Olivia Greenbaum is a 9-month-old infant admitted to the hospital with respiratory syncytial virus (RSV). She was born prematurely at 30 weeks' gestation. Her complications at birth included respiratory distress syndrome (RDS), suspected sepsis, and formula intolerance. She was discharged home after 8 weeks on soy-based formula. This is her first hospitalization since her birth. Olivia is Mr. and Mrs. Greenbaum's only child, and they are very anxious. Mrs. Greenbaum is her primary caregiver.Olivia is receiving supplemental humidified oxygen administered via oxygen tent at 40%. She is very fussy and is not tolerating separation from her mother well. She has a peripheral IV inserted in her right hand with D5 ¼ NSS with 10 mEq of potassium chloride infusing at 20 mL/hr. It is covered with a sock puppet. She is wearing a T-shirt and a disposable diaper. She is quite active within the crib. Her previous vital signs were as follows: temperature, 36.4°C (97.5°F); pulse, 84 beats/min; respirations, 38 breaths/min; blood pressure, 94/58 mm Hg.Mrs. Greenbaum spent the night and is currently sleeping in the recliner in Olivia's room. You enter the room and observe Olivia sleeping. She is pale with circumoral cyanosis. Her respiratory rate is 40 breaths/min with an audible expiratory wheeze. Her heart rate on the monitor is 86 beats/min; her pulse rate on the pulse oximeter is 62 beats/min. The pulse oximeter is currently showing an oxygen saturation level of 68%.
Prescribed Interventions
- Vital signs q4h
- Encourage coughing
- Oxygen via tent at 40%
- Continuous pulse oximetry when quiet; may obtain every hour intermittent pulse oximeter readings when active
- Maintain O2 saturation 93% to 97%. Adjust O2 in increments of 2% up to a max of 50%
- Isomil 6 to 8 oz every 4 hours when awake
- Intravenous fluids: D5 ¼ NSS with 10 mEq potassium chloride at 20 mL/hr
- Heart rate/resp. monitor
Developing Clinical Reasoning and Clinical Judgment
- What is your first priority after observing Olivia sleeping?
- Should you increase the oxygen being administered?
- What is your interpretation of her vital signs and oxygen saturation?
- Give examples of how to manage thermoregulation within an oxygen tent.
- Identify factors that affect the accuracy of the oxygen saturation reading.
- How frequently should Olivia's IV site be assessed? What is the function of the sock puppet?
- How do you encourage coughing in a 9-month-old infant?
Suggested Responses for Integrated Nursing Care
- Your first priority is to establish whether Olivia is hypoxic. You noted a rapid respiratory rate and circumoral cyanosis, both potential symptoms of hypoxia. The pulse oximeter heart rate does not match the cardiac monitor heart rate. Gently, without disturbing Olivia, you remove and replace the pulse oximeter.
- Your preliminary assessment is that the pulse oximeter is not accurately assessing her oxygenation. You are able to hold the probe to her toe and get a reading of 95%. Olivia begins to wake up. Take her apical heart rate, which is the most reliable site for infants and small children (see Chapter 2). Compare her apical pulse rate with the heart rate on the pulse oximeter as well as the heart rate on the cardiac monitor. Nurses must always verify that the equipment is accurately reflecting the patient's status. Next, you take her temperature, which is 97.1°F (36.2°C). The humidified oxygen is also cooling Olivia, making her hands, feet, and lips appear cold, blue, and dusky (refer to Chapter 14).
- Once Olivia is awake, she will not tolerate having the pulse oximeter probe on her toe and will keep pulling it off. You will need to check the oxygen saturation intermittently, as well as a more focused respiratory assessment (refer to Chapters 2 and 3). Your next priority is to warm her up. When children become chilled, they have increased energy expenditure. When infants are stressed beyond aerobic metabolism, they use anaerobic metabolism. This produces lactic acid, which increases the acidity of the blood, exacerbating respiratory distress. Urge her parents to bring in more clothes and to layer clothing to keep Olivia thermoregulated within the humidified tent. You do not need to increase the oxygen level; what at first looked like hypoxia is in fact hypothermia!
- The accuracy of a pulse oximetry reading is affected by several factors, including patient perfusion and peripheral vasoconstriction. Other factors that prevent the detection of oxygen saturation may be as simple as nail polish or artificial nails (see Chapter 14).
- Encouraging coughing in an infant is accomplished either through crying or laughing. Crying and laughing require deep breaths and will cause a patient to cough, thus promoting airway clearance. If the infant is periodically crying vigorously, that is sufficient. You can try tickling or playing peekaboo to get a 9 month old to laugh.
- Check this patient's IV site every hour to ensure there are no signs of infiltration (Chapter 16). The sock puppet is one way to disguise the IV site dressing while leaving it accessible for examination. If a young child can see the IV site dressing, they will often persist in trying to remove the tape and dressing despite all your efforts. If you cover the site, the child will not remember it is there. Piaget's theory of cognitive development includes the concept of object permanence. At 9 months old, a child cannot imagine what they cannot see—in other words, what is out of sight is out of mind. Other alternative to restraints may also be appropriate (refer to Chapter 4).