Jaundice and hepatitis

1. JAUNDICE &
HEPATITIS
PRESENTER-
Ms. Anshu
M.Sc Nursing
KGMU Institute of Nursing

2. INTRODUCTION
The term jaundice is derived from the
French word “jaune” which
means yellow.
Jaundice is not a disease, but rather a
visible sign of an underlying disease
process.

3. Jaundice in adults can be caused by a
variety of medical conditions, some of
which are serious and potentially life-
threatening.
Any adult who develops jaundice needs
to undergo a comprehensive medical
evaluation in order to determine its
cause.

4. DEFINITION
Jaundice is a yellowish discoloration of
the skin, mucous membranes and of
the white of the eyes caused by
elevated levels of the
chemical bilirubin in the blood
(hyperbilirubinemia).

5. EPIDEMIOLOGY
Jaundice typically present as a symptom
of a disease.
About 5% of the U.S population is
thought to have jaundice due to
hereditary causes.
About 10% American population has
jaundice due to cholelithiasis.

6. ANATOMY OF LIVER
The liver is a large,
highly vascular organ
located behind the ribs in
the upper right portion
of the abdominal cavity.
Weight=1200-1500g

7. LOBES OF LIVER

8. PHYSIOLOGY OF LIVER
• Cleans the blood
• Regulates hormones
• Helps with blood clotting
• Produces bile
• Produces important enzymes
• Maintains blood sugar levels

9. Haemoglobin Metabolism
Bilirubin is a product of metabolism of
haemoglobin (80%) and other haem
containing proteins (e.g. Myoglobin,
cytochrome P450: 20%)
Degredation of haemoglobin into
bilirubin takes place in macrophages.
Bilirubin is then excreted into plasma
and binds with albumin

10. What is bilirubin?
The breakdown product of Hgb from
injured RBCs and other heme
containing proteins.
Produced by reticuloendothelial system
(macrophage system)
Released to plasma bound to albumin
Hepatocytes conjugate it and extrete
through bile channels into small intest.

11. BILE METABOLISM

12. What causes  bilirubin?
Overproduction by reticuloendothelial
system
Failure of hepatocyte uptake
Failure to conjugate or excrete
Obstruction of biliary excretion into
intestine

15. Pathophysiology

17. TYPES OF JAUNDICE
Hemolytic jaundice
Hepatocellular jaundice
Obstructive jaundice
Hereditary hyperbilirubinemia

18. HEMOLYTIC JAUNDICE
Hemolytic jaundice is the result of an
increased destruction of the RBC, the
effect of which is to flood the plasma
with bilirubin so rapidly.
But the liver is functioning normally.

19. HEPATOCELLULAR JAUNDICE
Caused by the inability of damaged liver
cells to clear normal amount of bilirubin
from the blood.
Causes-
Hepatitis
Medications or chemical toxins(carbon
tetrachloride, chloroform, phosphorus)
alcohol

20. OBSTRUCTIVE JAUNDICE
Results from extrahepatic obstruction
may be caused by occlusion of bile duct
from a gallstone, an inflammatory
process, a tumor or pressure from an
enlarge organ

22. HEREDITARY
HYPERBILIRUBINEMIA
Increased serumbilirubin levels resulting
from any of several inherited diorders,
can also produce jaundice.
Eg- Gilbert’s syndrome- increased level
of unconjugated bilirubin that causes
jaundice.

23. RISK FACTORS
Heavy alcohol consumption
Pancreatitis
Liver cirrhosis
Viral hepatitis

24. SIGNS AND SYMPTOMS
pale-colored stools,
dark-colored urine,
skin itching,
nausea and vomiting,
Yellow sclera
diarrhea,

25. fever and chills,
weakness,
weight loss,
loss of appetite,
confusion,
abdominal pain,
headache
Yellowish skin

26. Clinical Features
Painless jaundice in older person with
epigastric mass & weight loss = biliary
obstruction from malignancy
Hepatomegaly with pedal edema, JVD,
and gallop = CHF

27. COMPLICATIONS
Chronic hepatitis
Cancer
Liver failure
Kidney failure
Hepatic encephalopathy (brain
dysfunction)
Death

28. Laboratory Tests
Hitory of patient
Physical examination
Serum bilirubin level (total and direct)-
0.3-1gm/dl
Liver aminotransferase levels-
sGPT-
Alk. Phos -
U/A for bilirubin and urobilogen

29. CBC
PT
Coombs test
Hgb electrophoresis
Viral hepatitis panel
U/S Gallbladder

30. abdominal ultrasound
computerized tomography (CT)scan
magnetic resonance imaging (MRI)
cholescintigraphy (HIDA scan).

31. PREVENTION OF
JAUNDICE
Avoid high-risk behaviors such as -
unprotected intercourse
• intravenous drug use
 implement universal precautions
when working with blood products and
needles. This can decrease your risk of
developing hepatitis B or hepatitis C.

