This is my croup assignment for paediatrics nursing. Croup is characterized by barking cough, inspiratory stridor and low-grade fever. It is normally caused by viral infection and it is most common in children of 6 months to 36 months. Croup can be misdiagnosed with acute epiglottitis, peritonsillar abscess, or foreign body obstruction and etc.

1. BSCN 3023 PAEDIATRIC NURSING
“CROUP”
Prepared by:
Nur Amira Binti Ahmad
Bachelor of Science In Nursing (Hons)
3067141001
Lecturer:
Madam Annamma Mathews
1

2. Learning objectives:
At the end of this case study, we will be able to :
1) Explain the patient’s personal information, provisional diagnosis, present medical and surgical history,
past medical and surgical history, and also family history.
2) State the birth history
3) State the immunization history
5) Explain the growth and development of the patient
6) Explain the disease condition including the definition, incidence, etiology, pathophysiology,
investigation, treatment, prevention of croup
7) Explain the medical management for patient with croup syndrome
8) Carry out the approprite nursing care plan for the patient with viral croup syndrome
2

3. IDENTIFICATION DATA
Name Miss A
Age 3 years old
Sex Female
Diagnosis Croup
Mother Madam S
Mother’s occupation Staff nurse at ‘B’ University Medical Center
3

4. CHIEF COMPLAINT
Sunday Miss A has had a “barky, croupy, cough” for 4 days. she
started having cough on Sunday. She has had nasal
drainage for several days and significant nasal congestion.
Monday (Day 1
of symptoms)
The cough worsened and and has a barky quality and is
worse when the patient lies down.
Tuesday (Day 2
of symptoms)
In the evening, Miss A experieced a spiked temperature of
38.2oC. Mother served Paracetamol and temperature went
down to 37.2oC. Miss A has a decreased appetite and taken
less fluids by mouth.
4

5. Birth History: The patient was a 36-week infant born to G1 P0→1
female. She weighed 3.1 kg at birth and had no complications.
She was breast fed as an infant.
Past medical & surgical history: NIL
Family medical history: No family medical and surgical history
noted
Family surgical history: Unknown
Antenatal history: Unknown
5

6. IMMUNIZATION
As for Miss A, the schedule of immunization is unknown.
Assuming she is getting all the immunization as her mother is a
nurse, thus by 3 years old she should already completed all the
doses of Hepatitis B, Dtap, Hib, Polio and MMR. She will next
take the booster injection at the age of 7 years old for MR & DT
vaccine.
6

7. Immunization schedule by Ministry of Health, 2016
7

8. PHYSICAL EXAMINATION
Vital signs
Height 85 cm
Weight 14 kg
Temperature 38.4 oC (normal core temperature: 37.0oC-37.2oC)
Pulse 131 bpm (normal heart rates: 70-110 bpm)
Respiratory
rate
32 bpm (normal respiratoty rate: 20-30 bpm)
Pulse
oxymetre
98% (normal: above 95%)
Blood
pressure
94/67 mm/Hg
(normal blood pressure: systolic: 75-110 mm/Hg diastolic: 45-80
mm/Hg)
8

9. FLUIDS REQUIREMENT
Body weight Fluid requirement/day Fluid requirement/hour
First 10 kg 100 ml/kg body weight 4 ml/kg body weight
Second 10 kg 50 ml/kg body weight 2 ml/kg body weight
Subsequent kg 20 ml/kg body weight 1 ml/kg body weight
Miss A requirement according to her weight:
14 kg = (100 x 10) + (50 x 4)
= 1000 + 200
= 1200 mls/day
Young children and infants have a greater fluid intake and output than adults and older children. The fluid
requirement is relative to their size and several physiological characteristics; blood volume is greater in the
neonate and decreases with age, as does the infant’s extracellular fluid. (Oxford Handbook of Paediatric Nursing,
2010)
9

