CEBU NORMAL UNIVERSITY

OSMEÑA BLVD CEBU CITY

COLLEGE OF NURSING

MEDICAL – SURGICAL NURSING

NURSING MANAGEMENT OF CLIENTS WITH
HEPATITIS C and HEPATITIS G

Submitted to:
Mr. Emiliano Ian Suson II

Submitted by:
Osmeña, Ervin Kyle
Reyes, Jacob
Matutes, Gina Leah
Mendoza, Hannah Rubia
Oliverio, Kimberly Kathe
Oporto, Reyna Gienica
Pactores, Reyna Rose
Pasa-ol, Cherry Mae
Pepito, Precious Dennica
Peque, Imma Christel
Pilayre, Johanna Feliz
Rallos, Judee Katherine
HEPATITIS C

DEFINITION

Hepatitis C is a form of liver inflammation that causes primarily a chronic disease. Acute hepatitis C is
rarely observed as the early disease is generally quite mild. Spread mainly by contact with infected blood
or percutaneous inoculation, or less commonly by sexual intercourse, the hepatitis C virus (HCV) causes
most cases of viral liver infection not due to the A and B hepatitis viruses. In fact, before other viral
types were found, hepatitis C was referred to as "non-A, non-B hepatitis." It is not a new infection, just
newly diagnosable and has been widely present for decades. It accounts for over 90% of cases of post-
transfusion hepatitis. Only 4% of cases of hepatitis are caused by the Hepatitis C virus; intravenous drug
use accounts for half of these.

CAUSATIVE AGENT: Hepatitis C virus

SIGNS AND SYMPTOMS

Children and adults who acquire the infection usually are asymptomatic, or have a nonspecific clinical
disease characterized by fatigue, malaise, anorexia, and weight loss. Jaundice is uncommon, and only
25% to 30% of symptomatic adults have jaundice. These symptoms usually last for 2 to 12 weeks. Unlike
hepatitis A and B viral infections, fulminant hepatic failure is rare, and only a few cases have been
reported. The most alarming aspects of HCV infection are its high rate of persistence and ability to
induce chronic hepatitis and cirrhosis.

In most patients, HCV can still be found in the blood six months after the start of acute infection, and
these patients are considered to be carriers. If the virus persists for one year, it is very unlikely to
disappear. About 20% of chronic carriers develop cirrhosis of the liver when the virus damages or
destroys large numbers of liver cells, which are then replaced by scar tissue. Cirrhosis may develop only
after a long period of time (as long as 20 years) and often even more has passed. Most (four in five)
patients will not develop cirrhosis and instead have a mild, chronic form of infection called chronic
persistent hepatitis and when they die, will die with, not of, the infection.

INCUBATION PERIOD: 15-160 days

PATHOPHYSIOLOGY

Before 1990, the main route of transmission was through contaminated blood transfusions in blood
products. But there has been a concern during these days that transmission of small amounts of blood
during tattooing, acupuncture and body piercing may facilitate the transmission of HCV. Although, the
virus may also be transmitted through sexual contact or through vertical transmission from mother to
infant, the incidence of such transmission is uncertain. Occupational exposure through incidents such as
unintentional needle sticks can result in infection. Most of the people inflected with HCV (75% of all
cases) are chronically infected and unaware of their infection because they are not clinically ill
(subclinical disease). However, 25% of people with HCV have clinical manifestation of the disease
(symptomatic disease). Persistent infection and chronic hepatitis are the hallmarks of HCV infection,
despite the generally asymptomatic nature of the disease. In contrast to HBV, HCV has a high rate of
progression to chronic disease and eventual cirrhosis, exceeding 50%. Indeed, Hepatitis C is the most
common cause of chronic hepatitis, cirrhosis and hepatocellular cancer in the world.

DIAGNOSTIC PROCEDURES

HCV RNA (Viral Load) Tests

A viral load test measures the amount of HCV RNA (genetic material) in the blood. This test is used to
confirm active HCV infection and can also help predict whether treatment is likely to be effective, and
show whether HCV medications are working. There are two types of viral load tests – qualitative
(measures the presence of the virus) and quantitative (measures the amount of virus). A viral load test
requires a blood sample.

Genotype Test

There are several strains of hepatitis C, called genotypes. These strains are very similar but have enough
genetic differences to classify them into six major genotypes: 1,2, 3, 4, 5, and 6. Genotype information is
important when considering HCV treatment because it can help predict treatment response. A genotype
test requires a blood sample.

HCV Antibody Tests

There are two common antibody tests used to detect HCV antibodies— HCV EIA and HCV RIBA. The HCV
RIBA test may be used to test for HCV antibodies, but it is generally only used to confirm a positive result
from an HCV ELISA in a person with no known risk factors. An HCV antibody tests requires a blood
sample.

