CARE OF CLIENTS WITH PROBLEM IN

NUTRITION, AND GASTRO-INTESTINAL,

METABOLISM AND ENDOCRINE,
PERCEPTION AND COORDINATION, (ACUTE
STUDENT’S ACTIVITY SHEET AND CHRONIC)
BS NURSING / THIRD YEAR
Session # 9 (2 hours and 30 minutes)

Materials:
LESSON TITLE: VIRAL HEPATITIS, NONVIRAL HEPATITIS, Book, pen and notebook, projector
AND HEPATIC CIRRHOSIS

LEARNING OUTCOMES: References:

Upon completion of this lesson, the nursing student can:
Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K.
1. identify the risk factors of the different types of hepatitis.
(2008). Brunner &Suddarth’s Textbook of
2. point out preventive measures on hepatitis.
Medical-Surgical Nursing 12th Edition.
3. determine the different clinical manifestations on hepatic
Lippincott Williams &Wilkins
cirrhosis.
4. recognize medical and nursing management of the disorders.

LESSON REVIEW / PREVIEW OR HOOK ACTIVITY (5 minutes)

The instructor will ask the students to answer the following.
1. Compare the various types of hepatitis: their causes, mode of transmission, and clinical manifestations.

MAIN LESSON (2 hours)

The students will study and read their book about this lesson (Chapter 39 of the book).

VIRAL HEPATITIS
Viral hepatitis is a systemic, viral infection in which necrosis and inflammation of liver cells produce a
characteristic cluster of clinical, biochemical, and cellular changes.

HEPATITIS A
Cause: Hepatitis A virus (HAV)
Mode of Transmission: Fecal-oral route; Person to person; Water-borne; Food-borne; Oral-anal sex
Incubation: 15 – 50 days
Clinical Manifestations: Flu-like; Preicteric: anorexia, headache, fever, malaise, fatigue; Icteric: Jaundice, dark urine,
tender liver
Outcome: mild; no carrier state

HEPATITI B
Cause: Hepatitis B virus (HBV)
Mode of Transmission: Parenteral; Intimate contact with carriers or with acute disease; Sexual and oral-oral contact;
Perinatal transmission from mother to infants
Incubation: 28 – 160 days
Clinical Manifestations: arthralgia, malaise, rashes, abdominal pain, anorexia, tender liver; may have or no jaundice
Outcome: may be severe; carrier state possible; increased risk of chronic hepatitis, cirrhosis, and hepatic cancer

HEPATITIS C
Cause: Hepatitis C virus (HCV)
Mode of Transmission: Blood and blood products; Exposure to contaminated blood through equipment/drug
paraphernalia; Sex with infected partner
Incubation: 15 – 160 days

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 Clinical Manifestations: Similar to HBV; less severe and anicteric
Outcome: Chronic carrier state; chronic liver disease; increased risk of hepatic cancer

HEPATITIS D
Cause: Hepatitis D virus (HDV)
Mode of Transmission: Same as HBV; HBV surface antigen is necessary for replication; pattern similar to hepatitis B
Incubation: 21 – 140 days
Clinical Manifestations: Similar to HBV
Outcome: Similar to HBV; but greater likelihood of carrier state, chronic hepatitis, and cirrhosis

HEPATITIS E
Cause: Hepatitis E virus (HEV)
Mode of transmission: Similar to HAV; although risk appears low
Incubation: 15 – 65 days
Clinical Manifestations: Similar to HAV; very severe in pregnant women
Outcome: Similar to HAV

Diagnostic Findings

HEPATITIS A
1. Hepatitis A antigen – in stool 7 to 10 days before illness and for 2 to 3 weeks after symptoms appear
2. HAV antibodies – are detectable when symptoms appear

HEPATITIS B
1. Hepatitis B surface antigen (HBsAg) – a marker of active replication and infection
- appears in the blood in 80-90% of infected patients 1 to 10 weeks after exposure to HBV and 2 to 8
weeks before the onset of symptoms
2. Anti-HBs (antibodies) – detected during late convalescence; usually indicates recovery and development of
immunity

HEPATITIS C
1. Non-Hepatitis A, Non-Hepatitis B, nor Hepatitis D, is considered as Hepatitis C

HEPATITIS D
1. Presence of Anti delta antibodies with HBAg

Prevention
HEPATITIS A HEPATITIS B HEPATITIS C
1. Scrupulous hand washing 1. Prevent transmission 1. Prevent transmission
2. Safe food and water supply 2. Active Immunization 2. Screening of blood
3. Effective sewage disposal 3. Passive Immunity
4. Vaccination 4. Screening of blood