10. WEIGHT
For Miss A the birth weight is 3.1kg and her weight now is:
3.1 kg x 4 = 12.4 kg (2 ½ years)
12.4 kg ± 2 kg = 14.4 kg
14 kg (age = 3 years old)
Miss A is in her normal body weight for a children at her age.
10

11. HEIGHT
For Miss A the birth length is unknown but her current height is 85
cm at the age of 3 years old. Thus, it is categorized as normal
height for a children at her age.
This is the average height value accordingly to age (Wong’s Clinical Manual of Paediatric Nursing, 6th
Edition)
 Average length at birth: 50 cm
 First 6 month: 2.5 cm/month
 Second 6 month: 1.25 cm/month
 By 1 year: increased approximately 50% of birth length
 During second and third year: 6-12 cm/year
 4 year: double of birth length
 5-6 years: average height is 106 cm – 123.5 cm or 6-8 cm/year
 7-12 years: average height is 111.8 cm – 162.3 cm/year
 At the age of 13 years: triple of birth length
11

12. Body Mass Index (BMI)
■ BMI as determined by calculations of weight and height, can overestimate weight status because it
does not account for increased fat-free mass, for example muscle. (Childhood Obesity, Oxford
Handbook of Paediatric Nursing 2010)
BMI Formula: Weight (kg) ÷ [Height (m)]2
BMI for Miss A is:
BMI = 14 kg ÷ (0.85 x 0.85) m
= 14 kg ÷ 0.7225 m
= 19.38 kg/m2
12

13. GROWTH & DEVELOPMENT
Age Gross motor Fine motor Speech/language Social
3 years
old
1) Goes up stairs one
foot per step
2) Down stairs two feet
per step
3) Jumps off bottom step
4) Stands on 1 foot for
seconds
5) Rides trycycle
Tower of 9
Imitates bridge
with cubes
Can count to 10.
Names 2 colours.
Nursery rhymes.
Understands “on”,
“in”, “under”
Dresses,
undresses
with help. Dry
by night. Play
with others.
13

14. WHAT IS CROUP?
■ Croup is a general term applied to a group of symptoms charazterized by
hoarseness, a resonant cough described as “barking” or “brassy”
(croupy), varying degrees of inspiratory stridor, and varying degrees of
respiratory distress resulting from swelling or obstruction in the region of
the larynx and subglottic airway. (Wong’s Nursing Care of Infants and
Children, 10th Edition).
14

15. INCIDENCE
■ “Croup mostly affects children between 6 and 36 months,
although it may occur in older children or infants as young
as 3 months. It is rare beyond 6 years of age.” (Wong’s Nursing
Care of Children and Infants, 10th Edition).
15

16. Etiology: Bacteria such as Mycoplasma pneumonia can also cause croup. The airway obstruction
symptoms of croup are classically worse at night and peak on the second or third night of the illness.
ETIOLOGY FREQUENCY SEVERITY PEAK INCIDENCE
Parainfluenza virus types 1
to 3 (type 1 is most
common)
Frequent
50 to 75 percent
Variable (usually severe with
type 3 virus)
Winter and spring
Enterovirus Occasional to frequent Usually mild Fall
Human bocavirus Occasional to frequent Usually mild Spring and fall
Influenza A and B viruses Occasional to frequent Variable (severe with
influenza A virus)
Winter
Respiratory syncytial virus Occasional to frequent Mild to moderate Winter
Rhinovirus Occasional to frequent Usually mild Fall
Adenovirus Occasional Mild to moderate Winter
Measles Rare Moderate to severe During measles epidemics
16

17. PATHOPHYSIOLOGY
Viral infection of the laryngeal mucosa
Inflammation, hyperemia, edema, epithelial necrosis and shedding, results in narrowing of the
subglottic region.
Breath more rapid and deep to compensate the narrowing of the upper airway
Airflow through the upper airway becomes turbulent (stridor). Chest wall begins to “cave-in”
during inspiration.
Inefficient asynchronous chest and abdominal movement, fatigued
Hypoxic and hypercapneic, and quickly develops respiratory failure and arrest.
17

