CROUP Core Competency 1: Definition: Croup or Laryngotracheobronchitis is a condition that causes an inflammation of the upper airways the voice

ce box (larynx) and windpipe (trachea). It often leads to a barking cough or hoarseness, especially when a child cries. General Signs and Symptoms: MILD - stuffy or runny nose - fever - hoarse, with a harsh, barking cough - wheezing - stridor - tachypnea - pale or cyanosis around the mouth - Croup is typically much worse at night. It often lasts 5 or 6 nights, but the first night or two are usually the most severe. Rarely, croup can last for weeks. Croup that lasts longer than a week or recurs frequently should be discussed with your doctor to determine the cause. SEVERE: - laryngitis - tracheitis - brochitis - epiglottitis - dehydration - airway obstruction (respiratory distress, respiratory arrest, atelectasis)

Core Compentency 2: Causes: Most cases of croup are caused by viruses, usually parainfluenza virus and sometimes adenovirus or respiratory syncytial virus (RSV). Viral croup is most common and symptoms are most severe in children 6 months to 3 years old, but can affect older kids too. Some children are more prone to developing croup when they get a viral upper respiratory infection. Most cases of viral croup are mild and can be treated at home. Rarely, croup can be severe and even life threatening.

The term spasmodic croup refers to a type of croup that develops quickly and may happen in a child with a mild cold. The barking cough usually begins at night and is not accompanied by fever. Spasmodic croup has a tendency to come back again (recur). - Allergies - Breathing in something that irritates your airway - Acid reflux

Risk Factors: Age: Croup tends to appear in children between 3 months and 5 years old, but it can happen at any age. Some children are more likely to get croup and may get it several times. Environment: (climate) Common on winter and rainy days Many children who come in contact with the viruses that cause croup will not get croup, but will instead have symptoms of a common cold. Hygiene Allergy

Core Competency 3: Viral croup usually goes away in 3 to 7 days. The outlook for bacterial croup is good with prompt treatment. If an airway obstruction is not treated promptly, respiratory distress (severe difficulty breathing) and respiratory arrest can occur.

Core Competency 4: Priority Nursing Diagnosis: (MILD) Ineffective thermoregulation r/t fever (SEVERE) Ineffective airway clearance r/t Laryngotracheobronchial obstruction

Core Competency 5: Diagnostic Test - Doctors can usually diagnose croup by listening for the telltale barking cough and stridor. They will also ask if your child has had any recent illnesses with a fever, runny nose, and congestion, and if your child has a history of croup or upper airway problems. - If a child's croup is severe and slow to respond to treatment, a neck X-ray may be done to rule out any other reasons for the breathing difficulty, such as a foreign object lodged in the throat,

a peritonsillar abscess (collection of pus at the back of the mouth), or epiglottitis (a inflammation of the epiglottis, the flap of tissue that covers the windpipe). An X-ray of a child with croup usually will show the top of the airway narrowing to a point, which doctors call a "steeple sign." Treatment: Most cases of croup can be safely managed at home, but call your health care provider for guidance, even in the middle of the night. Cool or moist air might bring relief. You might first try bringing the child into a steamy bathroom or outside into the cool night air. If you have a cool air vaporizer, set it up in the child's bedroom and use it for the next few nights. Acetaminophen can make the child more comfortable and lower a fever, lessening his or her breathing needs. Avoid cough medicines unless you discuss them with your doctor first. You may want your child to be seen. Steroid medicines can be very effective at promptly relieving the symptoms of croup. Medicated aerosol treatments, if necessary, are also powerful. Serious illness requires hospitalization. Increasing or persistent breathing difficulty, fatigue, bluish coloration of the skin, or dehydration indicates the need for medical attention or hospitalization. Medications are used to help reduce upper airway swelling. This may include aerosolized racemic epinephrine, corticosteroids taken by mouth, such as dexamethasone and prednisone, and inhaled or injected forms of other corticosteroids. Oxygen and humidity may be provided in an oxygen tent placed over a crib. A bacterial infection requires antibiotic therapy. Increasing obstruction of the airway requires intubation (placing a tube through the nose or mouth through the larynx into the main air passage to the lungs). Intravenous fluids are given for dehydration. In some cases, corticosteroids are prescribed.

