Hepatitis (Case Study)

5. The HCP prescribes NS for hydration. The nurse sets up a 1000 mL bag of normal saline to administer the prescribed dose of normal saline of 100 mL/hr per IV. The IV tubing has a drop factor of 12 drops/mL/min. The IV should infuse at how many drops per minute? (Enter the numerical value only. If rounding is required, round to the whole number.)__________________

20 The formula for IV is volume to be infused over the time in minutes multiplied by the drop factor. 100 mL/60 x 12 = 20 drops/minute

Chronic Hepatitis Biopsy results and screening indicate that Shanda's mother has chronic hepatitis B. The only significant history her mother recalls is receiving a blood transfusion with her past 2 surgeries back in the early 1970s. She is started on alpha-interferon, 10 million units subcutaneously 3 times a week for 16 weeks and lamivudine (Epivir) 150 mg PO daily. 21. Which adverse effects of interferon therapy should the nurse include in the teaching plan? A. Flu-like aches and pains. B. Tachycardia and postural hypotension. C. Fluid retention and weight gain. D. Urinary retention and dry mouth.

A. Because interferon is a biologic response modifier, it promotes improved immune system functioning and may initiate an inflammatory response, causing flu-like symptoms.

17. What recommendations for prophylaxis should the nurse provide for Shanda's roommates? A. Immune globulin. B. Interferon. C. A histamine-2 antagonist. D. An anticholinergic

A. Immune globulins is recommended for household members of people with hepatitis A.

Jaundice Since Shanda has jaundice, the nurse carefully observes his urine and stool. 7. Which observation about the stool is consistent with the presence of jaundice? A. Stool is clay-colored. B. Stool is currant jelly colored and has a ribbon like appearance. C. Stool is green and slimy. D. Stool is liquid and frothy, with a foul odor.

A. Stool will be light or clay-colored if conjugated bilirubin is not able to leave the liver.

Assessment 1. What additional information would be helpful to the nurse as related to Shanda's presentation? A. "Can you tell me more about your mission work?" B. "Have you ever been diagnosed with anemia?" C. "Do you have any underlying chronic illnesses?" D. "Tell me about your family history."

A. The social conditions in foreign countries can help to focus other areas of assessment.

16. Shanda is being discharged. While talking with the nurse, Shanda asks if she can return to school. What advise should the nurse give Shanda? A. You may return when your symptoms subside and you feel able to tackle the rigors of school. B. You will need to wait until your liver enzyme levels return to normal. C. Once your hepatitis antibody levels are negative, you'll be safe to return to school. D. It will be ok after 6 months with no relapse of symptoms.

A. Once Shanda feels able to return to school, she may do so. She should be instructed to follow good handwashing techniques.

Nursing Care 9. Which nursing diagnoses are important to include in Shanda's plan of care? (Select all that apply.) A. Impaired gas exchange. B. Activity intolerance. C. Impaired skin integrity. D. Impaired mobility. E. Imbalanced in nutrition, less than body requirements.

B, C, E A client with hepatitis often experiences fatigue and malaise, resulting in activity intolerance. Pruritus from increased bile salt excretion through the skin can cause itching. If the client responds by scratching, skin breakdown can happen. Since symptoms of acute hepatitis C include decreased appetite and nausea and vomiting, nutrition can be affected. Nurses need to be aware and monitor for this.

2. After a more thorough history and assessment, the healthcare provider (HCP) notes that Shanda reports being a little bit sore under her right rib cage. Based on this information, the nurse anticipates which priority lab test? A. CXR. B. ALT, AST. C. Serum electrolytes. D. Complete blood count.

B. An enlarged liver can produce soreness/tenderness under the right rib cage area.

8. Which observation about the urine is consistent with the presence of jaundice? A. Urine is thick and contains sediment. B. Urine is tea-colored. C. Urine is pale and dilute. D. Urine is reddish-orange

B. As excess bilirubin builds in the bloodstream, some is excreted in the urine, which causes a tea-colored appearance.

22. The nurse evaluates Shanda's mother's understanding of chronic hepatitis. Which statement indicates that more teaching is needed? A. "I should check with my HCP before taking any medications." B. "I can drink wine and mixed cocktails, but I have to limit to once a week." C. "I should ensure that I get plenty of rest during the day." D. "There is no specific medication that will cure my hepatitis."

