A 4-year-old child has been admitted to the hospital with nephrotic syndrome. The little boy has ascites and swollen legs and arms. The nurse on the med-surg unit is preparing for the child and his mother and father to arrive from the Emergency Department.
Critical Thinking Check
Bloom's Taxonomy: Application
What should the nurse make sure is in this child’s room?
Measuring tape to measure circumference of the stomach as well as the arms and legs to monitor if edema is getting worse
PUC (pediatric urine cup that sticks to the child under their clothes) to measure strict intake and output (I&O’s)
The family arrives to the room and the little boy gets weighed in and measured. The first set of vital signs show hypertension, as to be expected. The nurse sets up the television and call light and asks if there are any questions. Mom asks about when her son will be able to eat because he hasn’t eaten all day.
Critical Thinking Check
Bloom's Taxonomy: Application
What is the appropriate type of meal to have as a diet order?
In nephrotic syndrome, the kidneys lose so much protein that the liver tries to compensate and there is an increase in lipids in the blood.
There is also an excess of fluid retention, so sodium should also be restricted
Protein should be balanced based on the patient’s weight and needs – consult a dietician
The nurse checks the patient’s orders for an antihypertensive medication order to bring the blood pressure down. The eMAR shows Labetalol and a few other medications.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What other medications would the nurse expect to be ordered for this patient?
The plan involves monitoring serum albumin and urinalysis.
The patient is improving when the serum albumin increases and the protein in the urine decreases.
Daily weights, strict I&O’s and measurements will show improvement as well.
Inform the parents that our concern is fluid build-up on the lungs leading to infection so close monitoring of the respiratory system with O2 saturation and listening to breath sounds will help to catch any fluid build-up in the lungs early on for quicker treatment to prevent infection.
Daily weights will be performed and a decrease in weight is a sign of improvement as well as measurements of the wrists and ankles to monitor edema.
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 
