A 5-year-old child with hemolytic-uremic syndrome (HUS) is admitted to the pediatric intensive care unit. The child has oliguria, hypertension, and laboratory results showing hemoglobin 6.2 g/dL, platelet count 45,000/mm³, and elevated BUN and creatinine. Which nursing intervention should be the highest priority?
1Encourage increased fluid intake to prevent dehydration
2Administer aspirin for fever and discomfort management
3Provide a high-protein diet to support kidney function
4Monitor for signs of neurological complications and seizures✓ 정답
해설
Neurological monitoring is the highest priority due to the risk of cerebral edema and seizures in HUS patients. Other interventions are less critical or contraindicated in this acute setting.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a child with acute Hemolytic-Uremic Syndrome (HUS). HUS is characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury (AKI). The pathophysiology involves endothelial damage, often from Shiga toxin-producing E. coli (STEC), leading to platelet aggregation and fibrin deposition in small blood vessels. This causes red blood cell (RBC) destruction, low platelets, and clogging of the glomeruli, resulting in renal failure. In the acute phase, the most life-threatening complication is Key Point!neurological involvement, such as cerebral edema, hypertensive encephalopathy, or seizures, which can rapidly deteriorate the patient's condition.
Answer Rationale: Option ④ is correct because it directly addresses the most immediate threat to life. The child's lab values show severe anemia (Hgb 6.2 g/dL), severe thrombocytopenia (Platelets 45,000/mm³), and signs of renal failure (oliguria, elevated BUN/Creatinine). Hypertension is already present, which significantly increases the risk for intracranial hypertension and seizures. Key Point! Neurological changes (lethargy, irritability, visual disturbances, seizures) are often the first sign of worsening cerebral edema or hypertensive crisis in HUS, making continuous neurological assessment the highest nursing priority to prevent catastrophic outcomes.
Distractor Analysis:
Watch out for confusion! Option ①: Encouraging increased fluid intake is generally contraindicated in the oliguric phase of HUS. The child has oliguria and hypertension, indicating fluid overload and the kidneys' inability to excrete it. Forcing fluids could worsen hypertension and precipitate pulmonary edema or cerebral edema.
Option ②: Administering aspirin is contraindicated. The child has severe thrombocytopenia, and aspirin is an antiplatelet agent that would increase the risk of bleeding. Furthermore, fever management in children typically uses acetaminophen or ibuprofen (with caution in renal impairment), not aspirin, due to the risk of Reye's syndrome.
Option ③: Providing a high-protein diet is inappropriate during acute kidney injury. A high protein load increases nitrogenous waste products (BUN), which the failing kidneys cannot excrete, potentially worsening uremia. The diet for acute renal failure is typically restricted in protein, potassium, sodium, and phosphorus.
Related Concepts: The nursing priorities in HUS follow the ABC (Airway, Breathing, Circulation) framework, with neurological status being a critical component of "C" (Circulation/Cerebral perfusion). Management focuses on supportive care: managing hypertension, correcting electrolyte imbalances (especially hyperkalemia), possibly administering packed RBCs for severe anemia, and preparing for dialysis if renal failure is severe.Nursing Clinical Practice GuideClinical Scenario: You are the nurse in the PICU (Pediatric Intensive Care Unit) caring for Liam, a 5-year-old who developed HUS after a diarrheal illness. He is irritable, has a blood pressure of 142/90 mmHg, and urine output has been <1 mL/kg/hr for the past 6 hours.
Nursing Intervention Strategy:
Assessment (Priority: Neurological): Perform frequent neuro checks (every 1-2 hours). Use a pediatric Glasgow Coma Scale (GCS) or a simple AVPU (Alert, Voice, Pain, Unresponsive) scale. Monitor for headache, vomiting, visual changes, increased irritability, or seizure activity. Strictly monitor and document blood pressure.
Fluid & Electrolyte Management: Maintain strict I&O (Intake and Output). Weigh daily. IV fluids are typically restricted to "insensible losses + urine output" to prevent fluid overload. Monitor labs closely for hyperkalemia (peaked T-waves on ECG) and hyponatremia.
Medication & Transfusion Administration: Administer antihypertensives (e.g., IV labetalol, nicardipine) as ordered to control BP. If packed RBCs are ordered for severe anemia, administer slowly and monitor for transfusion reactions. Avoid nephrotoxic drugs.
Family Support & Education: Explain the disease process in simple terms. Reassure parents that most children recover kidney function. Teach them to report any signs of neurological change immediately.
Patient Safety and Precautions: Handle the child gently due to thrombocytopenia (risk of bruising/bleeding). Avoid intramuscular injections. Use a soft toothbrush. Implement seizure precautions (pad side rails, have suction and oxygen available).
Nursing Procedure & Medication FlowNeurological Assessment in a Child:
Observe: Level of consciousness, posture, facial symmetry.
Engage: Ask age-appropriate questions ("What's your favorite cartoon?").
Assess Motor Function: "Show me how you wiggle your toes." "Squeeze my fingers."
Check Pupils: Size, equality, reaction to light.
Document: Any change from baseline, even if subtle, must be reported to the provider immediately.
Blood Pressure Management: Use the correct cuff size (width 40% of arm circumference). Compare readings to age/height/sex percentiles. A systolic BP >95th percentile for age/height/sex indicates hypertension requiring intervention.
A Word from Your Senior Nurse
"In the whirlwind of a PICU admission with scary labs and a sick child, it's easy to get focused on the numbers. But your most powerful tool is your assessment. A child who becomes suddenly quiet or excessively irritable can be telling you their brain is under pressure long before a machine alarms. In HUS, the kidneys are the headline, but the brain is the breaking news. Your vigilant neuro checks are the early warning system that can trigger life-saving interventions. On the NCLEX, they test this priority-setting constantly: What kills first? In HUS, it's the brain. Remember that."
Hemolytic-Uremic Syndrome — A disorder characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury, often preceded by diarrheal illness.
Thrombocytopenia — A condition of low platelet count (<150,000/mm³), increasing the risk of bleeding.
Oliguria — Low urine output, defined as <1 mL/kg/hr in children, indicating impaired kidney function.
Hypertensive Encephalopathy — A medical emergency where severe hypertension causes cerebral edema, leading to headache, confusion, visual changes, and seizures.
Acute Kidney Injury — Sudden loss of kidney function, marked by elevated BUN and creatinine, oliguria, and fluid/electrolyte imbalances.