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hepatitis def.
inflammation of the liver
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most common cause hep.
- viral hepatitis
- types of it are A, B, C, D, E, G
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besides acute viral inf. (most common), what else causes hepatitis
- toxic chemicals/drugs
- alcohol
- autoimmune
- bacterial (rare): streptococci, salmonellae, e. coli
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how do you distinguish between the various types of viral hepatitis
you only can distinguish by the presence of antigens and antigenic subtypes, and the subsequent development of antibodies to them
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hepatitis A, B, and C: name the % of each in adults
- 50% Hep. B
- 30% Hep. A
- 20% Hep. C
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homologous immunity
infection w/ one kind of viral hepatitis provides immunity to that specific virus, but you can still get a different type of viral hepatitis (foex: one type of Hep C can still get another type of Hep C)
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what (generally) is happening to liver w/ hepatitis?
widespread inflammation
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what happens microscopically when the liver is inflammed
cytotoxic cytokines and natural killer cells come in and lyse the infected hepatocytes
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what specific microscopic process causes liver damage w/ hepatitis
hepatic cell necrosis, caused by the cytotoxic cytokines and natural killer cells which come in and lyse infected hepatocytes
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what happens to Kupffer cells w/ hepatitis (and def. of Kupffer cells)
- they proliferate and enlarge
- Kupffer cells = hepatic macrophages
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periportal inflammation - def, what could happen as a result
- interrupted flow of bile into intestine
- happens in hepatitis pts
- cholestasis may occur
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w/ hepatitis, what infiltrates the liver when there's this hepatic cell necrosis
- besides, NK cells and cytotoxic cytokines...
- lymphocytes
- macrophages
- plasma cells
- eosinophils
- neutrophils
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impaired bile excretion has what ramifications
build up of bile in blood, urine, and skin
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can liver cells regenerate in a hepatitis pt
yes, if no complications occur they may resume their normal appearance and function
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Hepatitis A transmission
- fecal contaminated food or drinking water
- fecal/oral route
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hep A incubation
- 15-50 days
- average = 28 days
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hep A infectivity - when does virus appear in serum
hep A antibodies appear in serum as stool becomes negative for virus
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when is there the greatest risk of transmission of Hep A
before clinical symptoms are apparent
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is there a chronic carrier state for hep A
no
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how to prevent Hep A
- good hygiene
- water treatment/community sanitation
- no raw shellfish
- safer sex
- Hep A vaccine (booster 6-12 mos after shot)
- immunoglobulin before exposure or w/in 2 weeks after exposure (protects about 2 months)
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difference between Hep A vaccine and immunoglobulin
- vaccine is for preexposure prophylaxis
- IG is for temporary (1 to 2 mos) passive immunity
- IG must be given w/in 2 weeks of exposure
- IG is for if you haven't had the vaccine
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Hep B incubation
- 45-180 days
- average = 56-96
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Hep B transmission
- percutaneous (parenteral
- permucosal
- sexual contact
- perinatal
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common ways of getting Hep B
- contaminated needles, syringes, and blood products
- sex w/ infected person
- asymptomatic carriers
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can a hep B pt be chronic
yes, for life
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which body fluids is the Hep B antigen present in, and which is it not in?
- almost every body fluid
- except: urine, feces (w/o GI bleed), breast milk, tears, sweat
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infectivity of hep B: when? how long? + sth else re: how long
- you're infective before and after symptoms appear
- 4-6 mos of infectiveness
- in carriers, you're infective for your whole life
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how do you know if you're a carrier for hep B
- if HBs-Ag (hep B surface antigen) is still in your serum for more than 6-12 mos
- 2-10% infected adults become chronic carriers
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what are hep B chronic carriers at a higher risk for
hepatocellular cancer
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desc the hep B vaccine
- series of 3
- for post-exposure prophylaxix use the Hep B immunoglobulin
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how prevent Hep B
- screen donor blood
- disposable equipment
- sterilize non-disposable equipment
- safer sex
- needle exchange
- stdard precautions
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Hepatitic C incubation period
- 14-180 days
- average = 56 days
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how is hep C spread
- blood and blood products: percutaneous exposure
- needles and syringes
- sex w/ infected person
- perinatal contact
- organ transplant
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when is a person infective/contageous when they have hep C
- 1-2 weeks before symptoms appear, through clinical course
- 75-85% will go on to dev chronic hepatitis
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how to prevent hep C
- screen donor blood
- use disposable equip
- sterilize nondisp equip
- safer sex
- screen for HCV antibodies
- NO VACCINE or IG AT THIS TIME
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is there a hep C vaccine?
