Running head: ALCOHOLIC HEPATITIS 1

Alcoholic Hepatitis

Julianna Brauchle

Cedar Crest College

ALCOHOLIC HEPATITIS 2

Abstract

The liver is the largest organ in the body and is situated on the right side of the abdomen. The

purpose of the liver is to filter the blood of chemicals and to metabolize certain drugs. One of the

substances that the liver filters out is alcohol. Over time, alcohol damages the liver. One

condition alcohol abuse can cause is hepatitis, which is an inflammation of the liver. This

condition can cause short- or long-term liver damage. With alcohol induced hepatitis, there are a

number of goals at the time of discharge, medications received while in the hospital and upon

discharge, environmental and exercise safe practices, treatments, and health teaching that are

necessary in the plan of care for these patients. The patient and family should also be aware of

signs and symptoms that need to be reported to the health care provider, appropriate diet, and

spiritual and psychosocial needs associated with alcohol induced hepatitis.

Keywords: liver, alcohol, hepatitis, discharge plan

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Alcoholic Hepatitis

Heavy drinking damages the liver, causing alcoholic hepatitis. This condition is an

inflammation of the liver, and is caused by an excessive consumption of alcohol. This condition

can cause short- or long- term liver damage (Mayo Clinic, 2017).

Jane is a 55-year-old female with no known allergies who presented to the emergency

department with a chief complain of nausea, vomiting, and diarrhea for the last two weeks. Jane

also admitted to the consumption of one liter of vodka a day for as long as she remembers. Jane’s

past medical history includes a pancreatic lesion, alcohol-induced pancreatitis, hypertension,

splenic artery aneurysm, and hyperbilirubinemia. Upon admission to the hospital, Jane also

tested positive for E. Coli bacteremia. Jane had been living in a care facility prior to admission to

the hospital.

Jane’s assessments were taken upon admission to the hospital unit. Jane presented with

+1 pitting edema in her lower extremities bilaterally, her skin and sclera were jaundiced, her

lungs sounds were decreased with a non-productive cough, and she was only oriented to person.

Jane also expressed the need to be straight catheterized due to an inability to urinate. As her

hospital stay progressed Jane became fully oriented to person, place, time, and situation. Jane’s

edema remained, she was still incontinent to stool but was able to ring the call bell when she

knew she needed to urinate which eliminated the need for straight catheterization. Jane felt

fatigued and that she was unable to get out of bed or stay awake.

Lab levels were drawn upon Jane’s admission. Her hemoglobin, hematocrit, and red

blood cell counts were all low due to malnutrition at 8.7 g/dL, 26.8%, and 2.52 million cells/ul

respectively. These levels were trending upwards by her discharge. Jane’s chloride level was

high at 112 mEq/L, indicating dehydration. Her CO2 level was low at 18 mEq/L, indicative of
ALCOHOLIC HEPATITIS 4

alcohol abuse. Jane’s prothrombin time (PT) was also high at 19.1 seconds, which is indicative

of liver disease.

In order to diagnose alcoholic hepatitis, diagnostic tests were performed. Jane underwent

and abdominal ultrasound, which showed hepatomegaly and fatty infiltration of her liver. She

also had an ultrasound of her kidneys which showed no hydronephrosis and that the left kidney is

larger than the right. She had an abdominal x-ray which showed no evidence of a bowel

blockage. Jane had a chest x-ray which showed decreased lung volumes but that her lungs were

clear.

Jane had been waiting to be medically cleared before being discharged. Jane was

approved for discharge to a different state nursing facility than the one she had previously been

residing. Jane has now been medically cleared for discharge.

Discharge Goals

Accompanying Jane’s discharge there are a number of goals for the transition process.

The first goal of discharge is that through the teach-back method, Jane will have a clear

understanding of alcoholic hepatitis, her prognosis, and the potential complications of alcoholic

hepatitis as evidenced by verbalization of discharge teaching and instructions given. The second

goal of discharge is that Jane will be able to identify the relationship of signs and symptoms of

alcoholic hepatitis to the condition and correlate symptoms with causative factors as evidenced

by verbalization of understanding by the end of discharge process. The third goal of discharge is

that Jane will initiate necessary lifestyle changes, such as the avoidance of alcohol, and

participate in treatment regimen by the end of discharge. The fourth goal of discharge is that Jane

will be able to perform activities of daily living (ADLs) and participate in desired activities at
ALCOHOLIC HEPATITIS 5

level of ability by the end of discharge. The fifth goal of discharge is that Jane will verbalize an

improved sense of energy at the time of discharge.

Discharge Instructions

Medications

I am now going to go over the medications that you will be receiving while in the

hospital, and how and when to take them when you are discharged. All of your medications are

taken orally. Since you are on an aspiration precaution, you can crush all of your pills and put

them in applesauce or pudding. If you would prefer to take them with water, your water must be

thickened to a nectar consistency.

