A 7-year-old child with acute post-streptococcal glomerulonephritis is admitted to the pediatric unit. The child presents with periorbital edema, hypertension (BP 140/90 mmHg), and oliguria. Laboratory results show proteinuria and hematuria. What is the priority nursing intervention for this child?
1Encourage increased fluid intake to prevent dehydration
2Monitor blood pressure every 2 hours and implement fluid restriction✓ 정답
3Administer high-protein diet to replace protein losses
4Provide vigorous diuretic therapy to reduce edema
해설
Priority nursing intervention is monitoring blood pressure every 2 hours and implementing fluid restriction to manage hypertension and fluid overload, which are life-threatening complications in APSGN. Other options (increasing fluids, high-protein diet, vigorous diuretics) are contraindicated or lower priority.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a child with Acute Post-Streptococcal Glomerulonephritis (APSGN). APSGN is an immune-mediated inflammation of the glomeruli following a streptococcal infection (like strep throat). The key pathophysiological problem is decreased glomerular filtration rate (GFR) due to inflammation and damage. This leads to three major clinical problems: fluid retention (edema, hypertension), proteinuria, and hematuria. The priority is managing the most immediate life-threatening complication.
Answer Rationale: Key Point! The child has significant hypertension (BP 140/90 mmHg) and oliguria, indicating severe fluid overload and potential for hypertensive encephalopathy (seizures, headache, altered mental status) or pulmonary edema. Therefore, the priority is to closely monitor BP and restrict fluids to reduce intravascular volume and control hypertension. This directly addresses the ABCs (Airway, Breathing, Circulation) by protecting cerebral and cardiac function.
Distractor Analysis:
Watch out for confusion! Encouraging increased fluid intake is contraindicated. The child is in a state of fluid overload (edema, hypertension, oliguria). Adding more fluid would worsen hypertension and could precipitate heart failure or encephalopathy.
Watch out for confusion! Administering a high-protein diet is incorrect. While protein is lost in urine, the damaged kidneys cannot properly excrete the waste products (like BUN and creatinine) from protein metabolism. A high-protein diet would increase the renal workload and worsen azotemia (buildup of nitrogenous wastes). A moderate or low-protein diet is typically recommended during the acute phase.
Watch out for confusion! Providing vigorous diuretic therapy is not the nurse's independent priority intervention. Diuretics may be prescribed by a physician, but their use requires careful monitoring. "Vigorous" therapy could lead to rapid fluid shifts, electrolyte imbalances (like hypokalemia), and dehydration, which is dangerous. The initial, priority nursing actions are monitoring and fluid restriction.
Related Concepts: The nursing management of APSGN follows the acronym "HOP": Hypertension management, Oliguria/fluid management, and Prevention of complications (infection, electrolyte imbalance). Bed rest is often encouraged during the acute phase to reduce metabolic demands. Antibiotics may be given to eradicate any lingering streptococcal infection, but they do not alter the course of the glomerulonephritis itself.
Concept Summary
Problem in APSGN
Pathophysiology
Nursing Priority/Intervention
Hypertension & Edema
Decreased GFR → Sodium & Water Retention → Increased Blood Volume
Monitor BP frequently (q2-4h). Implement fluid & sodium restriction.
Glomerulus: The filtering unit of the kidney. Inflammation here impairs its ability to filter waste and regulate fluid/electrolytes.
Renin-Angiotensin-Aldosterone System (RAAS): In APSGN, decreased renal perfusion activates RAAS, leading to vasoconstriction and sodium/water retention, exacerbating hypertension.
Antihypertensives: Medications like calcium channel blockers (e.g., amlodipine) or vasodilators may be used. ACE inhibitors/ARBs are often avoided in acute phase due to risk of worsening renal function in the setting of decreased GFR.
Diuretics: Loop diuretics (e.g., furosemide) may be used cautiously to promote diuresis and reduce edema/hypertension, but require monitoring of electrolytes (K+, Na+).
Memory Tips
Think "DAM" for APSGN priorities: Dangerous Hypertension, Assess Fluid (I&O, weight), Monitor for complications (encephalopathy).
Color Code: APSGN urine is often described as "cola-colored" or "tea-colored" due to hematuria. Nephrotic syndrome urine is "frothy" or "foamy" due to proteinuria.
Hypertension is the #1 enemy in APSGN. If you see high BP + child + recent strep infection, think fluid restriction and close monitoring first.
High-Frequency NCLEX Topics
APSGN is a classic pediatric renal disorder. The NCLEX loves to test:
1. Identifying Priority Assessments: Vital signs (especially BP) and neurological status.
2. Contraindicated Actions: Knowing NOT to give extra fluids or a high-protein diet.
3. Patient/Family Education: Importance of completing antibiotic therapy for strep infections to prevent APSGN, signs of recurrence (edema, dark urine).
Watch Out for Question Variations!
Instead of asking for the priority intervention, the question might ask: "Which finding requires immediate intervention?" Answer: Severe hypertension or a report of a severe headache (sign of encephalopathy).
