Hepatitis B
Key Points
- Hepatitis B (HBV) is a blood-borne virus transmitted via contaminated blood, sexual contact, and perinatal routes; it can become a chronic, lifelong infection.
- Unlike hepatitis A, HBV can progress to cirrhosis, liver failure, and hepatocellular carcinoma.
- Vaccine is available — HBV vaccine is on the standard newborn schedule and is recommended for all unvaccinated adults at risk.
- Chronic HBV is treated with antiviral agents (tenofovir, entecavir) to suppress viral replication.
- Nursing priorities: bleeding risk monitoring, fatigue management, nutrition support, and transmission prevention education.
Pathophysiology
HBV is a DNA virus that infects hepatocytes, triggering an immune-mediated inflammatory response. The liver becomes inflamed, and cellular necrosis occurs in varying degrees. When the infection lasts more than 6 months, it is classified as chronic hepatitis B.
Chronic HBV can progress to:
- Cirrhosis — irreversible hepatic fibrosis
- Liver failure — impaired synthetic and detoxification functions
- Hepatocellular carcinoma (HCC) — significantly elevated risk in chronic HBV carriers
Transmission Routes
| Route | Details |
|---|---|
| Blood/Parenteral | Needle sharing, needlestick injuries, blood transfusions (rare with current screening) |
| Sexual contact | Unprotected intercourse with infected partner |
| Perinatal | Mother-to-infant transmission during delivery or through breast milk |
Clinical Manifestations
- Early (acute): Fatigue, anorexia, nausea, vomiting — may be asymptomatic
- Progressing: Right upper quadrant (RUQ) pain, jaundice, dark urine, light-colored stools, enlarged liver
- Advanced/chronic: Ascites, hepatic encephalopathy (altered mental status from ammonia buildup), bleeding tendency
Nursing Assessment
NCLEX Focus
Monitor for signs of bleeding (elevated PT/INR, ecchymosis, gum bleeding) and hepatic encephalopathy (confusion, asterixis, elevated ammonia). These indicate severe hepatic dysfunction requiring escalation.
- Assess for jaundice: skin, sclerae, mucous membranes.
- Assess RUQ tenderness and hepatomegaly on abdominal exam.
- Assess for ascites: abdominal girth measurement, shifting dullness on percussion.
- Monitor vital signs, intake/output, and daily weight (fluid shifts).
- Monitor laboratory values: ALT/AST (elevated = hepatocyte damage), bilirubin (elevated = impaired bile excretion), PT/INR (elevated = impaired clotting factor synthesis), albumin (decreased = impaired protein synthesis), ammonia (elevated = encephalopathy risk).
- Assess for bleeding: hematuria, melena, ecchymosis, oozing from IV sites.
- Screen for serologic markers:
- HBsAg (hepatitis B surface antigen) = active infection
- Anti-HBs = immunity (past infection or vaccination)
- HBcAb = prior exposure
Nursing Interventions
- Activity: Prescribe bed rest during acute illness; schedule planned rest periods; energy-conserving techniques (sitting during activities).
- Nutrition: Consult dietician; high-carbohydrate, moderate-protein diet; small frequent meals; administer antiemetics before meals; avoid hepatotoxic substances (alcohol, acetaminophen, paracetamol, aspirin, sulfonamides).
- Fluid balance: Monitor for fluid overload (ascites); implement fluid restrictions if ordered; administer prescribed IV fluids.
- Bleeding precautions: Use electric razor, soft-bristle toothbrush, gentle oral care; monitor for melena and ecchymosis; avoid IM injections when INR is elevated.
- Skin integrity: Cool showers for pruritus (itching from bilirubin deposits); baking soda baths; avoid alkaline soaps; keep fingernails short.
- Emotional support: Non-judgmental communication; active listening; referral to support groups.
Hepatotoxic Drug Avoidance
Acetaminophen (paracetamol), aspirin, sulfonamides, and many anesthetics are hepatotoxic and must be avoided in hepatitis B patients. Notify all future health care providers of the hepatitis diagnosis before prescribing medications.
Pharmacology
| Drug | Class | Notes |
|---|---|---|
| Tenofovir (TDF, TAF) | Nucleotide reverse transcriptase inhibitor | Preferred first-line antiviral for chronic HBV; suppresses viral replication |
| Entecavir | Nucleoside analog | Alternative first-line agent; low resistance barrier; preferred if tenofovir contraindicated |
| Pegylated interferon-alfa | Immunomodulator | Finite treatment course; significant side effects (flu-like, depression, neutropenia) |
| HBV vaccine | Preventive | 3-dose series; part of newborn schedule; recommended for all high-risk unvaccinated adults |
| Hepatitis B immune globulin (HBIG) | Post-exposure prophylaxis | Administered after known HBV exposure (e.g., needlestick) or to newborns of HBsAg+ mothers |
Clinical Judgment Application
Clinical Scenario
A 42-year-old patient with chronic hepatitis B has increasing confusion, abdominal distension, and a serum ammonia level of 105 mcg/dL (normal <35).
- Recognize Cues: Mental status changes, ascites, elevated ammonia in chronic HBV patient.
- Analyze Cues: Hepatic encephalopathy is developing due to impaired ammonia detoxification.
- Prioritize Hypotheses: Neurological deterioration from hepatic encephalopathy is the priority concern.
- Generate Solutions: Notify provider; assess mental status and orientation; prepare for lactulose administration; restrict protein intake per orders.
- Take Action: Implement fall precautions, monitor ammonia levels, administer lactulose, restrict dietary protein.
- Evaluate Outcomes: Mental status normalizes, ammonia levels decrease with treatment.
Related Concepts
- hepatitis — Core acute/chronic hepatitis framework across viral and nonviral etiologies.
- hepatitis-c — Comparison of HBV vs. HCV transmission, chronicity, and treatment approaches.
- immune-system — Hepatic immune response and T-cell destruction of infected hepatocytes.
- digestive-system — Liver anatomy, bilirubin metabolism, and hepatic synthetic functions.
- active-and-passive-immunity — HBV vaccine (active immunity) and HBIG (passive immunity) for prevention.
- blood-sampling-modalities-and-preanalytical-safety — Needlestick precautions and standard precautions with HBV+ patients.
- hemostasis-coagulation-and-fibrinolysis — Coagulopathy management in impaired hepatic clotting factor synthesis.
Self-Check
- What serologic marker confirms active hepatitis B infection?
- Why must acetaminophen be avoided in patients with hepatitis B?
- What clinical finding indicates hepatic encephalopathy in a patient with chronic HBV?