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Cole McKean is a 4-year-old boy in the pediatric intensive care…
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 he or she 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 healthcare provider says, “This little fellow was ready to get rid of his tube.” She orders 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
