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HEPATIT IS
Update your
knowledge
of this silent
stalker
BY SUE PARINI, RN, CIC, BS, MA

www.nursingcenter.com

EACH TIME YOU TAKE precautions to

protect yourself against human immunodeficiency virus (HIV), remember this:
Youre much more likely to get hepatitis C
virus (HCV) from an accidental needle
stick. The most common chronic bloodborne disease in the United States, HCV is
also the leading reason for liver transplantation. Because its so prevalent, youve
probably cared for patients carrying the
virus, whether you know it or not.
In the United States, HCV is responsible
for about 30% of cases of acute viral
hepatitis, 60% to 70% of chronic hepatitis,
and 10% to 20% of cirrhosis, end-stage
liver disease, and liver cancer. An estimated 10,000 Americans die each year of HCV
and its complications, and that number is
expected to triple in the next 3 decades as

Nursing2003, April

57

the infection progresses in people

whove been asymptomatic.
Make sure youre prepared for
the challenge. In this article, Ill
describe whos at risk, how to manage the infection, and what you
can do to protect yourself from
occupational hazards. But first, lets
review the basics about this insidious pathogen.
Amorphous adversary

A single-stranded RNA virus, HCV

is a member of the Flaviviridae
family, which also includes West
Nile virus. It has a unique, hypervariable region that enables it to
mutate rapidly and evade the bodys
attempts to develop an effective
antibody response. To complicate
matters further, HCV has six genotypes and more than 50 subtypes.
Genotype 1, the least responsive to
therapy, is the most common strain
in the United States.
Because of HCVs ability to outsmart the human immune system,
no vaccine is presently available

and existing treatments dont

always produce long-term
improvement.
Whos vulnerable to HCV?

Risk factors for HCV infection

include the following:
history of illicit intravenous (I.V.)
drug use. An I.V. drug users chances
of contracting HCV increase with
years of drug abuse: 78% are infected after 1 year, 83% after 5 years,
and 94% after 10 years of drug
abuse. The virus can also be transmitted by sharing contaminated
straws used for snorting cocaine.
occupational exposure to blood by
needle-stick injury. An estimated
2,000 health care workers are
infected annually with HCV from
needle-stick or sharps injuries.
After such an injury, the incidence
of seroconversion (antibody
development) is 5% to 10%.
Seroconversion is influenced by
viral load (the amount of virus present) and the infectiousness of the
HCV strain.

perinatal exposure. A child born

to a woman whos HCV-positive
has a 5% to 6% chance of acquiring
the virus through the maternalfetal blood supply. Breast-feeding
isnt known to be a risk factor, but
a woman with HCV shouldnt
breast-feed if her nipples are
cracked or bleeding.
blood transfusion or organ transplant. Transmission of HCV has
been associated with transfusion of
clotting factor concentrates before
1985, blood transfusion or solid
organ transplant before 1992, and
transfusion or transplant from a
donor infected with HCV. These
methods of virus transmission have
become rare since the advent of
routine blood screening in 1992 and
virus inactivation procedures for
clotting factors initiated in 1985.
exposure to contaminated equipment. Inadequate cleaning and
decontamination of equipment
that penetrates the skin can transmit the infection. This is a risk for
anyone on hemodialysis and for

How HCV infection progresses

Early
Most people in the initial
stage of infection are
asymptomatic, but others
have flulike symptoms
(fatigue, joint and muscular pain, nausea and vomiting) 6 to 8 weeks after
the initial infection. About
10% of patients develop
jaundice. Fulminant infections are rare. If symptoms do occur, they usually subside in 3 to 8
weeks as alanine aminotransferase levels drop.

58

Chronic
About 80% of patients
develop chronic infection
after the acute stage
resolves, and most of
these patients are asymptomatic. When symptoms
occur, theyre usually mild
and intermittent and may
include fatigue, abdominal pain, and loss of
appetite.

Nursing2003, Volume 33, Number 4

Cirrhosis
Liver damage from HCV
develops over years, so
the younger a person is
when infected, the higher
the likelihood that hell
eventually develop cirrhosis. From 20% to 40% of
people infected with HCV
will develop cirrhosis
within 25 years. If cirrhosis develops, additional
signs and symptoms may
include muscle weakness,
nausea, weight loss, itching, dark urine, fluid
retention, and ascites.

