Nursing Notes: Hepatic Diseases & Intestinal Parasites in Children
Evidence-based comprehensive guide for nursing students
Introduction
Liver diseases and intestinal parasites represent significant health challenges in pediatric populations worldwide. These conditions require specific nursing knowledge and interventions tailored to the unique physiology and needs of children. This comprehensive guide explores the pathophysiology, clinical manifestations, diagnostic approaches, and evidence-based nursing interventions for these conditions.
Part 1: Hepatic Diseases in Children
Liver Structure and Function Review
The liver is the largest internal organ, located in the right upper quadrant of the abdomen. It performs over 500 essential functions including:
- Metabolism of carbohydrates, proteins, and fats
- Storage of vitamins and minerals
- Production of bile for digestion
- Detoxification of drugs and toxins
- Synthesis of clotting factors and plasma proteins
- Immune function and filtration of pathogens
Classification of Hepatic Diseases in Children
Hepatic Disease Classification Mind Map
Viral Hepatitis in Children
Viral hepatitis is a common cause of liver inflammation in children. The most common types affecting children are Hepatitis A, B, C, and E viruses, each with distinct epidemiology, transmission routes, and clinical courses.
| Characteristic | Hepatitis A | Hepatitis B | Hepatitis C | Hepatitis E |
|---|---|---|---|---|
| Transmission | Fecal-oral route | Blood, bodily fluids, perinatal | Blood, perinatal (less common) | Fecal-oral route, contaminated water |
| Incubation | 15-50 days | 60-180 days | 14-180 days | 15-60 days |
| Chronicity | No chronic infection | Can become chronic (90% in infants) | Can become chronic (50-80%) | No chronic infection (except in immunocompromised) |
| Clinical Features | Often asymptomatic in children, jaundice, fever, malaise | Often asymptomatic, can present with acute or chronic hepatitis | Usually asymptomatic, discovered incidentally | Jaundice, malaise, vomiting, more severe in pregnant women |
| Prevention | Vaccination, hygiene | Vaccination, screening | No vaccine, blood screening | Vaccine in some countries, clean water |
| Treatment | Supportive care | Antivirals if indicated | Direct-acting antivirals | Supportive care |
- A: Alimentary transmission (fecal-oral)
- B: Blood transmission (parenteral)
- C: Chronic potential (B & C)
- D: Detection via serology tests
- E: Epidemiological control measures (vaccines, hygiene)
Biliary Atresia
Biliary atresia is a rare but serious condition in which the bile ducts that carry bile from the liver to the gallbladder are blocked or absent. This leads to bile accumulation in the liver, causing progressive damage and ultimately liver failure if untreated.
Pathophysiology of Biliary Atresia
The exact cause remains unknown, but theories include:
- Immune-mediated bile duct destruction
- Viral infections (CMV, reovirus)
- Genetic factors
- Environmental toxins
Clinical Manifestations of Biliary Atresia
- Jaundice that persists beyond 2 weeks of life
- Acholic (clay-colored) stools
- Dark urine
- Hepatomegaly
- Failure to thrive
- Pruritus (in later stages)
- Portal hypertension (in advanced cases)
Clinical Pearl
The “Yellow Alert” campaign emphasizes the importance of investigating jaundice that persists beyond 14 days in term infants (or 21 days in preterm infants). Early diagnosis and surgical intervention for biliary atresia before 60 days of age significantly improves outcomes.
Diagnostic Approaches
- Laboratory tests: Elevated direct (conjugated) bilirubin, elevated liver enzymes (AST, ALT, GGT)
- Ultrasound: May show absent or abnormal gallbladder
- Hepatobiliary scintigraphy (HIDA scan): Assesses bile flow and excretion
- Liver biopsy: Gold standard for diagnosis, shows bile duct proliferation and fibrosis
- Intraoperative cholangiogram: Definitive test during surgical exploration
Management of Biliary Atresia
The primary treatment for biliary atresia is surgical intervention with the Kasai procedure (hepatoportoenterostomy), which aims to restore bile flow from the liver to the intestine.
