Vol.3, No.4, 228-232 (2011) Health
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Care strategies for patients with severe drug-induce d
Tingting Zhang, Yuan Liu, Qingqing Xu,Yaping Han*, Jun Li*
Department of Infectious Disease, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China;
*Corresponding Author: asian_peace@sina.com, prof.lijun@gmail.com; these authors contributed equally to this study.
Received 22 February 2011; revised 2 March 2011; accepted 14 March 2011.
Objective: The aim of this study is to analyse
the clinical characteristics of 32 patients with
severe drug-induced hepatitis, reinforce the
practice of unique nursing and holistic nursing,
improve the therapeutic effect, reduce the pa-
tients’ mortality, and increase their quality of life.
Methods: W e gi ve patients indiv idualized dietary
guidance, medication nursing, and psychologi-
cal care according to the characteristics of se-
vere hepatitis and its complications, using com-
prehensive medical treatment and combined
signs of Traditional Chinese Medicine. Results:
Overall, 22 (68.8%) out of 32 cases were im-
pro ved, 8 (25.0%) cases died, and 2 (6.2 %) cases
were discharged of free will. In addition, the av-
erage hospital stay was 28.75 days. Conclusion:
This study indicates that dietary guidance for
the patients with severe drug-induced hepatitis
varies with the individual. The result embodies
the concept of Traditional Chinese Med icine that
different treatment for the same disease and
different diet for the same disease. Special
nursing enriches the connotation of holistic
nursing. Both of them are vital for improving the
survival rate and promoting rehabilitation of
patient s with severe drug-induced hepatitis.
Keywords: Drug-Induce d L iv er In ju ry; S eve re
Hepatitis; Diet Nursing; Holistic Nur sing
Liver is the most important metabolic organ. It is the
primary place of drug metabolism and the major target
organ of poison reaction by drug. In recent years, as the
drug type augments, patients with drug-induced liver
disease have increased steadily. Among these cases, ad-
verse drug reaction accounts for 0.6% of the hospitalized
patients and drug-induced liver failure accounts for 0.3%
of the total inpatient mortality [1 ].Therefore, we took the
positive control of multiple organ failure caused by se-
vere hepatitis according to the clinical features of the
disease and the specific circumstances of different pa-
tients. At the same time, through various changes of the
tongue in traditional Chinese medicine, an appropriate
diet care strategy was formulated to play a positive and
effective role in reducing complications and improving
the survival rate and quality of life.
2.1. Clinical Data
2.1.1. General Information
From December 2002 to December 2008 our hospital
let in 32 cases of severe hepatitis complicated with
drug-induced liver injury, including 13 males and 19
females who se aver age ag e was 42, ag ing from 18 to 62.
All of them had medication history or history of expo-
sure to toxicants, including 29 (90.6%) cases of severe
chronic hepatitis and 3 (9.4%) cases of sub-acute severe
hepatitis. Clinical symptoms included extreme fatigue,
anorexia, dermatic and scleral icterus, dark urine, pro-
gressive jaundice, associated with fever, skin itching,
even oliguria, ascites or gastrointestinal bleeding, he-
patic encephalopathy, hepatorenal syndrome and distur-
bance of consciousness performance. Among 32 patients,
5 cases took anti-thyroid drugs for hyperthyroidism; 8
patients took medication for skin treatment; 3 cases were
treated with anti-tumor chemotherapy; 1 case took anti-
TB drugs; 3 cases took antibiotics; 2 cases took anti-
hypertensive; 6 patients took Chinese herbal medicine; 1
case once contacted with toxic chemicals complicated
with skin lesions and 3 patients were allergic to other
drugs accompanying skin lesions.
2.1.2 The Diagnostic Criteria
Classification and diagnosis of drug-induced hepatitis
T. T. Zhang et al. / Health 3 (2011) 2 28-232
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
was based on Maria score criteria for drug-induced liver
injury [2], the diagn osis of severe hepatitis was based on
diagnostic criteria revised by the tenth National Confer-
ence on Viral Hepatitis and Liver in 2000 [3].
2.2. General Nursing
2.2.1. Close Observation of Condition
Close observation of patients’ awareness and con-
sciousness: For mild and moderate hepatic coma patients
who had disturbance of consciousness, personality and
behavioral disorders, we should increase inspection, pro-
mptly notify the doctor, give early diagnosis and imme-
diate treatments; patients with Dysphoria took a fixed-
bedside barriers ,and were cared by hand to prevent the
occurrence of self-harm or falling off bed; depth hepatic
coma patients were regularly checked with temperature,
pulse, respiration, blood pressure, urine output changes.