Liver failure
About 20% of patients
who develop cirrhosis will
go into liver failure or
develop liver cancer.
Alcohol consumption,
male gender, and stores
of excess iron in the liver
are factors that accelerate
progression to cirrhosis.

www.nursingcenter.com

those exposed to tattooing, body

piercing, and nail manicuring
equipment that isnt adequately
cleaned.
sexual contact with an infected person. The risk of transmission from
this route appears to be low unless
the infected partner has a high viral
load, has acute HCV, or is menstruating. Having sexual contact with
multiple partners without barrier
protection increases the risk of
transmission.
To test or not to test

Testing for HCV is indicated for

anyone with unexplained elevated
liver enzymes; with unexplained
symptoms of liver disease, such as
jaundice; or with risk factors for
HCV infection.
Numerous assays are used to
identify HCV infection, measure the
patients viral load, and gauge his
response to treatment. (See Testing
for HCV.) All patients with HIV
should be tested for HCV using an
HCV RNA assay instead of antigen
testing. If testing reveals that a
patient has HCV, he may undergo a
liver biopsy to grade disease severity. He may be very anxious during
the diagnostic period, so answer his
questions honestly and completely
and try to allay his fears.
How disease progresses

In about 15% of patients, HCV

infection spontaneously resolves.
For most people infected, however,
the disease becomes chronic, progressing over years. The rate of
progression varies widely among
individuals. Theoretically, its possible for a person with HCV to live
with the infection and never develop serious symptoms. In reality,
this isnt likely. (See How HCV
Infection Progresses.)
In 80% of HCV-infected patients,
the disease becomes chronic and
progresses. Patients may develop
conditions such as Sjgrens synwww.nursingcenter.com

Testing for HCV

Your patient may undergo many of the following tests during diagnosis and
treatment for HCV infection.
A third-generation enzyme immunoassay (EIA-3) and a recombinant
immunoblot assay (RIBA) are basic tests used to determine the presence of
HCV antibodies. The EIA-3 test is standard, but it may not detect antibodies
during the early stage of infection, when antibody levels are low. This test
may have false-positive results. The RIBA test is usually done to confirm the
presence of HCV antibodies after a positive EIA-3. Neither test indicates
whether the patient has acute or chronic infection or if the infection has
resolved.
A qualitative HCV RNA polymerase chain reaction (PCR) test is administered
before the patient begins antiviral therapy to measure the viral load in his
blood. A positive result indicates active infection. This test can be used if the
results of the EIA-3 are inconclusive.
Target amplification PCR testing can be used to assess his response to
antiviral therapy.
Branched-chain DNA assays can help clarify an inconclusive RIBA, weakly
positive EIA-3, or negative EIA-3 if HCV infection is suspected. This test, like
the HCV RNA test, isnt standardized, so results can vary among labs and
should be interpreted in the context of the patients clinical picture.
Hepatitis C genotyping can help determine the viruss genetic nature, which
sheds light on the likelihood of treatment success, duration of therapy, and
prognosis.
A transcription-mediated amplification assay can detect the virus at very
low levels (5 to 10 international units/ml), but the test hasnt yet received
Food and Drug Administration approval.
Aminotransferase levels are elevated in up to 80% of patients with HCV and
fluctuate in about half these patients. Alanine aminotransferase and aspartate
aminotransferase increase up to 20 times the normal value in patients with
chronic HCV.
Other blood assays can provide clues to liver damage. Alkaline phosphatase and gamma-glutamyl transpeptidase levels are usually normal but
may be elevated if the patient has cirrhosis. A positive rheumatoid factor in
combination with low white blood cell and platelet counts also point to cirrhosis. Albumin levels and prothrombin time are normal until liver damage
occurs. Iron and ferritin levels may be slightly elevated when the patient has
cirrhosis.

drome (dryness of mucous membranes) and heart and circulatory

problems. B-cell lymphoma and
Type 2 diabetes have been linked
to HCV infection.
Patients with chronic HCV
infection may develop extrahepatic
manifestations or syndromes, such
as essential mixed cryoglobulinemia, glomerulonephritis (renal disease), and porphyria cutanea tarda
(skin sensitivity to sunlight).

