Increased in

AST is released from any damaged cell in which it is stored, so conditions that affect the liver, kidneys, heart, pancreas, RBCs, or skeletal muscle and cause cellular destruction demonstrate elevated AST levels.

• Angina pectoris (acute)
• Biliary tract obstruction
• Burns (severe, second/third degree)
• Cardiac dysrhythmias
• Cardiac catheterization, angioplasty, or surgery
• Cirrhosis
• Exercise (vigorous)
• Heart failure
• HELLP syndrome of pregnancy; variant of pre-eclampsia (hemolysis, elevated liver enzymes, low platelet count)
• Hemolytic anemias
• Hepatic cancer
• Hepatic infarction or necrosis (acute, initial)
• Hepatitis (drug or toxin induced)
• Hepatitis, viral (acute or reactivation)
• Infectious mononucleosis
• Infarction (kidney, liver)
• Muscle diseases (e.g., dermatomyositis, dystrophy, gangrene, polymyositis, trichinosis)
• Myocardial infarction (acute)
• Pancreatitis (acute)
• Reye syndrome
• Substance use disorder (alcohol)
• Trauma (related to injury or surgery of intestines or liver and other sites where AST is found)

Decreased in

• Hemodialysis (presumed to be related to a corresponding deficiency of vitamin B₆ observed in hemodialysis patients)
• Pregnancy (related to increased demand)
• Uremia (related to a buildup of toxins that modify the activity of coenzymes required for transaminase activity)
• Vitamin B₆ deficiency (e.g., beriberi, malnutrition) (related to the lack of vitamin B₆, a required cofactor for the transaminases)

Potential Problems: Assessment & Nursing Diagnosis/Analysis

Before the Study: Planning and Implementation

Teaching the Patient What to Expect

• Explain that this test can assist in assessing liver function.
• Explain that a blood sample is needed for the test.

Potential Nursing Actions

• Measuring and trending abdominal girth can assist in monitoring the progression of ascites with liver disease.

After the Study: Implementation & Evaluation Potential Nursing Actions

Avoiding Complications

• The patient with cirrhosis should be observed carefully for the development of ascites, in which case fluid and electrolyte balance requires strict attention.
• Bleeding can be a concern. Symptoms of bleeding risk include cool extremities, delayed capillary refill, decreased distal pulses, altered mental status, hypotension, tachycardia, decreased level of consciousness, easy bruising, hematemesis, weakness, shortness of breath, bloody or black stools. PT may be prolonged greater than 13.5 sec.
• Interventions/actions related to bleeding risk include the following: Obtain frequent vital signs to monitor for changes outside of patient baseline. Monitor for bleeding symptoms (stool, emesis, bruising). Monitor for shortness of breath. Administer oxygen as ordered. Administer ordered blood or blood products per facility protocol.
• Gas exchange can be a concern. Symptoms of gas exchange risk include orthopnea, dyspnea, shortness of breath at rest or with activity, pallor, shallow respirations, cyanosis, altered blood gas, increasing abdominal girth.
• Interventions/actions related to gas exchange risk include the following: Administer ordered oxygen with use of pulse oximetry to monitor oxygenation. Consider use of incentive spirometry and encourage deep breathing and repositioning. Position in high Fowler to maximize lung expansion. Obtain baseline abdominal girth, measure and mark each shift or as needed to monitor growth.
• Skin integrity can be a concern. Symptoms of altered skin integrity include reports itchy skin (dermatitis/pruritis), chronic scratching, dry scaly skin, yellow skin and sclera, visible scratch marks with or without scabbing, rash.
• Interventions/actions related to skin risk include the following: Assess the general condition of the skin. Note any scratches, bruises, excoriation, rash. Monitor bilirubin level (a level greater than 3 mg/dL facilitates jaundice and increases itching risk). Suggest that fingernails be kept short. Suggest the use of mittens to discourage scratching. Discuss how loose-fitting cotton clothing, cool room temperatures, and administration of antihistamines can help decrease itching. Discuss ways to protect the skin, such as use of tepid water, alkaline soap, and emollient lotions. Assess for easy bruising.

Treatment Considerations

General

• Monitor and trend AST. Compare with LFTs (ALT, Alb, ALP, TBil, DBil, TP) or other related studies to track the course of disease and response to treatment. Note that PT will be prolonged and INR increased if liver function is significantly damaged. Monitor and trend gamma-glutamyltranspeptidase (GGT), bilirubin, total protein, iron, electrolytes, folic acid, vitamin K, and thiamine in the presence of hepatitis.