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other name for hep D
delta virus
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hep D desc
- defective single-stranded RNA virus that cannot survive on its own
- requires helper of hep B to replicate
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how is hep D transmitted
- same as hep B
- percutaneous
- permucosal
- parenteral
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when is blood infectious w/ hep D
at all stages of hep D infection
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how to prevent hep D
- hep B vaccine reduces the risk of hep D
- no vaccine for hep D rekk
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hep E desc
- RNA virus
- transmitted by fecal-oral route
- mostly in developing countries
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hep E incubation
- 15-64 days
- average = 26-42 days
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what are hep E outbreaks associated w/
- contaminated water supply
- India, Asia, Mexico, Africa
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infectivity of hep E
- not known
- may be similar to hep A: most infective 2 wks before symptoms and lasts until 1-2 wks after start of symptoms
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vaccines/tests and hep E
- no vaccine to test or dx hep E
- there are some diagnostic tests in research labs to detect IgM and IgG anti-HEV in serum
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prevention of hep E
- good hygeine
- water treatment
- proper sanitation
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hep G and liver damage
hep G does not cause liver damage on its own
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how is hep G transmitted
- parenteral (blood and body fluids)
- sexually transmitted
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hep G prevention
- no vaccine available
- similar to hep B and C--
- screen donor blood
- safe sex
- use disposable equipment
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how long does acute phase of hepatitis last
1-4 months
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does everyone w/ hepatitis have symptoms
no -- 30% of acute hep B pts and 80% of acute Hep C pts are asymptomatic
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s/s hepatitis in the acute phase
- anorexia/wt loss
- nausea/vomitting
- hepatomegaly/splenomegaly
- right upper quadrant discomfort/tenderness
- constipation/diarrhea
- decreased sense of taste/smell
- malaise/fatigue
- headache
- fever
- arthralgias
- urticarcia
- jaundice (not all pts w/ viral hep have jaundice; "anicteric hepatitis")
- pruritis (secondary to accumulating bile salts under skin)
- dark urine
- bilirubinuria
- light stools
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anicteric hepatitis
hepatitis where the pt does not have jaundice
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pruruitis in the acute phase of hepatitis is secondary to what
bile salts accumulating under skin
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how long does chronic phase of hepatitis last
2-4 months
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s/s during chronic phase of hepatitis
- malaise
- easy fatigability
- hepatomegaly
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how many hepatitis infected people die of it
- less than 1%
- usually older adults and ppl w/ debilitating illnesses
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name some -ase's that indicate liver cell injury
- increased -- aspartate aminotransferase (AST)
- increased -- alanine aminotransferase (ALT)
- increased -- glutamyl transpeptidase (GGT)
- increased -- alk phos
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an increased alk phos means what's happening physiologically
impaired excretory fxn of the liver
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name some serum proteins that are helpful in diagnosing liver function
- albumin
- globulin
- prothrombin time
- urinary & serum bilirubin
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what does albumin lvl do w/ hepatitis
normal or decreased
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what does globulin lvl do w/ hepatitis
normal or increased
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what happens w/ prothrombin time w/ hepatitis
prolonged
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a decreased prothrombin time means what re: vit K and prothrombin
- means decreased vit K absorption in intestines
- means decreased production of prothrombin by the liver
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what happens to urinary and serum bilirubin w/ hepatitis
- the lvls might increase
- indicated liver cell damage
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serological markers for hepatitis testing
- surface antigens
- antibodies
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name some tests that help show liver function
- liver cell injury -ase's
- serum proteins (albumin etc)
- CBC
- surface antigens/antibodies for hep.
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what meds do you give a hepatitis pt. and what are each for
- Dimenhyrdinate/Dramamine - antiemetic
- trimethobenzamide/Tigan - antiemetic
- Diphenhydramine/Benadryl - sedative/hypnotic
- Chloral hydrate - sedative/hypnotic
- Prednisone - synthetic glucocorticoid
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what meds should you avoid in liver fx pts
those metabolized by liver, like phenothiazines (antipsychotics, b/c of cholestatic and hepatotoxic effects)
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if prothrombin time is elevated, do what
give vitamin K
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what kinds of pts do you give immunoglobulin therapy to
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what do you do, esp, for hep B pts (both chronic and virulent)
- decrease viral load
- decrease disease progression
- decrease rate of drug resistant sHBV
- give a-interferon and antiviral agents (these do all that: supress viral activity, decrease viral load, etc.)