Embarking on treatment

According to the National Institutes

of Health (NIH), anyone with HCV
who meets all of these criteria
should receive treatment:
ages 18 to 60
elevated alanine aminotransferase
(ALT) levels for more than 6
months
detectable levels of HCV RNA in
blood
mild to moderate liver damage
Nursing2003, April

59

revealed on biopsy.
Treatment benefits havent been
established for patients older than
60 because they have a high
adverse-effect profile. Although
antiviral drugs arent routinely recommended for children younger
than 18, research is continuing.
A patient diagnosed with cirrhosis through liver biopsy can
also be treated if he doesnt have
signs of liver decompensation,
such as ascites, jaundice, wasting,
variceal hemorrhage, or hepatic

encephalopathy.
The goal of treatment is to
decrease the viral load and reduce
liver damage, as indicated by normal ALT levels or improved liver
biopsy results. If treatment is
appropriate for your patient, follow
the NIHs 24- or 48-week course of
a standard or pegylated interferon
and ribavirin. Monotherapy with
standard or pegylated interferon is
an alternative if ribavirin is contraindicated.
Interferons are proteins with a

Caring for your patient during combination therapy

Before beginning therapy, the patient will undergo testing to determine the
severity of disease, based on the presence of antibodies, viral load, genotype,
serum aminotransferase levels, and liver biopsy results. Instruct the patient to
practice birth control during therapy and for 6 months after therapy ends.
(The duration of therapy varies according to genotype for patients on combination therapy. Patients on monotherapy undergo therapy for 48 weeks,
regardless of genotype.)
Initial therapy
The patient receives S.C. peginterferon injections and oral ribavirin.
At 1, 2, and 4 weeks
Assess the patient for adverse reactions to therapy and for disease symptoms.
Obtain a complete blood count and serum aminotransferase levels.
If the patients hemoglobin is less than 10 grams/dl or hematocrit is 30% or
lower, the ribavirin dose should be reduced in 200-mg increments.
If the patients hemoglobin is less than 8.5 grams/dl or hematocrit is less
than 26%, ribavirin therapy should be discontinued.
At 8, 12, and 16 weeks
Repeat assessment and testing as needed. Check thyroid-stimulating hormone levels every 3 to 6 months during therapy.
At 24 weeks
Assess serum aminotransferase levels and viral load. This marks the end of
therapy for patients with genotypes 2 and 3 and for patients with genotype 1
if the viral load is still positive. (Research shows that additional therapy for
genotype 1 doesnt seem to help.)
If the viral load is negative in patients with genotype 1, continue therapy for
another 24 weeks, then retest viral load.
After therapy ends
Check serum aminotransferase levels for 2 to 6 months. At 6 months posttherapy, check viral load.

60

Nursing2003, Volume 33, Number 4

molecular structure similar to that

of the proteins the body produces
for natural defense. Pegylated
interferons (peginterferon alfa-2a
[Pegasys] and peginterferon alfa-2b
[PEG-Intron]) have largely replaced standard interferons (alfa-2a
and alfa-2b) for treating HCV. Both
types work similarly in the body
and provide a constant level of
interferon in the blood, inhibiting
the virus through an even suppression. (For more information, see
Caring for Your Patient during
Combination Therapy.)
In a recent study, researchers
found that more patients who
received peginterferon alfa-2a plus
ribavirin had a sustained virologic
response (clearance of the virus)
compared with patients who
received interferon alfa-2b plus
ribavirin or peginterferon alfa-2a
alone. Research is continuing.
Possible adverse reactions to all
interferons include irritability, anxiety, personality changes, severe
depression, acute psychosis, and
suicide. If your patient has a history of serious psychiatric or neurologic conditions, he must be carefully evaluated before starting therapy and monitored closely throughout treatment.
Interferons are contraindicated
in anyone with severe depression
or serious psychiatric or neurologic
conditions, active substance abuse,
poorly controlled autoimmune disease, and conditions that suppress
bone marrow.
The mechanism of action of ribavirin is not clear. Its contraindicated in patients with preexisting
anemia (hemoglobin of 11 grams/
dl or less or hematocrit of 33% or
less), renal dysfunction, coronary
artery disease, or cerebrovascular
disease.
Any patient using interferons or
ribavirin must practice birth conwww.nursingcenter.com

