A nurse is caring for a patient with chronic hepatitis B on Tenofovir therapy, whose recent diagnostic results show elevated liver enzymes and high HBV DNA levels. Which nursing intervention is most critical to prevent further liver damage in this patient?

B) Educating the patient on the importance of alcohol cessation.

A) Encouraging the patient to continue taking Tenofovir as prescribed.

B) Educating the patient on the importance of alcohol cessation.

C) Scheduling frequent liver function tests to monitor disease progression.

D) Discussing with the healthcare provider about adjusting the antiviral regimen.

A patient with chronic hepatitis B and a history of alcohol use presents with elevated liver enzymes and high HBV DNA levels despite being on Tenofovir. Which nursing intervention is most appropriate to address the patient's condition and support treatment efficacy?

A) Educate the patient on the importance of strict adherence to medication schedules.

B) Recommend the patient increase fluid intake to flush out liver toxins.

C) Advise the patient to take over-the-counter vitamin supplements to support liver health.

D) Encourage the patient to consume a high-protein diet to promote liver regeneration.

A patient with chronic liver disease presents with worsening jaundice, increased fatigue, abdominal discomfort, and ascites. Given the current clinical findings, which nursing intervention should be prioritized to address the patient's condition?

B) Administer diuretics as prescribed to reduce fluid retention from ascites.

A) Encourage the patient to increase fluid intake to manage dehydration.

B) Administer diuretics as prescribed to reduce fluid retention from ascites.

C) Provide a high-protein diet to improve nutritional status and albumin levels.

D) Educate the patient on the importance of continuing antiviral medications.

A patient with a history of chronic liver disease presents with increased fatigue, abdominal discomfort, and jaundice. The patient's lab results show elevated liver enzymes, high bilirubin levels, decreased albumin, and a slight increase in INR. Based on these findings, which nursing intervention is the priority to address the patient's current symptoms?

D) Monitor vital signs closely due to possible hemodynamic instability.

A) Administer prescribed diuretics to manage ascites.

B) Educate the patient on the importance of alcohol cessation.

C) Prepare the patient for a potential liver biopsy to assess fibrosis.

D) Monitor vital signs closely due to possible hemodynamic instability.

A patient with liver dysfunction is experiencing significant fatigue, poor appetite, and weight loss despite some improvement in jaundice and ascites. Which intervention should the nurse prioritize to address the patient's nutritional concerns?

B) Collaborate with a dietitian to develop a high-calorie, low-sodium diet plan.

A) Encourage the patient to increase fluid intake to improve hydration.

B) Collaborate with a dietitian to develop a high-calorie, low-sodium diet plan.

C) Increase the dosage of diuretics to further reduce ascites and discomfort.

D) Educate the patient on the importance of strict antiviral medication adherence.

A patient with chronic liver disease is on a regimen that includes diuretics, modifications to antiviral therapy, and nutritional support. During a follow-up visit, the patient reports persistent fatigue and poor appetite, along with slight weight loss and ongoing ascites. Laboratory results show marginal improvement in liver enzymes, but bilirubin remains elevated. Which nursing intervention should be prioritized to address the patient's nutritional concerns and optimize his condition?

B) Encourage small, frequent meals to improve caloric intake.

A) Increase protein intake to promote liver regeneration.

B) Encourage small, frequent meals to improve caloric intake.

C) Recommend a low-sodium diet to manage ascites.

D) Suggest vitamin supplements to improve energy levels.

A patient with worsening hepatic dysfunction presents with increased abdominal distension and altered mental status. Which nursing intervention should be prioritized to address the suspected hepatic encephalopathy?

A) Administer lactulose as prescribed to reduce ammonia levels.

B) Encourage a low-protein diet to minimize nitrogenous waste.

C) Position the patient flat to enhance respiratory function.

D) Increase fluid intake to prevent dehydration.

A patient with advanced liver disease presents with increased abdominal distension, fatigue, and altered mental status. The healthcare team suspects hepatic encephalopathy and initiates lactulose therapy. Which assessment finding would indicate that the lactulose therapy is effective?

B) Improved orientation and mental clarity

A) Decrease in serum bilirubin levels

B) Improved orientation and mental clarity

C) Reduction in peripheral edema

A patient with liver cirrhosis is experiencing spontaneous bacterial peritonitis (SBP). Which nursing intervention should be prioritized to address the patient's current condition?

D) Initiating intravenous broad-spectrum antibiotics as prescribed

A) Administering intravenous albumin to improve oncotic pressure

B) Monitoring vital signs every 4 hours to assess for hemodynamic stability

C) Preparing the patient for immediate paracentesis to relieve abdominal discomfort

D) Initiating intravenous broad-spectrum antibiotics as prescribed

A patient with liver cirrhosis is experiencing spontaneous bacterial peritonitis (SBP) and has been started on intravenous antibiotics. Which nursing intervention is the most critical to prioritize in this situation to ensure patient safety and prevent further complications?

