A nurse is caring for the child the following day.

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Nurses' Notes

Day 2, 0730:

Drowsy and lethargic, but responsive to verbal stimuli. Nuchal rigidity present. Mucous membranes pink and moist. Cervical lymph slightly enlarged. Respirations are regular. No accessory muscle use noted. Breath sounds clear anterior posterior bilaterally. Heart rhythm regular without murmurs. Radial pulse 2+ bilateral. Capillary refill less than 2 seconds. Abdomen flat and non- distended. Bowel sounds active in all 4 quadrants. Extremities are warm and dry to touch. Good skin turgor.

Flow Sheet

Temperature 38.9° C (102" F)

Heart rate 104/min

Respiratory rate 24/min

Blood pressure 104/80 mm Hg

SpO2 98% on room air

A. Constipation: Constipation is not typically associated with nephrotic syndrome. While toddlers may experience constipation for various reasons, it does not indicate the protein loss, edema, or fluid retention characteristic of nephrotic syndrome.

B. Irritability: Irritability can be a nonspecific symptom in toddlers and may occur for many reasons, such as fatigue or discomfort, but it is not a hallmark sign of nephrotic syndrome and does not reflect the primary pathophysiology.

C. Increased urinary output: Nephrotic syndrome is generally associated with normal or decreased urinary output due to fluid retention and edema. Increased urine output is not consistent with the fluid shifts and hypoalbuminemia seen in this condition.

D. Increased abdominal girth: Increased abdominal girth is a key indicator of nephrotic syndrome in toddlers, resulting from fluid accumulation (ascites) due to hypoalbuminemia and edema. Monitoring for abdominal swelling helps identify disease onset or exacerbation.

A. Insert an indwelling urinary catheter during the procedure: An indwelling urinary catheter is not routinely required for a lumbar puncture in a child. It is invasive and only indicated if the child cannot void independently or if prolonged immobility is expected, which is not the case here.

B. Ensure the child voids prior to the procedure: Having the child void before the lumbar puncture helps reduce discomfort, prevent bladder injury, and facilitates proper positioning during the procedure. It is a standard pre-procedure nursing action.

C. Monitor for paresthesia and tingling in extremities following the procedure: Paresthesia, numbness, or tingling can indicate nerve irritation or injury during the lumbar puncture. Monitoring neurologic status after the procedure is essential to detect complications early.

D. Ensure the guardian has signed the consent form prior to the procedure: Obtaining informed consent from the guardian is legally and ethically required before performing an invasive procedure like a lumbar puncture. It ensures that the guardian understands the risks, benefits, and alternatives.

E. Apply pressure to the puncture site following the procedure: Applying gentle pressure after the lumbar puncture helps prevent bleeding, reduces the risk of hematoma, and minimizes post-procedure complications such as CSF leakage.

F. Limit the child's fluid intake following the procedure: Limiting fluid intake is not indicated after a lumbar puncture. In fact, encouraging fluids may help prevent post-lumbar puncture headache by maintaining CSF volume.

G. Position the child in a prone position during the procedure: The correct position for a lumbar puncture is usually lateral recumbent or sitting with the back flexed to widen the intervertebral spaces. Prone positioning is inappropriate for this procedure.