A 5-year-old child with acute post-streptococcal glomerulonephritis is admitted to the pediatric unit. The child presents with periorbital edema, hematuria, and hypertension. Which nursing intervention should be the highest priority?
The nurse is caring for a 7-year-old child diagnosed with acute post-streptococcal glomerulonephritis who was admitted 2 hours ago with significant periorbital edema, gross hematuria, and elevated blood pressure.
1Monitor blood pressure every 2 hours and implement seizure precautions✓ 정답
2Encourage increased fluid intake to promote kidney function
3Administer diuretics as ordered to reduce edema
4Provide a high-protein diet to replace protein lost in urine
해설
Highest priority is monitoring BP every 2 hours and implementing seizure precautions due to risk of hypertensive encephalopathy and seizures from severe hypertension in APSGN. Other interventions (increasing fluids, diuretics, high-protein diet) are less urgent or contraindicated.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a child with Acute Post-Streptococcal Glomerulonephritis (APSGN). APSGN is an immune-mediated kidney disease following a streptococcal infection, causing inflammation of the glomeruli. This leads to Key Point!Sodium and water retention (causing edema and hypertension) and glomerular damage (causing hematuria and proteinuria). The most life-threatening complication in the acute phase is Hypertensive Encephalopathy, which can progress to seizures.
Answer Rationale: The correct answer is ① Monitor blood pressure every 2 hours and implement seizure precautions. This directly addresses the ABCs (Airway, Breathing, Circulation) priority framework by managing the immediate threat to cerebral circulation. Severe hypertension (elevated BP) can rupture cerebral vessels or cause cerebral edema, leading to seizures. Frequent monitoring allows for early detection and intervention (e.g., administering antihypertensives), while seizure precautions (padded side rails, a safe environment) protect the patient from injury.
Distractor Analysis:
Watch out for confusion!② Encourage increased fluid intake is generally contraindicated in APSGN. The pathophysiology involves fluid retention, not dehydration. Increasing fluids would exacerbate hypertension and edema, potentially leading to pulmonary edema or worsening hypertensive crisis. ③ Administer diuretics as ordered is a correct medical order but is not the highest priority nursing intervention. The nurse's independent, priority action is vigilant assessment and monitoring to inform the need for and evaluate the effectiveness of medications like diuretics. ④ Provide a high-protein diet is incorrect and potentially harmful. While proteinuria occurs, the damaged glomeruli cannot handle a high protein load. The standard dietary management for APSGN is sodium and fluid restriction to manage hypertension/edema, and sometimes moderate protein restriction to reduce kidney workload.
Related Concepts: The priority is always patient safety from the most immediate threat. In APSGN, the triad of Hypertension, Edema, and Hematuria signals the need for neurovascular monitoring. Understanding the pathophysiological chain (infection → immune complex deposition → glomerular inflammation → impaired filtration → fluid/Na retention → hypertension) is crucial for predicting complications and planning care.
Concept Summary
Concept
Key Points for APSGN
Pathophysiology
Immune complexes deposit in glomeruli after Strep infection (e.g., strep throat). Causes inflammation, decreased GFR (Glomerular Filtration Rate), sodium/water retention, hematuria.
Major Symptoms
Periorbital edema (often first sign), hypertension, cola-colored urine (gross hematuria), mild proteinuria, possible fatigue.
1. Monitor BP & neuro status. 2. Implement fluid/sodium restriction. 3. Monitor I&O (Intake & Output), daily weights. 4. Provide rest. 5. Administer meds (antihypertensives, diuretics, antibiotics).
Dietary Management
Fluid restriction, sodium restriction, possible moderate protein restriction. Never encourage high fluids or high protein.
Side-by-Side Comparison!
Condition
Acute Glomerulonephritis (APSGN)
Nephrotic Syndrome
Primary Issue
Inflammation of glomeruli
Increased permeability of glomeruli
Key Lab Finding
Hematuria (cola-colored urine), mild proteinuria
Massive Proteinuria (>3.5g/day), Hypoalbuminemia
Edema Character
Periorbital, mild, related to fluid retention
Generalized, severe (anasarca), related to low albumin
Hypertension
Common and a major concern
May or may not be present
Dietary Focus
Fluid & Sodium restriction
Moderate Protein, Sodium restriction
Anatomy, Physiology & Pharmacology Points
Glomerulus: The kidney's filtering unit. Damage here impairs its ability to filter waste while retaining proteins and cells, leading to hematuria/proteinuria.
Renin-Angiotensin-Aldosterone System (RAAS): With decreased kidney perfusion (from inflammation), this system is activated, causing vasoconstriction and sodium/water retention → Hypertension.
Diuretics (e.g., Furosemide): Used to reduce edema and hypertension by promoting sodium and water excretion. Monitor for electrolyte imbalances (hypokalemia).
Antihypertensives: Often needed. Understand drugs like ACE inhibitors (protect kidney function) and calcium channel blockers.