Medical Management
1. Bed rest during acute stage
2. Nutritious foods
During anorexia period: small frequent feedings supplemented by IV fluids with glucose
3. Avoid alcohol and medications /herbs that may affect liver function
4. Pharmacologic:
HEPATITIS B: Alpha-interferon for 4 to 6 months
Lamivudine (Epivir) and Adefovir (Hepsera) – have improved seroconversion rates, loss of
detectable virus, improved liver function, and reduced progression to cirrhosis with
Lamivudine. Adefovir may be effective in people resistant to Lamivudine.

HEPATITIS C: Combination of two: Interferon (Intron-A) and Ribavirin (Rebetol)

NONVIRAL HEPATITIS

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 Certain chemicals have toxic effects on the liver and produce acute liver cell necrosis or toxic hepatitis
when inhaled, injected parenterally, or are taken by mouth. The chemicals most commonly implicated in this disease
are carbon tetrachloride, phosphorus, chloroform, and gold compounds. These substances are true hepatotoxins.
Drug-induced hepatitis is similar to acute viral hepatitis, but parenchymal destruction tends to be more extensive.
Medications that can lead to hepatitis include Isoniazid (Nydrazid), Halothane (Fluothane), Acetaminophen,
Methyldopa (Aldomet), and certain Antibiotics, Antimetabolites, and Anesthetic agents.

TOXIC HEPATITIS

Clinical manifestations
1. Anorexia, nausea, and vomiting - usual symptoms
2. Jaundice and hepatomegaly - noted on physical assessment.
3. Severe cases:
a. Fever rise
b. Persistent vomiting with the emesis containing blood
c. Severe clotting abnormalities and hemorrhages
d. Severe GI symptoms that may lead to vascular collapse
e. Delirium, coma, and seizures may develop
f. Death due to fulminant hepatic failure

Medical management
1. Early identification and removal of the hepatotoxin
2. Maintain fluid and electrolyte balance
3. Blood replacement
4. Liver transplant

DRUG-INDUCED HEPATITIS
Drug-induced liver disease is the most common cause of acute liver failure. Use of acetaminophen (found
in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of
acute liver failure.

Clinical manifestations
1. Onset is abrupt, with chills, fever, rash, pruritus, arthralgia, anorexia, and nausea
2. Later: jaundice, dark urine, and an enlarged and tender liver

If fever, rash, or pruritus occurs from any medication, its use should be stopped immediately.

Medical management
1. Removal of the offending medication
2. Short course of high-dose corticosteroids
3. Liver transplantation

HEPATIC CIRRHOSIS
Cirrhosis is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis (scar
formation) that disrupts the structure and function of the liver.

Types
1. Alcoholic cirrhosis: the most common type
2. Post necrotic cirrhosis: results from a late result of a previous bout of acute viral hepatitis.
3. Biliary cirrhosis: around the bile duct that results from chronic biliary obstruction and infection (cholangitis); much
less common type.

Pathophysiology
1. Alcohol consumption is considered the major causative factor.
2. Excessive alcohol intake is the major causative factor in fatty liver and its consequences.
3. Exposure to certain chemicals (carbon tetrachloride, chlorinated naphthalene, arsenic, or phosphorus) or
infectious schistosomiasis.
4. Twice as many men as women are affected.

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 5. Most patients are between 40 and 60 years of age.

Clinical Manifestations
Signs and symptoms of cirrhosis increase in severity as the disease progresses. Their severity is used to
categorize the disorder as compensated or decompensated cirrhosis.
1. Early:
a. Liver enlargement (hepatomegaly)
b. Abdominal pain
c. Intermittent jaundice and fever
d. Anorexia
e. Vomiting
2. Late:
a. Liver decreases in size as scar tissue contracts the liver tissue
b. Portal Obstruction and Ascites
c. Infection and Peritonitis
d. Gastrointestinal Varices
e. Edema (often affects the lower extremities, the upper extremities, and the presacral area)
f. Vitamin Deficiency and Anemia
g. Mental Deterioration

Compensated:
a. Intermittent mild fever
b. Vascular spiders
c. Palmar erythema (reddened palms)
d. Unexplained epistaxis
e. Ankle edema
f. Vague morning indigestion
g. Flatulent dyspepsia
h. Abdominal pain
i. Firm, enlarged liver
j. Splenomegaly