B. Because interferon is a biologic response modifier, it promotes improved immune system functioning and may initiate an inflammatory response, causing flu-like symptoms.

3. Shanda's lab results reveal an elevated liver enzymes. The healthcare provider (HCP) sends blood for hepatitis screening. The results indicate that Shanda has hepatitis. Based on her history, which type of hepatitis does the nurse suspect? A. Hepatitis C. B. Hepatitis A. C. Hepatitis D. D. Hepatitis B.

B. Hepatitis A is caused by contaminate fecal contamination of food or drinking water, poor sanitary conditions, improper handling of food, poor hygiene and crowded conditions. Spending time at a missionary site and being from a low socioeconomic area places Shanda at high risk.

20. In which position should the client be maintained immediately after the biopsy? A. Supine, with the head of the bed elevated no more than 30 degrees. B. Positioned on the right side with a pillow under the costal margin. C. Positioned on left side with the head of bed slightly elevated. D. Any comfortable position with the feet elevated.

B. Immediately after the biopsy, the client should remain on the right side for at least 2 hours. This position applies pressure to the liver capsule at the puncture site.

Clinical Manifestations Shanda is admitted to the hospital for further workup and teaching. While performing a physical assessment, the nurse notes that her skin has a slight yellow cast. 6. How should this finding be documented? A. Pruritus. B. Jaundice. C.Cyanosis. D. Purpura.

B. Jaundice occurs when excess bilirubin diffuses through the skin. Normal total serum bilirubin is 0.1 to 1.2 mg/dL in adults. Jaundice occurs when the total serum bilirubin exceeds 2.5 mg/dL. Jaundice is also often noted in the sclerae of the eyes.

19. Prior to the liver biopsy, it is most important for the nurse to be aware of which lab test result? A. Serum creatinine. B. Prothrombin time. C. Alkaline phosphatase. D. Serum calcium.

B. Since the biopsy is an invasive procedure and altered liver function can cause a prolonged prothrombin time, it is most important for the nurse to be aware of any potential for bleeding and to inform the HCP of an abnormal prothrombin time.

23. Shanda and her mother return in six weeks for a follow up appointment. The mother is diagnosed with a urinary tract infection. The nurse should question which medication that is prescribed for the mother? A. Nalidixic acid. B. Trimethoprim - sulfamethoxazole. C. Nitrofurantoin. D. Ampicillin.

B. This is a sulfa based drug that causes a drug-drug interaction with lamivudine.

11. Shanda states she has no real appetite and that food doesn't taste right. Which interventions should the nurse implement to help with Shanda's nutritional status? (Select all that apply.) A. Encourage Shanda to eat the largest meal at the end of the day when anorexia is less severe. B. Instruct the client to eat high fat foods. C. Develop a list of between meal snacks for the client to choose from. D. Explain the importance of taking an antiemetic immediately after meals. E. Encourage increased fluid intake, especially juices.

C, E This intervention individualizes care and takes into consideration both dietary requirements and client preferences. An adequate intake of fluids around 2500 to 3000 mL/day including nutritional juices is important.

24. Which information communicated by Shanda needs intervention from the nurse? A. My mother and I love baked potatoes with margarine. B. My mother snacks on a lot of sweets and sugared cola drinks. C. My mom only takes acetaminophen when she has a head ache or body aches. D. Sometimes when I am really busy, I will eat a high-calorie, protein bar.

C. Acetaminophen can cause hepatotoxicity in large doses. A client with hepatitis should avoid substances that may cause liver damage, such as hepatotoxic medications and alcohol.

12. The HCP places Shanda on contact precautions. What interventions are required by the nurse? A. Place the client in a private room. B. Ensure that all persons entering the room wear a gown and mask. C. Gown and gloves are to be used when handling urine or feces. D. Don mask only when in face to face contact with client.