A) Monitor vital signs and assess for signs of sepsis

B) Educate the patient about the importance of a low-sodium diet

C) Encourage increased fluid intake to promote kidney function

D) Administer lactulose to manage hepatic encephalopathy

Hepatitis - Nursing Case Study

Pathophysiology

• Primary mechanism: Hepatocyte Injury - Hepatitis involves liver inflammation primarily due to viral infections (e.g., Hepatitis A, B, C). The immune response to these viruses causes hepatocyte damage, leading to impaired liver function and inflammation.

• Secondary mechanism: Immune-Mediated Damage - The immune system's attempt to eradicate the virus results in further liver injury. This immune response can cause apoptosis or necrosis of liver cells, contributing to liver dysfunction and fibrosis.

• Key complication: Chronic Liver Damage - Persistent inflammation and immune-mediated injury can lead to chronic hepatitis. Over time, this may result in fibrosis, cirrhosis, or hepatocellular carcinoma, significantly impairing liver function and leading to severe clinical outcomes.

Patient Profile

Demographics:

45-year-old male, construction worker

History:

• Key past medical history: Diagnosed with Hepatitis B three years ago, history of alcohol use

• Current medications: Tenofovir 300 mg once daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Abdominal pain and jaundice

• Key symptoms: Fatigue, nausea, decreased appetite, dark urine, and itching

• Vital signs: Blood pressure 140/90 mmHg, heart rate 102 bpm, respiratory rate 20 breaths per minute, temperature 38.2°C (100.8°F)

Section 1

New Diagnostic Results:

Following the initial presentation, the healthcare team conducted a comprehensive evaluation, including liver function tests, complete blood count, and an abdominal ultrasound to assess the extent of liver damage and any potential complications. The laboratory results showed elevated liver enzymes: ALT at 180 U/L and AST at 160 U/L, indicating ongoing hepatocyte damage. The patient's bilirubin levels were also significantly increased at 3.5 mg/dL, correlating with his jaundice and dark urine. The ultrasound revealed mild hepatomegaly with early signs of fibrosis, but no detectable masses or significant ascites at this stage. These findings suggest a progression toward chronic liver damage with the potential for further fibrosis development.

The team also reviewed the patient's viral load, revealing a high HBV DNA level, which indicates active viral replication despite being on Tenofovir. This prompts a reevaluation of the current antiviral therapy regimen, considering the patient's adherence to medication and lifestyle factors, particularly his history of alcohol use, which could exacerbate liver damage and hinder treatment efficacy. The multidisciplinary team, including a hepatologist, discusses potential adjustments to the antiviral strategy, possibly incorporating additional agents or supportive therapies to manage symptoms and slow disease progression.

This diagnostic update underscores the importance of continuous monitoring and proactive management of chronic hepatitis B, particularly in patients with complicating factors such as alcohol use. The healthcare team must balance antiviral treatment optimization with lifestyle modifications to mitigate further liver damage. The patient's case will require ongoing assessment and adjustment of therapeutic interventions to prevent the transition to cirrhosis or hepatocellular carcinoma, pivotal in improving long-term outcomes. The next step involves a patient-centered approach, focusing on education about alcohol cessation and adherence to treatment while preparing for potential advanced interventions if the liver function deteriorates.

Section 2

Change in Patient Status:

Two weeks after the initial diagnostic update, the patient returns for a follow-up appointment, presenting with additional symptoms that suggest a change in his clinical status. He reports increased fatigue, abdominal discomfort, and a noticeable decrease in appetite, resulting in a weight loss of five pounds since his last visit. On physical examination, the patient exhibits worsening jaundice, with more pronounced scleral icterus and yellowing of the skin. Palpation reveals tenderness in the right upper quadrant, and there is a slight increase in abdominal girth, raising concerns about the development of ascites.

Vital signs show a decrease in blood pressure to 98/68 mmHg and a resting heart rate of 92 bpm, indicating possible hemodynamic instability. Laboratory tests reveal further elevation in liver enzymes: ALT at 210 U/L and AST at 190 U/L, alongside increased bilirubin levels, now at 4.2 mg/dL. Albumin levels have dropped to 2.8 g/dL, and there is a mild increase in INR, now at 1.5, suggesting a decline in synthetic liver function. The patient's viral load remains high, reinforcing the need for a reassessment of his antiviral regimen.

These findings indicate a progression in liver disease, with early signs suggestive of decompensation. The healthcare team considers the possibility of hepatic decompensation due to the patient's ongoing alcohol use and inadequate response to current antiviral therapy. This situation necessitates a multidisciplinary approach, incorporating additional support for alcohol cessation, potential modification of antiviral medications, and the introduction of diuretics to manage ascites. The team also discusses the possibility of referring the patient for a liver biopsy to assess the extent of fibrosis and to guide further management decisions. The primary goal is to stabilize the patient's condition and prevent further deterioration, while preparing for potential escalation in therapeutic interventions if necessary.

