3. Hepatitis: inflammation of the liver.
   1. Pathophysiology:
      1. Infection with either hepatitis A (formerly called infectious hepatitis), hepatitis B (formerly called serum hepatitis), hepatitis C (single-stranded RNV virus of the Flaviviridae family; usually asymptomatic), delta hepatitis (infection caused by a defective RNA virus that requires HBV to multiply), or hepatitis E (major etiological agent of the enterically transmitted non-A, non-B hepatitis worldwide)-inflammation, necrosis, and regeneration of liver parenchyma. Hepatocellular injury impairs clearance of urobilinogen-elevated urinary urobilinogen; and, as injury increases-conjugated bilirubin not reaching the intestines-decreased urine and fecal urobilinogen-increased serum bilirubin-jaundice.
      2. Failure of liver to detoxify products-increased toxic products of protein metabolism-gastritis and duodenitis.
   2. Risk factors:
      1. Exposure to virus.
      2. Exposure to carriers of virus.
      3. Exposure to hepatotoxins such as dry cleaning agents.
      4. Nonimmunized.
   3. Assessment:
      1. Subjective data:
         1. Anorexia, nausea.
         2. Malaise, dull ache in right upper quadrant, abdominal pain.
         3. Repugnance to food, cigarette smoke, strong odors, alcohol.
         4. Headache.
      2. Objective data:
         1. Fever.
         2. Liver: enlarged (hepatomegaly), tender, smooth.
         3. Skin: icterus in sclera of eyes, jaundice; rash; pruritus; petechiae, bruises.
         4. Urine: normal, dark.
         5. Stool: normal, clay colored, loose.
         6. Vomiting, weight loss.
         7. Lymph nodes: enlarged.
         8. Lab data:
            1. Blood-leukocytosis.
            2. Increased AST (SGOT), ALT (SGPT), and bilirubin levels, alkaline phosphatase.
            3. Urine-increased urobilinogen.
   4. Analysis/nursing diagnosis:
      1. Pain related to inflammation of liver.
      2. Impaired skin integrity related to pruritus.
      3. Activity intolerance related to fatigue.
      4. Risk for infection to others related to incubation/infectious period.
      5. Altered nutrition, less than body requirements, related to repugnance of food.

Contact Precautions

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1. Private room if the patient’s hygiene is poor. In general, patients with the same infection may share a room.
2. Masks are not indicated.
3. Gowns are indicated if soiling is likely.
4. Gloves are indicated for touching infective material.
5. Hands must be washed before and after touching the patient or potentially contaminated articles.
6. Contaminated articles should be discarded or bagged and labeled.