Priority: Think "Brain before Kidney." The immediate threat is to the brain from hypertension (seizures), not directly to the kidney itself.
Diet Don'ts: "No Salt, No Flood." Restrict sodium and fluids, do not increase them.
High-Frequency NCLEX Topics
APSGN is a classic pediatric condition. The NCLEX loves to test: 1) Identifying priority assessments (BP, neuro checks), 2) Recognizing contraindicated actions (increasing fluids), 3) Differentiating APSGN from Nephrotic Syndrome based on symptoms and lab values, and 4) Patient/parent education about follow-up care and preventing future strep infections.
Watch Out for Question Variations!
Instead of asking for the priority intervention, it might ask: "Which finding requires immediate notification of the provider?" Answer: A sudden spike in BP or signs of encephalopathy (headache, vomiting).
It could be a select-all-that-apply question: "Which actions are appropriate for a child with APSGN?" Correct answers would include: Monitor BP, weigh daily, enforce bed rest, provide low-sodium diet.
The scenario might shift to discharge teaching: "The nurse is preparing discharge instructions. Which statement by the parent indicates understanding?" Correct: "I will schedule follow-up appointments to check my child's blood pressure and urine."
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a pediatric unit. You receive report on Liam, a 7-year-old admitted with APSGN. His face, especially around the eyes, is puffy. His urine in the collection bag is dark tea-colored. His initial BP was 142/92 mmHg.
Nursing Intervention Strategy:
Assessment: Perform a focused assessment every 2 hours. This includes:
Vital Signs: Accurately measure BP using a correct-sized cuff.
Neurological Checks: Assess for headache, visual disturbances, irritability, or lethargy—early signs of rising intracranial pressure.
Fluid Status: Strict I&O measurement. Weigh the child daily at the same time, on the same scale, with similar clothing.
Edema: Assess degree of periorbital and dependent edema.
Safety & Seizure Precautions:
Raise padded side rails on the bed.
Keep the bed in a low position.
Ensure the call light is within reach.
Instruct the child and family to call for help if the child feels dizzy or strange.
Collaborative Care:
Administer prescribed antihypertensives and diuretics on time. Monitor for effect (decreased BP, increased urine output).
Coordinate with dietary services to provide a no-added-salt (NAS) diet and enforce the prescribed fluid restriction (e.g., 1000 mL/day).
Promote rest to decrease metabolic demands on the kidneys.
Patient Safety and Precautions:
Contraindication: Do NOT encourage oral fluids. Explain to the family that the child's body is holding onto too much fluid, and more intake could be dangerous.
Medication Caution: When giving loop diuretics like furosemide, monitor for signs of hypokalemia (muscle weakness, irregular pulse) and ensure the child voids after administration.
Key Monitoring: A sudden decrease in urine output could indicate worsening renal function. Report immediately.
Nursing Procedure & Medication FlowManaging Hypertension in APSGN:
1. Assessment: Verify order for BP monitoring frequency (e.g., q2h). Use proper technique.
2. Planning: Have emergency seizure protocol and antihypertensive medications (e.g., labetalol for IV use) readily available per protocol.
3. Implementation: If BP reaches a critical threshold (e.g., systolic > 160 mmHg in a child), follow the "call, assess, prepare, administer" flow: Call the provider, perform a rapid neuro assessment, prepare the emergency medication, and administer as ordered.
4. Evaluation: Re-check BP 15-30 minutes after administering an antihypertensive. Document trends and the child's response.
A Word from Your Senior Nurse
"In pediatrics, a child who can't tell you they have a headache is relying on you to see the signs. That periorbital edema isn't just a symptom to document—it's a red flag waving, telling you that pressure is building, not just in their face but potentially in their skull. Your vigilant, q2h blood pressure check is your stethoscope listening to the stability of their cerebral perfusion. Never underestimate the power of that basic nursing assessment. It's the difference between catching a hypertensive crisis early and managing it calmly versus responding to a full-blown seizure. Connect the dots from the strep throat they had two weeks ago to the dark urine today to the BP you're about to take. That's the kind of clinical reasoning that saves kids and will ace your NCLEX."
Acute Post-Streptococcal Glomerulonephritis — An immune-complex mediated inflammation of the glomeruli in the kidney, occurring 1-3 weeks after a Group A beta-hemolytic streptococcal infection (e.g., strep throat).
Hypertensive Encephalopathy — A medical emergency caused by severely elevated blood pressure leading to cerebral edema, resulting in headache, vomiting, confusion, visual changes, and seizures.
Seizure Precautions — Nursing safety measures to protect a patient at risk for seizures, including padded side rails, maintaining a low bed, keeping the airway clear, and having suction/oxygen available.
Fluid Restriction — A therapeutic limitation of total daily fluid intake, prescribed in conditions like APSGN or heart failure to prevent fluid overload, worsening edema, and hypertension.
Gross Hematuria — Urine that is visibly red, pink, or cola-colored due to the presence of blood (red blood cells), a hallmark sign of glomerular inflammation in APSGN.