Medication: Acetaminophen, Ibuprofen for fever Antibiotic therapy for bacteria Oxygen therapy for oxygen demand Corticosteroids for inflammation

Core Competency 6: Pharmacology Drug Name

Generic Name : dexamethasone,dexamethasone acetate , dexamethasone sodium phosphate

Brand

Name:

Oral, topical dermatologic aerosol and gel, ophthalmic suspension: Aeroseb-Dex, Decadron, Hexadrol, Maxidex Ophthalmic, ratio-Dexanamethasone (CAN) IM, intra-articular, or soft-tissue injection: Cortastat LA, Dalalone L.A., Decaject LA, DexasoneL.A., Dexone LA, Solurex LA IV, IM, intra-articular, intralesional injection; respiratory inhalant; intranasal steroid; ophthalmic solution and ointment; topical dermatologic cream: Cortastat, Dalalone, Decadron Phosphate, Decaject, Dexasone, Hexadrol Phosphate, Solurex Glucocorticoid, Category Hormone C

Classification:Corticosteroid, Pregnancy

Dosage ADULTS Systemic

&

Route

administration

Individualize dosage based on severity of condition and response. Give daily dose before 9 AM to minimize adrenal suppression. If long-term therapy is needed, alternate-day therapy with a short-acting steroid should be considered. After long-term therapy, withdraw drug slowly to

avoid adrenal insufficiency. For maintenance therapy, reduce initial dose in small increments at intervals until the lowest clinically satisfactory dose is reached. Oral (dexamethasone)

0.759 mg/day. Suppression test for Cushing's syndrome: 1 mg at 11 AM; assay plasma cortisol at 8 AM the next day. For greater accuracy, give 0.5 mg q 6 hr for 48 hr, and collect 24-hr urine to determine 17hydroxycorticosteroid (17-OHCS) excretion. Suppression test to distinguish Cushing's syndrome due to ACTH excess from that resulting from other causes: 2 mg q 6 hr for 48 hr. Collect 24-hr urine to determine 17-OHCS excretion.

IM (dexamethasone acetate)

816 mg; may repeat in 13 wk.

IV or IM (dexamethasone sodium phosphate)

0.59 mg/day. Cerebral edema: 10 mg IV and then 4 mg IM q 6 hr until cerebral edema symptoms subside; change to oral therapy, 13 mg tid, as soon as possible and taper over 57 days.

PEDIATRIC PATIENTS

Individualize dosage based on severity of condition and response, rather than by strict adherence to formulas that correct adult doses for age or body weight. Carefully observe growth and development in infants and children on long-term therapy.

IV

Unresponsive shock: 16 mg/kg as a single IV injection (as much as 40 mg initially followed by repeated injections q 26 hr has been reported). (dexamethasone acetate)

Intralesional ADULTS AND PEDIATRIC PATIENTS

416 mg intra-articular, soft tissue; 0.81.6 mg intralesional.

(dexamethasone sodium phosphate)

0.46 mg (depending on joint or soft-tissue injection site). Respiratory inhalant (dexamethasone sodium phosphate)

84 mcg released with each actuation.

ADULTS

3 inhalations tidqid, not to exceed 12 inhalations/day.

PEDIATRIC PATIENTS

2 inhalations tidqid, not to exceed 8 inhalations/day. Intranasal (dexamethasone sodium phosphate) Each spray delivers 84 mcg dexamethasone.

ADULTS

2 sprays (168 mcg) into each nostril bidtid, not to exceed 12 sprays (1,008 mcg)/day.

PEDIATRIC PATIENTS

1 or 2 sprays (84168 mcg) into each nostril bid, depending on age, not to exceed 8 sprays (672 mcg). Arrange to reduce dose and discontinue therapy as soon as possible.

Topical ADULTS AND PEDIATRIC PATIENTS

dermatologic

preparations

Apply sparingly to affected area bidqid. Ophthalmic solutions, suspensions

ADULTS AND PEDIATRIC PATIENTS

Instill 1 or 2 drops into the conjunctival sac q 1 hr during the day and q 2 hr during the night; after a favorable response, reduce dose to 1 drop q 4 hr and then 1 drop tidqid. Ophthalmic ointment

ADULTS AND PEDIATRIC PATIENTS

Apply a thin coating in the lower conjunctival sac tidqid; reduce dosage to bid and then qid after improvement.