For patients with retention catheterization, their records
of color and volume of urine were kept, while we disin-
fected urethral orifice twice a day and regularly replaced
urine bag and catheter, in order to reduce the incidence
rate of secondary infection of urinary tract. Regularly
ob- serve the changes in peripheral circulation of limbs,
turn the body over and do passive exercise to limbs in
time to prevent the formation of pressure sores, and to
reduce the development of venous thrombosis and mus-
cle atrophy.
2.2.2. Fever Nursing
Some of the drug-induced liver injury patients com-
plicated with severe hepatitis would develop fever since
a large number of liver cells underwent rapid necrosis.
For the same patients with a temperature below 39˚C,
we gave physical cooling, and encouraged them to drink
warm water; for patients whose body temperature was
above 39˚C, we used antipyretic drugs as directed,
timely replaced with clean underwear to keep the skin
clean and dry, and prevent pathogenic microorganisms
break when patients caught cold because they were wet
with sweat.
2.2.3. Medication Nursing
For severe drug-induced hepatitis patients, especially
those had liver injury associated with immune patho-
genesis, their livers not only seriously damaged, while
might also be in an over stressing state. Therefore, on the
one hand, we should weigh the advantages and disad-
vantages before using drugs. During the process of car-
rying out doctor’s order, we should carefully check and
timely advice doctors to avoid the use of specific drugs
which could lead to liver injury, such as azithromycin,
methimazole, ketoconazole, etc. On the other hand, we
should observe patients’ response to treatment carefully
when we made bedside rounds, timely communicate with
patients and their families to tell them the role of drugs
used in order to obtain the trust and cooperation of pa-
tients, and prevent new liver injury caused by abuse or
improper use of drugs. The effective drugs for drug-
induced liver injury should improve symptoms of toxic
liver injury, accelerate bile acid transport, promote bili-
rubin metabolism and repair liver cells, such as reduced
glutathione, ademetionine, hepatocyte growth-promoting
facors, alprostadil, etc.
2.2.4. Artifici a l L iver Treatment Nursing
Patients with severe drug-induced liver injury gener-
ally had significantly decreased immune function. We
used artificial liver support system and exchanged pa-
tient plasma with the fresh plasma of healthy people.
Toxic substances above middle molecular mass could be
cleared from the body and coagulation factors, albumin
and other substances were added to improve the internal
environment quickly and promote the regeneration of
liver cells. However, during the course of treatment, or
within 2 hours after it, a small number of patients would
have allergy symptoms, such as chills, fever, perioral
numbness, skin itching and hives, or even a drop in blood
pressure, laryngeal edema. Some patients might have
bleeding and infection in the puncture site. Nurses must
do ideological work among patients and well prepare
operational technique before the artificial liver treatment.
For example, they informed patients and their families of
the purposes, principles, precautions before and after
treatment and possible side effects, and appropriately
allayed their anxiety and fear. The operator must have
Skillful puncture technique, master instrumentation,
strictly observe variety state intraoperative and postop-
erative, give timely treatments to symptoms, and ac-
cording to the serum bilirubin (TBIL) level, prothrombin
activity (PTA), cholinesterase (CHE), total cholesterol
(TC) and the results of the rapid changes in T lympho-
cyte subsets [4], adjust the treatment opportunely, com-
municate with patients and their families in time to
strengthen their idea of overcoming the disease.
2.2.5. Psychological Care
For drug-induced liver injury patients complicated
with severe hepatitis, disease progressed rapidly. Espe-
cially among young women with deep jaundice, they com-
monly had the consciousness of worry or even panic.
Therefore, we talked with patients on our own in itiative,
took care of them as family members, established feel-
ings of kindness and trust for nursing staff among pa-
tients, to keep patients in an active, optimistic, coopera-
tive state.
T. T. Zhang et al. / Health 3 (2011) 2 28-232
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
2.3. Unique Care
2.3.1. The Principles of Diet Nursing
Diet nursing of severe hepatitis was important during
the medical treatment and rehabilitation process. Dietary
principle was not to aggravate the burden of liver, but to
make liver rejuvenesce. According to theory of Chinese
Traditional Medicine, for each indiviudal, we developed
a low-protein, low-fat, moderate-carbohydrate vitamin-
rich and low residue semifluid diet which was easy to
digest and can promote absorption. We also made a list
of appropriate food and food to be avoided, which fa-
cilitated memory and cooperation for patients’ families.
For sane patients, we usually encouraged them to eat
small, frequent meals and have a liquid or semi-liquid
diet, these patients needed approximately 1400-1600
kcal per day, which came from 20 g protein, 30 grams
fat, around 280 g carbohydrate. Patients with ascites or
renal dysfunction should control sodium and water in-
take. Gastrointestinal bleeding patients must fast 48-72
hours after the bleeding stopped and then they could be
given a small amount of low-temperature, no-residue
liquid diet which gradually transited to a semi-liquid diet.