18. CLINICAL MANIFESTATION
o Non-specific cough, rhinorrhea, and fever.
o Barking cough, stridor, and respiratory distress most commonly develops
suddenly during the evening or at night.
o The clinical signs of severe obstruction include pallor and lethargy, marked
intercostals and sternal indrawing, restlessness and tachycardia. Cyanosis is a
late sign and always indicates very severe obstruction.
o Stridor typically occurs only during inspiration; but with more severe distress,
can be biphasic, occurring during expiration as well. Fever can occur and be
high (up to 40°C).
18

19. TYPES OF CROUPS
Acute Epiglottitis Acute Ltb Acute Spasmodic
Laryngitis
Acute Tracheitis
Age group
affected
2-5 year but varies Infant or child <5 year 1-3 year 1 month to 6 year
Etiologic
agent
Bacterial Viral Viral with allergic
component
Viral or bacterial with
allergic component
Onset Rapidly progressive Slowly progressive Sudden, at night Moderately progressive
Major
symptoms
Dysphagia
Stridor
Drooling
High Fever
Rapid Pulse And
Respirations
Stridor
Brassy Cough
Hoarseness
Dyspnea
Restlessness
Low-Grade Fever
Uri
Croupy Cough
Stridor
Hoarseness
Dyspnea
Restlessness
Croupy Cough
Purulent Secretions
High Fever
No Response To Ltb
Therapy
Treatment Humidifoed Oxygen
Airway Protection
Fluids
Antibiotics
Cortocosteroids
Fluids
Nebulizer
Cool Mist Antibiotics
Fluids
(Wong’s Nursing Care If Infants And Children, 10th Edition)
19

20. DIFFERENTIAL DIAGNOSIS
■ 1) Acute epiglottitis or acute supraglottitis is a serious obstructive inflammatory
process that occurs principally in children between 2 and 5 years of age but can
occur from infancy to adulthood. The obstruction is supraglottic as opposed to the
subglottic obstruction of larygngitis. (Wong’s Nursing Care of Children and Infant,
10th edition)
A. Normal epiglottis B. Inflammed epiglottis
20

21. DIFFERENTIAL DIAGNOSIS cont..
■ 2) Bacterial tracheitis is an infection of the mucosa and soft tissues of the upper
trachea, is a distinct entity with features of both croup and epiglottitis. The disease
may cause a severe airway obstruction and the incidence are most common in 5 to
7 years old children. (Roosevelt, 2011)
Normal trachea Inflammed trachea
21

22. DIFFERENTIAL DIAGNOSIS cont..
■ 3) Peritonsillar / retropharyngeal abscess presents with fever,
drooling, a change in voice quality and neck extension and painful
neck movements.
22

23. DIFFERENTIAL DIAGNOSIS cont..
■ 4) Foreign body aspiration has an abrupt onset of cough without fever,
often in a setting of the child playing with small objects.
23

24. DIFFERENTIAL DIAGNOSIS cont..
■ 5) Anaphylaxis presents as acute onset (minutes to hours) of an allergic reaction
following exposure to an allergen and presenting with generalised urticaria, pruritus,
swollen lips-tongue-uvula, respiratory compromise with dyspnoea and wheeze,
hypotension, hypotonia, collapse and abdominal pain.
24

25. DIAGNOSTIC MODALITIES
1) A diagnosis can usually be made from a clinical assessment
■ Includes an examination of skin colour, hydration, breath sounds and air
movement. In cases of severe croup, or if atypical signs are present
suggesting a different diagnosis, further investigations are necessary.
2) Pulse oximetry
■ To determine the percentage of oxyhemoglobin in blood pulsating
through a network of capillaries. A low reading of oxygen ssaturation on
pulse oximetry (<95%) indicates significant respiratory impairment.
3) Blood test
■ Blood test will be used to check for infection and the amount of oxygen
in the patient’s blood.
25