Section 3

After the healthcare team initiated the new management plan, including the introduction of diuretics and modifications to the antiviral regimen, the patient returns for a follow-up evaluation one week later. During this visit, he reports some improvement in abdominal discomfort but continues to experience significant fatigue and poor appetite. On examination, his jaundice appears slightly reduced, but scleral icterus remains prominent. The patient has lost an additional two pounds, further emphasizing nutritional concerns. Palpation of the abdomen shows persistent tenderness in the right upper quadrant, and although his abdominal girth has slightly decreased, ascites are still present.

Repeat vital signs reveal a slight improvement in blood pressure, now at 102/70 mmHg, and a heart rate of 88 bpm, suggesting some stabilization of his hemodynamic status. Laboratory tests show a marginal decrease in liver enzymes, with ALT at 198 U/L and AST at 185 U/L. However, bilirubin levels remain elevated at 4.0 mg/dL, and albumin levels are still low at 2.7 g/dL, indicating ongoing impaired liver function. The INR has slightly improved to 1.4, but still reflects compromised synthetic function. The patient's viral load shows a slight reduction, suggesting a modest response to the adjusted antiviral therapy.

Despite these mixed outcomes, the patient's clinical picture prompts the healthcare team to explore additional interventions. Nutritional support is prioritized, including consultation with a dietitian to address weight loss and optimize dietary intake. Consideration is given to adjusting diuretic therapy to better manage ascites, while ongoing support for alcohol cessation is reinforced. The team continues to monitor closely for signs of further decompensation, with plans to escalate care if necessary. The potential need for liver transplantation discussions is introduced, given the patient's risk of progressive liver failure. This comprehensive approach aims to stabilize the patient's condition, improve quality of life, and prevent further complications.

Section 4

During a subsequent follow-up appointment two weeks later, the patient presents with noticeable changes in his clinical status. He reports increased abdominal distension and discomfort, accompanied by a sense of fullness and difficulty breathing, particularly when lying flat. His fatigue has worsened, leading to increased daytime somnolence, and he admits to feeling more disoriented at times. The physical examination reveals a marked increase in abdominal girth, with significant ascites and shifting dullness on percussion. His scleral icterus persists, and there is now mild peripheral edema in the lower extremities. Vital signs indicate a slight decline in hemodynamic stability, with a blood pressure of 94/66 mmHg and a heart rate of 96 bpm.

Laboratory tests reveal a concerning trend, with a rise in bilirubin levels to 5.2 mg/dL and further decline in albumin to 2.5 g/dL, suggesting exacerbated hepatic dysfunction. The INR has increased to 1.6, indicating a worsening synthetic function, while liver enzymes remain elevated, with ALT at 210 U/L and AST at 195 U/L. The viral load has stabilized, showing no further reduction, which raises concerns about the effectiveness of the current antiviral therapy. These findings prompt the healthcare team to suspect the development of hepatic encephalopathy, given the patient's altered mental status and worsening liver function.

In response to these developments, the team initiates a more aggressive management plan. Lactulose is introduced to address the suspected hepatic encephalopathy by reducing ammonia levels. Diuretic therapy is adjusted, and paracentesis is considered to alleviate the ascites and improve respiratory function. The dietitian intensifies nutritional support, focusing on high-calorie, high-protein intake to counteract malnutrition. The potential need for liver transplantation is emphasized, with a referral to a transplant center to evaluate candidacy. This escalation in care aims to stabilize the patient's condition and address the acute complications, while long-term solutions are explored to prevent further deterioration.

Section 5

Two weeks later, during another follow-up appointment, the healthcare team observes a mix of progress and new challenges in the patient's condition. The introduction of lactulose has shown some positive effects, as the patient reports a slight improvement in mental clarity and a reduction in episodes of disorientation. However, he continues to experience significant fatigue and daytime somnolence. The increased diuretic therapy, combined with a successful paracentesis procedure that removed approximately 3 liters of fluid, has provided some relief from abdominal distension and improved his breathing, allowing him to lie flat more comfortably at night.

Despite these interventions, new complications arise. The patient now exhibits signs of spontaneous bacterial peritonitis (SBP), indicated by fever, abdominal pain, and a positive ascitic fluid analysis showing an elevated white blood cell count with a predominance of neutrophils. His vital signs reflect this change, with a temperature of 100.8°F, blood pressure at 90/60 mmHg, and a heart rate of 104 bpm. This development necessitates the initiation of intravenous antibiotics and close monitoring to prevent further deterioration. Laboratory tests reveal a further increase in bilirubin levels to 6.0 mg/dL and a slight worsening of his albumin at 2.3 g/dL, underscoring the ongoing hepatic dysfunction.

The emergence of SBP and the persistent hepatic dysfunction underscore the urgency for a comprehensive reassessment of the patient's management plan. The healthcare team discusses the patient's situation with the transplant center, emphasizing the need for expedited evaluation as a potential liver transplant candidate. This ensures that all avenues are explored to provide the patient with the best possible chance of recovery and long-term health. The team also considers the possibility of adjusting antiviral therapy, given the stable viral load, to optimize liver function and control of the hepatitis infection.