Nursing Interventions for Biliary Atresia
Preoperative Care
- Monitor nutritional status and growth
- Administer vitamin supplements (A, D, E, K)
- Provide parent education and emotional support
- Monitor for signs of complications
Postoperative Care
- Monitor for surgical complications
- Assess for signs of improved bile flow (stool color)
- Administer antibiotics as prescribed
- Provide nutritional support (medium-chain triglycerides)
- Educate parents on medication administration
Important Considerations
Even with successful Kasai procedure, many children with biliary atresia will eventually require liver transplantation. Long-term monitoring for portal hypertension, liver failure, and growth is essential. Biliary atresia is the most common indication for pediatric liver transplantation.
Autoimmune Hepatitis
Autoimmune hepatitis (AIH) is an inflammatory liver condition characterized by the presence of circulating autoantibodies and elevated immunoglobulins. It can affect children of all ages, with a peak incidence in adolescent girls.
Types and Features
| Characteristic | Type 1 AIH | Type 2 AIH |
|---|---|---|
| Autoantibodies | ANA, ASMA, anti-SLA/LP | Anti-LKM1, anti-LC1 |
| Age at Onset | Adolescents and young adults | Younger children (2-14 years) |
| Gender Predilection | Female predominance (F:M = 4:1) | Strong female predominance (F:M = 9:1) |
| Clinical Presentation | Variable; can be acute or insidious | Often more severe, acute presentation |
| Response to Treatment | Generally good | May be more resistant to treatment |
Clinical Presentation of Autoimmune Hepatitis
The presentation can range from asymptomatic with incidental finding of elevated liver enzymes to acute liver failure. Common symptoms include:
- Fatigue and malaise
- Jaundice
- Abdominal pain
- Hepatomegaly and/or splenomegaly
- Extrahepatic manifestations: arthralgia, rash, amenorrhea
Management of Autoimmune Hepatitis
Treatment goals include remission of inflammation, prevention of fibrosis, and symptom management.
- First-line therapy: Corticosteroids (prednisone) with or without azathioprine
- Second-line therapy: Mycophenolate mofetil, cyclosporine, tacrolimus
- Liver transplantation: For cases of fulminant hepatic failure or end-stage liver disease
Nursing Considerations in Autoimmune Hepatitis
- Monitor for medication side effects (especially steroids)
- Provide education on immunosuppression risks
- Monitor growth and development
- Assess for signs of disease progression
- Support adherence to medication regimen
- Screen for psychological impacts of chronic illness
Liver Function Assessment
Nursing Assessment Parameters
Physical Assessment
- Skin color and scleral icterus (jaundice)
- Liver size and tenderness
- Spleen size
- Abdominal distention (ascites)
- Peripheral edema
- Spider angiomas
- Palmar erythema
- Neurological status (encephalopathy)
Laboratory Evaluation
- Liver enzymes: ALT, AST, ALP, GGT
- Bilirubin (total and direct)
- Synthetic function: albumin, prothrombin time
- Complete blood count
- Specific disease markers (viral serology, autoantibodies)
- Ammonia levels (if encephalopathy suspected)
- L: Lab abnormalities (elevated enzymes, bilirubin)
- I: Irritable mood changes (encephalopathy)
- V: Visible changes (jaundice, ascites)
- E: Eating difficulties (anorexia, nausea)
- R: Right upper quadrant pain/tenderness
Nursing Interventions for Hepatic Diseases
Evidence-Based Nursing Care
Nutritional Support
- High-calorie, adequate protein diet (adjust in encephalopathy)
- Fat-soluble vitamin supplementation (A, D, E, K)
- Medium-chain triglyceride formulas when indicated
- Frequent small meals if anorexia present
- Regular growth monitoring
Medication Management
- Careful medication administration
- Monitoring for drug interactions
- Assessment of hepatotoxicity risk
- Education on medication purpose and side effects
- Promotion of medication adherence
Complication Prevention
- Monitor for signs of bleeding (coagulopathy)
- Assess for fluid overload or dehydration
- Observe for signs of infection
- Screen for complications of portal hypertension
- Monitor neurological status (encephalopathy)
Psychosocial Support
- Age-appropriate education about the disease
- School liaison and accommodations
- Family education and support
- Addressing body image concerns
- Support groups and resources
Parent Education Points
- Recognition of worsening symptoms requiring medical attention
- Importance of medication adherence and regular follow-up
- Nutrition requirements and dietary restrictions
- Infection prevention strategies
- Growth and development monitoring
- School accommodations and activity modifications as needed
Part 2: Intestinal Parasites in Children
Introduction to Pediatric Intestinal Parasites
Intestinal parasites are organisms that live in the gastrointestinal tract and derive nutrients at the host’s expense. They represent a significant global health burden, particularly affecting children in resource-limited settings, but also occurring in developed countries.