Nursing Responsibilities for blood sample collection:

BEFORE THE TEST

1.Explain to the client:
•The purpose of the test
•The procedure, including the site from which the blood sample is likely to be obtained
•That momentary discomfort may be experienced when the skin is pierced
•That food, fluids, and drugs are to be withheld before to the test
2.Obtain a thorough history regarding possible ingestion of contaminated water or foods, environmental
sanitation factors conducive to occurrence, recent blood transfusion, parenteral exposure to materials
contaminated by blood or body fluids, personal contact through sexual activity, or presence of
pregnancy (the infection could be transmitted to the infant).
3.The condition of the veins should be noted, and the use of tortuous, sclerotic veins or those in which
phlebitis has previously occurred should be avoided, as should the use of an extremity with an
intravenous (IV) site or heparin lock. If the extremity must be used, obtain the sample from a site
distal to the IV or heparin lock. (Extremities with functioning hemodialysis access sites should not be
used, nor should the arm on the affected side after mastectomy.)
4.The skin is prepared by cleansing with an antiseptic such as povidone-iodine (Betadine) or 70
percent alcohol and is allowed to air-dry or is dried with sterile gauze. (Drying prevents dilution
of the sample with antiseptic.) For the immunosuppressed patient, povidone-iodine should be
used, followed by a 70 percent alcohol pad taped over the site for 10 minutes—the site should be
allowed to air-dry or be dried with sterile gauze before the venipuncture.
5.Assess the client’s understanding of the explanations provided.
6.Assess the client’s degree of anxiety about the procedure.
7.Assess the infant’s or child’s need for restraint and reassurance.
8.Ensure that food, fluid, and medication restrictions have been followed.
9.Fill out the requisition accurately and include all information that is requested on the form.

DURING THE TEST

1.Note the client’s response to the procedure and provide support if needed.
2.Obtain the blood sample using proper technique and standard precaution procedures.
3.Avoid possible invalid testing caused by prolonged use of a tourniquet; excessive suction on the
syringe; vigorous shaking of the specimen in a tube or expulsion from the syringe into a tube; moisture
in the syringe or tube; leakage of air into the syringe or tube; contamination of the site, equipment, or
blood.
4.Provide support to the client if the puncture is not successful and another must be performed to
obtain the blood sample.
5.Select appropriate evacuated tubes or syringe, needle, and laboratory tubes, depending on tests to be
performed.
6.Note obstruction of vascular access device or catheter caused by blood clotting, and notify the
physician.

AFTER THE TEST

1.Apply the necessary pressure to the puncture site until the bleeding stops. If oozing continues, elevate
the extremity and apply a pressure type of dressing.
2.Remain with the client until the bleeding has completely stopped.
3.If the client is experiencing excessive and lingering pain or syncope, allow the client to lie down and
rest.
4.Assess for extreme anxiety and signs of possible shock state such as tachycardia and hypotension.
5.Check the venipuncture site in 5 minutes for hematoma formation.
6.If the client is immunosuppressed, check the puncture site every 8 hours for signs and symptoms of
infection or septicemia, such as fever, chills, petechiae, and inflamed joints.
7.Monitor vascular device or catheter insertion site for redness, swelling, pain, and purulent drainage
indicating infection and monitor for sepsis caused by contamination during the procedure.
8.If the specimen cannot be transported to the laboratory within a reasonable time or if analysis is
delayed, arrange for proper storage to prevent deterioration or contamination that can cause
inaccurate results.

Liver Biopsy

Liver biopsies are used to measure the extent of liver damage, including the degree of inflammation, the
extent of fibrosis (fibrous tissue), and the general health of the liver.

Liver biopsy involves obtaining a sample of hepatic tissue for histological and cytologic evaluation. The
test may be performed by percutaneous needle biopsy (closed biopsy) or through surgical incision (open
biopsy). This test is indicated when liver disease is suspected but is not evidenced by less invasive
procedures such as ultrasounds and CAT scans. Liver biopsy, especially when performed by the
percutaneous method, is not without its attendant risks: Bleeding within the liver, damage to hepatic
tissue, and infection may occur. Therefore, this procedure is performed only when absolutely necessary.

Nursing Responsibilities for Liver Biopsy:

NURSING CARE BEFORE THE PROCEDURE

1.Explain to the client: That the procedure will be performed by a physician The method that will be
used to obtain the sample (percutaneous [closed] biopsy or surgical [open] biopsy) The type of
anesthesia to be administered (local infiltration for needle biopsies, general anesthesia for open
biopsies) That foods and fluids are withheld for 6 to 8 hours before the procedure That if a needle
biopsy is performed, it will be necessary to remain motionless and breathe as instructed during certain
portions of the procedure (Allow client to practice holding the breath after an expiration.) That if a
needle biopsy is performed, the client may experience slight discomfort in the area of the right
shoulder when the biopsy needle is introduced That if a needle biopsy is performed, a pressure
dressing will be applied to the site That after a needle biopsy, the client must lie on the right side with
a rolled towel or small pillow under the site to create pressure and prevent bleeding and that this
position must be maintained for at least 2 hours That bed rest is required for 24 hours after the
procedure That vital signs will be monitored closely for at least 24 hours after the test That any
unusual or persistent discomfort or any difficulty breathing should be reported immediately
2.Ensure that a signed consent for the procedure has been obtained.
3.If the skin at the biopsy site is unusually hirsute, it may be necessary to shave the site before the
procedure.
4.If an open biopsy is to be performed, the physical preparation is the same as for any surgical
procedure requiring general anesthesia.
5.For a percutaneous needle biopsy, the client’s vital signs are taken and compared with baseline
readings.
6.The client should void immediately before the procedure and be provided with a hospital gown.
7.Administer a sedative, if necessary, as ordered.