Decompensated:
a. Ascites
b. Jaundice
c. Weakness
d. Muscle wasting
e. Weight loss
f. Continuous mild fever
g. Clubbing of fingers
h. Purpura (due to decreased platelet count)
i. Spontaneous bruising
j. Epistaxis
k. Hypotension
l. Sparse body hair
m. White nails
n. Gonadal atrophy

Assessment and Diagnostic Findings

1. Increased levels: serum enzymes alkaline phosphatase, AST, ALT, and GGT; bilirubin; globulin
2. Decreased levels: serum albumin; cholinesterase
3. Prolonged Prothrombin time
4. Ultrasound scanning is used to measure the difference in density of parenchymal cells and scar tissue
5. CT, MRI, and radioisotope liver scans give information about liver size and hepatic blood flow and obstruction
6. Liver biopsy – confirms the diagnosis

Nursing Diagnoses

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 1. Activity intolerance related to fatigue, muscle wasting
2. Imbalanced nutrition: Less than body requirements related to chronic gastritis, decreased GI motility, anorexia
3. Impaired skin integrity related to edema, jaundice, poor nutrition
4. Risk to injury and bleeding related to altered clotting mechanisms, muscle wasting
5. Ineffective breathing pattern related to ascites, fluid in the thoracic cavity
6. Fluid volume excess related to sodium and water retention

Medical Management
1. Antacids or histamine-2 (H2) antagonists - decrease gastric distress and minimize the possibility of GI bleeding
2. Vitamins and nutritional supplements - promote healing of damaged liver cells and improve the patient’s general
nutritional status
3. Potassium-sparing diuretics such as Spironolactone or Triamterene (Dyrenium) - decreases ascites
4. Adequate diet and avoidance of alcohol.
5. Colchicine, an anti- inflammatory agent - may increase survival time in patients with mild to moderate cirrhosis
6. Medications such as Angiotensin system inhibitors, Statins, Diuretics, Immunosuppressants, and Glitazones -
possess antifibrotic activity for the treatment of cirrhosis.
7. Albumin infusion
8. Herb milk thistle (Silybum marianum) - treats jaundice and other symptoms because of its healing and
regenerative properties for liver disease. Silymarin from milk thistle has anti-inflammatory and antioxidant
properties that may have beneficial effects, especially in hepatitis.
9. Oxygen therapy may be required in liver failure - oxygenates damaged cells and prevents further cell
destruction.
10. Paracentesis

Nursing Management
A. Promote Rest
1. To permit the liver to reestablish its functional ability; reduces the demands on the liver and increases the
liver’s blood supply
2. If the patient is hospitalized: measure and record weight and fluid intake and output daily
3. Adjust the patient’s position in bed for maximal respiratory efficiency, which is especially important if ascites
is marked, because it interferes with adequate thoracic excursion
4. After nutritional status improves and strength increases: encourage the patient to increase activity gradually
B. Improve Nutritional Status
1. Nutritious, high-protein diet, if tolerated, supplemented by vitamins of the B complex, as well as A, C, and
K
2. If ascites is present: small, frequent meals
3. Patients with prolonged or severe anorexia and those who are vomiting or eating poorly: enteral or
parenteral feeding
4. Patients with fatty stools (steatorrhea): water-soluble forms of fat-soluble vitamins A, D, and E (Aquasol A,
D, and E)
5. Folic acid and iron to prevent anemia
6. If with signs of impending or advancing coma: protein in the diet is decreased temporarily (protein is
restricted if encephalopathy develops; incorporating vegetable protein to meet protein needs may decrease
the risk for encephalopathy)
7. Restrict sodium to prevent ascites.
C. Provide Skin Care
Providing careful skin care is important because of subcutaneous edema, the patient’s immobility,
jaundice, and in- creased susceptibility to skin breakdown and infection.
1. Frequent changes in position to prevent pressure ulcers
2. Avoid irritating soaps and the use of adhesive tape to prevent trauma to the skin
3. Apply lotion and minimize scratching to irritated skin
D. Reduce Risk of Injury
1. Side rails should be in place and padded with blankets or other materials in case the patient becomes
agitated or restless
2. Orient the patient to time and place and explains all procedures to minimize agitation
3. Assist patient in getting out of bed
4. Use electric razor rather than a safety razor; soft-bristled toothbrush; apply pressure to all venipuncture
sites; and maintain a sharp-free environment

