# A 6-year-old child with nephrotic syndrome is being discharged home after initial treatment. Which discharge instruction is most important for the nurse to emphasize to the parents? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542530 > language: ko > subject: Child Health ## 문제 A 6-year-old child with nephrotic syndrome is being discharged home after initial treatment. Which discharge instruction is most important for the nurse to emphasize to the parents? ## 보기 1. Encourage increased fluid intake to prevent dehydration 2. Monitor for signs of infection and seek immediate medical attention for fever **✔ 정답** 3. Provide a high-protein diet to replace lost albumin 4. Restrict all physical activities until proteinuria resolves **정답: 2** ## 해설 Children with nephrotic syndrome are at high risk for infections due to immunosuppressive medications and loss of immunoglobulins in urine. Monitoring for signs of infection and seeking immediate medical attention for fever is the priority discharge teaching to prevent serious complications. ## 심화 해설 Understanding the Priority Discharge Need in Nephrotic Syndrome The most important discharge instruction centers on infection monitoring and prompt response to fever. This priority is rooted in the dual threat of immunosuppression faced by these children: the pathophysiology of nephrotic syndrome itself and the medications used to treat it. Why Infection Risk is the Critical Concern Children with nephrotic syndrome are in a state of relative immunosuppression. The disease causes a urinary loss of immunoglobulins and complement proteins, which are essential for opsonizing and clearing bacteria. This inherent vulnerability is compounded by the mainstay of treatment: corticosteroids and other immunosuppressive agents like mycophenolate mofetil. As highlighted in a recent case report, patients with nephrotic syndrome are at a heightened risk of infections due to both the underlying disease pathophysiology and the effects of immunosuppressive therapies [1]. This creates a clinical scenario where a common childhood illness or even a live vaccine can lead to severe, disseminated, and life-threatening complications. A fever in this context is not a routine symptom; it is a potential harbinger of spontaneous bacterial peritonitis, sepsis, or a severe varicella-zoster virus infection, which necessitates immediate medical evaluation [1]. Analysis of Incorrect Options - Option 1: Encourage increased fluid intake to prevent dehydration. This instruction is potentially dangerous. In nephrotic syndrome, the primary problem is fluid overload due to low serum oncotic pressure from massive proteinuria. The kidneys retain sodium and water, leading to edema. Encouraging increased fluid intake would exacerbate edema and could lead to hypertension and pulmonary edema. Fluid management typically involves a "no-added-salt" diet and often a mild fluid restriction during the edematous phase, not encouragement. - Option 3: Provide a high-protein diet to replace lost albumin. While it seems logical to replace lost protein, a high-protein diet is not recommended. The underlying issue is a glomerular basement membrane defect causing protein leakage, not a dietary deficiency. Increasing protein intake can actually worsen hyperfiltration injury in the kidneys, further damaging the glomeruli and increasing proteinuria. The standard of care is to provide an age-appropriate, adequate-protein diet with sufficient calories to promote growth and spare protein. - Option 4: Restrict all physical activities until proteinuria resolves. Complete activity restriction is unnecessary and detrimental to a child's development and psychosocial well-being. While contact sports should be avoided during periods of significant edema or while on anticoagulation due to the risk of splenic or renal injury, normal age-appropriate play and activity are encouraged. The goal is to promote a normal childhood experience, with modifications made only for specific risks like severe edema or immunosuppression. Connecting to Clinical Practice The discharge teaching must equip parents to act as the first line of defense against infection. They need clear, actionable parameters, such as checking and recording the child's temperature if they feel warm or appear ill, and understanding that a temperature of 38.0°C (100.4°F) or higher requires an immediate call to the healthcare provider or an emergency department visit. Parents should also be taught to avoid exposing the child to individuals with known active infections and to understand the critical safety concerns around live vaccines for both the patient and household contacts while the child is on immunosuppressive therapy [1].References (research sources) - [1]Post-varicella vaccination uveitis in a child with nephrotic syndrome receiving immunosuppressive treatment: a case report.Case reportAndrade C, de Almeida Cordeiro M, Baeta Baptista R, Sousa Nunes B, Garcia AM, Milheiro Silva T, Valente Pinto M. (2025) · DOI: 10.3389/fped.2025.1567164 ## 임상 시나리오 Nephrotic Syndrome Discharge PrioritiesInfection surveillance is the cornerstone of home care The highest priority is teaching parents to monitor for signs of infection and seek immediate care for a fever of 38°C (100.4°F) or higher. This is due to immunosuppression from urinary loss of immunoglobulins and the effects of corticosteroids. Fluid management must be carefully balanced. Do not push fluids during active edema; instead, follow a "no added salt" diet and monitor daily weights with the same scale to track fluid status. Dietary teaching should emphasize a well-balanced, age-appropriate diet with normal protein intake. High-protein diets are avoided as they can worsen renal damage. CautionA fever in a child on steroids is a medical emergency. Steroids mask the classic signs of severe infection like peritonitis. Immediate evaluation, blood cultures, and empiric antibiotics are often required. ## 핵심 개념 - **Nephrotic Syndrome** — A kidney disorder causing the body to excrete too much protein in the urine, leading to edema, hypoalbuminemia, and hyperlipidemia. - **Immunosuppression** — Reduced efficacy of the immune system due to urinary loss of immunoglobulins and complement proteins, compounded by corticosteroid therapy. - **Spontaneous Bacterial Peritonitis (SBP)** — A severe, life-threatening bacterial infection of ascitic fluid, a major risk for nephrotic children with ascites presenting with fever. - **Corticosteroids** — Mainstay anti-inflammatory and immunosuppressive medication used to induce remission in nephrotic syndrome, which masks signs of infection. - **Opsonization** — The process by which pathogens are marked for destruction by the immune system; impaired in nephrotic syndrome due to loss of complement proteins. ## 같은 주제 문제 - [A 5-year-old child with nephrotic syndrome is being assessed by the nurse. 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