Activity

• Interventions/actions related to decreased activity include the following: Assess normal baseline level of activity, nutritional status, and cardiopulmonary status prior to activity. Use pulse oximetry to monitor oxygen status with activity. Assess the need for assistive equipment prior to activity (walker, cane, etc.). Consider fall precaution strategies (gait-belt, 1:1 assistance). Monitor sleep pattern to assess level of fatigue.

Fatigue

• Interventions/actions related to fatigue include the following: Obtain a history of normal activity level for baseline comparison. Teach how to manage energy effectively and pace activities. Encourage periods of rest to conserve oxygen and decrease metabolic demands. Assess activity tolerance and increase as tolerated. Facilitate spacing of planned activities away from meal times to prevent exhaustion affecting nutritional intake. Encourage small, frequent meals. Keep frequently used items within reach. Administer ordered acid suppression medications, antiemetics, and antidiarrheals. Limit visitors to prevent exhaustion as socialization contributes to fatigue.

Safety Considerations

• Fall risk can be a concern. Symptoms of fall risk include unsteady gait, decreased ability to complete activities of daily living independently, decreased visual acuity or hearing, fatigue, weakness, difficulty following instructions, improper assistive device use, altered color perception, changed center of gravity, delayed response and reaction times. Assess fall risk on admission, transfer, post-fall, and change of condition.
• Interventions/actions related to fall risk include the following: Follow established organizational fall prevention protocols. Identify previous fall history and frequency. Move the patient closer to the nurses' station for easier observation. Enlist the support of reliable family members as partners in preventing falls. Assess for disease-related symptoms such as orthostatic hypotension or urinary incontinence. Review medications to identify any pharmacological contributors to fall risk.
• Environmental factors that decrease fall risk include moving frequently used items close to the bed to decrease desire to get up. Answer call lights in a timely manner to decrease risk of getting up. Place the bed in the lowest possible position. Raise side rails judiciously as the situation requires. Encourage the use of well-fitting shoes with nonskid soles. Ensure the room is well lit to prevent tripping. Encourage the use of eyeglasses, hearing aids, assistive devices.

Nutritional Considerations

• Insufficient nutrition can be a concern. Symptoms of insufficient nutrition include decreased serum total protein and albumin, weight loss, deceased dietary intake, weakness, lack of interest in food or eating, pale mucous membranes, mouth sores, fatigue, listlessness, fatty stools, pale mucous membranes, stool clay colored or melena, dark foul-smelling urine, decreased muscle tone.
• Monitor and trend laboratory values that evaluate nutritional status (Alb, TP, K⁺) including transferrin, RBC count, WBC count, and electrolytes. Collaborate with health-care provider (HCP) on replacement strategies. Increased AST levels may be associated with liver disease.
• Consider specific dietary recommendations. Recommendations will vary depending on condition and severity. For example, recommend a diet of soft foods if esophageal varices develop, fat substitutes for bile duct disease, or limitations on salt intake if ascites develop. Encourage eating a well-balanced diet that includes foods high in fiber, as appropriate. Correlate laboratory values with IV fluid infusion, and collaborate with the HCP and pharmacist to adjust enteral and parenteral nutrition to patient caloric needs.
• Interventions/actions related to insufficient nutrition include the following: Assess current eating patterns and attitudes toward food. Recommend swallowing evaluation as indicated. Record daily weight, calorie count, and counseling with dietary consult. Consider supplementation of diet with vitamins and folic acid. Facilitate a pleasant eating environment and provide culturally appropriate foods from home. Discourage caffeinated or carbonated drinks as they may sate the appetite. Consider companionship during meals to enhance appetite. Administer ordered nutritional supplements. Facilitate adequate pain and nausea control to improve caloric intake.

Clinical Judgement

• Consider the best commonsense approach to implement fall precautions in a culturally sensitive manner that will foster patient and family adoption and adherence, thereby decreasing potential injury.

Followup Evaluation and Desired Outcomes

• Agrees to cease drinking alcohol if substance use disorder (alcohol) is a causal factor in disease development. Seeks support from family, community, faith-based, or medical professional to assist in remaining free from substance use disorder (alcohol) and maintenance of positive lifestyle changes.
• Recognizes the link between improved nutrition and improved health.
• Seeks psychological counseling to address, fear, anxiety, or depression associated with diagnosis and prognosis.