The question could shift to discharge teaching: "The nurse is preparing discharge instructions. Which statement by the parent indicates a need for further teaching?" The incorrect statement would be: "I will encourage my child to drink plenty of fluids."
It might combine with medication administration: The priority before giving an antihypertensive medication is assessing the patient's current blood pressure.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a pediatric unit. You receive report on Michael, a 7-year-old admitted with APSGN. His mother states he had a sore throat two weeks ago that wasn't treated. This morning, his face was puffy, and he hasn't urinated much. On assessment, BP 142/92, HR 110, mild periorbital edema, and he's slightly irritable.
Nursing Intervention Strategy:
Immediate Assessment (First 15 mins):
Vital Signs: Accurately measure BP using a correct-sized cuff. Compare to previous readings.
Neurological Check: Assess for headache, visual disturbances, dizziness, or change in level of consciousness (LOC) – early signs of hypertensive encephalopathy.
Respiratory Assessment: Auscultate lung sounds for crackles (indicating pulmonary edema).
Establish strict Intake and Output (I&O) and obtain a daily weight (same scale, same time, minimal clothing).
Planning & Implementation:
Collaborate with the healthcare team to establish a fluid restriction order (e.g., "Maintenance fluids minus estimated insensible losses" or a specific daily volume). Calculate carefully.
Educate Michael and his mother about the fluid restriction. Use creative strategies: small cups, ice chips (count as fluid), favorite fluids at designated times. Provide mouth care to alleviate thirst.
Implement a no-added-salt (NAS) diet. Collaborate with dietary services.
Administer antihypertensive medications as ordered, always assessing BP before administration.
Provide quiet activities and enforce bed/chair rest to reduce cardiac workload and promote diuresis.
Evaluation & Ongoing Monitoring:
Trend the BP readings. Is the hypertension improving with fluid restriction and medication?
Monitor I&O closely. The goal is a gradual return to normal urine output. Sudden large output may indicate recovery or over-diuresis.
Watch for resolution of edema and improvement in laboratory values (BUN, creatinine).
Patient Safety and Precautions:
Never assume a child with edema needs more fluids. In APSGN, edema is from retention, not dehydration.
Seizure Precautions: Have oxygen and suction available at the bedside. If a child develops a severe headache or becomes lethargic, notify the physician immediately – this is a neurological emergency.
Infection Control: APSGN itself is not contagious, but the preceding strep infection is. Practice good hand hygiene. If the child still has an active strep infection, follow droplet precautions until 24 hours of antibiotics have been given.
Nursing Procedure & Medication FlowManaging Fluid Restriction in a Child:
1. Calculate Total Allowable Fluid: Often based on body weight (e.g., 500 mL + 20 mL/kg for each kg over 10 kg). Double-check the calculation.
2. Distribute Fluids: Divide the total over 24 hours. Allot more during waking hours. Include all sources: IV fluids, oral liquids, ice chips, gelatin, soup.
3. Document Meticulously: Record every mL in and out on the I&O sheet. Measure urine output using a graduated cylinder.
4. Medication Administration Caution: Many liquid medications contain water. Consult pharmacy to see if these volumes need to be counted toward the fluid restriction. Some can be given in concentrated form.
A Word from Your Senior Nurse
"Seeing a child with a puffy face and high blood pressure can be unsettling. Remember, your vigilant monitoring is their first line of defense against serious complications like seizures. In clinical practice, I've found that explaining 'why' to both the child and parent is key. Instead of just saying 'you can't drink much,' explain, 'Your kidneys are taking a little rest right now, so we need to help them by not giving them too much extra work with extra fluid.' This builds trust and cooperation. For the NCLEX, always ask yourself: 'What is the greatest threat to this patient's safety right now?' In APSGN, it's almost always the hypertension. That mindset will guide you to the correct priority every time."
Acute Post-Streptococcal Glomerulonephritis — An immune-complex mediated inflammation of the glomeruli occurring 1-3 weeks after a group A beta-hemolytic streptococcal infection, characterized by hematuria, proteinuria, edema, hypertension, and oliguria.
Hypertensive Encephalopathy — A medical emergency caused by severely elevated blood pressure leading to cerebral edema, resulting in symptoms like headache, vomiting, confusion, seizures, and visual disturbances. A key complication to monitor for in APSGN.
Oliguria — Decreased urine output, typically defined as less than 1 mL/kg/hr in children or less than 400 mL/day in adults. In APSGN, it results from decreased glomerular filtration rate (GFR).
Intake and Output (I&O) — The meticulous measurement and recording of all fluids entering the body (oral, IV, tube feedings) and exiting the body (urine, vomit, diarrhea, drainage). A cornerstone of fluid management in renal and cardiac conditions.
Periorbital Edema — Swelling around the eyes, often an early and characteristic sign of fluid retention in conditions like APSGN and nephrotic syndrome, due to the loose connective tissue in that area.