1. HEPATITIS B

2. Hepatitis B is a systemic, viral infection in which
necrosis and inflammation of liver cells produce
a characteristic cluster of clinical, biochemical,
and cellular changes. It is caused by a double-
stranded DNA virus called, the hepatitis B virus
(HBV).

3. Most people (more than 90%) who contract HBV
infection develop antibodies and recover
spontaneously in 6 months. The mortality rate
from hepatitis B has been reported to be as high
as 10%. Another 10% of patients who have
hepatitis B progress to a carrier state or develop
chronic hepatitis with persistent HBV infection
and hepatocellular injury and inflammation. It
remains a major worldwide cause of cirrhosis and
hepatocellular carcinoma.

4. Epidemiology
HBV infects more than 350 million people
worldwide. Studies show that in the
Philippines there is a Hepatitis B carrier rate of
9%. This means that out of 10 people at least
1 is a carrier of Hepatitis B. It is estimated that
more than 7.7 million people are chronically
infected with Hepatitis B, of whom between
1.1 and 1.9 million are expected to die
prematurely of cirrhosis or liver cancer.

5. • Transmission
• The HBV is transmitted primarily through
blood (percutaneous and permucosal routes).
HBV can be found in blood, saliva, semen, and
vaginal secretions and can be transmitted
through mucous membranes and breaks in
the skin. HBV is also transferred from carrier
mothers to their infants.

6. Risk Factors
 Frequent exposure to blood, blood products, or other body fluids
 Health care workers: hemodialysis staff, oncology and
chemotherapy nurses, personnel at risk for needlesticks, operating
room staff, respiratory therapists, surgeons, dentists
 Hemodialysis
 Male homosexual and bisexual activity IV/injection drug use
 Close contact with carrier of HBV
 Travel to or residence in area with uncertain sanitary conditions
 Multiple sexual partners
 Recent history of sexually transmitted disease
 Receipt of blood or blood products (eg, clotting factor concentrate)

7. • Pathogenesis
• Shortly after the virus enters a new host, it’s initial
response is to infect liver cells, called hepatocytes. The
virus' main target is the liver because the virus
possesses surface antigens specific for receptors found
on liver cells only. The binding of these viral antigens to
hepatocyte receptors induces viral entry by receptor-
mediated endocytosis and uncoats in the cytoplasm.
Generally, the liver is responsible for purifying blood
and processing nutrients. A healthy liver is essential to
the functioning of blood, lymph, and bile production. If
the liver fails, all other organs in the body will soon
start to fail.

8. • Clinical Features
• PATHOGNOMONIC SIGN
• Jaundice, icteric mucous membranes, dark urine and
clay-colored stools.
• Clinically, the disease closely resembles hepatitis A, but
the incubation period is much longer (1 to 6 months).
Signs and symptoms may be insidious and variable.
Fever and respiratory symptoms are rare; some
patients have arthralgias and rashes. The liver may be
tender and enlarged to 12 to 14 cm vertically. The
spleen is enlarged and palpable in a few patients; the
posterior cervical lymph nodes may also be enlarged.

9. ASSESSMENT
• table

10. OBJECTIVE SUBJECTIVE PROBLEM IDENTIFIED
• Fatigue • Fatigue
ACTIVITY/REST
• Weakness • Activity intolerance
• General Malaise
• Bradycardia (in severe • Impaired skin integrity
CIRCULATION
hyperbilirubinemia) • Disturbed body image
• Jaundiced sclera, skin, mucous
membranes
• Diarrhea • Dark urine, clay-colored stools • Imbalanced nutrition: less than
ELIMINATION
• Constipation body requirements
• Fluid volume deficit
• Loss of appetite, weight loss • Ascites • Imbalanced nutrition: less than
FOOD/FLUID
• Weight gain—edema, ascites body requirements
• Nausea, vomiting • Fluid volume excess
• Ineffective breathing pattern
• Disturbed body image
• Irritability, drowsiness, lethargy, • High risk for injury
NEUROSENSORY
asterixis
• Abdominal cramping, RUQ • Muscle guarding, restlessness • Chronic pain and discomfort
PAIN/DISCOMFORT
tenderness
• Joint pain
• Headache
• Blood transfusions or organ • Fever—usually low grade • Hyperthermia
SAFETY
transplant received prior to viral • Urticaria, maculopapular lesions, • Pain
screening tests irregular patches of erythema • Impaired skin Intergrity
• Tattoos (possible equipment • Spider angiomas, palmar • Disturbed Body Image
source) erythema, gynecomastia in men
• Itching (pruritus) (sometimes present in alcoholic
hepatitis)
• Splenomegaly, posterior cervical
node enlargement
SEXUALITY • Lifestyle or behaviors increasing
risk of exposure—unprotected
sexual intercourse with infected
person