26. 4) Radiography
■ A chest radiograph is not part of the standard assessment. Only 50% of
patients with croup show the classic "steeple" sign on plain neck
radiography. The steeple sign results from a narrowed column of
subglottic air seen on a posterior-anterior radiograph.
5) Laryngoscopy
■ Direct or indirect laryngoscopy is not usually required and is indicated if
there is a concern for an anatomical malformation of the upper airway,
possible aspiration of a foreign object, or should the child rapidly
deteriorate or not respond to routine therapy in the anticipated manner.
DIAGNOSTIC MODALITIES cont…
26

27. TREATMENT
GROUP Analgesic/ anti-pyretic
CONTENT Acetaminophen
DOSAGE 125 mg/ml
ROUTE Oral
INDICATION For the treatment of mild to moderate pain, including
headache, migraine, neuralgia, toothache, sore
throat, period pains, aches and pains.
For the reduction of fever and to be used as an
adjunctive treatment to relieve symptoms of cold
and flu.
SPECIAL
PRECAUTION
• Leave at least 4 hours between doses
• Do not give more than 2 doses. This is to ensure
that fever that may be due to a serious infection is
quickly diagnosed. If your child is still feverish after
two doses, consult the physician.
• Do not give to babies less than 2 months of age
SIDE EFFECT Nausea, vomiting, in case of hypersensitivity, rash,
itching, trouble breathing 27

28. TREATMENT
GROUP Glucocorticoid
CONTENT Dexamethasone
DOSAGE 0.6 mg/kg not to exceed 16 mg
ROUTE Oral
INDICATION Dexamethasone is used to treat many different inflammatory
conditions such as allergic disorders, skin conditions, ulcerative
colitis, arthritis, lupus, psoriasis, or breathing disorders.
SPECIAL
PRECAUTION Do not receive a "live" vaccine while using dexamethasone. The
vaccine may not work as well during this time, and may not fully
protect you from disease. Live vaccines include measles,
mumps, rubella (MMR), oral polio, rotavirus, typhoid, varicella
(chickenpox), H1N1 influenza, and nasal flu vaccine
SIDE EFFECT  Sleep problems (insomnia), mood changes;
 Acne, dry skin, thinning skin, bruising or discoloration;
 Slow wound healing;
 Increased sweating;
 Headache, dizziness, spinning sensation;
 Nausea, stomach pain, bloating;
 Muscle weakness; or
 Changes in the shape or location of body fat (especially in
arms, legs, face, neck, breasts, and waist).
28

29. TREATMENT
GROUP Steroid
CONTENT Budesonide
DOSAGE 500 mg stat
ROUTE Inhalation
INDICATION Pulmicort RESPULES is indicated for the
maintenance treatment of asthma and as
prophylactic therapy in children 12 months to 8
years of age.
SPECIAL
PRECAUTI
ON
May mask signs if infection. Lower down the
immune system, therefore do not have any
immunizations/vaccinations.
SIDE
EFFECT
White patches or sores inside the oral cavity or on
lips, runny or stuffy nose, sneezing, cough,
noseblees, headache 29

30. PREVENTION
Hand washing The most effective ways to reduce the risk for croup is to teach children to wash their hands frequently
throughout the day. Hand washing can help to prevent the spread of cold and flu viruses that can lead to
croup.Help children get in the habit of washing their hands before eating, after going to the bathroom, after
sneezing or coughing into their hands, and after playing outside or with pets.
Avoid close
contact
Other ways to prevent the spread of viruses that can lead to croup include avoiding contact with other
children and adults who are sick and eliminating the child's exposure to smoke, dust, and other respiratory
irritants and allergens.
Yearly
vaccination
Vaccination also can reduce a child's risk for developing croup. immunisation against
influenza is recommended as this may actually prevent croup caused by the influenza virus (influenza-
induced croup). These vaccines (immunizations) include the following:
 Diphtheria (part of DTaP, DT vaccines)
 Haemophilus influenza type b (Hib vaccine)
 Measles (part of MMR, MR, and measles vaccines)
30