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2 things pt needs to remember re: taking care of themself at home now that they have hepatitis
- rest (degree of strictness varies)
- nutrition - assists hepatocytes to regenerate; pt needs to keep wt. up, vit K and B-complex
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which hepatitises are sexually transmitted
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which hepatitisis are percutaneous transmitted
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which hepatitis uses immune globulin
hep A
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what time in life are you most likely to get hep A?
under age 15
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when is hep A no longer infectious
within a week after jaundice
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prognosis for hepatocellular carcinoma
usually fatal
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when is hep B usually acquired
perinatally (mother to child)
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which hepatitises become chronic
- hep B (plus, causes wide spectrum of acute/chronic illnesses like cirrhosis)
- hep C (is often anticteric, or w/o jaundice)
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what body systems are involved in the transmission of meningitis
- upper respiratory tract
- bloodstream (penetrating skull wounds or # sinuses in basal skull #s)
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what bacteria cause meningitis
- almost any bacteria
- Streptococcus pneumoniae
- Neisseria meninitidis
previously, Haemophilus influenzae, but H. influenza vaccine lowered this number significantly
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meningitis triad of symptoms
- nuchal rigidity
- positive Brudzinski sign (lifting of legs painful when lifting head)
- positive Kernig sign (legs fully bent hip/knee, extention of knee is painful)
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common s/s meningitis
- fever/chills
- severe headache
- stiff neck
- n/v
- photophobia
- decreased LOC
- increased ICP
- coma
- seizures
- skin rash and petechiae (meningococcus)
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complications of meningitis
- hemiparesis
- dysphasia
- hemianopsia
- hydrocephalus (secondary to adhesions)
- Waterhouse-Friderichson Syndrome
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Waterhouse-Friderichson Syndrome: what is it? s/s?
- petechiae
- DIC and adrenal hemorrhage
- cause of death in 1% meningitis pts
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what would you find in the CSF of a meningitis pt
- increased protein
- WBC (increased PMNs)
- gram stain it and culture it
- usually purulent and turbid
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what kinds of tests to dx meningitis
- history and physical
- CSF analysis
- CBC
- coagulation profile
- electrolyte levels
- glucose (decreased w/ some types)
- platelet count
- blood culture
- CT scan
- MRI
- PET scan
- skull xray studies
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what kind of drugs might sb w/ meningitis be on
- IV fluids
- IV antibiotics (ampicillin, penicillin, cephalosporins)
- Codeine (for headache)
- Acetaminophen/aspirin (for fever)
- Antiseizure/antiepileptic (IV Phenytoin or Dilantin)
- Furosemide or mannitol (for diuresis)
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other interventions to be aware of (non med) for meningitis pts
- bed rest
- hypothermia
- clear liquids as well as tolerated
- fluid balance
- maintain resp/circulatory systems
- reduce ICP
- manage bacterial shock
- isolation
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nurses should assess what for meningitis pt
- increased ICP?
- LOC and GCS score?
- Cardiopulmonary fx?
- Regulation?
- Elimination?
- Fluids/electrolytes?
- Activity and rest?
- Nutrition?
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what to implement, as a nurse, in a case of acute meningitis
- health promotion
- assess VS (slow cooling fever)
- neurological evaluation (mental distortion, confusion, anxiety)
- monitor fluids (I/O)
- assess lungs and skin, + head and neck pain
- photophobia
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what to implement, as a nurse, in a case of home care, hospital-leaving meningitis
- nutrition (high protein, high calorie, in small freq. feedings)
- progressive ROM for neck and legs
- residual effects are uncommon, but assess for vision, hearing, cog. skills, motor/sensory abilities
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somebody who's just had acute meningitis needs to remember what re: nutrition
- high calorie
- high protein
- small, frequent feedings
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residual effects of meningitis
- they are uncommon, but include--
- vision
- hearing
- cognitive skills
- motor/sensory abilities
- assess for all these!
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3 causes of VIRAL meningitis
- enteroviruses (human-borne)
- arboviruses (spread by blood-sucking insects!)