11. DIAGNOSTIC STUDIES
• BLOOD TESTS
Hepatitis B viral panels (antibody/antigen tests)
– Detect antibodies to the various viruses.
• Alanine aminotransferase (ALT)
– Considered best liver enzyme test for detecting hepatitis.
– Elevation usually occurs before other symptoms, such as
jaundice, are noted.

12. • Alkaline phosphatase (ALP)
– Usually only slightly elevated unless severe biliary obstruction is
present.
• Complete Blood Count
– RBCs are decreased because of shortened life span of RBCs - liver
enzyme alterations or hemorrhage.
– WBCs may be abnormally low (leukopenia) or high (leukocytosis);
monocytes may be increased (monocytosis), and lymphocytes may be
increased and atypical in appearance.
• Serum Albumin
Measures the main body protein manufactured by the liver.
Level is decreased.

13. • Prothrombin time (PT)
Evaluates the body’s ability to produce a clot in a
reasonable amount of time.
May be prolonged - liver dysfunction.
• Serum Bilirubin
High level indicates the liver is incapable of
adequately removing bilirubin in a timely manner
due to blockage of bile ducts or liver disease, such as
acute hepatitis.

14. • LIVER SCAN
May be indicated for differential diagnosis, to identify underlying chronic
liver disease, or for evaluating organ function.
Helps estimate the severity of parenchymal damage.
• LIVER BIOPSY
Considered if diagnosis is uncertain or if clinical course is atypical or
unduly prolonged.
Provides initial assessment of disease severity in client
• URINALYSIS
Checks the urine for bilirubin for the nonjaundiced client.
Elevated bilirubin levels and proteinuria and hematuria may occur.
• STOOL ANALYISIS
Clay-colored stools indicate lack of normal bile excretion into the intestine.

15. MEDICAL MANAGEMENT
Pharmacology
• Alpha-interferon
-is the single modality of therapy that offers the most promise of all agents
that has been used to treat chronic hepatitis B.
-a regimen of 5 million units daily or 10 million units three times weekly for
16 to 24 weeks results in remission of disease in approximately one third
of patients.
-a prolonged course of treatment may also have additional benefits and is
currently under study.
-it must be administered by injection and has significant side effects, including
fever, chills, anorexia, nausea, myalgias, and fatigue. Delayed side effects
are more serious and may necessitate dosage reduction or
discontinuation. These include bone marrow suppression, thyroid
dysfunction, alopecia, and bacterial infections.

16. • Lamivudine (Epivir)
-an antiviral agent.
-have revealed improved seroconversion rates, loss of detectable
virus, improved liver function, and reduced progression to cirrhosis
-it can be used for patients with decompensated cirrhosis who are
awaiting liver transplantation
• Adefovir (Hepsera)
-an antival agent.
-may be effective in people who are resistant to lamivudine.
• Antacids and Antiemetics
-measures to control the dyspeptic symptoms and general malaise.

17. NURSING MANAGEMENT
 Convalescence may be prolonged, with complete symptomatic recovery
sometimes requiring 3 to 4 months or longer. During this stage, gradual
resumption of physical activity is encouraged after the jaundice has
resolved.
 The nurse identifies psychosocial issues and concerns, particularly the
effects of separation from family and friends if the patient is hospitalized
during the acute and infective stages. Even if not hospitalized, the patient
will be unable to work and must avoid sexual contact. Planning is required
to minimize social isolation. Planning that includes the family helps to
reduce their fears and anxieties about the spread of the disease.
 Bed rest may be recommended, regardless of other treatment, until the
symptoms of hepatitis have subsided. Activities are restricted until the
hepatic enlargement and levels of serum bilirubin and liver enzymes have
decreased. Gradually increased activity is then allowed. Adequate
nutrition should be maintained. Proteins are restricted if symptoms
indicate that the liver’s ability to metabolize protein byproducts is
impaired.

