# 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?

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## 문제

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?

## 보기

1. Encourage increased fluid intake to prevent dehydration
2. Monitor blood pressure every 2 hours and implement fluid restriction **✔ 정답**
3. Administer high-protein diet to replace protein losses
4. Provide vigorous diuretic therapy to reduce edema

**정답: 2**

## 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.

## 심화 해설

Correct Answer: 2. Monitor blood pressure every 2 hours and implement fluid restriction

Understanding the Pathophysiology

Acute post-streptococcal glomerulonephritis (APSGN) is an immune-complex mediated disease, not a direct bacterial infection of the kidneys. Following a pharyngeal or skin infection with nephritogenic strains of group A beta-hemolytic Streptococcus, the body forms antigen-antibody complexes. These complexes deposit in the glomerular basement membrane, activating the complement system and causing a diffuse inflammatory response [1]. This inflammation damages the glomeruli, the kidney's filtering units, leading to a predictable clinical picture.

The child's presentation—periorbital edema, hypertension (140/90 mmHg), oliguria, proteinuria, and hematuria—is a classic constellation of symptoms resulting from this glomerular injury [2]. The inflamed glomeruli have a reduced glomerular filtration rate (GFR). This means the kidneys cannot effectively filter waste products or, critically, regulate fluid and electrolyte balance. The result is a state of fluid volume overload. Sodium and water are retained, leading directly to the edema and, more dangerously, hypertension. The oliguria is a direct consequence of the decreased GFR, and the proteinuria and hematuria result from the damaged filtration membrane allowing proteins and red blood cells to leak into the urine.

Analyzing the Priority Intervention

The priority nursing intervention is driven by the most immediate life-threatening complication, which in this case is severe hypertension due to fluid volume overload. The goal of management is to support the child while the acute inflammation resolves, focusing on controlling the effects of the impaired renal function [1].

- Option 2 is correct. Implementing strict fluid restriction and monitoring blood pressure (BP) every 2 hours directly targets the core problem of fluid volume overload. Restricting intake prevents further worsening of the edema and hypertension, while frequent BP monitoring is essential for early detection of hypertensive urgency or emergency, a serious complication of APSGN [2]. This is a critical safety measure that directly manages the primary risk.

- Option 1 is incorrect and dangerous. Encouraging increased fluid intake would exacerbate the existing fluid volume overload. Since the kidneys are in a state of oliguria and cannot excrete the excess fluid, this intervention would worsen the edema and elevate the BP further, potentially precipitating hypertensive crisis or pulmonary edema.

- Option 3 is incorrect. A high-protein diet is not indicated and could be harmful. The proteinuria is not due to a lack of protein intake but to a leaky glomerular membrane. Increasing dietary protein in the setting of a reduced GFR would increase the load of nitrogenous waste products on the already damaged kidneys, which they are unable to clear effectively. Management typically involves a diet with controlled protein and sodium, not a high-protein diet.

- Option 4 is incorrect as a priority nursing intervention. While diuretic therapy is a common medical treatment to manage fluid overload and hypertension, it is not an independent nursing action. The nurse's priority is to assess and monitor the patient's response to therapy. Vigorous diuresis can lead to electrolyte imbalances and must be carefully managed by the healthcare provider. The nurse's role is to implement fluid restriction and provide the BP monitoring data that guides the medical team's decision on whether and how aggressively to use diuretics [1].References (research sources)

- [1]AsPNA Clinical Practice Guidelines for the management of infection-related glomerulonephritis.GuidelineMeena J, Sinha A, Krishnasamy S, Alba AA, Aziz MA, Begum A, Chan EY, Kari JA, Pattaragarn A, Perera I, Shen Q, Singh G, Bagga A, Glomerular Disease Working Group, Asian Pediatric Nephrology Association. (2026) · DOI: 10.1007/s00467-026-07146-4

- [2]Acute Post-streptococcal Glomerulonephritis in a Pediatric Population: A Five-Year Retrospective Study.Research articleBajracharya P, Khadgi A, Shrestha S, Silwal R, Tandukar A. (2024) · DOI: 10.7759/cureus.56082

## 임상 시나리오

Managing Fluid Volume Excess in Pediatric APSGNPrioritizing safety when the kidneys fail to filter
The core problem in Acute Post-Streptococcal Glomerulonephritis (APSGN) is fluid volume overload from a damaged glomerular basement membrane. The priority is strict intake and output (I&O) monitoring and fluid restriction to prevent worsening hypertension.

Monitor blood pressure every 2 to 4 hours. A BP of 140/90 mmHg in a 7-year-old is a hypertensive crisis risk. The primary danger is hypertensive encephalopathy, signaled by headache, vomiting, or visual changes.

CautionNever encourage oral fluids to "flush the kidneys." The child is oliguric, not dehydrated. Additional fluid will directly increase circulatory volume, elevating blood pressure and risking pulmonary edema.

## 핵심 개념

- **Acute Post-Streptococcal Glomerulonephritis (APSGN)** — An immune-complex mediated kidney disorder following infection with nephritogenic group A beta-hemolytic Streptococcus, causing glomerular inflammation and reduced GFR.
- **Oliguria** — Decreased urine output, often defined as less than 1 mL/kg/hr in children, a direct consequence of reduced glomerular filtration rate.
- **Fluid Volume Overload** — A state of excess body fluid caused by sodium and water retention due to impaired kidney function, leading to edema and hypertension.
- **Hypertension** — Elevated blood pressure, a critical finding in APSGN resulting from fluid overload, which poses a risk for hypertensive encephalopathy and requires strict monitoring.
- **Glomerular Filtration Rate (GFR)** — The rate at which blood is filtered by the glomeruli; it is decreased in APSGN due to inflammatory damage, impairing waste and fluid regulation.

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