C. Hepatitis A is transmitted by the fecal-oral route; therefore, precautions should be used when handling contaminated specimens.

10. Which priority nursing intervention should the nurse implement for the diagnosis of impaired skin integrity? A. Provide a detergent type soap when taking a shower. B. Use alcohol based lotions daily and prn. C. Massage skin with an emollient several times a day. D. Encourage frequent ambulation during the day.

C. If pruritus is a problem, special skin care and protection are needed. Eliminate bath soaps and apply emollient lotions.

Diagnostic Tests During the time her mother is with her, Shanda's mother becomes ill and is seen by Shanda's HCP. During the workup, her mother is evaluated and her liver function tests show increased levels. The HCP schedules her for a liver biopsy on an outpatient basis. 18. An increase in which diagnostic lab test reflect that the liver is not functioning adequately? A. Serum blood urea nitrogen (BUN). B. Serum albumin. C. Serum bilirubin. D. Serum lipase.

C. Serum bilirubin generally increases when the liver is damaged, along with other serum liver enzymes such as aspartate aminotransferase, alanine aminotransferase, and serum alkaline phosphatase.

Discharge Teaching Shanda's acute symptoms are resolved, and she is preparing to be discharged home. 15. Which discharge instruction should the nurse include in the teaching plan? A. Follow a gluten free diet. B. Avoid crowded settings. C. Do not share personal hygiene items. D. May use acetaminophen for headaches and mild pain.

C. Sharing personal hygiene items (i.e., nail clippers, razors, etc.) may increase the risk for virus transmission.

Cultural Awareness Some of Shanda's family members have arrived from Mexico to be with her during her illness. Shanda asks if she can use an over the counter (OTC) herbal supplement to help her liver heal. 14. Which herbal supplement should the nurse recommend? A. Ginkgo. B. Ginger. C. Milk thistle. D. Echinacea.

C. This supplement is used for antitoxin properties and to protect against liver disease.

13. Shanda's mother is going to stay with her in the hospital until Shanda is discharged. What teaching should the nurse provide related to use of the in room bathroom? A. You should only use the bathroom down the hall. B. Shanda is recovering well. No specific interventions are needed now. C. You will only need to use a disposable toilet seat protector when using the bathroom and you will be ok. D. It is important that you wash your hands for at least 15 seconds after using the bathroom.

D. Hepatitis A is spread by the fecal-oral route. Transmission is prevented by proper handwashing.

4. When Shanda receives the diagnosis, she is upset and asks, "I am scared, does this mean I am dying?" What is the best response by the nurse? A. I would feel that way too if I were you. This has to be a shock. B. Why would you think something like that? C. Would you like me to contact your roommate? D. You must feel scared and afraid. Tell me more about that.

D. This reflects the client's feelings and encourages more exploration of concerns.

Communication: Depression After three months of treatment, Shanda and her mother visit the health clinic. Shanda is recovering well, she began a new semester, and she has a full time job to help cover her medical expenses. She and her mother moved into a smaller single bedroom apartment closer to her school. She has adhered to her prescribed regimen and has been getting plenty of rest. Shanda reports that her energy level and appetite are back to normal. Shanda is worried about her mom. Her mom is homesick and does not like being alone when Shanda is gone. She does not speak English well, and has only met a few people since she has been living with Shanda. Coupled with not feeling herself has caused a change in the mother's behavior. The nurse notes that the mother is quiet and only interacts with the nurse minimally. The nurse notes that the mother's energy level is still low and she lacks enthusiasm to participate in any activities. When the nurse asks how she is doing, the mother states, "This is a terrible feeling. I don't know if I want to go on like this." 25. What is the best initial response by the nurse? A. "Most people taking interferon feel depressed." B. "A positive attitude is an important part of healing." C. "It sounds like you may need an antidepressant." D. "You seem very discouraged right now."

D. This response displays active listening and acknowledges the mother's statement. It also invites further disclosure.