trol during therapy because these

drugs can cause birth defects.
Treating a patient
whos also HIV-positive

At least one-third of patients infected with HIV are also infected with
HCV. Patients with both infections
who have CD4 counts below 500
cells/mm3 have a more rapidly
advancing rate of hepatic fibrosis
than those with normal CD4
counts. HIV-positive patients with
low CD4 counts may never know
they have HCV unless they have an
HCV RNA assay. Most experts
agree that clinicians should stabilize CD4 counts before attempting
to treat the HCV infection.
Similar to HIV, HCV has a singlestrand makeup that requires protease to produce infective virions
(virus particles). Because of this
shared need for protease, researchers are trying to develop protease
inhibitors that can combat HCV in
the same way they fight HIV.
Monitoring for reactions

Explain to your patient that treatment will last from 6 to 12 months.

During this time, hell receive medication in oral and injection forms
(combination therapy) or injection
form only (monotherapy). Instruct
him to notify his health care
provider of any adverse reactions
he experiences.
Common adverse reactions to
interferons include fatigue, muscle
aches, headaches, nausea, vomiting,
weight loss, skin irritation at the
injection site, low-grade fever, irritability, depression, mild bone marrow suppression, and reversible hair
loss. These reactions usually are
mild to moderate and occur during
the first few weeks of therapy.
Because nonsteroidal antiinflammatory drugs and acetaminophen can cause liver toxicity in
www.nursingcenter.com

patients with hepatitis, low-dose

acetaminophen to relieve flulike
symptoms is preferred. Antidepressants may be indicated for
depression.
The most common adverse reaction to ribavirin is anemia. Most
patients experience a 2.5-to-3.0gram/dl decrease in hemoglobin
and a 5%-to-10% decrease in
hematocrit. Usually, the decrease
occurs within the first month of
therapy. Teach patients to watch for
symptoms of anemia while theyre
on ribavirin therapy: fatigue, shortness of breath, palpitations, and
headaches. Other potential adverse
effects include itching, skin rash,
nasal congestion, sinusitis, and
bronchitis.
The HCV genotype and the
patients viral load influence the
success of treatment. The longterm sustained response to combination therapy is 30% for genotype
1, compared with 60% to 70% for
the other genotypes. Also, patients
with a viral load of less than 1 million copies/ml respond to therapy
better than those with higher viral
loads.
Other treatment options

The transjugular intrahepatic portosystemic shunt (TIPS) is a nonsurgical procedure used to treat
patients with portal hypertension.
Once used only for patients awaiting liver transplantation, TIPS is
now also used to treat patients
with HCV infection who have massive ascites and who havent
responded to diuretics or other
conservative measures and to treat
patients with variceal bleeding
thats refractory to medical or
endoscopic treatment. By relieving
portal pressure, TIPS decreases
ascites and esophageal varices.
The procedure entails percutaneously creating a tract between

the hepatic and portal vein, using a

transjugular approach. The clinician uses a balloon to dilate the
parenchymal tract and inserts a
stent to keep the tract open. The
blood shunts around the portal
system, decreasing portal hypertension.
Complications of TIPS include
hepatic artery laceration, sepsis,
hepatic encephalopathy, and systemic fluid overload.
Transplantation is reserved for
end-stage treatment of HCV and
liver failure.
Reducing your occupational risk

Youre 20 to 40 times more likely

to acquire HCV than HIV from an
accidental needle stick. Until
researchers discover a cure or a
vaccine, you need to rely on vigilant occupational controls to protect yourself from infection.
Reduce your risk with the following measures:
Know how to use the safetyengineered devices in your organization and use them consistently.
Dont use a device thats not safetyengineered if a safety-engineered
alternative is available.
Make sure youre properly educated and prepared to use available
safety devices.
Fully explain procedures to your
patient, including your expectation that he wont move while
receiving an injection, despite
possible discomfort.
If your patient cant understand
or follow directions, take appropriate action before continuing. For
example, if he cant understand
what youre saying, get someone to
interpret or find another way to
communicate, such as using a picture board.
Avoid recapping nonsafety
devices or any other device. If you
must recap a needle, use the oneNursing2003, April

