The nurse is reviewing the Nurses' Notes from week 1 at 1215.

Which of the following actions should the nurse include in the plan of care? Select all that apply.

The evaluation of therapeutic effectiveness in Minimal Change Nephrotic Syndrome (MCNS) focuses on the reversal of the core pathological symptoms: edema and fluid shifts. Effective corticosteroid therapy (Prednisone) repairs the glomerular basement membrane, stopping the leakage of protein into the urine. As serum albumin levels rise, fluid moves from the tissues back into the vascular space, leading to improved peripheral perfusion, resolution of edema, and normalization of hydration status.

Rationale for correct findings:

• Improved skin turgor indicates better hydration status and restoration of intravascular volume. Initially, the child had skin tenting, suggesting dehydration despite edema from fluid shifting into interstitial spaces. Resolution of tenting shows that fluid balance is improving and circulating volume is more stable. This is an important sign that treatment is helping correct nephrotic fluid imbalance.

• A capillary refill of less than 2 seconds reflects normal peripheral perfusion and improved circulation. Previously, delayed capillary refill suggested poor intravascular volume and decreased tissue perfusion. Improvement indicates better vascular filling and more effective fluid management. This supports that the prescribed therapy is successfully improving circulatory status.

• Resolution of periorbital edema is a strong indicator that excess fluid retention is decreasing. Periorbital swelling is a classic early sign of nephrotic syndrome caused by hypoalbuminemia and fluid leakage into tissues. Its absence suggests reduced protein loss and better fluid regulation. This finding strongly supports therapeutic improvement.

• A soft, formed bowel movement indicates improvement from the previous loose, liquid stools and hyperactive bowel sounds. This suggests better gastrointestinal function, improved nutritional intake, and reduced fluid loss from diarrhea. Stabilization of bowel patterns helps support hydration and overall recovery. It reflects improved systemic status after treatment.

Rationale for incorrect findings:

• The presence of any edema suggests that fluid retention has not completely resolved. Although nonpitting edema may be less severe than previous pitting edema, it still indicates persistent abnormal fluid accumulation. Full therapeutic effectiveness would ideally show resolution of edema rather than its continued presence. This finding requires continued monitoring rather than being considered a clear success.

• An elevated temperature is concerning and does not indicate improvement. Fever may suggest infection, which is especially important because prednisone therapy suppresses immune function. Children receiving corticosteroids are at increased risk for infection and require close observation. This finding suggests a possible complication rather than effective therapy.

• This blood pressure is elevated for a 7-year-old child and is concerning rather than reassuring. Hypertension may result from steroid therapy, fluid retention, or renal complications. It does not indicate successful resolution of nephrotic syndrome and may require further evaluation. Elevated blood pressure should be followed closely rather than considered a sign of effective treatment.

Peritonitis is the most frequent and serious complication of peritoneal dialysis (PD), particularly in pediatric patients where the risk of contamination is higher. It involves the inflammation of the peritoneum, usually caused by the introduction of bacteria through the dialysis catheter or during bag changes. For a toddler, early detection is vital to prevent systemic sepsis and damage to the peritoneal membrane, which acts as the filtering surface for the procedure.

Rationale:

A. A report of abdominal cramping during the infusion of the dialysis fluid is common and does not necessarily indicate peritonitis. This sensation often occurs if the dialysate is infused too rapidly, if the fluid is too cold, or due to the initial stretching of the peritoneal cavity. The nurse should monitor the toddler's comfort and consider slowing the infusion rate or warming the fluid, but cramping alone is typically a mechanical or temperature-related issue.

B. Edema at the tube insertion site is more indicative of a localized exit-site infection or a fluid leak rather than generalized peritonitis. An exit-site infection can eventually lead to peritonitis if left untreated, but it is characterized by local redness, warmth, and swelling around the catheter itself. Peritonitis, by contrast, is an internal infection of the entire abdominal lining that presents with systemic and effluent changes rather than localized skin findings.

C. A cloudy appearance of the dialysate draining from the toddler is the hallmark sign of peritonitis. The cloudiness is caused by the presence of white blood cells (leukocytes) and potentially bacteria or fibrin within the effluent fluid. The nurse should immediately recognize this change in clarity as a medical priority, obtain a sample for culture and sensitivity, and notify the healthcare provider, as prompt initiation of intraperitoneal antibiotics is required to treat the infection.

D. The development of a moist cough during the procedure may indicate fluid volume overload or the upward displacement of the diaphragm by the dialysate, which can compromise respiratory effort. This is a concerning finding that requires the nurse to assess the toddler’s breath sounds and respiratory rate, but it is a pulmonary or volume-related complication rather than an inflammatory or infectious manifestation of the peritoneal lining.