Hepatitis C (HCV) is a viral infection that

Hepatitis C (HCV) is a viral infection that affects the blood and overtime, can cause damage to the liver resulting in various complications.  It defines itself from other forms of Hepatitis such as A and C, by how it is transmitted in addition to its effect on the liver. According to the Centers for Disease Control and Prevention (CDC) (2014), 2.7 to 3.9 million people in the United States suffer from the disease chronically, which only pertains to reported cases. HCV is an infection that has the capability to go unnoticed for longer periods of time due to mild symptoms.  To increase the understanding and awareness of HCV, this paper will discuss the disease condition, diagnostics, modes of treatment and nursing interventions to yield positive outcomes in patients.Disease Condition Hepatitis C is transmitted via the blood and prevention may or may not be attainable for some. Risk factors of HCV can be segregated into two groups: modifiable, which can be controlled by the person and non-modifiable, those that cannot be changed. Modifiable risk factors include intravenous (IV) drug use (sharing needles and other equipment), occupational exposure, direct contact with blood or open sores, sharing of razors and other personal items that come in contact with blood, and sexual behavior, specifically men who have intercourse with men, or are generally promiscuous. This risk increases when partners are coinfected with human immunodeficiency virus (HIV) (Dan, Moses-Eisenstein & Valdiserri, 2015).  Non-modifiable risk factors include perinatal transmission, persons already coinfected with HIV, blood transfusions prior to 1992 and being born within the years of 1945-1965 (“baby-boomer generation”). The CDC (2014) states that the higher rate of incidence in baby-boomers isn’t exactly known, however it may be attributed to  infection control procedures and universal precautions not being adopted at that time. The etiology of hepatitis C is dependant on the transmission through blood exposure due to any of the previously stated risk factors.  Today, transmission of the virus is most often caused by the sharing of needles and other drug paraphernalia that comes into contact with the infected users blood (during past or present use). It is rising in the baby-boomer generation as this cohort is being tested and made aware of the possibility of infection, which may partially be related to medical practices in their past.  While the disease may occur acutely or chronically, there are those that may have an accelerated disease course attributed to other comorbidities such as, fatty liver disease, hepatitis B, HIV and substance abuse issues (Pozza, Hill, Hefner, Vawtner & Hassanein, 2017).  Early education on prevention or minimization of risk factors, as well as proper management of existing infection and other health issues, can have the positive effect of lowering transmission and slowing progression a present condition.Hepatitis C can occur acutely and possibly resolve on their own or, affect the patient in a chronic matter.  It occurs due to transmission from one infected individual to another through the blood. “Like other viruses, HCV’s structure is stored in a person’s ribonucleic acid (RNA) which converts into a form suitable for transmission” (Crusse and Kent, 2015, p.42).  HCV can be one of six genotypes and in the United States, the most commonly occurring is genotype 1 followed by 2 and 3.  A concerning issue with HCV is that in its chronic form, the virus progresses slowly for many years until the liver is impacted because of the lack of noticeable manifestations it produces. Manifestations of acute HCV most often occur within the first few months from the time of infection. Chronically, symptoms may take years to be apparent and overtime, the liver becomes fibrosed (healed scar tissue), eventually putting the patient in the stage of cirrhosis.  While a patient can be asymptomatic, the first  physical differences that can be experienced may be fatigue, fever, jaundice of the sclera or skin and darkening of the urine, nausea, and vomiting, much like the flu (Crusse & Kent, 2015).   Owing to the fact that the liver is known for metabolization, damage to it causes a buildup of bilirubin, which causes the yellow tinged skin that is seen with jaundice. The darkening of urine is related to an excess of bilirubin in the bloodstream which is being excreted in higher amounts through urine. As the disease progresses and liver fibrosis becomes more severe, symptoms worsen and are more evident due to advanced liver disease. In addition to the early manifestations, others include, caput medusae, asterixis, clay colored stool, ascites, spider angiomas, palmar erythema and hepatic encephalopathy (Pozza et al., 2017).  Excessive liver fibrosis causes the scar tissue to block blood flow, resulting in portal hypertension and in turn, manifests as caput medusae (engorged veins) and/or ascites as the pressure causes a fluid shift into the abdomen. Asterixis occurs as a result of the damaged liver being unable to metabolize ammonia (toxins) to urea which then builds up in the body. As this worsens, toxins accumulate further leading to hepatic encephalopathy as evidenced by a change in mental status. Spider angiomas and palmar erythema occur more frequently in alcohol related cirrhosis. The extent of cirrhosis causes poor metabolism of hormones, specifically estrogen, which says in the circulation and causes visible lesions on the skin. In men, higher levels of estrogen can cause gynecomastia and sexual disturbances. In women hormones can cause missed menstrual periods or experience vaginal bleeding after menopause (Huether & McCance, 2012). DiagnosisSerologic screening is the first step in determining if further diagnostic testing is needed in order to confirm a diagnosis of HCV.  While not everyone is tested for the hepatitis C infection, attention is guided toward groups that are have higher risk factors than others. These patients may also be asymptomatic at the time of initial testing.  