Nursing Case Study for Hepatitis
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Outline
Joann S. is a 71-year-old female patient who is a direct admit to the medical surgical unit after being sent from her physician’s office for further evaluation with a diagnosis of “weakness and failure to thrive.” She is accompanied by her spouse of 53 years, Anthony, with whom she resides. She is a retired office manager with several adult children and prior to this admission lived at home without medical assistance. She appears confused and cannot stand even though she moves all extremities.
Her speech is slurred, but Anthony reports, “The doctor said something about her liver. That’s weird to me because she doesn’t drink or take any medicine except vitamins. How could there be anything wrong with her liver? I don’t understand. She stopped being able to walk a few days ago and really isn’t eating or drinking.”
What assessments and initial check-in activities should the nurse perform to best assist the patient?
What physical and/or neurological assessment findings does the nurse anticipate seeing for this patient? Why?
Are there specific history details the nurse may ask the patient and/or spouse about? Why?
- With liver impairment, substances (chronic or acute use) must be addressed. Because of her age (Baby Boomer who was born between 1945-1965), she is at higher risk for hepatitis C due to potentially risky behavior when she was younger, blood transfusion prior to screening began in 1992, etc. This generation represents the highest incidence of Hepatitis C virus which may remain undiagnosed and cause liver failure after time. Transmission of this virus was highest in the 1960s through 1980s.
The nurse obtains vital signs from the patient and performs a focused physical assessment:
BP 90/50 mmHg SpO2 90% on Room Air
HR 120 bpm and regular Ht 172.7 cm
RR 28 bpm Wt 89.6 kg
Temp 36.6°C
The patient is oriented to self only. Her skin appears tan with a yellowish tinge, and she complains of itching. She has many bruises in various stages of healing on her extremities and her sclera are bright yellow. The abdomen is distended and tender with palpation.
The physician orders laboratory studies that include blood alcohol content, urine drug screen, complete blood count, hepatic panel, coagulation studies, Hepatitis C Virus Antibody, and an abdominal ultrasound.
The labs result with the following values:
BAC: 0.0 percent
UDS: Negative for amphetamines, methamphetamines, benzodiazepines, barbiturates, marijuana, cocaine, PCP, methadone, opioids
WBC 14,000/mm3
HGB 9.2 g/dL
HCT 27.6%
Platelets 40,000 cells/µL (40 x 109/L)
Albumin 2.6 g/dL
Aspartate Aminotransferase (AST) 701 U/L
Alanine Aminotransferase (ALT) 501 U/L
Ammonia 150 mcg/dL
Bilirubin (total) 5 mg/dL
Partial thromboplastin time 50 seconds
Prothrombin time (PT) 18 seconds
International Normalized Ratio 1.6
Hepatitis C virus (HCV) Antibody: reactive
The abdominal ultrasound shows an enlarged liver and fluid accumulation in the abdomen (ascites).
Prioritize the top nursing interventions/considerations based on the diagnostic data.
- Safety concerns like bleeding risk and confusion due to elevated ammonia are key. She is also at high risk for skin breakdown. Standard precautions should always be initiated but infection control (hep C), bleeding risk, confusion may impact this – the nurse must be especially vigilant because of all these factors. There should be no further abdominal palpation due to findings. Respiratory status should be monitored due to the ascites fluid occupying space in the thoracic cavity. Frequent turning and assistance with repositioning are important.
The nurse questions alcohol and drug use labs. Why are they important? What about the other abnormal lab values? What is their significance?
- Just because the patient and family deny ETOH or drug use, it is important to check before going forward. If there is chronic use of these substances, then withdrawal protocols should be put in place by the provider. This patient has low platelets, so she is at risk for bleeding. Her bilirubin count explains her jaundice and itching. The ammonia level causes her confusion, so until this is addressed, frequent re-orientation and such would be futile. Neuro checks should be routine, not stroke protocol. The Acetaminophen level is dangerously high so the provider must be notified. The AST/ALT values and ratio indicate liver failure which is the highest priority. The HCV indicates she is positive for Hepatitis C, for more details an RNA test may be ordered.
The hospitalist sees the patient and changes the admission diagnosis to “Hepatitis with liver failure.” Anthony asks why she is confused and about the skin/eye color variances but states he does not understand what the doctor said. Joann appears sedated but wakes with verbal stimuli. She is slow to answer and continues to be disoriented.
What is the best way to explain the patient’s decreased level of consciousness and appearance to her family?
- Always breakdown patient and family teaching to layman’s terms when possible. Frequently check for comprehension and re-explain as needed using simpler and simpler terms.