Eat slowly and avoid hard, sticky, excitant food or a
residue diet. Hepatic coma or pre-hepatic coma patients
require a few more calories than common patients. We
should focus on the control of protein intake, appropri-
ately increase the amount of carbohydrates, use nasal
feeding liquid diet and intravenous nutrition if necessary.
Patients associated with glucose metabolism disorder
should change carbohydrate intake timely. A proper diet
not only facilitated normal bowel movements, but also
ensured daily nutrition supply to the body, promoted the
recovery from the illness and was of great significance
to reduce complicatio ns.
2.3.2. Recipe for Different Symptoms
Traditional Chinese Medicine is known as “medicine
that can be used both as food or medicine”, which means
that most of the traditional Chinese medicine derived
from food .It is said that the diet cures more than the
doctor and better wait on the cook than on the doctor.
The Tongue picture is one of the bases of treatment
based on symptom differentiation and signs to identify
etiology. Disease in the viscera and bowels is usually
reflected by the tongue picture. Changes of tongue coat
reflect the depth of pathogenic factors, while changes of
tongue substance often reflect the rise and decline of qi
and blood. Patients’ tongue coat changes more rapidly.
We should observe the changes of tongue coat daily and
adjust the recipe of patients appropriately. Humid Heat Stagnation Type
Patients with red tongue substance and yellow greasy
tongue coat, bitter taste to the mouth and dry pharynx,
general fever , dark less urine ,uncomfortable defecation,
often use capillaris Capsella porridge, spaghetti with
yam and duck breast, snail soup, watermelon peel rind
bean soup, water chestnuts cane juice, Chin ese small iris
to clear away heat and promot diuresis. Hepatosplenic Disorder, Incoordination
between the S pleen and Stomach Ty pe
Patients with pale tongue substance and thick greasy
tongue coat, chest and hypochondrium discomfort, no
appetite, abdominal distention after eating, disorders of
defecation, use coicis semen rice gruel, dried tangerine
peel yams duck breast porridge, lotus root Hawthorn
juice, shepherd’s purse, to disperse the depressed liver-
energy and regulate vital energy, invigorate spleen and
stomach. Hepatic and Renal Yin Deficiency Type
Patients with red tongue substance, less saliva, less or
peeling tongue coat, dark and gloomy face, emaciation,
sultriness and dry mouth, gingival bleeding, urine defi-
ciency, use loach sp aghetti, sea cucumbers Capsella por-
ridge, capillaris Capsella yams juice, chrysanthemum
leaves to nourish liver and kidney; insomnia patients
with pulmonary tuberculosis and excessive phlegm, add
honeysuckle lily soup and so on to calm the nerves and
clean away the lung-heat. Spleenic and Renal Yang Asthenia Type
Patients with pale tongue substance, smooth white
tongue coat, abdominal fullness and distention, abdomen
shaped like frogs, tired and afraid of cold, cold limbs and
edema, urine deficiency, watery stool, choose red dates
millet gruel, duck breast and shepherd’s purse porridge,
Chinese goosebeery and hawthorn juice, spinach, etc., to
warm spleen and kidney, disslove qi and promote diure-
sis. Deficiency of Both Qi and Blood Type
Patients with deep red tongue substance and without
tongue coat, tongue curl and atrophy or dry and scorched,
looking gloomy, tired and fatigue, hepatosplenomegaly,
scaly skin, itching, most of whom were seriously sick,
use red bean rice gruel, shepherd’s purse porridge, lotus
root and hawthorn juice, to replenish the vital essence
and remove heat, supplement qi and activate blood cir-
2.3.3. The Role of Diet Nursing in the
Prevention of Complications
In clinical practice, for patients who took corticoster-
oid drugs for treatment, first, we evaluated the risk fac-
tors for bleeding, in addition to the preventive use of
T. T. Zhang et al. / Health 3 (2011) 2 28-232
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
gastric mucosal protection drugs. Dietary regulation was
of significance in preventing the occurrence of stress
ulcer. We usually gave a small amount of high-quality
low-protein, high-carbohydrate, low-fat semi-liquid or
liquid diet to the patients; while for hepatic encephalo-
pathy or pre-hepatic encephalopathy patients with high
blood ammonia concentration, we not only strengthened
the observation of the consciousness and awareness of
patients, but also strictly limited the patients’ intake of
animal proteins. We determined the supply of plant pro-
teins according to clinical symptoms and ammonia lev-
els, which was not only one of the most important meas-
ures to control ammonia increase and to prevent hepatic
encephalopathy, but also the key point of prognosis for
patients who ha d alrea dy had hepati c coma.
