A 4-year-old child with hemolytic-uremic syndrome (HUS) is admitted to the pediatric intensive care unit. The child has oliguria, elevated blood pressure, and laboratory results showing hemoglobin 6.8 g/dL, platelet count 45,000/mm³, and elevated BUN and creatinine. What is the priority nursing intervention?
1Monitor strict intake and output and maintain fluid restriction as ordered✓ 정답
2Administer packed red blood cells immediately to correct anemia
3Encourage increased oral fluid intake to prevent dehydration
4Prepare the child for immediate platelet transfusion
해설
In HUS with oliguria and acute kidney injury, strict fluid management is critical to prevent fluid overload and complications like pulmonary edema. Other options (immediate transfusions or increased fluids) are not priority as they can worsen the condition.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a child with Hemolytic-Uremic Syndrome (HUS), a condition characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury (AKI). The pathophysiology involves endothelial damage, often triggered by infection (e.g., E. coli O157:H7), leading to platelet aggregation in small vessels, RBC destruction, and impaired renal function. The patient presents with oliguria, hypertension, and lab-confirmed anemia, thrombocytopenia, and azotemia (elevated BUN/Creatinine). In this acute phase, the primary threat is fluid overload and hypertensive crisis due to the kidneys' inability to excrete fluid and waste products.
Answer Rationale: Key Point! The priority is Monitoring strict intake and output (I&O) and maintaining fluid restriction. This directly addresses the life-threatening complications of oliguric renal failure: pulmonary edema, worsening hypertension, and heart failure. Fluid restriction is calculated as "insensible losses (approx. 400 mL/m²/day) + urine output," and strict monitoring is essential to prevent positive fluid balance. This intervention aligns with the nursing process principle of addressing the most immediate threat to physiological stability (Airway, Breathing, Circulation, with a focus on fluid volume status here).
Distractor Analysis:
Watch out for confusion! Option ②, administering packed red blood cells (PRBCs) immediately, is incorrect because transfusion in HUS carries a significant risk. Transfused platelets and RBCs can be rapidly destroyed in the microangiopathic process, potentially worsening thrombosis and renal injury. Transfusions are typically reserved for severe, symptomatic anemia (e.g., hemodynamic instability, severe fatigue) and are given slowly and cautiously.
Option ③, encouraging increased oral fluids, is dangerous and contraindicated. The child is oliguric, indicating the kidneys cannot handle excess fluid. Increasing intake would precipitate or exacerbate fluid overload and hypertension.
Option ④, preparing for immediate platelet transfusion, is generally avoided. Platelet transfusion can theoretically "fuel the fire" of the thrombotic microangiopathy, leading to further clot formation. It is usually reserved for active, life-threatening bleeding or prior to an invasive procedure.
Related Concepts: The management of HUS is primarily supportive, focusing on meticulous fluid and electrolyte balance, hypertension control (often with medications like IV hydralazine or labetalol), nutritional support, and, in severe cases, renal replacement therapy (dialysis). The anemia and thrombocytopenia often improve as the underlying disease process resolves.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse in the PICU caring for Liam, a 4-year-old recently admitted with bloody diarrhea now diagnosed with HUS. He is irritable, pale, and has not voided in 8 hours. His blood pressure is 10% above the 95th percentile for his age.
Nursing Intervention Strategy:
1AssessmentPerform focused assessments every 1-2 hours: vital signs (especially BP), breath sounds (for crackles indicating pulmonary edema), weight (daily on the same scale), precise I&O (weigh diapers 1 gm = 1 mL), and peripheral edema. Monitor neurologic status for signs of hypertensive encephalopathy (headache, vomiting, seizures, vision changes).
2Care & Implementation* Fluid Management: Adhere strictly to the calculated fluid restriction order (e.g., "Maintain IV fluids at 800 mL/24hr + replace urine output mL for mL"). Use an IV pump for all infusions. Meticulously document all intake (IV, oral, meds) and output (urine, stool, emesis).
* Hypertension Management: Administer antihypertensive medications as ordered, monitoring for effectiveness and side effects (e.g., hypotension).
* Safety & Monitoring: Implement bleeding precautions due to thrombocytopenia (soft toothbrush, avoid IM injections, pad side rails). Monitor for signs of bleeding (petechiae, bruising, melena). Handle the child gently.
3Patient/Family EducationExplain the reason for fluid restriction ("His kidneys need rest and can't get rid of extra water right now"). Teach parents to recognize signs of fluid overload (swelling, rapid breathing) and hypertension.
Patient Safety and Precautions: Key Point! Never force fluids in an oliguric patient. Double-check all IV infusion rates. Transfuse blood products only with a physician's order and specific criteria, and administer them slowly while monitoring closely for transfusion reactions.
Nursing Procedure & Medication FlowStrict I&O Procedure: 1) Use a dedicated I&O sheet. 2) For infants/young children, weigh diapers: (Wet diaper weight - Dry diaper weight) in grams = urine volume in mL. 3) Measure all oral liquids in a graduated cup. 4) Include flush volumes from IV medications in intake. 5) Calculate and report the net fluid balance (Intake - Output) at the end of each shift.Antihypertensive Medication (e.g., IV Labetalol): Administer via IV push slowly or as a continuous infusion per protocol. Monitor blood pressure frequently (e.g., every 5-15 minutes during titration) to avoid precipitous drops.
A Word from Your Senior Nurse
"In the whirlwind of a PICU admission with scary lab values like a hemoglobin of 6.8 g/dL, it's tempting to think 'transfusion!' is the top priority. But in HUS, your most powerful nursing tool is your I&O sheet and your vigilant assessment for fluid overload. Protecting those failing kidneys from further stress by managing fluid balance is the cornerstone of care. Remember, in pediatrics, small volumes matter immensely. That extra 30 mL of juice or an unchecked IV drip rate can tip a fragile child into pulmonary edema. Master the art of meticulous fluid management—it's a fundamental skill that saves lives."
Hemolytic-Uremic Syndrome — A disorder characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury, often preceded by gastroenteritis (e.g., from E. coli O157:H7).
Oliguria — Decreased urine output, typically defined as <1 mL/kg/hr in infants and children or <400 mL/24hr in adults. A key sign of acute kidney injury.
Intake and Output (I&O) — The precise measurement of all fluid entering (intake) and leaving (output) a patient's body. Critical for managing fluid balance in patients with renal, cardiac, or critical illness.
Fluid Restriction — A therapeutic limitation of total daily fluid intake, prescribed to prevent or treat fluid overload in conditions like heart failure, renal failure, or SIADH.
Thrombotic Microangiopathy — Pathological process of blood clot formation in small arteries and capillaries, leading to mechanical damage to red blood cells (schistocytes) and platelet consumption. The underlying mechanism in HUS and TTP.