Cole McKean is a 4-year-old boy in the pediatric intensive care unit (PICU). He weighs 22 kg. He was admitted 3 days ago after nearly drowning in a neighbor's pool. He was submerged for 5 to 10 minutes. The neighbor initiated CPR and the rescue team had a heart rate established within 10 minutes of their arrival. The aspirated pool water caused a severe inflammatory response resulting in pulmonary edema. Cole is intubated with an endotracheal tube (ETT) and is on a mechanical ventilator. Throughout the past 2 days, he has been producing copious bronchial secretions and has required suctioning about every 2 hours. Today, his breath sounds are clearer and he requires less frequent suctioning. He is being weaned off oxygen. The care plan for today includes possible extubation. An arterial line is in place in his left radial artery, infusing NSS at 2 to 3 mL/hr. A peripherally inserted central catheter (PICC) line with an infusion of D5 ½ NSS at 75 mL/hr is inserted into his right arm. His heart rate, respiratory rate, and arterial waveform are being monitored. The pulse oximeter sensor is applied to his right toe. He has an indwelling urinary catheter to gravity drainage and a nasogastric tube in place and set to low intermittent suction. Cole is receiving sedation but is opening his eyes at times and moving his extremities. He is becoming more active.Suddenly, the alarm goes off on the ventilator. You look at Cole. His eyes are open and he is making crying sounds. You know when a child is properly intubated they cannot make sounds. You notice that his oxygen saturation level has dropped to 81% and his color is dusky. He is breathing on his own around the tube and his abdomen is rounded. You and the pediatric intensivist assess Cole's respiratory status and oxygenation and decide to remove the ETT and begin oxygen at 40% via face mask. When you place Cole on the face mask, his oxygen saturation returns to the mid-90s. The health care provider says, “This little fellow was ready to get rid of his tube.” She prescribes a follow-up arterial blood gas (ABG) to be drawn in 15 minutes.
Prescribed Interventions
- Continuous pulse oximetry
- Foley to gravity
- Maintain O2 saturation 92% to 98%
- I&O
- Oxygen 40% via face mask
- Nasogastric tube to low intermittent suction
- Vital signs q1h
- Neurologic checks q1h
- Intravenous fluids: D5 ½ NS at 75 mL/hr
- Endotracheal suctioning prn
- Arterial line: NSS 2 to 3 mL/hr
Developing Clinical Reasoning and Clinical Judgment
- Describe your initial actions in response to a possible extubation.
- How can the technique of drawing ABGs be adapted for a pediatric patient?
- How will Cole's response be evaluated now that he is on an oxygen mask?
- Develop a care plan that will allow Cole rest and sleep periods, but also allow hourly assessments.
- Identify the nursing skills involved in monitoring Cole's respiratory status.
Suggested Responses for Integrated Nursing Care
- When a patient is intubated, the patency of this airway is a critical priority. When you hear Cole cry, you must determine if his ETT is in the proper place (refer to Chapter 14). Listen with your stethoscope over the lung fields and abdomen. If you do not hear ventilator-induced breath sounds over the lung fields, then the ETT is not in place. Because a child's neck is so short, it is not difficult to displace a tracheal tube into the esophagus. If this occurs, you may hear ventilator-cycled sounds in the abdomen. Signs that an ETT is not in the correct position include unstable oxygen saturation levels, cyanosis, and abdominal distention. In Cole's situation, you determine that the ETT is no longer in the lungs. All patients on mechanical ventilation must have an Ambu bag and a mask of the correct size at the bedside. Cole did not require mask-bag respirations at this time, but he has the potential for this need.
- When you are evaluating Cole's response, the ABG results will guide clinical decision making regarding oxygen delivery. In Cole's case, 10 to 15 minutes after changing to the 40% oxygen mask, you draw an ABG (see Chapter 18). The results come back as follows: Pao2, 82 mm Hg; Paco2, 46 mm Hg; pH, 7.34; Hco3, 20 mEq/L. This ABG shows that Cole's oxygen level is acceptable and there is no indication to support immediate reintubation. Continue to assess Cole's respiratory status and oxygenation (see Chapters 3 and 14) and obtain ABGs periodically, as prescribed, to evaluate Cole's response to treatment.
- Monitor and assess Cole's respiratory status: observe his work of breathing, count his respiratory rate, observe his color, and auscultate breath sounds (refer to Chapters 2, 3, and 14). If he shows no significant respiratory distress and has a stable respiratory rate and clear breath sounds, he is responding well to the change in his oxygen source. In addition, continuously monitor the oxygen saturation level via pulse oximetry. Immediately report any increases or decreases in oxygen saturation to the health care provider.
- Because children have a small total blood volume, the blood drawn back in the arterial line is usually not discarded but returned to the patient after the laboratory sample is drawn. Smaller volumes of blood are sent to the laboratory in pediatric specimen tubes. The setup for a pediatric arterial line delivers a smaller volume of fluid when the inline flushing device is activated (see Chapter 18).
- When a patient, especially a child, is critically ill, cluster your hands-on care so that the patient will have a significant amount of time to sleep and rest between interventions. One of the initial assessments a nurse makes in an intensive care setting is to determine that each of the monitoring devices is accurately displaying the patient's status (see Chapters 14 and 15). After you determine that the monitors accurately reflect the patient's vital signs, obtaining alternating sets of vital signs from the patient and from the monitor may be permitted, according to hospital policy (refer to Chapter 2). Consider interventions to decrease discomfort and increase patient comfort (Chapter 10). Maintain a quiet environment (Chapter 10). Because of the noise and activity of the intensive care unit, many infant and child intensive care units dim the lights at night to create day/night cycles for the children.