Case Study

BSN2-5 Group 4
Table of contents

Significance of the Clinical

01 Case Study 04 Manifestations

02 Patient Profile 05 Pathophysiology

Laboratory and
03 Etiologic Factors 06 Diagnostic Tests
Table of contents

Medical
07 Management 09 Care Plans

08 Drug Study 10
Application of NX
Theories
Significance Of The Case Study

● Rich and detailed information

● Real-life application
● Theory development and testing
● Contextual understanding
● Exploration of rare phenomena
● Insights into causality
● Multidisciplinary approach
● Basis for future research
● Informing practice
 Patient Profile

Biographic Data Chief Complaints

Name: Mary Jane Co The patient is having infrequent

Age: 19 years periods and having difficulties in
Address: 1834 R. Hidalgo St., Brgy. 307 urination since she attend the
Quiapo, Manila emergency department and patient is
Birthdate: February 19, 2004 having with presumed urinary tract
Race: Filipino infection (UTI).
Occupation: None
Gravida: 2 (G2)
Gestational Age: 22 weeks
Living Situation: Council flat with partner
 HISTORY OF THE
PRESENT
ILLNESS
Patient is a 19-year-old
pregnant woman, referred to
the antenatal clinic by her
general practitioner. She is
currently 22 weeks gestation
in her second pregnancy. She
attended the emergency
department 2 weeks ago with
a presumed urinary tract
infection. She reports having
infrequent periods since her
last normal vaginal delivery
18 months ago. Pt tested
positive for Hepatitis-B.
PAST MEDICAL Vital
HISTORY Signs
Patient had a substance use BP: 107/ 65 mmHg
disorder. She is currently 22 Pulse Rate: 90/mins
weeks gestation in her Respiratory Rate: 17 cpm
second pregnancy. She SpO2: 96%
reports having infrequent Temperature: 36.5 °Celsius
periods since her last normal
vaginal delivery 18 months
ago.
Patient had infrequent periods
and presumed UTI 2 weeks
ago and found out she was
pregnant.
REVIEW OF ANATOMY &
PHYSIOLOGY OF REPRODUCTIVE MEDICAL DIAGNOSIS
SYSTEM
The patient is diagnosed with
Hepatitis B surface antigen
based on the tests and
investigation taken. Additional
research is required, including
liver function testing and an
antigenicity test to assess the
risk of transmission. Hepatitis C
should also be checked for at
this point because she is at high
risk for infection.
ETIOLOGIC FACTORS - Predisposing
Factors
● Smoking doubles your
risk of abnormal bleeding
during pregnancy and
delivery. Smoking raises
your baby’s risk for birth
defects, including cleft
lip, cleft palate, or both. A
cleft is an opening in your
baby’s lip or in the roof of
her mouth.
Modifiable
● Alcohol use during ● The greatest risk to
pregnancy can cause
birth defects and
developmental
disabilities collectively
known as fetal alcohol
spectrum disorders
(FASDs). It can also
cause other pregnancy
problems, such as
miscarriage, stillbirth,
and prematurity.
both the pregnant
person and the
developing baby is
from untreated OUD,
when drugs such as
heroin or fentanyl or
prescription opioids are
being misused.
Pregnant people with
untreated OUD are
at risk of overdose
and death.
 ETIOLOGIC FACTORS - Predisposing
Factors
Non - Modifiable

● Hepatitis B can be easily ● The vaccine prevents ● Adolescent mothers

passed from a pregnant
woman with hepatitis B to
her baby at birth. This
can happen during a
vaginal delivery or a
c-section. If you have
hepatitis B, health care
providers can give your
baby a set of shots at
birth to prevent your baby
from getting infected.
most – but not (aged 10–19 years)
all–rubella infections face higher risks of
during pregnancy. If a eclampsia, puerperal
pregnant woman is not endometritis and
immune to rubella and systemic infections
catches it during the than women aged
first 5 months of 20–24 years, and
pregnancy, she usually babies of adolescent
passes the disease on mothers face higher
to her fetus. risks of low birth
weight, preterm birth
and severe neonatal
condition.
ETIOLOGIC FACTORS - Predisposing
Factors