32. vaccination against hepatitis A and
hepatitis B. There is currently no
available vaccine against hepatitis C.
Avoid potentially contaminated food
products or unsanitary water, as this
may decrease your risk of developing
hepatitis A.

33. When travelling to areas where malaria
is endemic, take the recommended
precautions and prophylactic
medications in order to prevent the
development of malaria.
Avoid alcohol and smoking, as it is a
risk factor for the development of
pancreatic cancer, as well as many
other malignancies.

34. MANAGEMENT
GOAL-
To relief symptoms
To prevent complications

35. 1. Pain management-
give analgesics
2. Antibiotics
3. IV fluids – to prevent dehydration
4. Blood Transfusion- in case of
anaemia and haemolysis
5. Anti-viral therapy

36. Neonatal Jaundice
1. Physiological jaundice
2. Pathological jaundice

37. NURSING MANAGEMENT
ASSESSMENT-
Assess for general condition of patient.
Assess for pain
Assess for any other complication

38. NURSING DIAGNOSIS
Acute pain related to disease condition
Imbalanced Nutrition Less Than Body
Requirements related to nausea and
vomiting
Impaired skin integrity related to
pruritis

39. HEALTH EDUCATION AND
DISCHARGE TEACHING
Encourage for healthy diet.
Advice for consumption of clean food
and water.
Hand hygiene
Safe intercourse
Adhere to medication

41. HEPATITIS
DEFINITION-
Hepatitis refers to an inflammatory
condition of the liver

42. Etiology
Can have many causes
 Drugs (Bromfenac,Troglitazone,Pemoline
etc)
 toxins
 alcohol
 viral infections (A, B, C, D, E)
 other infections (parasites, bacteria)
 physical damage

43. PATHOPHYSIOLOGY
Due to etiology
Exposure to hepatitis virus
Infection and inflammation
of liver
Hepatocyte damage
Necrosis of the parts of liver,
alteration of liver function

44. Hepatitis Terms
Acute Hepatitis: Short-term
hepatitis.
 Body’s immune system clears the virus
from the body within 6 months
Chronic Hepatitis: Long-term
hepatitis.
 Infection lasts longer than 6 months
because the body’s immune system cannot
clear the virus from the body

45. Types
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E

46. Hepatitis A
What is it?
 Infection of the liver caused by
Hepatitis A virus
Incubation period
 30 days on average (range 15-50
days)

47. Geographic Distribution of HAV
Infection
HAV Prevalence
High
Intermediate
Low
very Low

48. Hepatitis A
TRANSMITION -
by consuming food or water
contaminated by feces from a
person infected with hepatitis A.

49. Hepatitis A
Prevention
 Shot of immunoglobulin up to 2 weeks
after exposure
 Good hand washing
 Cook food well
 Good diaper hygiene
 Only drink clean water
 VACCINation-
Children after 12 months
Adults 18 yrs or old (combo of hep A and
hep B, given in 3 shots-0,1,6 months)

50. Hepatitis B
What is it?
 Hep B is a serious disease caused by a
Hep B virus that infects the liver
 Can cause lifelong infection, cirrhosis
(liver scarring), liver cancer, liver
failure and death

51. Geographic Distribution of Chronic HBV
Infection
HBsAg Prevalence
8% - High
2-7% - Intermediate
<2% - Low

52. Hepatitis B
Incubation period
 1-6 months
 chronic carriers remain infectious

53. MODE OF TRANSMITION
Transmitted through puncture wounds
or contact with infectious body fluids,
such as blood, saliva, or semen.
Injection drug use
having sex with an infected partner
sharing razors of infected person

54. 10%
90%
Chronically infected
Clear the infection
HEPATITIS B

55. Hepatitis B
VACINATION-
 All babies- at birth, 1month (4weeks),
6month (24weeks)

56. Hepatitis C
What is it?
 Hep C is a liver infection caused by a
virus
 Also known as non A, non B hepatitis

57. Hepatitis C
Incubation period
 15-160 days
 chronic carriers remain infectious

58. Hepatitis C
 Shared injection equipment
 Blood transfusion
 Blood transfer ( tattoo, piercing)
 Sex
 Mother to child (<5%)
• How it is transmitted ?

59. 85%
15%
Chronically infected
Clear the infection
HEPATITIS C

60. Hepatitis C
PREVENTION-
 Do not share injection equipment(it’s a
universal precaution).
 Do not donate blood or plasma, organs or
sperm
 Do not share toothbrushes, razors
 Cover areas of open skin
 Use of safer sex techniques

61. Hepatitis D
This is also called delta hepatitis.
Hepatitis D is a serious liver disease
caused by the hepatitis D virus (HDV).

62. MODE OF TRANSMITION
Transmitted through puncture wounds
or contact with infected blood.
Hepatitis D is a rare form of hepatitis
that occurs in conjunction with hepatitis
B infection

63. Hepatitis E
Hepatitis E is a waterborne disease
caused by the hepatitis E virus (HEV).
Hepatitis E is mainly found in areas with
poor sanitation and is typically caused
by ingesting contaminated food and
water.

