Case analysis presentation

1. Case analysis presentation Viral Croup Presented by Rachel Adejoh RN, BSN, MSRN Coppin State University. Helene Fuld School of Nursing Dr. Robin Warren Primary Health Care of Children- Clinical Nursing 641 December 2, 2013

2. Introductory statement • Viral Croup can be defined as an acute self -limiting inflammation of the larynx, trachea,and bronchial three. Hay, W., Levin, M., Sondheimer, J., Deterding, R., & Abzug, M., (2012). • Viral Croup which is also known as Laryngotracheobronchitis caused by para-influenza virus will be discussed according to the rubric guide for case analysis and presentation.

3. A concise clinical profile of the case • Mother denies nausea, vomiting, and diarrhea. • baby is having normal diaper wetness and changing of six to seven diapers in a day, and the baby equally producing tears when he cries. • A six months old African American baby boy brought in by his mother to the sick visit clinic hours after four days of running nose and cough with no fever.

4. Presenting problem • Mother was concerned about the cough characteristics that have changed to hoarse and barky. • The presenting problem was a history of running nose, cough with no fever for four days

5. Symptom analysis • Mother denies drooling, baby rubbing his eyes, sneezing, wheezing, and any toddler in the house that can insert foreign object in the nose. • mother agreed to the baby having hoarse voice and the cough sounds like he is barking and dry • The baby was analyzed with differential diagnosis of upper respiratory infection, foreign body in the upper airway, epiglottitis, Allergic rhinitis, bacteria tracheitis, asthma and sinusitis.

6. Pertinent physical examination and diagnostic finding • The ear shows mild erythematous tympanic membrane. • The nose shows mild nasal turbinate erythema. • symmetrical chest with the use abdominal muscles when breathing. • The baby was also retracting with positive nasal flaring at rest and audible stridor.

7. Significant positive findings and pertinent negatives • No air hunger, cyanosis, fever, wheezing. • Respiratory distress as evidenced by audible stridor, retraction (use of abdominal muscle to breath) and a barking cough after four days of upper respiratory infection.

8. Treatment plan • Nebulized racemic epinephrine was ordered at 8.4ml/kg to be diluted in inhale sterile water or saline was ordered but was out of stock. • dexamethasone 0.6mg/kg Intramuscularly • Mother was re-assured, oxygen via nasal cannula placed. • Pulmicort (inhaled budesonide) is also proven to be effective which was not available at the clinic.

9. Follow up plan to include referral/consultation; if applicable • Call primary care provider or go to emergency room for worsening symptoms. • Referral to pediatric pulmonologist for evaluation . • The baby was called in to emergency room right away giving a complete and concise history of physical examination. • Follow up after discharge from the hospital with discharge recommendations.

10. Integrated developmental and health promotion strategies • and it affects children of three months to three years of age is mostly common in the fall and early winter which is the season we are in right now. • mother was educated on the disease process to be a prodrome of upper respiratory infection

11. Integrated developmental and health promotion strategies cont’d • Supportive therapy can be adopted like keep the child well rehydrated; steam shower for ten to fifteen minutes followed by cool night air is helpful as well. • Mother was also made to understand that in mild cases, supportive therapy can be adopted like keep the child well rehydrated; steam shower for ten to fifteen minutes followed by cool night air is helpful as well.

12. Integrated developmental and health promotion strategies cont’d • Minimal handling or avoiding crowded environment can be helpful since upper respiratory infection are mostly airborne ( breathed in the organism). • The need to keep well child visit and immunization up to date was emphasized. • Having a humidifier at home will also help to decrease air dryness

13. Strengths and limitations of the primary care delivered • We were to start nebulized racemic epinephrine with other medications like dexamethasone, budesonide inhaler before they were out of stock. • The ability to recognize the presentation as Viral Croup from accurate history taking and a comprehensive physical. • Initiation of treatment from the clinic by placing oxygen on the baby via nasal cannula

14. Strengths and limitations of the primary care delivered cont’d • Appropriate referral was made. • place to have budesonide inhaler ( Pulmicort) ordered to be available as one of their formulary rescue medication. They concluded not to have the epinephrine nebulizer since it requires cardiac monitoring. • The limitations of the care delivered were the unavailability of the rescue medications. • Debriefing of the case was done with the medical director.

15. References • Mohamad, N., Sjam’un, A., Ismail, F., Solayar, L., Mohamed, S., Abidin, S., Tan, B., Yow, K., Hasan, N., Hamizol, S. (2013). Acute Stridor- Diagnostic Challenges in Different Age Groups. Emergency Medicine: 7 (2). doi:10.4172/21657548.100015 • Wang, R., Waters, A., Clement, W., & Kubba, H.(2013). The management of recurrent croup in children. The Journal of Laryngology & Otology . 05 (127) DOI:http://dx.doi.org/10.1017/ S0022215113000418. • Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. (2013). Nebulized epinephrine for croup In children. Cochrane Database of Systematic Reviews. DOI:0.1002/14651858.CD0066 19. • Hay, W., Levin, M., Sondheimer, J., Deterding, R., & Abzug, M. (2012). Current Pediatric Diagnosis &Treatment,(21 ed) The McGraw-Hill Companies, INC.