THE PROCEDURE
1.For an open biopsy, the samples are collected during the operative procedure.
2.For a percutaneous needle biopsy, the client is assisted to the supine or the left lateral position with
the right hand under the head.
3.The biopsy site is exposed, cleansed with antiseptic, and draped with sterile drapes. The skin and
subcutaneous tissues are then infiltrated with a local anesthetic. The syringe is attached to the biopsy
needle.
4.The client is then instructed to take a deep breath, exhale forcefully, and hold his or her breath. The
biopsy needle is then inserted, rotated to obtain a core of liver tissue, and quickly removed. It is
important that the client Nursing Alert remain motionless during biopsy needle insertion.
5.After the needle is removed, the client may resume normal breathing.
6.A pressure dressing is applied to the site.
7.The sample is expelled from the needle into a container with formalin solution and sent to the
laboratory immediately.

NURSING CARE AFTER THE PROCEDURE

1.Care and assessment after an open biopsy include care in the same manner as for anyone who has had
surgery requiring general anesthesia.
2.For a percutaneous biopsy, position client on the right side with a rolled towel or small pillow under
the biopsy site to create pressure and prevent bleeding.
3.Maintain this position for at least 2 hours.
4.Maintain complete bed rest for 24 hours after the test.
5.Resume foods and fluids withheld for the test.
6.If ordered, administer analgesics for post biopsy discomfort.
7.Advise the client not to cough or strain after the procedure because it can increase intra-abdominal
pressure.
8.Take and record vital signs as for a postoperative client, whether the biopsy was performed by open or
closed technique (i.e., every 15 minutes for the first hour, every 30 minutes for the next 2 hours, every
hour for the next 4 hours, and then every 4 hours for 24 hours).
9.Assess the biopsy site for bleeding, hematoma formation, bile leakage, and inflammation each time
vital signs are taken.
10.Assess the client’s comfort level and immediately report pleuritic pain, persistent right shoulder pain,
or abdominal pain.
11.Assess the client’s respiratory status and immediately report any signs or symptoms of respiratory
distress.

TREATMENT

Standard immune globulin for passive immunity

 Advised to rest
 Low fat, high carbohydrates diet
 IV of 10% glucose for appetite improvement
 Antiemetic for nausea
 Parenteral Vitamin K for prolonged prothrombin time
 Antihistamines for relief of pruritus
 Removal of causative agent by lavage
 Acetylcysteine for acetaminophen poisoning
 Corticosteroids (drug-induced hepatitis)

COMPLICATIONS

 Fulminant hepatic failure

 Renal failure
 Liver fibrosis
 Cirrhosis

MISCELLANEOUS

 Hepatitis C is the most common cause of chronic hepatitis, cirrhosis and hepatic cellular cancer
in the world.
 Hepatitis C is now considered by the Department of Health as an epidemic in the Philippines.
 1 out of 5 individuals with HCV also has the Hepatitis G virus.
HEPATITIS G

DEFINITION

A form of hepatitis, caused by the hepatitis G virus (HGV), that is transmitted by infected blood or blood
products. It can also be transmitted by sharing personal items contaminated with the virus, by vertical
transmission (mother to newborn), and by various sexual activities. Infection is of widespread
occurrence and causes generally asymptomatic to mild disease. It is seen in patients after drug
transfusions, in patients undergoing hemodialysis, and in IV drug abusers. It is also seen in infants born
to infected mothers. The virus is not primarily replicated in the liver and may only be associated with
hepatitis rather than the cause of infection.

INCUBATION PERIOD: 14 to 145 days

CAUSATIVE AGENT: hepatitis G virus (HGV)

SIGNS AND SYMPTOMS: nausea, jaundice, vomiting, dark-colored urine, loss of appetite, fatigue and
general flu-like symptoms.

PATHOPHYSIOLOGY

The etiology of some liver disease in man remains unknown. Twenty-five per cent of cases of fulminant
hepatitis have an unknown origin; 17.5% of cirrhosis remains cryptogenic. HGV was cloned from a
patient with chronic hepatitis whose plasma had transmitted hepatitis to tamarin monkeys. It is a
member of the flaviviridae family and has 25% homology with HCV. Risk factors are similar to those for
Hepatitis C. Its presence in liver tissue is probably due to serum contamination. It is doubtful whether it
is a hepatotrophic virus. Persistent infection is common, but does not lead to chronic liver disease. It
does not play a major role in idiopathic fulminant hepatic failure or in chronic liver disease in man. It is
prevalent in liver transplant recipients, but does not have a long-term harmful effect on graft. It does
not worsen the course of concurrent HCV infection. HGV does not seem to be a serious human
pathogen.