- The elevated ammonia is causing confusion. This must be treated, and the patient’s safety is always considered as she is at high risk for fall/injury/skin breakdown. Ammonia is a waste product managed by the liver. Her liver is not functioning correctly right now, so the ammonia built up making her get more and more confused. She cannot help how she is acting right now.
A new order to begin a scheduled dose Lactulose 20 mg orally every 6 hours is written, with the first dose to be given now.
The nurse works to retrieve the medication and notes that the concentration is 10 mg/15 mL. How many milliliters of lactulose should the nurse give? What is the rationale for this medication? What are some nursing considerations for this medication?
- The dose of Lactulose that is ordered is 20 mg. The nurse has 10 mg/15 mL available. Therefore, the nurse should give 30 mL to the patient. Lactulose is synthetic sugar that acts as a laxative and is given to help with lowering ammonia levels. It is thick and sweet tasting. Due to its mechanism of action, it causes frequent loose stools; therefore, the nurse should be prepared for bedpans/cleanup/skin protection.
What patient education topics would need to be covered?
- For this patient, just because she is confused, does not mean leaving her out of education/counseling. Just make sure the patient’s family is included. Allow for questions.
- She is a safety and infection control risk so those topics should be covered. Explain medications are necessary to lower toxic chemicals her liver cannot handle.
Explain hepatitis C transmission including her risk factors. Discuss patient and family needs/wants in case she is unable to rebound from this condition (i.e., hospice).
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Transcript
Hey everyone. My name is Abby. We’re going to go through a case study for hepatitis together. Let’s get started. In this scenario, our patient Joanne is 71 years old, and she is a direct admit to the med-surg unit after being sent home from her physician’s office for further evaluation, with a diagnosis of weakness and failure to thrive. She is accompanied by Anthony, her spouse of 53 years. She’s a retired office manager with several adult children and prior to this admission, lived at home without medical assistance. Today, she’s presenting confused and cannot even stand even though she moves all extremities. Her speech is even slurred, but her husband reports, “The doctor said something about her liver. That’s weird to me because she doesn’t drink or take any medicine except for vitamins. How could there be anything wrong with her liver? I don’t understand. She stopped being able to walk a few days ago and really isn’t eating or drinking.” With this information, let’s take a look at our critical thinking checks number one, number two and number three below.
Perfect. Those lab results come back with the following values: Her blood alcohol content came back at 0%. Her urinary drug screening was negative for all controlled substances, like amphetamines, methamphetamines, benzos, barbiturates, marijuana, cocaine, PCP, methadone, and opioids. Her CBC showed her white blood cells at 14, a hemoglobin of 9.2, hematocrit 27.6, and platelets of 40,000.
Now, let’s take a little closer look at her liver specific labs: The LFTs or her liver function tests came back with her AST at 701, her ALT at 501, and her ALP at 380. Albumin came back at 2.6, ammonia 150 and her bilirubin of 5. Coagulation studies are also so important when looking at liver function, her PTT came back at 50 seconds. Her PT came back at 18 seconds and her INR 1.6. She was also tested for the Hep C virus antibodies, which came back as reactive. The abdominal ultrasound also resulted showing that she has an enlarged liver and an accumulation of fluid in the abdomen. Also known as ascites. Does any of this sound abnormal to you? Let’s take a look at our critical thinking checks number four and number five below.
Excellent. If you need any further clarification, go to the gastrointestinal course for some more info to supplement your knowledge. In this scenario, the hospital sees the patient and changes the admission diagnosis to hepatitis with liver failure. Anthony asks why she is confused and about the skin/eye color variances but states he does not understand what the doctor said. Joanne appears sedated, but she does wake with verbal stimuli. However, she is slow to answer and continues to be disoriented. Now that we have that information, let’s take a look at our critical thinking check number six below.
Great job. A new order is placed to administer a scheduled dose of lactulose. Lactulose was ordered 20 milligrams, every six hours the first dose to be given now. With this new order in mind, we can take a look at our critical thinking checks number seven and number eight below.
Great job, guys that wraps up this case study on hepatitis. Please take a look at the attached study tools and test your knowledge with a practice quiz. We love you guys, now go out and be your best self today. And as always, happy nursing!
References:
Sources: please note for all lab values, nursing.com data used. “Normal” values are not included, only abnormal. For all meds pdr.net or rxlist.com used; for condition, uptodate.com Overview of the management of chronic hepatitis C virus infection
Authors:Sanjiv Chopra, MD, MACPPaul J Pockros, MDSection Editor:Adrian M Di Bisceglie, MD updated June, 2021 AND Acute liver failure in adults: Management and prognosis
Authors:Eric Goldberg, MDSanjiv Chopra, MD, MACPJonah N Rubin, MDSection Editor:Robert S Brown, Jr, MD, MPH last updated Sept, 2021
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