Therapeutic actions

Dexamethasone is a synthetic glucocorticoid which decreases inflammation by inhibiting the migration of leukocytes and reversal of increased capillary permeability. It suppresses normal immune response

Indications

Hypercalcemia associated with cancer Short-term management of various inflammatory and allergic disorders, such as rheumatoid arthritis, collagen diseases (SLE), dermatologic diseases (pemphigus), status asthmaticus, and autoimmune disorders Hematologic disorders: Thrombocytopenic purpura, erythroblastopenia Trichinosis with neurologic or myocardial involvement Ulcerative colitis, acute exacerbations of MS, and palliation in some leukemias and lymphomas Cerebral edema associated with brain tumor, craniotomy, or head injury Testing adrenocortical hyperfunction Unlabeled uses: Antiemetic for cisplatin-induced vomiting, diagnosis of depression Intra-articular or soft-tissue administration: Arthritis, psoriatic plaques Respiratory inhalant: Control of bronchial asthma requiring corticosteroids in conjunction with other therapy Intranasal: Relief of symptoms of seasonal or perennial rhinitis that responds poorly to other treatments Dermatologic preparations: Relief of inflammatory and pruritic manifestations of dermatoses that are steroid-responsive Ophthalmic preparations: Inflammation of the lid, conjunctiva, cornea, and globe

Adverse effects

Growth retardation, osteoporosis, peptic ulcer, glaucoma and subcapsular cataracts, vertebral compression fractures. Cushing-like features, pancreatic dysfunction and pancreatitis, GI upsets, increased appetite, increased fragility of the skin. Increased susceptibility to infection. Topical application: Dermal atrophy, local irritation, folliculitis, delayed wound healing, systemic absorption and toxicity with occlusive dressing on application to large areas of the body and broken skin. Topical application to eye: Corneal ulcers, glaucoma and reduced visual ability.

Inhalation: Hoarseness, candidiasis of mouth and throat. Intra-articular inj: Aseptic necrosis of bone and joint damage.

Potentially Fatal: HPA supression; CV collapse on rapid IV admin.

Contraindications

Hypersensitivity; active untreated infections; ophthalmic use in viral, fungal disease of the eye.

Nursing Assessment

considerations

History for systemic administration: Active infections; renal or hepatic disease; hypothyroidism, ulcerative colitis; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF, hypertension, thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; lactation History for ophthalmic preparations: Acute superficial herpes simplex keratitis, fungal infections of ocular structures; vaccinia, varicella, and other viral diseases of the cornea and conjunctiva; ocular TB Physical for systemic administration: Baseline body weight, T; reflexes, and grip strength, affect, and orientation; P, BP, peripheral perfusion, prominence of superficial veins; R and adventitious sounds; serum electrolytes, blood glucose Physical for topical dermatologic preparations: Affected area for infections, skin injury

Interventions

For systemic administration, do not give drug to nursing mothers; drug is secreted in breast milk. WARNING: Give daily doses before 9 AM to mimic normal peak corticosteroid blood levels. Increase dosage when patient is subject to stress. Taper doses when discontinuing high-dose or long-term therapy. Do not give live virus vaccines with immunosuppressive doses of corticosteroids. For respiratory inhalant, intranasal preparation, do not use respiratory inhalant during an acute asthmatic attack or to manage status asthmaticus.

Do not use intranasal product with untreated local nasal infections, epistaxis, nasal trauma, septal ulcers, or recent nasal surgery. WARNING: Taper systemic steroids carefully during transfer to inhalational steroids; adrenal insufficiency deaths have occurred. For topical dermatologic preparations, use caution when occlusive dressings, tight diapers cover affected area; these can increase systemic absorption. Avoid prolonged use near the eyes, in genital and rectal areas, and in skin creases. points

Teaching Systemic administration

Do not stop taking the oral drug without consulting your health care provider. Avoid exposure to infection. Report unusual weight gain, swelling of the extremities, muscle weakness, black or tarry stools, fever, prolonged sore throat, colds or other infections, worsening of this disorder.

Intra-articular administration

Do not overuse joint after therapy, even if pain is gone.

Respiratory inhalant, intranasal preparation

Do not use more often than prescribed. Do not stop using this drug without consulting health care provider. Use the inhalational bronchodilator drug before using the oral inhalant product when using both. Administer decongestant nose drops first if nasal passages are blocked.

Topical

Apply the drug sparingly. Avoid contact with eyes. Report any irritation or infection at the site of application.

Ophthalmic

Administer as follows: Lie down or tilt head backward and look at ceiling. Warm tube of ointment in hand for several minutes. Apply one-fourth to one-half inch of ointment, or drop

suspension inside lower eyelid while looking up. After applying ointment, close eyelids and roll eyeball in all directions. After instilling eye drops, release lower lid, but do not blink for at least 30 seconds; apply gentle pressure to the inside corner of the eye for 1 minute. Do not close eyes tightly, and try not to blink more often than usual; do not touch ointment tube or dropper to eye, fingers, or any surface.

Wait at least 10 minutes before using any other eye preparations. Eyes will become more sensitive to light (use sunglasses). Report worsening of the condition, pain, itching, swelling of the eye, failure of the condition to improve after 1 week.