- HIV and HSV (herpes simplex virus)
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transmission of VIRAL meningitis
most often spread by direct contact w/ respiratory secretions
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clinical manifestations of VIRAL meningitis
- headache
- fever (moderate or HIGH)
- photophobia
- stiff neck
- *no symptoms of brain involvement*
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diagnostic assessments for VIRAL meningitis
- CSF exam (via lumbar puncture)
- no organisms on Gram stain or acid-fast smears
- polymerase chain reaction (PCR)
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most important method for diagnosing CNS viral infection
Polymerase chain reaction (PCR) -- detects viral-specific DNA or RNA
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how do you manage viral meningitis
- managed symptomatically because the disease is self-limiting
- rare sequelae may include: persistent headaches, mild mental impairment, lack coordination
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prognosis for viral meningitis
full recovery is expected
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rare sequelae for viral meningitis may include (3)
- persistent headache
- mild mental impairment
- lack of coordination
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special s/s of viral meningitis in young children
- poor feeding/vomitting
- marked irritability
- frequent seizures w/ high pitched cry
- bulging fontanel
- nuchal rigidity may or may not be present
- Brudzinski/Kernig signs not helpful to dx.
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in children, what age are majority of viral meningitis infections
between 1 month and 5 yrs
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pneumonia def.
acute inflammation of the lung parenchyma ("tissues") caused by an organism
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who is predisposed to pneumonia (lots of em!)
- aging
- air pollution
- altered consciousness (alcoholism, head injury, szs, anesthesia, drug OD, CVA)
- altered oropharyngeal flora secondary to ABX
- bed rest and prolonged immobility
- chronic diseases
- HIV
- immunosppressive drugs
- inhalation of noxious substances
- intestinal and gastric feedings via NG/NI tube
- malnutrition
- tracheal intubation
- upper resp tract infections
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how is pneumonia transmitted (3)
- aspiration
- inhalation
- hematogenous spread from primary infections elsewhere in body (S. aureus)
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7 types of pneumonia
- community-acquired (CAP)
- hospital-acquired (HAP)
- ventilator-associated (VAP)
- health-care-associated (HCAP)
- fungal pneumonia
- aspiration pneumonia
- opportunistic pneumonia
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who is at risk for community acquired pneumonia
- over 65 yrs
- smokers
- alcoholics
- multiple medical comorbidities
- immunosuppressive diseases
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def. of community-acquired pneumonia
lower resp tract infection of the lung parenchyma w/ onset in the community, or during first two days of hospitalization
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a few facts about community acquired pneumonia
- causative organisms identified only 50% of time
- incidence is increasing
- 6th leading cause of death in USA
- highest in winter months
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def. of hospital acquired pneumonia
more than 48 hrs after admission
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def. of ventilator associated pneumonia
more than 48-72 hrs after endotracheal intubation
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def. of health care associated pneumonia
- new onset pneumonia that was:
- (1) hospitalized in acute care for 2 or more days w/in 90 days of the infection
- (2) resided in a long-term care facility
- (3) received recent IV ABX, chemo, or wound care w/in 30 days of infection
- (4) attended hospital or chemodialysis clinic
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health care associated pneumonia is w/ what kinds of organisms
primarily bacterial
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what kinds of things cause health care associated pneumonia
- immunosuppressive therapy
- debility
- endotracheal intubation
- contaminated respiratory therapy equipment
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who gets fungal pneumonia
- seriously ill pts, like...
- corticosteroids
- antineoplastics
- immunosuppressive drugs
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s/s fungal pneumonia
similar to bacterial pneumonia
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name some fungal infections of the lung (p.576 LEWIS)
- histoplasmosis
- blastomycosis
- aspergillosis
- candidiasis
- pneumocystis pneumonia (PCP)
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risk factors for aspiration pneumonia
- hx loss of consciousness (CVA, szs, anesthesia, head injury, ETOH abuse)
- tube feedings
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aspiration pneumonia def.
abnormal entry of secretions or substances into lower airway from mouth or stomach
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opportunistic pneumonia def.