61

handed technique.
Think before you do: Plan handling and disposal of all sharps
before using them.
Dispose of sharps promptly in
sharps disposal containers.
Always use an alcohol-based
hand rub or wash your hands after
removing gloves.
Dont eat, drink, handle contact
lenses, or engage in any similar
activity in any setting where blood
or body fluids could be present.
If you sustain an accidental needle stick or come in contact with

your patients blood in any other

way, take steps to reduce your risk
of infection (see What to Do after
Youve Been Exposed to Body Fluid).
Living with HCV

As a nurse, you play a significant

role in teaching your patient, advocating for him, and helping him
live with HCV. Educating him on
proper nutrition and nutritional
restrictions is an important part of
providing care. Offer the following
guidelines:
Stop high-risk behaviors, such as

What to do after youve been exposed to body fluid

If youve been exposed to a patients blood or other body fluid, you can
reduce your risk of infection by
1. cleaning the exposure site. Wash the wound with soap and water.
If your eyes or any other mucous membranes were exposed, flush them
with water.
2. immediately reporting the exposure to the department specified
by your institutions policy. Youll proceed through the following steps:
Determine your risk of infection. Youll need to provide information on the
type of fluid you were exposed to. Was it blood, bloody fluid, or another
potentially infectious fluid or tissue? Youll also need to describe how you
were exposed. For example, was it through a percutaneous injury, fluid contact with a mucous membrane or nonintact skin, or a bite?
Evaluate the exposure source. Your risk of infection will be assessed by
testing the patient or blood source for hepatitis B virus (HBV) surface antigen,
anti-HCV, and HIV. In some states, consent is required for HIV testing. Your
risk of exposure to HBV, HCV, and HIV will be assessed.
Assess your immune status for HBV infection. Your HBV vaccination status
will be assessed. If you havent received the HBV vaccine series, immunoglobulin can be administered. If youve received the HBV vaccine series, your
immune status will be verified.
Evaluate your need for postexposure prophylaxis . Your need for postexposure prophylaxis will be assessed. For information on specific prophylaxis
guidelines, see Updated U.S. Public Health Service Guidelines for the
Management of Occupational Exposures to HBV, HCV, and HIV and
Recommendations for Postexposure Prophylaxis, Morbidity and Mortality
Weekly Report, U.S. Department of Health and Human Services, June 29,
2001 (available at http://www.cdc.gov/mmwr/preview/mmwrhtml/
rr5011a1.htm).
Evaluate sharps exposure. Youll be asked whether you were using a safetyengineered device and at what point the exposure occurred: before, during,
or after activation. Youll also be asked how a similar exposure could be prevented.
3. receiving follow-up testing and counseling whether or not you
receive postexposure prophylaxis. Let the appropriate person know if
youve had any acute illnesses since the exposure.

62

Nursing2003, Volume 33, Number 4

using illicit drugs, having unprotected sex, and drinking alcohol.

Drinking alcohol dramatically
increases the risk of liver cancer in
someone with HCV.
Stop smoking. Research shows
that smoking can cause elevated
ALT levels.
Restrict protein intake. Because
liver damage decreases the ability
to handle protein, a patient with
liver disease must restrict his protein intake to 0.8 grams/kg of body
weight per day. If he has decompensated cirrhosis, he must restrict
protein to 10% to 15% of his diet
each day, and the protein must
come from vegetable sources only.
Because many patients experience
nausea late in the day, advise your
patient to eat his highest-calorie
meal in the morning to ensure adequate nutrition.
Watch vitamin and supplement
intake. Your patient should take
only those vitamins and supplements prescribed by his health care
provider.
Decrease dietary salt and fat. Most
patients with HCV infection
should follow a no-salt or low-salt
(2,200 mg/day) diet. Explain to
your patient that excess salt can
make ascites (abdominal fluid
retention) worse. Further, most
patients should also restrict fat to
25% of daily calories.
Reassure your patient that HCV
isnt transmitted by casual contact,
but that he must take certain precautions to protect himself and
others. Give him these guidelines:
Dont donate blood, tissues, or
semen.
Dont share razors, nail-grooming
items, toothbrushes, or other items
that could be contaminated with
blood.
Keep open wounds and sores
covered.
Follow hand hygiene recommendations.
Use barrier protection during
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sexual intercourse and avoid multiple partners and high-risk sexual