Classification of Common Intestinal Parasites
Protozoa (Single-celled)
- Giardia lamblia
- Entamoeba histolytica
- Cryptosporidium parvum
- Blastocystis hominis
Helminths (Worms)
- Nematodes (roundworms): Ascaris, Enterobius (pinworm), hookworms
- Cestodes (tapeworms): Taenia saginata, Taenia solium
- Trematodes (flukes): Schistosoma, Fasciola
Epidemiology and Risk Factors
Intestinal parasites affect more than 3.5 billion people worldwide, with the highest prevalence in tropical and subtropical regions with inadequate sanitation, poor hygiene, and limited access to clean water.
Risk Factors for Parasitic Infections
- Poor personal hygiene, especially inadequate handwashing
- Lack of access to clean water and proper sanitation
- Walking barefoot on contaminated soil
- Consumption of undercooked or raw meat/fish
- Consumption of unwashed fruits and vegetables
- Attendance at daycare centers
- Immunocompromised status
- International travel to endemic areas
Transmission Routes Mind Map
Common Intestinal Parasites in Children
Overview
Giardia lamblia is a flagellated protozoan parasite that colonizes the small intestine, causing giardiasis. It’s one of the most common parasitic infections worldwide and a frequent cause of diarrheal illness in children.
Transmission & Life Cycle
- Fecal-oral route through ingestion of cysts
- Contaminated water (most common source)
- Contaminated food
- Direct person-to-person contact
- Excystation occurs in duodenum with trophozoites attaching to intestinal wall
Clinical Manifestations
- Acute or chronic diarrhea (often foul-smelling, greasy)
- Abdominal cramps and bloating
- Nausea and anorexia
- Weight loss/failure to thrive
- Fatigue
- May be asymptomatic (especially in endemic areas)
Diagnosis & Treatment
- Diagnosis: Stool examination for cysts/trophozoites, stool antigen tests, PCR
- Treatment:
- Metronidazole (first-line therapy)
- Tinidazole (alternative)
- Nitazoxanide (FDA-approved for children)
Nursing Considerations
- Monitor hydration status and electrolyte balance
- Assess nutritional status and growth parameters
- Educate on medication administration and side effects
- Implement infection control measures to prevent transmission
- Provide education on prevention through hand hygiene and water safety
Overview
Pinworm infection (enterobiasis) is the most common helminthic infection in the United States and other temperate regions. It particularly affects school-aged children and can spread easily within families and institutionalized settings.
Transmission & Life Cycle
- Ingestion of eggs through contaminated hands, food, or objects
- Auto-infection through hand-to-mouth contact after scratching
- Adult worms live in cecum and adjacent bowel
- Female worms migrate to perianal area at night to lay eggs
- Eggs mature within 6 hours and become infective
Clinical Manifestations
- Perianal/perineal itching (especially at night)
- Sleep disturbances
- Irritability
- Secondary bacterial infections from scratching
- Occasionally, migration to female genital tract
- Many infections are asymptomatic
Diagnosis & Treatment
- Diagnosis: Scotch tape test (applied to perianal area in morning before bathing)
- Treatment:
- Pyrantel pamoate (single dose, repeat in 2 weeks)
- Mebendazole (single dose, repeat in 2 weeks)
- Albendazole (single dose, repeat in 2 weeks)
- Treatment of all household members often recommended
Clinical Pearl
The “flashlight test” can sometimes reveal adult pinworms in the perianal area when performed at night (2-3 hours after the child has fallen asleep), as this is when female worms typically migrate to lay eggs.