pneumonia that pts get who have altered immune responses, who are thus highly suceptible to resp infections
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who gets opportunistic pneumonia
- altered B and T-cell fx
- decreased bone marrow fx
- decreased levels/fx of neutrophils and macrophages
- severe protein/calorie malutrition
- radiation/chemo/corticosteroid pts (for extended time)
- pneumocystis carinii (HIV pts)
- cytomegalovirus (CMV) pts -- a type of herpes virus, transplant recipients esp. vulnerable
- fungi
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most common cause of bacterial pneumonia (organism)
- Streptococcus pneumoniae
- so, it's called: Pneumococcal pneumonia
- S. pneumoniae is also called pneumococcus
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4 stages of the pneumococcal pneumonia disease process
- congestion
- red hepatization
- gray hepatization
- resolution
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congestion stage of the pneumococcal pneumonia disease process pathophysiology
- after pneumococcus reached alveoli there is an outpouring of fluid into the alveoli
- the organisms multiply in the serous fluid, and the infection is spread
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red hepatization stage of the pneumococcal pneumonia disease process pathophysiology
- massive dilation of the cappillaries
- alveoli are filled w/ organisms, neutrophils, RBCs, and fibrin
- lung appears red and granular (similar to the liver, hence "hepatization")
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gray hepatization stage of the pneumococcal pneumonia disease process pathophysiology
- blood flow decreases
- leukocytes and fibrin consolidate in the affected part of the lung
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resolution stage of the pneumococcal pneumonia disease process pathophysiology
- complete resolution and healing occur if there are no complications
- exudate becomes lysed and is processed by the macrophages
- normal lung tissue is restored
- gas exchange returns to normal
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clinical manifestations of bacterial pneumonia
- sudden onset of symptoms
- fever
- shaking chills
- shortness of breath
- cough productive of purulent sputum (rust-colored in pneumoncoccal)
- pleuritic chest pain
- elderly: confusion/stupor rekk maybe only s/s
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clinical manifestations of viral pneumonia
- variable
- atypical presentation w/ chills, fever, dry/nonproductive cough
- extrapulmonary symptoms
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complications of pneumonia
- pleurisy (inflammation of pleura)
- pleural effusion (resolves w/in 1-2 weeks)
- atelectasis in 1 or more lobes (usually clears w/ effective cough and deep breathing)
- bacteremia
- lung abscess
- empyema (pus and fluid in pleural cavity)
- pericarditis (spread of the infecting organism via infected pleura or via hematogenous route to the pericardium)
- meningitis (check for disoriented, confused, or somnolent- do lumbar puncture if yes)
- endocarditis (infecting organism attacks endocardium and heart valves)
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what is empyema
- complication of pneumonia
- pus and fluid in pleural cavity
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what is pericarditis
- complication of pneumonia
- spread of infectious organism to pericardium through the infected pleura or through some hematogenous route
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what if a pneumonia pt is disoriented, confused or somnolent
do a lumbar puncture because maybe they've developed meningitis as a complication of their pneumonia
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what is endocarditis
- complication of pneumonia
- infectious organism attacks the endocardium and valves of the heart
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what should you look for in your respiratory examination if suspected pneumonia
- pulmonary consolidation noted by percussion
- fremitus (frictions between parietal and visceral pleura)
- bronchial breath sounds
- crackles ("rales") -- fluid in small airways
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what kinds of test will the doctor order for a pneumonia pt
- chest xray
- gram stain sputum
- pulse oximetry or ABGs
- blood tests
- cultures of sorts
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what kinds of treatments are helpful to a BACTERIAL pneumonia pt
- ABX
- oxygen therapy
- anagesics
- antipyretics
- activity restriction
- increased fluids
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what kinds of treatments are helpful to a VIRAL pneumonia pt
- no definitive treatment
- antiviral drugs (i.e. influenza A.)
- neuraminidase inhibitors (i.e. influenza A and B)
- pneumococcal vaccine
- nutritional therapy
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who should get the pneumococcal vaccine
- chronic disease ppl
- ppl recovering from severe illness
- ppl over 65
- residents of LTC
- at risk ppl
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can you give pneumonia and flu vaccines at same time
yes, but different sites please
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what subjective data will you collect on a pneumonia pt
- past health history (lung cancer? COPD? DM? etc)
- meds (use ABX? corticosteroids? chemo?)
- surgery (endotrach? gen. anesthesia?)
- cigarettes? alcohol?
- prolonged bed rest?
- pain w/ breathing? sore throat?
-
what objective data will you collect for pneumonia pt
- fever
- tachypnea
- percussion
- sputum color etc
- tachycardia
- LOC change
- lab values
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what does nurse teach for pts in hospital w/ pneumonia
awareness of complications and manifestations of pneumonia
-
what does nurse teach pneumonia pt when they're being discharged or at home?
- medications
- need to rest
- resp exercises
- follow up care
-
what are you going to look for in a pediatric who has pneumonia
- high fever
- cough -- unproductive to productive w/ white sputum
- rhonchi or crackles
- dullness w/ percussion
- chest pain
- retractions
- nasal flaring
- pallor to cyanosis
- irritable, restless, or lethargic
- anorexia, n/v, diarrhea, abd pain
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