behaviors.
Dont use illicit drugs and dont
share drug paraphernalia.
Also warn him not to take any
medication, including over-thecounter and herbal preparations,
without consulting his health care
provider and to get vaccinated
against hepatitis A and B if he hasnt
received the vaccinations or had
the diseases.
Maintaining quality of life

Several assessment tools are available to measure your patients quality of life, such as the Hepatitis
Quality of Life Questionnaire and
the 36-item Short-Form Health
Survey. By gauging his quality of
life, you can suggest appropriate
interventions and resources for
improvement.
Provide your patient with HCV
information about community and
on-line support groups. A good

starting point is the American

Liver Foundation (http://www.
liverfoundation.org). Learning
about the latest findings on his disease can increase his sense of control.
Finally, remind him to visit his
health care provider every 6 to 12
months for assessment, even if he
feels well.
Armed with the latest nursing
interventions, you can guide your
patient through the maze of diagnosis, treatment, and day-to-day
management of chronic HCV
infection.
SELECTED REFERENCES
Centers for Disease Control and Prevention:
National Hepatitis C Prevention Strategy: A
Comprehensive Strategy for the Prevention and
Control of Hepatitis C Virus Infection and its
Consequences, Summer 2001, http://www.
cdc.gov/ncidod/diseases/hepatitis/c/plan/
index.htm.
Fleming, J.: Cur rent Treatments for Hepatitis,
Journal of Infusion Nursing. 25(6):379-382,
November/December 2002.
Fried, M., et al.: Peginterferon Alfa-2a Plus
Ribavirin for Chronic Hepatitis C Virus Infection, The New England Journal of Medicine.
347(13):975-982, September 2002.

Iosue, K.: Chronic Hepatitis C: Latest Treatment Options, The Nurse Practitioner.
27(4):32-40, April 2002.
Kuehne, F., et al.: Treatment for Hepatitis C
Virus in Human Immunodeficiency VirusInfected Patients: Clinical Benefits and Costeffectiveness, Archives of Internal Medicine .
162(22):2545-2556, December 2002.
National Institutes of Health: Consensus Development Conference StatementManagement
of Hepatitis C: 2002, http://www.consensus.nih.
gov/cons/116/091202116cdc_statement.htm.
Tossing, G.: Treating Hepatitis C in HIV-HCV
Coinfected Patients, Infection. 30(5):329,
October 2002.
This article, which was updated and revised by
the author, originally appeared in the March
issue of Nursing2001.
Sue Parini is infection control manager at Paradise
Valley Hospital in National City, Calif.

S E L EC T E D W E B S I T E S
Hepatitis C Support Project
http://www.hcvadvocate.org/
HIVandHepatitis.com
http://www.hivandhepatitis.com/
National Center for Infectious Diseases
http://www.cdc.gov/ncidod/diseases/
hepatitis/c
The Hepatitis Information Network
http://www.hepnet.com/hepc/
Last accessed on March 5, 2003.

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63

C
E

Hepatitis C: Update your knowledge of this silent stalker

PURPOSE To provide an update on HCV and strategies for the care of patients with this disease.
OBJECTIVES After reading the preceding article and taking this test, you should be able to: 1. Outline HCV risk factors and implications for health care.
2. List HCV diagnostic studies and stages of disease progression. 3. Identify management strategies for patients with HCV.