64. COMMON SIGNS AND
SYMPTOMS
fatigue
flu-like symptoms
dark urine
pale stool
abdominal pain
loss of appetite
unexplained weight loss
yellow skin and eyes, which may be
signs of jaundice

65. Signs and Symptoms of
Hepatitis
There are three phases of Hepatitis –
Preicteric
Icteric
Posticteric.

66. Preicteric phase
nausea / vomiting
decreased appetite / weight loss
Fever
Fatigue
headache and joint pain
rt upper quadrant abdominal pain
enlarged spleen/liver/lymph nodes
rash and itching of the skin (urticaria).

67. Icteric phase
These symptoms include the symptoms
of preicteric phase
jaundice (yellowing of the skin)
pruritus (intense / persistent itch)
clay or light-colored stools and dark
urine

68. Posticteric phase
which involves the cessation of the
above noted symptoms
liver enlargement
continued fatigue

69. Complications of Hepatitis
chronic liver disease
cirrhosis (scarring of the liver)
cancer of the liver

70. DIAGNOSTICS TEST
Complete history of patient
Physical examination
Serum bilirubin
Liver function test
Ultrasound
Liver biopsy
Viral Antibody Testing

71. MANAGEMENT
GOAL-
To minimize infectivity and liver
inflammation
To treat symptomatic causes
To prevent complication

72. HEPATITIS A
Hepatitis A isn’t usually treated.
Bed rest may be recommended if
symptoms cause a great deal of
discomfort.
For vomiting or diarrhoea give high
fluid and caloric diet to prevent
malnutrition or dehydration.

73. HEPATITIS B
Acute hepatitis B doesn’t require specific
treatment. Chronic hepatitis B is treated
with antiviral medications.
ANTIVIRAL THERAPY-
Lamivudine
adefovir

74. Hepatitis C
Antiviral medications are used to treat
both acute and chronic forms of
hepatitis C
Treatment
 Interferon A and Ribavirin (suggest 40%
“cure” rate)

75. Hepatitis D
Hepatitis D is treated with a medication
called alpha interferon.

76. Hepatitis E
There are currently no specific medical
therapies to treat hepatitis E
It typically resolves on its own. People
with this type of infection are often
advised to get adequate rest, drink
plenty of fluids, get enough nutrients,
and avoid alcohol.

77. NURSING MANAGEMENT
ASSESSMENT-
Assess for pain
Assess for nausea, vomiting and
diarrhoea
Check and record for weight

78. Nursing Diagnosis:
1. Acute Pain related to swelling of
the liver
2. Breathing Pattern related to intra-
abdominal fluid collections ascites
decreased lung expansion and
accumulation of secretions
3. Imbalanced Nutrition Less Than
Body Requirements related to
nausea and vomiting

79. NURSING INTERVENTION
1. Acute pain related to swelling of
the liver
Monitor and record vital signs.
assess the severity,frequency, and
characteristic of pain.
Provide divertional activities such as
reading newspapers.
administer medication as ordered.

80. 2.Imbalanced Nutrition Less Than
Body Requirements related to
nausea and vomiting
Monitor the inclusion of diet / calories.
Give a little meal in the frequency often.
Provide oral care before meals.
Encourage intake of orange juice,
beverage and candy carbonate heavy
throughout the day.
Keep an eye on blood glucose.

81. 3.Impaired skin integrity related to
pruritis
Assess for pruritis.
Nails of the patient should be cut short
to prevent skin injury.
Apply emollient, don’t leave the skin
dry.
Apply antibiotic ointment if any injury is
present

82. HEALTH EDUCATION AND
DISCHARGE TEACHING
 Get regular medical care
 Get needed rest
 No alcohol, no over the counter drug use
 Avoid chemical fumes and other
environmental toxins
 Get vaccinated.

84. CONCLUSION
HEPATITIS A B C D E
Mode of
transmission
Faeco -
oral
Body fluid Body fluid Body fluid Faeco - oral
Immunization available available Not
available
Not
available
Not
available
Severity More sever

85. CONCLUTION
Liver is chemical factory of human
body.
Hepatitis is a viral infection which
causes inflammation of liver.
Its timely management is important to
prevent complications.

86. EVALUATION

87. Questions
1) Unconjugated hyperbilirubinemia usually
results from a intra- or extrahepatic biliary
obstruction.
 A. True
 B. False
Ans- (b)

88. 2) All patients with jaundice should be
admitted to the hospital for further workup.
 A. True
 B. False
Ans- (b)

89. 3) A marker of acute hepatocyte injury
&/or hepatocyte death is:
 A. PT
 B. ALT
 C. Albumin
 D. Direct bilirubin
 E. Ammonia
Ans- (b)

90. 4) In which of the following phase clay
coloured stool is present?
A) pre-icterus phase
B) icterus phase
C) post-icterus phase
D) all phase
Ans- b)