18. Dietary Management of Viral
Hepatitis
Recommend small, frequent meals.
Provide intake of 2000 to 3000 kcal/d during
acute illness.
Although early studies indicate that a high-
protein, highcalorie diet may be beneficial,
advise patient not to force food and to restrict
fat intake.
Carefully monitor fluid balance.

19. If anorexia and nausea and vomiting persist,
enteral feedings may be necessary.
Instruct patient to abstain from alcohol during
acute illness and for at least 6 mo after
recovery.
Advise patient to avoid substances
(medications, herbs, illicit drugs, and toxins)
that may affect liver function.

20. PROMOTING HOME AND
COMMUNITY-BASED CARE

21. Teaching Patients Self-Care
• Because of the prolonged period of convalescence, the
patient and family must be prepared for home care.
Provision for adequate rest and nutrition must be
ensured. The nurse informs family members and
friends who have had intimate contact with the patient
about the risks of contracting hepatitis B and makes
arrangements for them to receive hepatitis B vaccine
or hepatitis B immune globulin as prescribed. Those at
risk must be made aware of the early signs of hepatitis
B and of ways to reduce risk by avoiding all modes of
transmission. Patients with all forms of hepatitis should
avoid drinking alcohol and eating raw shellfish.

22. Continuing Care
• Follow-up visits by a home care nurse may be needed to
assess the patient’s progress and answer family members’
questions about disease transmission. During a home visit,
the nurse assesses the patient’s physical and psychological
status and confirms that the patient and family understand
the importance of adequate rest and nutrition. The nurse
also reinforces previous instructions. Because of the risk of
transmission through sexual intercourse, strategies to
prevent exchange of body fluids are recommended, such as
abstinence or the use of condoms. The nurse emphasizes
the importance of keeping follow-up appointments and
participating in other health promotion activities and
recommended health screenings

23. PREVENTION
• Active Immunization: Hepatitis B Vaccine
• Hepatitis B vaccine provides long-term protection against
HBV infection. Hepatitis immune globulin may be effective
for unvaccinated persons who are exposed to the infection
if given within 7 days of exposure. Hepatitis vaccination is
recommended for preexposure and postexposure
prophylaxis.
• The vaccine also is recommended for all persons who are at
high risk for exposure to the virus. The vaccines are
administered intramuscularly in three doses; the second
and third doses are given 1 and 6 months, respectively,
after the first dose. The third dose is very important in
producing prolonged immunity. Hepatitis B vaccination
should be administered to adults in the deltoid muscle.

24. GUIDE ON HEPATITIS B
IMMUNIZATION
Route Intramuscular
Site Outer portion of the left
thigh
Number of Dose 3 doses
Age at First Dose Within 24 hours after birth
Dosage 2 drops
Storage Temperature 2 to 8 °C

25. Prevention of Hepatitis
Encourage proper community and home
sanitation.
Encourage conscientious individual hygiene.
Instruct patients regarding safe practices for
preparing and dispensing food.
Support effective health supervision of
schools, dormitories, extended care
facilities, barracks, and camps.
Promote community health education programs.

26.  Facilitate mandatory reporting of viral hepatitis to local
health departments.
 Recommend vaccination for all children 1 year of age
and older.
 Recommend vaccination for travelers to developing
countries, illegal drug users (injection and noninjection.
drug users), men who have sex with men, and people
with chronic liver disease, and recipients (eg,
hemophiliacs) of pooled plasma products.
 Promote vaccination to interrupt community-wide
outbreaks.

27. EVALUATION
• PROGNOSIS
• Some people rapidly improve after acute hepatitis B. Others have a
more prolonged disease course with very slow improvement over
several months, or with periods of improvement followed by
worsening of symptoms.
• A small group of people (about 1% of infected people) suffer rapid
progression of their illness during the acute stage and develop
severe liver damage (fulminate hepatitis). This may occur over days
to weeks and may be fatal.
• Other complications of HBV include development of a chronic HBV
infection. People with chronic HBV infection are at further risk for
liver damage (cirrhosis), liver cancer, liver failure, and death.