Among all the 32 patients who had been treated, 10
were treated with the artificial liver support system, 3
patients who got skin lesions were treated with corticos-
teroids, through a reason able diet nursing combined with
immunological regulation and comprehensive treatment.
No case had stress ulcer. As a result, in 22 (68.8%) cases
we had seen improvements after treatment, in 8 (25.0%)
cases the patients died, and in 2 (6.2%) cases the patients
abandoned the treatment and discharged of free will. The
average hospital days of stay were 28.75.
Drug-induced liver injury is an iatrogenic disease
caused by drug or its metabolites. In the United States,
the most common medicine that can cause severe hepati-
tis is acetaminophen that belongs to antipyretic and an-
algesic class [5]. In China, anti-tuberculosis drugs and
Chinese herbal medicine are the most common cause
[6-9]. In recent years, the number of drug-induced liver
hepatitis cases increases rapidly [10] leading to the high
concern of society. Liver has a special anatomy location,
which undertakes internal blood filtation and external
detoxification of intestinal products [11], especially, oral
drugs which are absorbed via the gastrointestinal tract
carry out biotransformation and metabolism in liver.
Hence, drug concentration is significantly higher in liver
than in blood and other organs. Poor Daily diet not only
can impede rehabilitation but also has the potential of
increasing the degree of liver injury, causing hepatic
encephalopathy, upper gastrointestinal bleeding and other
serious complications. Therefore, appropriate diet can
provide proper nutrition to the body and promote the
repair and regeneration of liver cells.
Zhang zhongjing, the r enowned Chinese doctor of the
Eastern Han Dynasty, said in “Synopsis of Golden Cham-
ber”: “The taste of the food can help us get away from
diseases, which can also be harmful to the body, if it is
appropriate, it will benefit us, otherwise people will get
sick.” Chinese classic work “Huang Di Nei Jing” also
states: “Poison attacks evil, the five common cereals
support us, five kinds of fruits help us, five kinds of
animals benefit us, and five kinds of vegetables supple-
ment us, eat when the taste of food is appropriate to re-
plenish essence.” They indicated that improper food and
drug intake are closely related to the occurence of dis-
ease. There are more complications in patients with
drug-induced severe hepatitis, and especially gastroin-
testinal bleeding and hepatic encephalopathy are most
common. For these patients, the diet principle developed
by us was: combining patients’ tongue picture, select
food that was rich in nutrition and had a effect of
liver-protecting, lowering the transaminase, treating
jaundice, preventing hemorrhage and hepatic coma.
Moreover, the quantity of good quality protein which
produced low nitrogen was limited, in order to improve
hepatic steatosis, reduce nitrogen resources, and improve
the immune function of patients; To improve patients’
appetite and ensure heat supply to body for patients
whose jaundice had not resolved, it was recommended to
use a small amount of vegetable oil in cooking and avoid
fried food; consume carbohydrates in moderation to pro-
mote the use of amino acids in liver; and sufficient vita-
min supply to strengthen detoxification function of liver
and help liver cells repair. In the early stage of disease,
semi- fluid or soft rice which was easy to digest and nu-
tritious was selected. During comvalescent stage, a nor-
mal diet which was a less amount but had a good quality
was chosen to reduce the burden of the liver as the pri-
mary consideration. We made the use of the theory of
symptoms differentiation related to traditional Chinese
medicine, and developed personalized recipe for the pa-
tients with drug-induced severe hepatitis. A rational and
scientific diet not on ly could enhance the patients’ ab ility
to resist disease, but also was of great significance to
prevent gastrointestinal bleeding and hepatic encephalo-
Our Traditional Chinese Medicine is extensive and
profound, in clinical practice. With the reduction of pa-
tient mortality and improvement of the life quality of
patients as a starting point, we cooperated with medical
workers, inspected personnel and multi-force. We took
Western medicine as the main treatment which was sup-
plemented by basic nursing, diet nursing, holistic nurs-
ing and psychological care, and reinforced various as-
pects to adjust immune function of patients, gradually
restore the balance between entrails, qi and blood, yin
and yang, so that the ineffective treatment rate of pa-
tients in this group was significantly lower than the 63.6%
T. T. Zhang et al. / Health 3 (2011) 2 28-232
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
reported at home [8]. This result indicated that the ther-
apy and care strategies using traditional Chinese medi-
cine together with western medicine and coordinating
exterior-interior relationship had a positive impact on the
outcome of patients with severe drug-induced hepatitis.
We thank Zhang Zhengfang Director for her warm guidance of die-
tary regulation for patients. This study was supported by the National
Natural Science Foundation grant (30,972,618), the funding for Ji-
angsu Province Key Laboratory (200707) and key medical personnel
in Infectious Diseases (RC2007049) and the funding for Guiding Re-
search Projects of Health Department of Jiangsu Province, China
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