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1. Which is correct about HCV?

a. Youre more likely to get HIV from an accidental needle stick than HCV.
b. HCV is the second most common chronic
bloodborne disease in the United States.
c. HCV is the leading cause for liver transplants.
d. Youll probably never care for a patient with
HCV because its rare.
2. In the United States, HCV is responsible for
a. 10,000 annual deaths.
b. 60% of acute viral hepatitis cases.
c. 70% of cirrhosis cases.
d. 20% of chronic hepatitis cases.
3. Which is correct about HCV?
a. Its a double-stranded DNA virus.
b. It mutates rapidly and can outsmart the
human immune system.
c. Genotype 6, the least responsive to therapy,
is the most common strain in the United
States.
d. A vaccine for HCV became available in1992.
4. Which of the following is a known risk
factor for HCV infection?
a. sharing contaminated straws to snort cocaine
b. breast-feeding
c. receiving transfusions of clotting factor concentrates between 1985 and 1992
d. receiving a solid organ transplant after 2000
5. Which is correct about HCV testing?
a. Test anyone with unexplained elevated platelet
counts.
b. Perform antigen testing, instead of an HCV
RNA assay, in patients with HIV.
c. Test patients with unexplained jaundice.
d. If testing reveals HCV, TIPS can grade disease
severity.

6. Which best describes HCV progression?

a. HCV infection typically resolves spontaneously.
b. The disease becomes chronic in about 15% of
patients.
c. Most people with HCV never develop serious
symptoms.
d. The disease becomes chronic and progresses
in 80% of HCV-infected patients.

7. A patient with HCV should get treatment if

he meets criteria from the NIH, which include
a. ages 5 to 17.
b. elevated ALT levels for more than 12 months.
c. detectable blood levels of alkaline phosphatase.
d. mild to moderate liver damage revealed on
biopsy.
8. Which is correct about HCV treatment?
a. Treatment benefits havent been established
for patients older than age 50.
b. Treatment is indicated for patients with cirrhosis and signs of liver decompensation.
c. The goal of treatment is to decrease viral load
and reduce liver damage.
d. Antiviral drugs are routinely recommended for
children younger than age 18.
9. Which is correct about pegylated interferons?
a. The NIH recommends a 12-week course of a
standard or pegylated interferon and ribavirin.
b. Both peginterferon alfa-2a and peginterferon
alfa-2b provide a constant level of interferon in
the blood.
c. Researchers found that more patients who
received peginterferon alfa-2a had a sustained
virologic response than patients who received
ribavirin alone.
d. Standard interferons have largely replaced
pegylated interferons.
10. Ribavirin is contraindicated in patients
a. with preexisting anemia.
b. with poorly controlled autoimmune disease.
c. with active substance abuse.
d. with severe depression.
11. Which is correct about HIV/HCV
coinfection?
a. At least one-half of patients infected with HIV
are also infected with HCV.
b. Patients with CD4 counts above 500 cells/mm3
have a more rapidly advancing rate of hepatic
fibrosis than those with normal CD4 counts.
c. Clinicians should treat HCV infection before
stabilizing CD4 counts.
d. Researchers are developing protease inhibitors
that combat HCV the same way they fight HIV.

12. A common adverse reaction to interferons is

a. nasal congestion.
c. reversible hair loss.
b. sinusitis.
d. bronchitis.
13. Which is correct about TIPS?
a. Its a surgical procedure performed on patients
with systemic hypertension.
b. Its used only as a bridge to liver transplant.
c. It decreases ascites by relieving portal pressure.
d. It creates a tract between the hepatic artery
and the portal vein.
14. Nutritional guidelines for HCV-infected
patients include
a. increasing protein intake.
b. abstaining from drinking alcohol.
c. eating the highest-calorie meal in the evening.
d. restricting fat to 40% of daily calories.
15. To measure viral load, before beginning
antiviral therapy, perform a
a. RIBA test.
b. branched-chain DNA assay.
c. qualitative HCV RNA PCR test.
d. target amplification PCR test.
16. A blood assay in an HCV-infected patient
who has liver damage may show
a. decreased ferritin levels.
b. elevated alkaline phosphatase.
c. decreased gamma-glutamyl transpeptidase levels.
d. decreased iron levels.
17. About 10% of HCV-infected patients
develop jaundice
a. in the early stage.
b. in the chronic stage.
c. when they have cirrhosis.
d. when they have liver failure.
18. Which step can reduce your risk of infection after HCV exposure?
a. receiving immunoglobulin if youve completed
the HBV vaccine series
b. testing your blood for anti-HCV
c. follow-up testing and counseling only if you
receive postexposure prophylaxis
d. cleaning the exposure site

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