Increased in

Related to release of ALT from damaged liver, kidney, heart, pancreas, red blood cells, or skeletal muscle cells.

• AIDS (related to hepatitis B co-infection)
• Acute autoimmune hepatitis
• Biliary tract obstruction (passage of stone from common bile duct can produce moderate, transient increase)
• Budd-Chiari syndrome (acute)
• Burns (severe)
• Cirrhosis
• Fatty liver (e.g., acute fatty liver of pregnancy)
• HELLP syndrome of pregnancy; variant of pre-eclampsia (hemolysis, elevated liver enzymes, low platelet count)
• Hepatic cancer
• Hepatic infarction or necrosis
• Hepatitis (drug or toxin induced)
• Hepatitis, viral (acute or reactivation)
• Infectious mononucleosis
• Muscle injury from intramuscular injections, trauma, infection, and seizures (recent)
• Muscular dystrophy
• Myositis
• Nonalcoholic fatty liver disease
• Pancreatitis (acute)
• Pre-eclampsia
• Shock (severe)
• Substance use disorder (alcohol)
• Wilson disease (acute)

Decreased in

• Pyridoxal phosphate deficiency (related to a deficiency of pyridoxal phosphate that results in decreased production of ALT)

Potential Nursing Problems Assessment and Nursing Diagnosis

Before the Study: Planning and Implementation

Teaching the Patient What to Expect

• Discuss how this test can assist with evaluation of liver function and help identify liver disease.
• Explain that a blood sample is needed for the test.

After the Study: Implementation & Evaluation Potential Nursing Actions

Avoiding Complications

• The patient with cirrhosis should be carefully observed for the development of ascites, in which case fluid and electrolyte balance requires strict attention.

Treatment Considerations

• Monitor and trend labs: ALT. ALT levels may be lower than expected in liver disease attributable to substance use disorder (alcohol) related to a dietary deficiency of pyridoxyl-5–phosphate, an essential cofactor for ALT synthesis. Compare with LFTs (Alb, ALP, AST, TBil, DBil, TP) or other related studies to track the course of disease and response to treatment. Monitor blood alcohol and ammonia levels. If liver function is significantly damaged, PT will be prolonged and INR increased. Trend PT, INR, H&H, and ABG results.

Bleeding, Risk

• Complete frequent checks of vitals signs to monitor for changes outside of patient’s baseline.
• Monitor for bleeding symptoms (stools, emesis, bruising).
• Monitor for shortness of breath; administer oxygen as ordered.
• Administer ordered blood and blood products per facility protocol.

Confusion, Risk

• Observe for altered attention span, inability to give an accurate history, loss of concentration, inability to follow commands, behavior that is inappropriate or violent, inappropriate affect.
• Institute fall precautions, assist with activity, low bed position, restraints as necessary.
• Attempt reorientation to person, place, time, and purpose.
• Administer prescribed medications, lactalose, nonhepatic metabolized sedatives.
• Encourage family to assist in providing an emotionally stable environment.

Fluid Volume, Deficit

• Facilitate management of fluid volume deficit.
• Collaborate with health-care provider (HCP) regarding administration of IV fluids to support optimal hydration.
• Monitor laboratory values that reflect alterations in fluid status: K⁺, BUN, Ca, Cr, Hgb, and Hct.
• Administer replacement electrolytes, as ordered, to manage underlying cause of fluid alteration.
• Monitor urine characteristics (color, dark) and respiratory status.
• Monitor and trend vital signs.
• Perform a daily weight with strict intake and output.

Fluid Volume, Excess

• Facilitate management of fluid volume excess.
• Monitor for abdominal ascites, measuring and trending abdominal girth.
• Monitor and trend laboratory values: Alb, TP, and globulin.
• Assess for dehydration and increase fluids if present; fluid shifts from intravascular to extravascular can result in concerns related to hydration status.
• Administer ordered diuretics and monitor urinary output in response to therapeutic intervention.
• Trend vital signs and daily weight, and perform strict intake and output.
• Assess lungs for crackles, and evaluate for shortness of breath.
• Assess neck for jugular venous distention.
• Assess for dependent edema in hands and feet.

Gas Exchange, Risk

• Administer oxygen as ordered; monitor and trend pulse oximetry.
• Position in high Fowlers to maximize lung expansion.
• Obtain baseline abdominal girth, measure and mark each shift or as needed to monitor growth.
• Consider use of incentive spirometry.
• Encourage deep breathing and repositioning.

Gastrointestinal

• Perform nasogastric intubation to remove gastric secretions and decrease pancreatic secretions, which may result in autodigestion.
• Monitor nasogastric tube for patency and amount of drainage.
• Assess bowel sounds frequently.
• Measure and trend abdominal girth to monitor degree of abdominal distention.

Nutrition

• Facilitate management of insufficient nutrition.
• Measure weight daily.
• Evaluate for muscle wasting.
• Strictly monitor intake and output.
• Consider a careful nutritional history that includes cultural food preferences.
• Discuss frequent small meals with a diet high in calories from carbohydrates.
• Consider recommending diet and vitamin supplements an possible parenteral nutrition.
• Consider prescribed medications that may assist are antiemetics, and acid suppression agents.

Pain

• Refrain from activities that may increase pain.
• Apply heat or cold to the best effect in managing pain, and monitor pain severity.
• Collaborate with the patient in selecting the best pain management modality with consideration of cultural implications.

Skin, Risk

• Assess skin general condition noting any scratches, bruises, excoriation, rash.
• Monitor bilirubin level as a level greater than 3 mg/dL facilitates jaundice and increases itching risk.
• Discuss ways to protect the skin such as use of tepid water, alkaline soap, and emollient lotions.
• Suggest keeping short fingernails and the use of mittens to discourage scratching.
• Encourage use of loose-fitting cotton clothing, cool room temperatures, and administration of antihistamines can help decrease itching.

Nutritional Considerations

• Encourage a well-balanced diet that includes foods high in fiber.
• Consider that dietary recommendations will vary depending on disease condition and severity (e.g., a soft food diet is recommended if esophageal varices develop, fat substitutes are recommended if bile duct disease is diagnosed, and salt intake should be limited if ascites develop).
• Discuss how a diet low in protein and other foods such as onions, gelatin, or string beans can decrease ammonia levels and may improve cognitive function.
• Monitor and trend laboratory values that evaluate nutritional status (Alb, TP, K⁺), and collaborate with HCP on replacement strategies.
• Administer ordered enteral or parenteral nutrition and evaluate the patient’s response.
• Correlate laboratory values with IV fluid infusion, and collaborate with the HCP and pharmacist to adjust to patient needs.
• Collaborate with the patient to ensure adequate pain control.
• Monitor and trend vital signs for alterations associated with metabolic imbalances.

Clinical Judgement

• Consider why personal choices have resulted in poor health outcomes, and which interventions are most likely to result in adaptation to a more healthy lifestyle and improved health.

Followup Evaluation and Desired Outcomes

• Acknowledges contact information provided for the Centers for Disease Control and Prevention (www.cdc.gov /diseasesconditions).
• Understands information regarding causative factors of pancreatitis and liver disease, the disease process, and proactive lifestyle changes to better manage health.
• Accepts the importance of adhering to the medication regimen as prescribed to limit pancreatic secretions and decrease pain.