Jenny G., a 48-year-old recovering IV drug abuser, presents with general malaise, anorexia, abdominal pain, and slight jaundice. She is currently staying in a women’s shelter and looking for a job. She is divorced, with two grown children whom she hasn’t been in contact with for years.
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CC: “When I was on drugs, I felt fine. Now that I’m clean, I feel crappy.” Lab results: Elevated alanine aminotransferase (ALT) Hepatitis C antibody positive Hepatitis A antibody positive
Additional subjective data that the patient might share are related to the drug withdrawal symptoms, such as hypersomnia, appetite increase, depression, or agitation. Such symptoms are common for the first days of withdrawal. Further, insomnia, fatigue, and anxiety together with drug craving and mood swings can be expected as well. Objective data will consider symptoms of hepatitis C and A: bruising, bleeding, changes of color of the skin and eyes also known as jaundice (identified), weight loss, fluid buildup in the abdomen, swelling of legs; fatigue, abdominal pain, loss of appetite, dark urine, joint pain, and itching (Mayo Clinic, 2017; Mayo Clinic, 2018). HIV symptoms, such as body rash, fever, headaches, swollen lymph nodes, mouth ulcers, night sweats, and vomiting also need to be considered (NHS, 2017). National guidelines on hepatitis A, hepatitis C, HIV, should be considered. U.S. Preventive Services Task Force’s recommendation statement on hepatitis C points out that illicit drug use and unprotected sex are risk factors for hepatitis C (2013). Same risk factors apply to HIV and hepatitis A.
The following tests are recommended: SMA 12, CDC count (with differential), hepatitis B surface antigen/surface antibody, RPR test, HIV serum antibody test, PPD test, urine screen for drug/alcohol abuse (Medscape, 2016). A liver-spleen scan is necessary. A consult with an addiction specialist and a psychiatrist or therapist who has experience in treating psychological symptoms of drug withdrawal can help establish what additional therapies (cognitive-behavioral or others) can be used.
Medical diagnoses include: hepatitis A, hepatitis C. Nursing diagnoses are the following: drug withdrawal with subsequent fatigue, abdominal pain, and anorexia caused by hepatitis A and hepatitis C, imbalanced nutrition, infection risk, and activity intolerance. Legal and ethical concerns include the disclosure of the information related to conditions to the family and the insurance provider of the patient, as well as the obligatory written reporting of a particular disease (hepatitis A and C, in this case). The disclosure of private information regarding the conditions to the patient’s family can be done only if written or oral consent is obtained.
The medical plan of care will consist of pegylated interferon (Peg-IFN) and ribavirin (RBV) up to 48 weeks depending on the effectiveness of the treatment (NHS, 2015). EPCLUSA (sofosbuvir 400mg/velpatasvir 100 mg) is a new drug approved by the FDA to treat all types of HCV that can be used in patients with advanced cirrhosis (American Liver Foundation, 2016). Metoclopramide or trimethobenzamide can be used to reduce nausea and vitamins B, C, and B12 to address possible macrocytic anemia (Dunphy, Winland-Brown, Porter, & Thomas, 2015). There is no cure for hepatitis A. Nursing care plan includes monitoring food and calorie intake, encouraging fluid intake (juices), monitoring weight, controlling edema formation, providing rest, prescribing paracetamol in case of pain, ensuring that the environment is well-ventilated, prohibiting alcohol, controlling self-care and hygiene, and educating the patient about the necessary sex avoidance to ensure that their partner(s) are not going to be infected.
Herbal supplements such as silymarin, green tea extract, naringenin, glycyrrhizin, and vitamin D are complementary therapies; vitamin D showed the best efficiency (Halegoua-De Marzio & Fenkel, 2014). Healthy people’s objectives include “reduce new hepatitis C infections” and “increase the proportion of persons aware they have a hepatitis C infection” (Healthy People, 2018). The patient’s relatives, nurses who work with her, psychiatrists or therapists, and nutritional specialists should be involved to understand how information from them and support from the family can enhance treatment. Additional patient teaching includes using different needs and prohibiting needle sharing, no engagement in unsafe sex without barrier protection, no alcohol or drug intake, and careful monitoring of symptoms. The suggested billing codes are G0472, 87902, 86708, 80076, and 86701.
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American Liver Foundation. (2016). Advances in medications to treat hepatitis C. Web.
Dunphy, L. M., Winland-Brown, J., Porter, B., & Thomas, D. (2015). Primary care: Art and science of advanced practice nursing. Philadelphia, PA: FA Davis.
Halegoua-De Marzio, D. L., & Fenkel, J. M. (2014). Complementary and alternative medications in hepatitis C infection. World Journal of Hepatology, 6(1), 9-14.
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