Assess vital signs, peripheral pulses, capillary refill, skin turgor, and mucous membranes for volume and perfusion. Check for ascites or edema and measure abdominal girth to track fluid shifts. Watch for bleeding: hematuria, melena, ecchymosis, oozing gums, oozing puncture sites, since prothrombin falls and clotting times prolong when vitamin K absorption is impaired and the damaged liver makes less prothrombin. Monitor Hb/Hct, Na, albumin, and clotting times for hydration, sodium and protein status, and bleeding risk.

Use small-gauge needles and hold pressure longer after venipuncture to limit bleeding into tissue. Have the patient use cotton or sponge swabs and mouthwash, or a soft-bristled toothbrush, to spare the gums. Provide IV fluids (usually glucose), electrolytes, and protein hydrolysates for replacement in an acute toxic state.

Give medications as indicated:

• Vitamin K supports return of fluid from tissue to circulation and prevents coagulation problems when clotting factors and PT are depressed.
• Antacids or H2-receptor antagonists: cimetidine (Tagamet) neutralize and reduce gastric secretions to lower bleeding risk.
• Diphenoxylate with atropine (Lomotil) reduces fluid and electrolyte loss from the GI tract.
• Fresh frozen plasma, infused as indicated, replaces clotting factors when coagulation defects are present.

3. Promoting Gradual Ambulation and Managing Fatigue

Monitor for returning anorexia and liver tenderness or enlargement, which signal exacerbation and the need for more rest and a changed regimen. Track serial liver enzyme levels, since a premature rise in activity risks relapse. Institute bed or chair rest during the toxic state in a quiet environment with limited visitors, since activity and an upright position reduce hepatic blood flow and circulation to the liver cells. Change position frequently and give good skin care.

Cluster tasks and protect long uninterrupted rest. Prioritize role responsibilities and line up alternative caregivers and community resources. Teach energy conservation: sit to shower and brush teeth, keep needed materials at hand, and schedule rest periods. Increase activity as tolerated with passive or active ROM, since prolonged bed rest is debilitating. Encourage stress management (progressive relaxation, visualization, guided imagery) and quiet diversion (radio, TV, reading).

Give sedatives and antianxiety agents as indicated: diazepam (Valium), lorazepam (Ativan). Barbiturates and the antianxiety agents prochlorperazine (Compazine) and chlorpromazine (Thorazine) are contraindicated because of hepatotoxicity. In toxic hepatitis, give the antidote or assist with inpatient procedures (lavage, catharsis, hyperventilation) by route of exposure to limit tissue damage.

4. Preventing Skin Breakdown and Maintaining Skin Integrity

Inspect skin for redness and breakdown. Encourage cool showers and baking soda or starch baths, avoid alkaline soaps, and apply calamine lotion for itching. Provide diversion to reduce scratching. If the urge to scratch is uncontrollable, have the patient use knuckles, keep fingernails short, apply gloves on the comatose patient or during sleep, use loose-fitting clothing, and provide soft cotton linens. A soothing bedtime massage can promote sleep. Avoid comments about the patient's appearance to limit psychological stress.

Give medications as indicated:

• Antihistamines: diphenhydramine (Benadryl), azatadine (Optimine) relieve itching; use cautiously in severe hepatic disease.
• Antilipemics: cholestyramine (Questran) bind bile acids in the intestine to prevent absorption; watch for nausea and constipation.

Use isolation technique for enteric and respiratory infection per policy and model effective handwashing, which is the most effective barrier to transmission. Types A and E spread by oral-fecal route, contaminated water, milk, and food (especially undercooked shellfish); types A, B, C, and D spread by contaminated blood and blood products, needle punctures, open wounds, and contact with saliva, urine, stool, and semen. HBV and HCV incidence has risen among healthcare providers and high-risk patients. Toxic and alcoholic hepatitis are not communicable and need no special measures. Monitor and restrict visitors as indicated, since exposure to infection (especially respiratory) raises the risk of secondary complications. Explain isolation, which may last 2 to 3 wk from onset depending on type and symptoms, so the patient understands the reason and feels less stigmatized. Give information on gamma globulin, ISG, H-BIG, and HB vaccine (Recombivax HB, Engerix-B) through the health department or physician; immunoglobulins can prevent viral hepatitis after exposure depending on type and incubation period.

Give medications as indicated:

• Antiviral drugs: vidarabine (Vira-A), acyclovir (Zovirax) treat chronic active hepatitis.
• Interferon alfa-2b (Intron A) treats hepatitis C symptoms and may temporarily improve liver function.
• Ribavirin, used with interferon, improves its effectiveness. These treatments improve but do not cure the disease.
• Antibiotics appropriate to the causative agent (Gram-negative, anaerobic bacteria) treat bacterial hepatitis or limit secondary infection.

5. Providing Emotional Support

Assess the financial impact on the patient and significant other, since lost role function and prolonged recovery create money problems. Set aside time to listen and encourage the patient to voice feelings about being ill, the cost and length of illness, the risk of infecting others, the stigma, and in severe illness, fear of death. Verbalization lowers anxiety and depression and supports coping. Avoid moral judgments about lifestyle, which damage self-esteem and erode trust.

Discuss recovery expectations, which may run up to 6 mo and strain the family. Offer diversion matched to energy level. Suggest the patient wear bright reds, blues, or blacks instead of yellows or greens, since yellow and green intensify jaundiced skin tones. Jaundice usually peaks within 1 to 2 wk, then resolves over 2 to 4 wk. Refer to a case manager, discharge planner, social services, or community agencies as needed.

6. Patient Education and Health Teaching

Assess understanding of the disease, expectations, prognosis, and treatment options, including liver transplantation in fulminating disease with liver failure. Teach prevention and transmission: contacts may need gamma globulin; do not share personal items; use strict handwashing and sanitize clothes, dishes, and toilet facilities while liver enzymes are elevated; avoid intimate contact such as kissing and sexual contact, and avoid infections, especially URI. Specifics vary with the type of hepatitis.

Resume activity as tolerated with adequate rest, restricting heavy lifting, strenuous exercise, and contact sport. Activity can resume before serum bilirubin returns to normal (which may take up to 2 mo), but strenuous activity is limited until the liver returns to normal size. Continued rest prevents relapse, which occurs in 5% to 25% of adults, and energy may take 3 to 6 mo to return to normal. Help the patient find diversion, continue a balanced diet to support healing and tissue regeneration, and maintain bowel function with fluids, dietary roughage, and moderate activity.

Discuss the dangers of OTC and prescribed drugs (acetaminophen, aspirin, sulfonamides, some anesthetics), since many are toxic to or metabolized by the liver and can cause cumulative toxicity and chronic hepatitis; have the patient tell future providers of the diagnosis. Discuss restrictions on donating blood, since most state laws bar donors with any hepatitis history. Stress followup physical exam and labs, since the disease may take months to resolve and symptoms lasting longer than 6 mo may require liver biopsy to confirm chronic hepatitis. Review avoidance of alcohol for a minimum of 6 to 12 mo or longer, since it irritates the liver and impairs recovery. Refer to a drug or alcohol treatment program as indicated.