Modifiable Non - Modifiable

● Smoking ● Poverty
● Drinking Alcohol ● Deficient knowledge
● Using of Substances ● Illiteracy
● Influence of the environment
CLINICAL MANIFESTATIONS

Subjective Data Objective Data

● Pt having difficulties in urination. ● BP: 107/ 65 mmHg

● Pt is having very infrequent period. ● Pulse Rate: 90/mins
● Pt is experiencing an abdomen ● Respiratory Rate: 17 cpm
pain. ● SpO2: 96%
● Temperature: 36.5 °Celsius
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY - Pathogenic
Mechanisms
LABORATORY AND DIAGNOSTIC TESTS
● Hepatitis profile establishes the type of hepatitis
- The hepatitis virus panel is a series of blood tests used to detect current or past infection
by hepatitis A, hepatitis B, or hepatitis C. It can screen blood samples for more than one
kind of hepatitis virus at the same time. Antibody and antigen tests can detect each of
the different hepatitis viruses.

● Liver function studies show disease stage.

- These tests can help determine an area of the liver where damage may be taking place
and, depending on the pattern of elevation, can help organize a differential diagnosis.
Elevations in ALT and AST disproportion to elevations in alkaline phosphatase and
bilirubin denote hepatocellular disease. An elevation in alkaline phosphatase and
bilirubin in disproportion to ALT and AST would characterize a cholestatic pattern.

● PT is prolonged.
- This may be caused by conditions such as liver disease, vitamin K deficiency, or a coagulation
factor deficiency (e.g., factor VII deficiency). The PT result is often interpreted with that of the
PTT in determining what condition may be present.
LABORATORY AND DIAGNOSTIC TESTS
● WBC count is elevated.
- Often white blood cells do not function correctly in patients with liver disease,
which can be the result of the white cells not reacting to infection in a normal
and effective way or produce an abnormal and exaggerated response leading
to liver damage.

● Liver biopsy may be performed if chronic hepatitis is suspected.

- A test that takes a sample of tissue from the liver for examination. A liver
biopsy is not a routine procedure, but is performed when it is necessary to
determine the presence of liver disease and to look for malignancy, cysts,
parasites, or other pathology.
 MEDICAL MANAGEMENT
Screening and vaccination:
- Universal screening for Hepatitis B is recommended for all pregnant women,
regardless of previous testing or vaccination.
- All HBsAg-positive women should have household contacts, other children and
sexual partners screened. Those that are non-immune or not already infected
should be vaccinated.
- All healthcare workers should be vaccinated and take standard precautions
against exposure to blood and bodily fluids should be used

Antenatal management:
- HBsAg-positive women, particularly those with a high viral load, should be
counselled about the potential risk of transmission with invasive procedures. NIPT
may be an option for some women.
 MEDICAL MANAGEMENT
In those requiring invasive procedures, amniocentesis is probably safer than CVS, and
transplacental amniocentesis is best avoided, if possible, All HBsAg-positive women
should be tested for HBeAg anti-HBe, and HBV DNA level, to identify pregnancies at
increased risk of post-exposure prophylaxis failure. Women should also have an
assessment of liver function (Grade A). Women with a high viral load in the third
trimester (>200,000IU/ml, equivalent to 6 log copies/ml) should be offered antiviral
therapy during late pregnancy to reduce viral load prior to delivery, and the risk of
mother-to child transmission of Hepatitis B. In women who are candidates for antiviral
therapy, tenofovir is recommended as a suitable first-line agent. There is good evidence
supporting the use of tenofovir to reduce perinatal transmission of Hepatitis B in
pregnant women with a high viral load, If not already associated with a Chronic
Hepatitis Clinical Service, pregnancy is an appropriate opportunity to refer to such a
service, both to assist with immediate decision making regarding antiviral therapy in
pregnancy if necessary, and to facilitate long-term follow-up of the patient +/- other
affected family members.
 MEDICAL MANAGEMENT
Intrapartum Care:
- Invasive procedures such as fetal scalp electrodes and fetal scalp blood sampling
in labour should be avoided. Hepatitis B infection should not alter mode of delivery
and caesarean section should be reserved for usual obstetric indications

