A nurse is caring for a patient with Goodpasture's syndrome who is experiencing progressive kidney dysfunction and pulmonary hemorrhage. Which nursing intervention should be the priority?
A 28-year-old male patient with Goodpasture's syndrome is admitted to the medical unit with worsening dyspnea, hemoptysis, and decreased urine output. Laboratory results show elevated creatinine and BUN levels, and chest X-ray reveals bilateral pulmonary infiltrates.
1Monitor respiratory status and oxygen saturation continuously✓ 정답
2Encourage increased fluid intake to prevent dehydration
3Administer prescribed diuretics to reduce fluid retention
4Position the patient in Trendelenburg position to improve circulation
해설
Continuous respiratory monitoring is the priority for Goodpasture's syndrome with pulmonary hemorrhage, as it can rapidly lead to life-threatening respiratory failure. Other interventions are less critical in this acute setting.
Understanding the Priority: Airway and Breathing in Goodpasture's Syndrome
The correct answer is to monitor respiratory status and oxygen saturation continuously.
In a patient with Goodpasture's syndrome, the immune system mistakenly attacks the basement membranes in both the kidneys and the lungs. This dual attack explains the patient's presentation: the pulmonary component causes pulmonary hemorrhage, evidenced by the worsening dyspnea, hemoptysis, and bilateral infiltrates on the chest X-ray. The renal component leads to rapidly progressive glomerulonephritis, indicated by the elevated creatinine and BUN and decreased urine output.
When applying the ABC (Airway, Breathing, Circulation) prioritization framework, a patient with active pulmonary hemorrhage is at immediate risk for a compromised airway and impaired gas exchange. Continuous monitoring of respiratory status and oxygen saturation is the priority nursing action because it allows for the early detection of life-threatening deterioration, such as massive hemoptysis or respiratory failure, which requires immediate intervention. While the kidney dysfunction is serious, it does not pose the same imminent threat to life as a breathing problem does.
The other options are not the priority and some are contraindicated:
- Option 2: Encouraging increased fluid intake is dangerous for a patient with kidney dysfunction and decreased urine output, as it can lead to fluid volume overload, worsening pulmonary edema and hypertension.
- Option 3: Administering diuretics may be a part of the medical management for fluid retention, but it is not the nurse's immediate priority over assessing and ensuring a patent airway and effective breathing.
- Option 4: Positioning the patient in Trendelenburg position is contraindicated. This head-down position would increase pressure in the pulmonary vasculature and could worsen respiratory distress and hemoptysis. The patient should be positioned with the head of the bed elevated to facilitate breathing.
The provided reference materials do not contain information on Goodpasture's syndrome, pulmonary-renal syndromes, or the nursing management of acute respiratory compromise. Therefore, this explanation is based on core NCLEX-RN principles of prioritization and the established pathophysiology of the condition.
Goodpasture's Syndrome: Priority AssessmentManaging Active Pulmonary Hemorrhage
In Goodpasture's syndrome, the immune system attacks the basement membrane of the lungs and kidneys. The immediate life threat is pulmonary hemorrhage, not kidney failure. Apply the ABC framework: a patient with worsening dyspnea and hemoptysis has a compromised airway and breathing.
The priority nursing action is continuous monitoring of respiratory status and oxygen saturation. This allows for early detection of rapid deterioration such as massive hemoptysis or respiratory failure, which require immediate intervention like intubation.
Caution
Do not encourage fluid intake in patients with oliguria (decreased urine output) as this can cause fluid overload and worsen pulmonary edema. Avoid the Trendelenburg position, which compromises breathing by pushing abdominal contents against the diaphragm.
Goodpasture's syndrome — A rare autoimmune disorder where antibodies attack the basement membrane in the kidneys and lungs, causing glomerulonephritis and pulmonary hemorrhage.
ABC prioritization — A triage framework prioritizing Airway, Breathing, and Circulation; used to identify the most immediate life-threatening condition.
pulmonary hemorrhage — Bleeding into the lung tissue or alveolar spaces, presenting with dyspnea, hemoptysis, and hypoxemia, which can rapidly compromise the airway.
hemoptysis — The coughing up of blood from the respiratory tract, a key sign of active pulmonary bleeding.
Trendelenburg position — A supine position with the feet elevated higher than the head; contraindicated in respiratory distress as it increases pressure on the diaphragm.