31. NURSING CARE PLAN
■ 1) Hyperthermia related to viral infection
■ 2) Ineffective breathing pattern due to barking cough secondary to
croup
■ 3) Risk of dehydration related to less oral intake secondary to croup
31

32. Date: 22nd December 2016
Time: 11.00 AM
Nursing Diagnosis
Supporting Data
Hyperthermia related to viral infection
Objective data: Patient’s body temperature 38.4oC
Goal Patient’s body temperature will decrease to normal (38.4oC to 37.2oC) after 4 hours of intervention and throughout
hospitalization.
Nursing Intervention 1. Assess patient’s vital signs (body temperature, pulse, breathing rate and blood pressure) and the underlying conditions.
As a baseline data for further intervention
2. Provide patient with tepid sponge
Tepid sponge can help in lowering the body temperature by dehydrating the surface of the skin
3. Remove excess clothing, encourage patient to wear thin cotton clothing
To facilitate the evaporation process and help in lowering the body temperature
4. Advise patient to take enough oral fluid as per body requirement
Additional fluid helps in lowering body temperature by preventing dehydration
5. Maintain bed rest and reduce vigorous activity
Vigorous activities can increase the metabolic process which cause increase in the body temperature
6. Provide antipyretic medication as ordered by the physician
To help in reducing the body temperature
7. Inform doctor after administering the medication
For further intervention if the fever does not subside
8. Document the medication given in the drug chart and patient’s filE 32

33. Date: 22nd December 2016
Time: 11.00 AM
Nursing Diagnosis Ineffective breathing pattern due to barking cough secondary to croup
Goal Patient will maintain an effective breathing pattern after interventions and throughout hospitalization.
Nursing Intervention 1. Assess for signs and symptoms of an ineffective breathing pattern (e.g. shallow or slow respirations, limited chest excursion, tachypnea,
dyspnea, use of accessory muscles when breathing).
As a baseline data for further intervention
2. Observe for breathing patterns
Increase work of breathing can indicate the abnormalities in the patient
3. Auscultate breath sounds at least every 4 hours
This is to detect decreased or advetitious breath sounds
4. Utilize pulse oximetry
To check oxygen saturation and pulse rate
5. Lace client in a semi- to high Fowler's position unless contraindicated; position with pillows to prevent slumping
To help the patient in breathing effectively and have a maximal lung expansion
6. Maintain a clear airway by encouraging patient to mobilize own secretions with successful coughing.
This facilitates adequate clearance of secretions
7. Encourage frequent rest periods and teach patient to pace activity.
Extra activity can worsen shortness of breath. Ensure the patient rests between strenuous activities
8. Avail a fan in the room
Moving air can decrease feelings of air hunger
9. Educate patient or significant other proper breathing, deep breating exercise, pursed-lips breathing
These techniques promotes deep inspiration, which increases oxygenation and prevents atelectasis. Controlled breathing
methods may also aid slow respirations in patients who are tachypneic. Prolonged expiration prevents air trapping.
33