Postpartum:
- All infants receive the first dose of the hepatitis B vaccine within 24 hours of birth
(often called the "birth dose") and to complete the vaccine series with additional
shots at 1 month and 6 months of age.
- During the postpartum period, the mother's liver function should be monitored
every 1-2 months. All HBsAg-positive women should be enrolled in ongoing care,
and have a plan formed for the management of their HBV.
 MEDICAL MANAGEMENT
Breastfeeding:
- Provided appropriate immunoprophylaxis has been given at birth, breastfeeding by
HBsAg-positive women has not been shown to increase rates of perinatal
transmission. Breastfeeding is not contraindicated in women with HBV receiving
tenofovir.

Postpartum and long term follow up:

- HBsAg-positive women receiving antiviral therapy in pregnancy should be
monitored closely for several months post-partum for hepatitis flares. Lifelong
follow up should be offered to HBsAg-positive women for monitoring of
complications such as liver disease and hepatocellular carcinoma.
DRUG STUDY
● Drug Name
Generic Name: Tenofovir Disoproxil Fumarate
Brand Name: Tenofo-B
Dosage 8 mg/kg Maximum: 300 mg
Route Oral administration
Frequency: Once a day

● Classification / Mechanism of Action

Classification:
Pharmacologic class: Nucleoside reverse transcriptase inhibitor (NRTI)
Therapeutic class: Antiretroviral
Mechanism of Action:Inhibits the activity of HIV-1 reverse transcriptase and HBV
reverse transcriptase by competing with the natural substrate deoxyadenosine 5'
triphosphate and, after incorporation into DNA,by DNA chain termination.
DRUG STUDY
● Indications
- Viread (tenofovir disoproxil fumarate) is an antiretroviral drug that is indicated in combination
with other antiretroviral agents for the treatment of HIV-1 infection in adults and pediatric
patients 12 years of age and older. Viread is also used to treat chronic hepatitis B.

● Contraindications
- Hypersensitivity to tenofovir disoproxil fumarate or its components

● Adverse Reactions
- Body as a Whole: Asthenia.
- CNS: Headache.
- GI: Nausea, vomiting, diarrhea, flatulence, abdominal pain, anorexia.
- Hematologic: Neutropenia.
- Metabolic: Increased creatine kinase, AST, ALT, serum amylase, triglycerides, serum glucose.
DRUG STUDY
● Nursing Responsibilities
Assessment and Drug effects:

- Lab tests: Monitor baseline and periodic renal function and LFTs; monitor periodically
serum electrolytes, and ABGs if lactic acidosis is suspected.
- Monitor for S&S of bone abnormalities (e.g., bone pain, stress fractures).
- Monitor closely patients receiving other nephrotoxic agents for changes in serum
creatinine and phosphorus. Withhold drug and notify physician for creatinine clearance
<60 mL/mins
- Withhold drug and notify physician if patient develops clinical or lab findings suggestive
of lactic acidosis or pronounced hepatotoxicity (e.g., hepatomegaly and steatosis even
in the absence of marked transaminase elevations).
DRUG STUDY
● Nursing Responsibilities
Patient and Family education:

- Take this drug exactly as prescribed. Do not miss any doses. If you miss a dose,
take it as soon as possible and then take your next dose at its regular time. If it is
almost time for your next dose, do not take the missed dose. Wait and take the
next dose at the regular time. Do not double the next dose.
- Report any of the following to physician: unexplained anorexia, nausea, vomiting,
abdominal pain, fatigue, dark urine.
- Do not breastfeed while taking this drug.
Care Plans
EXPECTED OUTCOME OF THE STUDY
● The patient will understand the procedure.
● The client will verbalize understanding of the disease process, prognosis, and potential
complications.
● The client will verbalize understanding of therapeutic needs.
● The client will initiate necessary lifestyle changes and participate in treatment regimen.
● The patient will follow the care plan and verbalize comprehension of the current situation.
● The client will identify and/or engage in activities appropriate to the situation.
● The client will prevent or minimize maternal injury.
● The client will understand the risk for preterm delivery.
● Transmission of Hepatitis B from infected mothers to infants will be reduced.
Care Plans
ASSESSMENT
● Assess for any unusual or persistent abdominal pain.
● Assess for vaginal bleeding or spotting.
● Assess for weight loss; poor muscle tone.
● Assess if the patient is having any symptoms such as nausea, vomiting, joint pain, or fever. • Assess
for changes in fetal movement.
● Assess if there is an increase in pelvic pressure.