Nursing Considerations
- Educate on proper collection technique for Scotch tape test
- Teach importance of hand hygiene and nail trimming
- Advise daily bathing and regular underwear/bedding changes
- Emphasize importance of treating all household members
- Address any psychosocial concerns (embarrassment, stigma)
Overview
Ascariasis is the most common helminthic infection globally, affecting an estimated 800 million to 1.2 billion people. It’s caused by Ascaris lumbricoides, the largest intestinal nematode parasite of humans, which can grow to 15-35 cm in length.
Life Cycle of Ascaris
Clinical Manifestations
- Pulmonary phase:
- Löffler’s syndrome (cough, wheeze, dyspnea)
- Eosinophilic pneumonitis
- Fever
- Intestinal phase:
- Abdominal pain and distention
- Nausea and vomiting
- Anorexia and weight loss
- Malnutrition
- Complications:
- Intestinal obstruction
- Biliary obstruction
- Pancreatic duct obstruction
- Appendicitis
Diagnosis & Treatment
- Diagnosis:
- Stool microscopy for eggs
- Occasionally, adult worms passed in stool
- Imaging studies for complications
- Eosinophilia in blood during migration
- Treatment:
- Albendazole (single dose)
- Mebendazole (single dose or 3-day course)
- Pyrantel pamoate (single dose)
- Surgical intervention for obstruction
Warning Signs Requiring Immediate Attention
- Severe abdominal pain, vomiting, and distention (intestinal obstruction)
- Jaundice and right upper quadrant pain (biliary obstruction)
- Severe respiratory distress during pulmonary phase
- Passage of worms from mouth or nose (rare but distressing)
Nursing Considerations
- Monitor nutritional status and growth parameters
- Observe for complications, especially in heavy infections
- Provide education on hand hygiene and food safety
- Address psychosocial impact (fear, disgust) if worms are visible
- Educate on proper stool sample collection
- Emphasize preventive measures for communities in endemic areas
Comprehensive Assessment for Suspected Giardiasis
| Assessment Area | Key Questions/Observations | Significance |
|---|---|---|
| History |
|
Identifies exposure risk factors |
| Stool Characteristics |
|
Distinguishes giardiasis from other causes of diarrhea |
| Nutritional Assessment |
|
Evaluates impact on nutritional status and malabsorption |
| Hydration Status |
|
Assesses severity and complication risks |
| Associated Symptoms |
|
Supports diagnosis and evaluates systemic impact |
Diagnostic Approaches for Intestinal Parasites
Direct Methods
- Stool examination:
- Direct wet mount (for motile trophozoites)
- Concentration techniques
- Permanent stained smears
- Multiple specimens may be needed (3 samples)
- Scotch tape test: For pinworm eggs
- String test (Entero-Test): For Giardia and others
- Endoscopy with biopsy: For suspected tissue invasion
Indirect Methods
- Immunologic tests:
- Enzyme immunoassays (EIA)
- Rapid diagnostic tests
- Direct fluorescent antibody (DFA)
- Molecular methods:
- PCR-based assays
- Multiplex PCR panels
- Serologic tests: For tissue-invasive parasites
- P: Pattern of bowel movements and stool characteristics
- A: Alimentary symptoms (abdominal pain, bloating, nausea)
- R: Risk factors and exposures
- A: Appetite and nutritional status
- S: Systemic manifestations (fever, fatigue, weight loss)
- I: Impact on daily activities and quality of life
- T: Travel history and environmental exposures
- E: Education needs regarding prevention and treatment
Management of Intestinal Parasitic Infections
Nursing Care for Children with Intestinal Parasites
Assessment
- Comprehensive history and physical examination
- Hydration status evaluation
- Nutritional assessment
- Growth monitoring
- Identification of high-risk behaviors
Interventions
- Administration of antiparasitic medications
- Management of symptoms (diarrhea, pain)
- Rehydration therapy if needed
- Nutritional support
- Implementation of infection control measures
Education
- Proper medication administration
- Hand hygiene techniques
