Concerns

Good morning.

Today, we have some concerns. They aren't anything emergent, but definitely something to be watching.

Today's swelling is definitely worse. Today should be the worst of it.

Ok, so here's what we are watching:

• heart rate
• Ethan is typically mid-high 50's resting. He was sitting low-mid 50's until today. Today, he's in the 80's which could be indicative of pain. He is on Precedex which is known to lower the heart rate, plus he's been given a bolus of morphine and tylenol and his HR is still in the 80's. 
• oxygen
• he is on the ventilator and has been sitting at high 90's and even 100 oxygen saturation level, but today he's dropped to 89-low 90's. They have upped his PEEP from 5 to 7 and upped his oxygen level from 30% to 40% (room air is 21%). They are getting ready to do a strong suction and bag him to really make sure his lungs are clear. 
• temperature
• he's running at around 102 degrees
• blood pressure
• it has been all over the place from elevated on day 1, to "soft"/low, but his MAP is fair
• urination
• they removed the foley yesterday to give his body a chance to urinate on its own, but he hasn't. They had to do an in/out cath this morning and released over 500 cc's of urine. They are giving him until later this afternoon to pee or else the foley goes back in. They are trying to avoid it to decrease the infection risk. He has been given multiple doses of Nubain to help with the retention.
• bleeding
• Dr. Runyan came in this morning and assured me that the blood drainage from the mouth and nose are normal and expected. He said we can do an Afrin spray to help close off the flow, but his labs still look good enough; they are lower, but not transfusion low.
• swelling
• today should be the peak of swelling. It's pretty intense as you can see above, but normal. We are putting ice packs on his cheeks for 15 minute intervals.
• feeding
• we restarted feeds last night at a super slow rate and he has tolerated them fine so far
• extubation
• won't happen until Monday, likely. He's still too swollen now and will still be tomorrow, so it won't be done then, and they don't like to extubate on the weekends with a case like this.

I've had a few moments of availability to educate some nursing and PA students which is always awesome. I respect that the team on board right now refer back to me for those teachable moments. They haven't discounted any of my concerns and take everything into consideration. Or, they explain why he's responding a certain way so I can be put at ease about it. So far, no "God complexes" from anyone caring for him.

+++HOLD PLEASE+++

Ok, I'm back. Ethan's sedative wore off enough for him to try to bolt up. Good thing my reflexes are pretty fast when it comes to him and that the RT was right outside and saw it and came running in, too. We got the nurse to bolus some versed and he's asleep comfortably again. We were even able to clean up his bloody mouth/face/nose since he was nice and asleep again. This boy and how he keeps us on our toes!