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6. Social isolation related to isolation precautions.
5. Nursing care plan/implementation:
   1. Goal: prevent spread of infection to others.
      1. Isolation according to type
         1. Hepatitis A:
            1. Contact precautions.
            2. Private room preferred.
            3. Gown/gloves for direct contact with feces.
            4. Hand washing when in direct contact with feces.
         2. Hepatitis B: blood and body fluid precautions.
            1. Needle/dressing precautions.
            2. Private room not necessary.
            3. Gown: only if enteric precautions also necessary.
            4. Hand washing: use gloves when in direct contact with blood.
         3. Hepatitis C: blood and body fluid precautions.
            1. Same as hepatitis B, except when in countries with fecal-oral form, then use hepatitis A precautions also.
         4. Delta:
            1. Same as hepatitis B.
      2. Passive immunity for contacts.
         1. Hepatitis A: hepatitis A vaccine (Havrix, VAQTA), immune serum globulin (ISG), administered before and after exposure.
         2. Hepatitis B: hepatitis B immune globulin (HBIG) (Recombivax HB, Energix-B) or ISG.
         3. Hepatitis C: prophylaxis not as effective; IG may be given.
         4. Delta: same as for hepatitis B.
      3. Goal: promote healing.
         1. Diet as tolerated:
            1. NPO with parenteral infusions, when in acute stage.
            2. High protein, high carbohydrate, low fat, offered in frequent small meals.
            3. Push fluids, if not contraindicated; I&O.
         2. Medications:
            1. Antiviral for patients with persistently elevated ALT levels.
            2. Interferon for initial treatment of hepatitis C.
      4. Goal: monitor for worsening of disease process, failure to respond to prescribed treatment.
         1. Observe urine-dark due to presence of bile and stool, clay colored.
         2. Observe sclera, lab tests for increasing jaundice.
         3. Mental confusion, unusual somnolence may indicate decreased liver function.
         4. Weigh daily-increase indicates fluid retention and possible ascites.
      5. Goal: health teaching.
         1. Diet and fluid intake to promote liver regeneration.
         2. Importance of rest and limited activity to reduce metabolic workload of liver.
         3. Personal hygiene practices to prevent contamination.
         4. Avoid: alcohol, blood donations, and contact with communicable infections.
         5. Follow-up case referral; may take 6 months for full recovery.
         6. Teach contacts about available immunizations.
   2. Goal: promote comfort.
      1. Bed rest to combat fatigue and reduce metabolic needs until hepatomegaly sub-
      2. sides; semi-Fowler’s or supine positioning, b. Oral hygiene ql-2h to decrease nausea.
      3. ROM exercises to maintain muscle strength.
      4. Measures to reduce pruritus:
         1. Mild, oil-based lotion to reduce itching.
         2. Nails cut short, cotton gloves, long-sleeved clothing to prevent skin injury from scratching.
         3. Environment: cool and dry.
         4. Cool wet soaks to skin.
         5. Diversional activities.
         6. Medications as ordered:
            1. Emollients to relieve dry skin.
            2. Topical corticosteroids to reduce inflammation.
            3. Antihistamines to reduce itch.
            4. Tranquilizers and sedatives to allow rest and prevent exhaustion.
6. Evaluation/outcome criteria:
   1. Tolerates food; nausea and vomiting decreased.
   2. Signs of infection/inflammation absent.
   3. No complications, hemorrhage, liver damage, ascites.
   4. No jaundice noted.

TABLE 7-24	Etiology, Incidence, Epidemiological, and Clinical Comparison of Hepatitis A, Hepatitis B, Hepatitis C, and Delta Hepatitis
	Hepatitis A	Hepatitis B	Hepatitis C	Delta Hepatitis
Incubation	2-6 weeks	4 weeks-6 months	Variable: 14-160 days; average, 50 days	Same as hepatitis B
Communicable	Until 7-9 days after jaundice occurs	Several months-as long as virus present in blood	As long as virus present in blood	As long as virus present in blood
Transmission	Fecal-oral; blood; sexual	Parenteral; sexual; perinatal	Percutaneous, via contaminated blood, parenteral drug abuse; some fecal-oral forms; sexual, perinatal	Parenteral; blood
Sources	Crowding; contaminated food, milk, or	Contaminated needles, syringes, surgical instru-	Persons who have received 15 or more blood transfusions; IV drug users; persons traveling to contaminated areas	Contaminated needles, syringes
Portal of entry	GI tract; asymptomatic	Integumentary: blood plasma or transfusions	Blood	Integumentary: blood
HB antigen	Not present	Present	Not present	Present as with hepati-
Incidence	Sporadic epidemics; increased in children	Increased in ages 15-29, particularly in heroin addiction; occupational hazard for laboratory workers, nurses, physicians	All ages groups; higher in adults because of exposure to risk factors	Same as hepatitis B
Immunity	Preexposure: immune globulin, 0.02 mL/kg Postexposure: within 2 wk of exposure, as above	Preexposure: hepatitis B vac- Postexposure: immune globulin with high amounts of anti-HBs (HBIG); hepatitis B vaccine	None; immune globulin may be given
Prevention	Hand washing, use of gloves; hepatitis A vaccine	Care when handling products contaminated by blood, use of gloves; Hepatitis B vaccine	Same as hepatitis B	Same as hepatitis B
Severity	Mild	Mild to moderate	Mild to moderate	Moderate to severe
Fever	Common	Uncommon	Uncommon	Uncommon
Nausea/ vomiting	Common	Common	Common	Common