INTERVENTION
● Initiating Patient Education and Health Teachings
- Identifies areas of lack of knowledge or misinformation and provides opportunity to give
additional information as necessary.
● Include the Patient in Decision Making
- Shared decision-making between the physician and the female patient regarding the planning
process could ease the patient's anxiety and further provide understanding of the current
condition and risk factors of the disease that could arise during pregnancy.
Care Plans
● Providing Emotional Support
- Contract with patient regarding time for listening. This will encourage discussion of feelings/concerns.
Establishing time enhances trusting relationship. Providing opportunity to express feelings allows
patient to feel more in control of the situation. Verbalization can decrease anxiety and depression and
facilitate positive coping behaviors.

● Managing Fatigue, Bed Rest and Physical Activity

- Increase activity as tolerated and demonstrate passive or active ROM exercises. Prolonged bed rest
can be debilitating. This can be offset by limited activity alternating with rest periods.

● Preventing Skin Breakdown and Maintaining Skin Integrity

- Observe skin for areas of redness, and breakdown. Early detection of problem areas allows for
additional intervention to prevent complications/promote healing. Increase activity as tolerated, and
demonstrate passive or active ROM exercises. Prolonged bed rest can be debilitating. This can be
offset by limited activity alternating with rest periods.
Care Plans
● Provide supplemental feedings and TPN if needed.
- May be necessary to meet caloric requirements if marked deficits are present and symptoms are
prolonged.

● Strictly Advice the Patient to Stop Smoking, Alcohol and Drug Abuse
- To prevent further illness and complications during the pregnancy. The use of alcohol, drugs, and
tobacco can affect a pregnant woman in a variety of ways. There is no safe amount of tobacco at any
time in pregnancy. Smoking doubles the risk in abdominal bleeding during the pregnancy and
delivery. Furthermore, if a patient is suffering from chronic liver disease, alcohol causes even more
damage.
 APPLICATION OF NX THEORIES
Using the theory of Lydia E. Hall for caring with the patient that have Hepatitis B.
This theory contains of three independent but interconnected 3C’s: the core,
the care and the cure. The core is the person or patient to whom nursing care is
directed and needed. The core has goals set by himself and not by any other
person. The core behaved according to his feelings, and value system. The care
circle explains the role of nurses. The cure is the attention given to patients by the
medical professionals.

Connecting Jean Watson’s theory of human caring to a patient with Hepatitis B

involves embracing the essence of her caring philosophy and applying it to the
specific needs and experiences of the patient. In the context of Hepatitis B, a
nurse or caregiver can embody Watson’s theory by demonstrating genuine
concern, empathy, and understanding towards the patient’s physical and
emotional struggles.
APPLICATION OF NX THEORIES

- By engaging in authentic communication, the caregiver can establish a

trusting and supportive relationship with the patient, promoting a sense of
safety and comfort during their healthcare journey. Moreover, applying
Watson’s transpersonal caring concept, the caregiver can respect the
patient’s unique cultural background and values while empowering them to
actively participate in their treatment decisions. This holistic approach to care
not only addresses the physical symptoms but also acknowledges the
emotional and psychological impact of the illness, thereby promoting healing
and well-being on multiple levels for the Hepatitis B patient.
References

- Pathophysiology Made Incredibly Easy (Incredibly Easy Series), 4th Edition by

Springhouse
- https://www.hepatitis.va.gov/hbv/screening-tests-interpretation.asp
- https://www.hepatitis.va.gov/hbv/index.asp https://pubmed.ncbi.nlm.nih.gov/24954675/
Thank You!

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