34. Date: 22nd December 2016
Time: 11.00 AM
Nursing Diagnosis
Supporting Data
Risk of dehydration related to less oral intake secondary to croup
Subjective data: Patient’s mother declare that her daughter resist to take anything by oral due to loss of appetite
Goal Patient will not experince episode of dehydration after intervention and throughout hospitalization.
Nursing Intervention 1. Assess patient’s vital signs especially blood pressure and heart rate, skin turgor and oral mucous membranes for signs of dehydration
As a baseline data for further intervention
2. Assess alteration in mentation/sensorium (confusion, agitation, slowed responses)
Alteration in mentation/sensorium may be caused by abnormally high or low glucose, electrolyte abnormalities, acidosis,
decreased cerebral perfusion, or developing hypoxia
3. Monitor fluid status in relation to dietary intake.
Most fluid comes into the body through drinking, water in food, and water formed by oxidation of foods
4. Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours
A normal urine output is considered normal not less than 30ml/hour. Concentrated urine denotes fluid deficit
5. Administer parenteral fluids as prescribed. Consider the need for an IV fluid challenge with immediate infusion of fluids for patients with
abnormal vital signs
Fluids are necessary to maintain hydration status. Determination of the type and amount of fluid to be replaced and infusion
rates will vary depending on clinical status.
6. Provide comfortable environment by covering patient with light sheets
Drop situations where patient can experience overheating to prevent further fluid loss
7. Emphasize importance of oral hygiene.
Fluid deficit can cause a dry, sticky mouth. Attention to mouth care promotes interest in drinking and reduces discomfort of
dry mucous membranes
34

35. CONCLUSION
o Croup can be defined as a group of symptoms charazterized by hoarseness, barking cough, inspiratory
stridor, and respiratory distress resulting from swelling or obstruction in the region of the larynx and
subglottic airway.
o Croup generally a viral infection. However, for some cases it can be cause by bacterial infection,
Mycoplasma pneumoniae. The symptoms that will be experinced by the patient are barking cough,
stridor, and respiratory distress. The patient also can be accompanied with a fever which can be up to
40oC.
o As for diagnostic studies, the most reliable is clinical assesment which the physician will observe the
child throughly. Pulse oxymetri also can be a crucial tools in assesing for croup syndrome. The reading
of oxygen saturation below than 95% can signal respiratory problem.
o Pharmacological treatment used most likely are antipyretic to reduce fever, glucocortocosteroid to
decrease the inflammation process and antibiotic may be use if bacterial infection suspected.
o As the saying goes, prevention is better than cure. Thus, thic croup syndrome can be prevented among
the children if the parents really emphasizing on hand hygiene, avoid the contact with person infected
with croup (or any other respiratory problem) and the most important this is to take yearly vaccination
for the children!
35

36. REFERENCES
■ Books
1) Paediatric Protocols For Malaysian Hospitals. (2013). 3rd ed. Putrajaya: Kementerian Kesihatan Malaysia,
p.28.
2) Hockenberry, M. and Wilson, D. (2015). Wong's nursing care of infants and children. 10th ed. St. Louis,
Missouri: Elsevier Mosby.
3) Glasper, E., McEwing, G. and Richardson, J. (2010). Oxford handbook of paediatric nursing. 1st ed. Oxford:
Oxford University Press.
■ Internet
1) Healthcommunities.com. (2016). Croup Diagnosis - Croup - HealthCommunities.com. [online] Available at:
http://www.healthcommunities.com/croup/children/croup-diagnosis.shtml [Accessed 21 Dec. 2016].
2) Healthcommunities.com. (2016). Croup Diagnosis - Croup - HealthCommunities.com. [online] Available at:
http://www.healthcommunities.com/croup/children/croup-diagnosis.shtml [Accessed 21 Dec. 2016].
3) Drugs.com. (2016). Pulmicort Flexhaler - FDA prescribing information, side effects and uses. [online]
Available at: https://www.drugs.com/pro/pulmicort-flexhaler.html [Accessed 21 Dec. 2016].
4) News-Medical.net. (2016). Pulmicort (Budesonide) Drug / Medicine Information. [online] Available at:
http://www.news-medical.net/drugs/Pulmicort.aspx [Accessed 21 Dec. 2016].
5) Drugs.com. (2016). Croup (Inpatient Care) - What You Need to Know. [online] Available at:
https://www.drugs.com/cg/croup-inpatient-care.html [Accessed 23 Dec. 2016].
36

37. Thank you for “LISTENING”
37