Those that require this testing begin by receiving an anti-HCV test. Antibodies become detectable in about 6 weeks from the infection in 45% of people, the remaining 55% may not develop antibodies for 6-12 months. It must be noted that antibodies can be present after an infection that has resolved on its on or successful antiviral therapy; this will yield a positive result. At this stage, further testing will be needed to determine if the infection is active (Van Leeuwen & Bladh, 2015) . If the result from the anti-HCV test is positive, the patient would then receive the qualitative HCV-RNA test which will tell the healthcare provider whether HCV is actively present in the patient’s blood. Low levels can be detected and the qualitative test is also used to determine if patients have had a good result with their drug therapy by coming back negative; this will also be the result when one spontaneously clears of the infection. A positive result confirms the present infection.  The HCV RNA quantitative test measures viral load which is the amount of viral particles in the blood. It is done before during and after therapy to determine the effectiveness of the treatment regimen. The lower the viral load is when therapy is commenced, the better the chance of  “curing” (undetectable HCV levels) the virus.  To determine treatment for the patient, the HCV genotype (HVCG) is done. This helps determine the type of treatment one receives as well as how long the therapy will last (Pozza et al., 2017).Certain labs are done, such as liver function tests to help establish if liver disease is present. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are used, however, the ALT is more specific to the existence of disease, but not severity. AST can be found elsewhere in the body and is not as reliable. Considering that protein is formed in the liver, albumin levels are checked because low levels could be a sign of chronic liver disease.  If liver damage is assumed, a liver biopsy will be done to discern the extent of inflammation, presence of fibrosis, necrosis or disease (cancer is linked to HCV). The biopsy is also done prior to any treatment begins (Crusse & Kent, 2015). TreatmentThe priority goal when undergoing treatment is “curing” the disease, or having viral load levels become so low they are undetectable when HCV-RNA is tested. After treatment has concluded, the HCV being undetectable for six months is also a desirable result. Medications used for the treatment of acute and chronic HCV are the same, if needed. In some instances, acute HCV resolves on its own, other times, it progresses into the chronic form. There are factors that help guide healthcare providers to decide upon treatment regimens which include: any prior treatment for HCV, presence and severity of liver failure, ability to tolerate treatment, viral load, and genotype (Crusse & Kent, 2015).Pegylated interferon (PEG-INF) and ribavirin, both antiviral agents, are commonly used in conjunction with one another.  PEG-INF is given weekly for 48 weeks, subcutaneously and ribavirin is given twice daily by mouth, for 48 weeks. Patients may feel feverish, have headaches, insomnia, depression, and/or alopecia as side effects. According to Dan et. al., (2015), the combination of ribavirin and PEG-INF is no longer the preferred treatment in the United States(as of July 2015). Newer combination drugs with a shorter treatment time, fewer side effects and improved “cure” rates are being utilized more frequently. Simeprevir (Olysio) and sofosbuvir (Sovaldi) and ledipasvir-sofosbuvir (Harvoni) are the more popular drugs and treatment time is around 12-24 weeks long. Hepatitis C is the most common indication for a liver transplant (LI) in the United States. If liver failure has occured due to the virus, LI is a viable option, but the patient must be made aware they will need to continue medications, start immunosuppressants to fight rejection of the donor liver and HCV may return, LI increases life by at least five years.. Likelihood of a patient undergoing the procedure is dependent on multiple factors, some being their viral load, immune status and immunosuppressive regimen. Those with current substance abuse problems will not likely be candidates nor will active cancer, HIV infection or advanced heart and lung diseases. FIND CITATIONThe nurse should assess how the patient feels about their diagnosis, any questions or concerns they may have and their readiness to adhere to their treatment regimen.  The goal of a “cure” should be reinforced and help the patient feel empowered; be sure they understand this is a manageable disease and they can lead a normal life. Women of child-bearing age must be told to use a backup method of birth control as simeprevir (Olysio) can lower its effectiveness. Teach signs and symptoms of a worsening infection and to contact their health care provider as soon as possible. Patients should be aware they will require ongoing assessments and testing to monitor medication effectiveness and to check if their viral load is decreasing (Crusse & Kent, 2015). Nursing CareHepatitis C brings about many concerns for the patient’s well-being whether it is acute, chronic or in the rehabilitative stage.  Inadequate nutrition, fatigue and knowledge deficit are all issues that should be priority for the nurse to manage to better the patient’s condition.  As many people are not aware of their infection, they may attribute their symptoms to another condition or something temporary that does not need medical attention. It is the job of the nurse to identify these issues and prepare a plan using assessments, education and interventions to ensure a positive outcome. The first issue to be addressed is imbalanced nutrition: less than body requirements. This is related to anorexia the patient may be reporting, altered use of carbohydrates and proteins not being properly metabolized by the liver and/or nausea and vomiting related to epigastric pain. Poor nutritional intake can negatively affect the patient’s outcome, mood, recovery and energy.  