You are currently prescribed ciprofloxacin, which is an anti-infective, for your E. Coli

bacteremia. You are prescribed to take this by mouth until the prescription is done, which will be

five more days after you are discharged. It is important that you continue to take this after you

are discharged in order to completely treat the infection. With this medication, there is a risk for

anaphylactic reactions so please report a rash and any problems breathing to your health care

provider. While taking this drug, you should also wear sunscreen and protective clothing as this

medication makes you more sensitive to the sun. Ciprofloxacin can cause further damage to your

liver, so report any worsening jaundice, dark urine, or a tender abdomen to your health care

provider.

Escitalopram oxalate, also called Lexapro, is a selective serotonin reuptake inhibitor used

to treat your depression. This prescription is taken orally once daily. This is a prescription that

you will be discharged with, and it is important that you take this medication as directed. This

medication can cause a syndrome called serotonin syndrome to occur, so you should watch for a

fever, increased agitation, tremors, sweating, and diarrhea. If you notice any of these symptoms
ALCOHOLIC HEPATITIS 6

it is important to notify your primary health care provider immediately. It is also imperative that

you monitor yourself, and have your family members watch for increased suicide ideation, as

this is an adverse reaction of this drug.

Folic acid is a water soluble vitamin that you are currently prescribed for your alcoholic

hepatitis. This drug stimulates the production of red blood cells, white blood cells, and platelets.

This drug is to be taken orally and will not be prescribed for you when you are discharged. The

folic acid may tinge your urine to be a more intense yellow. Folic acid can also cause an allergic

or hypersensitivity reaction, so it is important that if you develop a rash you must notify your

health care provider.

Furosemide, or Lasix, is a diuretic that you are prescribed for your hypertension and the

fluid that has accumulated in your legs. Lasix will help to take away the fluid that you currently

have built up in your legs. You will continue to take this drug when you are discharged. This

drug should be taken in the morning. This drug can cause low level of potassium in the blood, so

it is important that you maintain a diet that is adequate in potassium with the guidance of your

primary care provider. Report any rashes, muscle weakness, cramps, nausea, dizziness,

numbness, or tingling of the extremities to your health care provider immediately.

While in the hospital, you are prescribed Heparin. This is an anticoagulant that is used in

the prevention of deep vein thrombosis, or clots. This drug can cause excessive bleeding, so if

you notice that your gums are bleeding, that you are getting nose bleeds, are finding unusual

bruises, that your stools are black and tarry, you should notify your health care provider

immediately. This is not a drug that you will be sent home with.

Lactulose is an osmotic drug that you are currently prescribed to reduce the amount of

ammonia levels in your blood and improve your mental status due to your alcoholic cirrhosis,
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and you will be taking this after you are discharged. This drug will be taken orally and can be

mixed with fruit juice, water, or milk to improve the taste. If you take this drug on an empty

stomach it will increase the rate in which the drug works. This drug can cause belching,

flatulence, or abdominal cramping. Your primary care provider should be notified if these side

effects become bothersome, or if diarrhea starts to occur.

Thiamine is another water soluble vitamin that you are prescribed due to your alcoholic

hepatitis. This drug is used to replace any deficiencies. Foods containing thiamine include whole

grain and enriched cereals, meats, and fresh vegetables. Side effects of this drug are extremely

rare and mostly occur in IV administration, but include restlessness and weakness, vascular

collapse, bleeding, and nausea. This is also a drug that you will be taking orally and that you will

not continue taking this after discharge.

Environment and Exercise

The environment in which you should be in should be an alcohol free environment. In

order to prevent further damage to the liver, you should refrain from consuming any alcohol,

even in social situations. It is important that you attempt to remain in an alcohol free

environment as not to tempt yourself into drinking.

Exercise is encouraged when looking at alcoholic hepatitis. It is found that exercise

decreases liver inflammation, and is beneficial in the treatment of alcoholic hepatitis (Oh,

Tanaka, Warabi, & Shoda, 2013). Specifically, low impact exercises like swimming and walking

are exercises to consider partaking in at 10 minute intervals (U.S. Department of Veterans

Affairs, 2016). You can start by exercising once a day, and then slowly increasing that amount as

you feel comfortable. You should attempt to partake in these types of exercises as they can be

extremely helpful in at the very least slowing the progression of your disease process.
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Treatment

While in the hospital, you were diagnosed with alcoholic hepatitis. This means that your

liver is inflamed and it is not working properly. If you know what a fish tank looks like, you

know that there is a filter to help keep the water clean. This is what your liver does for your

blood. Since this part of your body is not working, toxins such as alcohol are not getting filtered

out of your blood, which can be dangerous.