- Food and water safety
- Prevention of re-infection
- Environmental sanitation
Medication Administration Considerations
| Medication | Common Use | Nursing Considerations |
|---|---|---|
| Metronidazole | Giardia, Entamoeba |
|
| Albendazole | Most helminths |
|
| Mebendazole | Pinworms, Ascaris, hookworms |
|
| Nitazoxanide | Giardia, Cryptosporidium |
|
| Pyrantel pamoate | Pinworms, Ascaris, hookworms |
|
Prevention of Intestinal Parasites
Parent and Child Education for Prevention
Personal Hygiene
- Before eating or preparing food
- After using the toilet
- After changing diapers
- After handling pets
Food and Water Safety
Environmental Controls
- Proper disposal of human waste
- Regular cleaning of toilet facilities
- Avoiding barefoot walking in endemic areas
- Control of flies and other vectors
- Proper washing of shared toys in childcare settings
Community Health Nursing Approach to Parasitic Infections
Addressing intestinal parasites effectively requires a comprehensive community health approach, especially in endemic areas or in settings like daycares where transmission can be rapid.
- Surveillance: Monitoring for outbreaks in childcare settings or communities
- Mass treatment: In some endemic areas, periodic deworming campaigns
- Environmental interventions: Improving water supplies, sanitation facilities
- Health education: School-based programs on hygiene and prevention
- Integration: Combining parasite control with other child health initiatives
Study Resources
Key Points: Hepatic Diseases
- Viral hepatitis in children often presents differently than in adults, with many cases being asymptomatic
- Biliary atresia requires early intervention (ideally before 60 days) for best outcomes
- Autoimmune hepatitis has two main types with different autoantibody profiles
- Assessment of liver disease includes physical findings, laboratory values, and imaging
- Nutritional support is a critical component of liver disease management in children
- Early recognition of complications can prevent progression to liver failure
Key Points: Intestinal Parasites
- Intestinal parasites are classified as protozoa (single-celled) or helminths (worms)
- Transmission occurs primarily through fecal-oral route, contaminated food/water, or soil
- Clinical manifestations range from asymptomatic to severe, depending on parasite load and host factors
- Diagnosis often requires specialized stool examinations, sometimes with multiple samples
- Treatment is specific to the parasite identified and may require repeat dosing
- Prevention focuses on hygiene, food/water safety, and environmental controls
NCLEX-Style Practice Questions
1. A 4-year-old child is brought to the clinic with complaints of perianal itching that worsens at night. The mother reports the child has been irritable and not sleeping well. The nurse suspects:
A. Giardiasis
B. Enterobiasis (pinworm infection)
C. Ascariasis
D. Hepatitis A infection
Answer: B. Enterobiasis (pinworm infection)
2. The nurse is assessing a 2-month-old infant with jaundice. Which of the following findings would be most concerning for biliary atresia?
A. Dark yellow urine
B. Clay-colored stools
C. Mild hepatomegaly
D. Elevated unconjugated bilirubin
Answer: B. Clay-colored stools
3. When providing discharge instructions to the parent of a child diagnosed with giardiasis, which of the following should the nurse include?
A. “Your child should avoid swimming for at least 2 weeks after treatment.”
B. “This infection will resolve without treatment in most healthy children.”
C. “A single dose of medication will eliminate the infection completely.”
D. “This infection can only be contracted through person-to-person contact.”
Answer: A. “Your child should avoid swimming for at least 2 weeks after treatment.”
4. A child with autoimmune hepatitis is prescribed prednisone. The nurse should monitor for which of the following side effects?
A. Hypothermia
B. Hypoglycemia
C. Growth suppression
D. Decreased appetite
Answer: C. Growth suppression