In the chronic form of HCV, effects will be more visible, and noticeable by the healthcare provider as well as the patient (Ackley & Ladwig, 2014).Whether the virus is acute or chronic the nurse will need to perform frequent assessments on the patient’s weight, their eating habits and frequency, food aversions or likes and refer them to a dietitian for further investigation.  In any form of HCV, the ability to eat, swallow, cook, shop for themselves and afford groceries must be assessed as that may contribute to the overall lack of nutrition. Monitoring for signs of poor nutrition should be done such as, bruising, easily plucked hair, muscle wasting, and a significant decrease in body weight.  Offer meals high in carbohydrates and protein (if not contraindicated). If patient tires easily, encourage them to rest prior to meals (Ackley & Ladwig, 2014).In the acute setting, laboratory results should be checked as they are ready for abnormal results. Specifically, irregular numbers for total protein, hemoglobin and hematocrit, electrolytes and albumin; albumin below the normal level is indicative of poor nutritional status.  They should also be weighed daily, at the same time with similar clothing on.  Record food intake for each meal, make food appealing and avoid disliked foods. Encourage the patient to use a food diary, especially when being discharged and while rehabilitating. Good oral hygiene should be provided and visualization of healthy mucosa as saliva aides in the digestion of food. With appropriate and timely interventions by the nurse and dedication by the patient, the preferred outcome would be for the patient to regain or maintain their current weight status (Ackley & Ladwig, 2014).Another matter the nurse should be alert to is the possibility of fatigue. This can be related to anemia (as some erythropoietin is produced in the liver), malnutrition, lack of endurance, anxiety and depression. Some characteristics that may be seen in patients experiencing fatigue are lowered concentration as well as libido, lack of energy, lethargy or verbalized need for increased amount of energy. Again, it should be noted that these side effects can be confused for another condition or even a temporary “funk” the patient feels they are experiencing. In chronic or acute HCV conditions, the nurse should assess the normal sleep patterns experienced as well as any lack of rest and nutrition.  The patient should be asked what activities they were able to tolerate prior to symptoms beginning and their ability to perform activities of daily living. Teach the patient relaxation techniques such as guided imagery, meditation or diversional activities like television, radio or reading. (Ackley & Ladwig, 2014).In the chronic form of HCV, it is important to determine if the disease is interfering with their personal or family life as well as their ability to work.  If anemia is suspected, monitor blood counts and administer medications accordingly. Encourage the patient to keep a journal of their activities and how they tolerate them, additionally, teach the client to alternate between periods of rest and exercise.  During the acute stage, promote adequate bed rest by limiting visitors and providing for a quiet environment. and nutritional support. Administer medications to aid in a relaxed state if patient is exhibiting anxious behavior. Enlist physical therapy to aid in forming a plan to build up the patient’s activity tolerance when they are ready to do so.  Monitor liver enzymes when they become available to determine if the patient’s condition is resolving or if interventions need to be altered. (Ackley & Ladwig, 2014).Deficient knowledge related to the disease process is of major concern to the nurse.  Often, patients are not aware that they were exposed to the hepatitis C virus or that they are actually infected. The nurse should first determine how much the patient actually knows about the disease and correct any misconceptions as well as determining their readiness to learn and ability. Ask them their history to aid in determining how they obtained the virus. Allow the patient to ask any questions at this time and after doing so, a plan can be formulated (Ackley & Ladwig, 2014).In the chronic or acute form of HCV teach the patient, in simple terms, what the disease is and how it can be transmitted. The new diagnosis may cause the patient to be distraught, give them time and information to take home to read and process later. Signs of depression and suicidal ideation have been seen along with this diagnosis and a psychological assessment should be done each visit.  Patients should receive vaccines, including those for Hepatitis A and B. A full health history should be taken, especially if any substance abuse has occured or if the patient consumes alcohol. Over the counter drugs need to be assessed and inform the patient they will need to ask their healthcare provider before taking any new ones as they can be toxic to the liver. If the patient is female, infer if they are pregnant or plan to become pregnant as fetal abnormalities can occur with the drugs used to treat HCV (Crusse & Kent, 2015). If the patient is diagnosed with the chronic form of HCV, it is imperative they understand ongoing testing is needed 4 weeks after treatment begins and every 12  to determine if their condition is improving and to monitor side effects. Advise patients to monitor weight and diet, as obesity can contribute to the exacerbation of liver damage. When patient is considered “cured” of HCV, the still will need follow up visits as the virus has the capability to recur (Dan, et. al., 2015). ConclusionHepatitis C can be a confusing and frightening disease for the patient to comprehend when they are first diagnosed. The nurse plays a substantial role in the betterment of their patients and guides them to make the best possible choices toward their care.  Through their profession nurses are capable of helping people in their most vulnerable of times; with education, they have the ability to help slow transmission, improve health and promote awareness. With additional support from their families and healthcare team, the patient should feel as though they have the tools to improve their own condition and feel that they can lead a fulfilling life.