Treatment for alcoholic hepatitis is dependent upon the stage of the disease you are

currently at. Compensated patients are considered to be self-sufficient, and should be encouraged

to follow-up every six months for blood tests and liver ultrasounds (Grattagliano, Ubaldi,

Bonfrate, & Portincasa, 2011). Patients who chronically use alcohol excessively are at an

increased risk for malnutrition and fluid and electrolyte imbalances. Malnutrition is also

associated with vitamin and mineral deficiencies (Fowler, 2013). Because of this, folate and

other vitamin replacements are indicated to manage your alcohol withdrawal (Morrison, Sgrillo,

& Daniels, 2014).

Ammonia is generally metabolized in the liver, and when patients have liver damage the

ammonia is not metabolized correctly, causing it to back up into systemic circulation (Fowler,

2013). Because of this, you are prescribed lactulose, which reduces the amount of ammonia that

remains in your blood circulation (Fowler, 2013).

A liver biopsy is routinely done to confirm the diagnosis of advanced chronic hepatitis

(Grattagliano et al., 2011). Before this is completed, however, blood tests should be done at least

two times and at least two to three months apart, and if abnormalities persist and a liver

ultrasound is inconclusive, then the patient is referred for a liver biopsy. You have not yet had
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two blood tests yet, therefore a liver needle biopsy is not indicated at this stage in your disease

process.

Health Teaching

https://youtu.be/l8sdRhqPlWQ

Observable Signs and Symptoms

Signs and symptoms which are indicated to report to a physician while you are at the

nursing home include a high fever that is prolonged, if you notice that your abdomen is getting

larger very quickly, if you or your family notice any changes in your mood and behavior. If you

notice that your abdomen is getting larger, it may be a sign of fluid accumulation in your

abdomen. Toxins that would normally be broken down by the liver can accumulate in your

blood, since the liver is not functioning properly, which will cause changes in mood and

behavior, and can also lead to confusion. These symptoms can be potentially dangerous and you

will need to notify your primary care physician right away.

Diet/Nutrition

Due to your aspiration precautions, your physician has prescribed nectar thick liquids for

you. This means that any liquid you consume must be thickened with a powder that the staff at

your nursing home should provide. If you have any questions or concerns on this, you should

notify us at the number on the card in your folder.

Due to your diuretic that you are prescribed, you are at an increased risk for a low

potassium level. This means that you should ensure you are getting an adequate amount of

potassium through your diet. Potassium rich foods include potatoes, bananas, beans, broccoli,

and chicken.
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While you were not specifically prescribed a low sodium diet, it may be beneficial sure to

your edema to try to go easy on salty foods. It is also important for you to get enough protein and

calories in your diet, since you are more susceptible to malnutrition.

Spiritual/Psychological Needs

It was previously discussed with you that you have options available as far as support

groups and counseling services that you are able to join. There are pamphlets regarding these

services included in the discharge folder as well. These services include Alcoholics Anonymous,

which can help deter you from drinking, Bereavement counseling, and local chaplains that can

travel to your nursing home. There is also information on the spiritual support person that is

provided at your nursing home.

There is also information on several psychologists and psychotherapists in the area

included in the folder. Some of these professionals accept insurance, which may aid in the

payment of these services.

Discharge Details

Jane Doe was provided with teaching instructions using the teach-back method. The

patient and her family verbalized an understanding by repeating back information on her

diagnosis and important medication regimen questions back to the nurse. The patient and her

family were provided with a formal written copy of discharge instruction which include: dietary

restrictions, signs and symptoms to monitor for at home, questions were addressed, follow-up

appointments were scheduled with cards included in the folder. Jane’s discharge condition was

unchanged since the previous assessment (at 11/28/17 1200), she was alert and oriented x 4, vital

signs stable and unchanged, and pain denied. The discharge team will follow up with a phone

call in one to two days post-discharge. The patient and her family were provided with phone
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numbers to call with any questions or concerns. The patient was escorted out the front door via

wheelchair and left in the care of her family and nursing home staff at 1600 on 11/28/18.

Conclusion

Patient information was extracted from patient chart and a clear and concise

comprehensive discharge plan was made. This discharge plan included correct medications

administration information, exercise and environmental safety information, treatments, health

teaching, observable signs and symptoms to report to the physician, dietary information, and

spiritual and psychological needs.

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Grattagliano, Ubaldi, Bonfrate, & Portincasa (2011). Management of liver cirrhosis between

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Mayo Clinic. (2017, August 04). Alcoholic hepatitis. Retrieved November 29, 2017, from

https://www.mayoclinic.org/diseases-conditions/alcoholic-hepatitis/symptoms-

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doi:10.1097/01.nurse.0000456465.49886.97

Oh, S., Tanaka, K., Warabi, E., & Shoda, J. (2013). Exercise reduces inflammation and oxidative

stress in obesity-related liver diseases. Medicine & Science in Sports & Exercise,45(12),

2214-2222. doi:10.1249/mss.0b013e31829afc33

U. S. Department of Veterans Affairs. (2006, July 25). Viral hepatitis. Retrieved from

https://www.hepatitis.va.gov/patient/daily/diet/single-page.asp