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 E. Monitor and Manage Potential Complications:
1. Bleeding and Hemorrhage
2. Hepatic Encephalopathy
- Monitor mental and neurologic status
3. Fluid Volume Excess
- Observe for signs of ascites: fluid retention: lower extremity swelling, and dyspnea
- Monitor intake and output, daily weight changes, changes in abdominal girth, and edema
- Monitor for nocturia and, later, for oliguria

CHECK FOR UNDERSTANDING (20 minutes)

The instructor will prepare 10-15 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.
Multiple Choice

(For 1-15 items, please refer to the questions in the Rationalization Activity)

RATIONALIZATION ACTIVITY (DURING THE FACE TO FACE INTERACTION WITH THE STUDENTS)
The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss
among their classmates for 20 minutes.

1. When planning home care for a client with hepatitis A, which preventive measure should be emphasized to protect the
client’s family?
A. Keeping the client in complete isolation.
B. Using good sanitation with dishes and shared bathrooms.
C. Avoiding contact with blood-soiled clothing or dressing.
D. Forbidding the sharing of needles or syringes.
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. Which of the following will the nurse include in the care plan for a client hospitalized with viral hepatitis?
A. Increase fluid intake to 3000 ml per day
B. Adequate bed rest
C. Bland diet
D. Administer antibiotics as ordered
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

3. Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention for his comfort?
A. Give tepid baths.
B. Avoid lotions and creams.
C. Use hot water to increase vasodilation.
D. Use cold water to decrease the itching.
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?
A. “Now I can never get hepatitis again.”
B. “I can safely give blood after 3 months.”
C. “I’ll never have a problem with my liver again, even if I drink alcohol.”

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D. “My family knows that if I get tired and start vomiting, I may be getting sick again.”
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis?
A. Elevated hemoglobin level
B. Elevated serum bilirubin level
C. Elevated blood urea nitrogen level
D. Decreased erythrocyte sedimentation rate
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. A female client who has just been diagnosed with hepatitis A asks, “How could I have gotten this disease?” What is the
nurse’s best response?
A. “You may have eaten contaminated restaurant food.”
B. “You could have gotten it by using I.V. drugs.”
C. “You must have received an infected blood transfusion.”
D. “You probably got it by engaging in unprotected sex.”
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. A male client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:
A. Severe abdominal pain radiating to the shoulder.
B. Anorexia, nausea, and vomiting.
C. Eructation and constipation.
D. Abdominal ascites.
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important?
A. Allowing complete independence of mobility
B. Applying pressure to injection sites
C. Administering antibiotics as prescribed
D. Increasing nutritional intake
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for:
A. Malaise
B. Stomatitis
C. Hand tremors
D. Weight loss
Answer: _____

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Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________________________________________

10. A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic encephalopathy.
Which of the following nursing interventions are appropriate to prevent skin breakdown? Select all that apply.
A. Range of motion every 4 hours
B. Turn and reposition every 2 hours
C. Abdominal and foot massages every 2 hours
D. Alternating air pressure mattress
E. Sit in chair for 30 minutes each shift
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

11. A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient’s blood pressure
because of which change that is associated with the liver failure?
A. Hypoalbuminemia
B. Increased capillary permeability
C. Abnormal peripheral vasodilation
D. Excess rennin release from the kidneys
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

12. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic
encephalopathy in her?
A. Asterixis
B. Chvostek’s sign
C. Trousseau’s sign
D. Hepatojugular reflex
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

13. Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the
client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary
measures to follow if the client states an intention to increase the intake of:
A. Pork
B. Milk
C. Chicken
D. Broccoli
Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

14. The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client has deficient
vitamin K absorption caused by this hepatic disease?
A. Dyspnea and fatigue
B. Ascites and orthopnea
C. Purpura and petechiae
D. Gynecomastia and testicular atrophy

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Answer: _____

Rationale:________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________________________________________

15. A patient with severe cirrhosis of the liver develops hepatorenal syndrome. Which of the following nursing assessment
data would support this?

A. Oliguria and azotemia

B. Metabolic alkalosis
C. Decreased urinary concentration
D. Weight gain of less than 1 lb. per week
Answer: _____
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

LESSON WRAP-UP (5 minutes)

Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track
how much work they have accomplished and how much work there is left to do. This tracker will be part of the student
activity sheet.

You are done with the session! Let’s track your progress.

Two Roses and a Thorn

Each student must note two topics or concepts he or she enjoyed learning about, and another they didn’t like or
still have questions about.

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