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Nursing Guide to Pediatric Croup: Nursing Diagnosis, Interventions, & Care Plans

Updated On 8 Minute Read

Croup Etiology and Epidemiology 

Croup is an infection that causes upper airway inflammation and obstruction. The infectious organism, viruses or bacteria, invade the mucosa of the upper respiratory tract (trachea, larynx, and bronchi,) causing an inflammatory reaction. This reaction consists of: 

  • Edema
  • Endothelial damage
  • Loss of ciliary function
  • Mucous production 

The inflammation affects the subglottic space, causing a high-pitched sound (i.e., stridor) during inspiration. 

Laryngotracheitis, or viral croup, is the most common form of croup and the most frequent cause of acute respiratory distress in children. 

The most common pathogens responsible for croup are: 

These viruses cause airway inflammation and resistance and increased work of breathing. Bacterial croup is less common, but is caused by the following pathogens (Sizar & Carr, 2021): 

  • Corynebacterium diphtheriae
  • Staphylococcus aureus
  • Streptococcus pneumoniae
  • Hemophilus influenzae
  • Moraxella catarrhalis 

Incidence and Prevalence 

  • Croup is less common in females than it is in males and most commonly occurs between the ages of 3 months to 3 years.
  • It is uncommon to see croup in children over the age of 6 (Smith & Heering, 2017).
  • Symptoms typically resolve in 2 days, although they might persist for up to a week in some children.
  • Only around 5% of children with croup have symptoms severe enough that require hospitalization. Out of those children hospitalized, approximately 1 to 3% are intubated, which has a mortality rate of 0.5% (Smith & Heering, 2017). 

Risk factors for croup include: 

  • Contact with an infected individual within past 7 days
  • Anatomically defective larynx
  • Allergies
  • History of croup
  • Recurrent upper respiratory infections 

Symptoms of croup in children include (Bhatia, 2020): 

  • A loud “barky” cough
  • Fever
  • Stridor
  • Respiratory distress
  • Tachypnea
  • Retractions
  • Hoarseness
  • Cyanosis (in severe cases) 

Croup Diagnosis 

  • Croup is often diagnosed based on clinical presentation. Because of the barking style of the cough, it is usually apparent to the clinician.
  • If the diagnosis is unclear, the child should have anteroposterior and lateral x-rays of the neck and chest taken. Subepiglottic narrowing (steeple sign) is detected to confirm a diagnosis.
  • Clinicians should perform pulse oximetry on all children who present with croup. Those with respiratory distress should have arterial blood gas measurements taken (Bhatia, 2021).
  • In addition to pulse oximetry, the clinician may order laboratory tests including:
    • CBC w/diff
    • Throat culture to r/o bacterial cause
    • Rapid antigen tests 

The Westly Croup Scale is a tool that can assist clinicians in determining the severity of croup. Scores range from 0 to 17 based on the following factors: 

  • Stridor
  • Retractions
  • Cyanosis
  • Level of consciousness
  • Airway entry 

Each item is scored from 0 to 5, depending on the category, and totaled. The score indicates severity level: 

  • A score of < or = 2 indicates mild croup.
  • A score of 3 to 5 indicates moderate croup.
  • A score of 6 to 11 indicates severe croup.
  • A score of > 12 indicates respiratory failure is imminent. 

Based on the score, the clinician can then determine the best course of treatment/management. 

Croup Management 

The majority of children with croup have minimal symptoms that can be treated at home with hydration, antipyretics, and using a humidifier or steam from sitting in a bathroom. Some clinicians may prescribe or give a child with moderate croup: 

  • A single dose of a long-acting corticosteroid (oral dexamethasone [Decadron®] or prednisolone [Orapred®])
  • Inhaled budesonide (Pulmicort Respules®) 

A child may require hospitalization for the following: 

  • Increasing respiratory distress
  • Tachycardia
  • Lethargy
  • Cyanosis
  • Hypoxemia
  • Dehydration 

Inpatient treatment typically consists of (Bhatia, 2020): 

  • Humidified oxygen (for saturations below 92%)
  • Racemic (AsthmaNefrin®) or L-epinephrine (Vaponephrene®)
  • High dose (IM or IV dexamethasone [Decadron®]
  • Monitoring of arterial blood gases to determine CO2 retention 

If the child exhibits respiratory fatigue through frequent desaturations and a PaCO2 is >45 mm Hg, the child will require endotracheal intubation. 

Alternately, clinicians may treat with heliox. Heliox is a helium-oxygen blend, which (Moraa et al., 2018): 

  • Is similarly beneficial as epinephrine in the short term.
  • Is indicated for children with moderate to severe croup treated with dexamethasone.
  • Serves as a bridge until steroid takes effect. 

Croup Nursing Care Plan

Nursing Considerations 

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for croup are listed below. 

Assessment 

Keep in mind the following with your assessment of the child with croup (Gray, 2017): 

  • The most important aspect of assessment is determining the degree of airway obstruction.
  • Obtain a history of illness, including sudden onset of symptoms, especially exhibited at night.
  • Caregivers may report a history of rhinorrhea, fever, and irritability within the last 1 to 4 days, although some children do not exhibit these symptoms.
  • If the child exhibits drooling or is sitting in a "tripod" position, epiglottis, a life-threatening illness, should be considered and emergent intervention provided.
  • Observe the child while taking a history, trying not to disturb the child until necessary because crying or agitation can worsen the symptoms of croup. 

Respiratory Assessment 

  • The respiratory rate and the employment of accessory muscles of respiration, tracheal pull, and central cyanosis presence (or absence) should all be evaluated.
  • A stethoscope will be required to listen to the child's breath sounds effectively. Count the respiratory rate for 1 minute with their chest exposed so that you can observe for the following symptoms associated with respiratory distress:
    • Nasal flaring
    • Head bobbing
    • Accessory muscle retractions
    • Grunting
  • Your respiratory assessment should consider overall appearance. Not only should you examine the child's breathing effort, but you should continuously monitor for any symptoms of agitation, fatigue, or a decreased level of consciousness.
  • Immediate treatment or intervention is necessary if the child is demonstrating symptoms of severe respiratory distress, including:
    • Stridor during rest
    • Tracheal tug
    • Chest wall retractions
    • Fluctuating heart and respiratory rate 

Nursing Diagnosis/Risk For 

  • Sleep pattern disturbance
  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Activity intolerance
  • Anxiety
  • Fatigue
  • Hyperthermia
  • Deficient knowledge
  • Deficient fluid volume 

Interventions 

Nursing interventions for croup include: 

  • Provide humidified air.
  • Administer oxygen, if needed.
  • Administer medications as prescribed.
  • Encourage increased fluid intake.
  • Provide clearance of secretions by encouraging gentle suctioning and coughing exercises.
  • Allow for periods of rest.
  • Stress to the caregivers the importance of keeping the child relaxed by cuddling.
  • Keep the child’s head elevated.
  • Assist in decreasing the child's anxiety by keeping them as comfortable as possible, allowing them to be held by their caregiver and avoiding unnecessary painful interventions.
  • Encourage the caregivers to verbalize concerns and inquire about their child's illness.
  • Inform and explain to the caregivers the signs and symptoms that indicate worsening of the condition's and next steps.
  • Instruct caregivers to alert clinicians if the child has a fever >101°F or any signs of respiratory distress.
  • Monitor:
    • Vital signs
    • Pulse oximetry
    • Response to treatment 

Croup Expected Outcomes 

The child will: 

  • Demonstrate adequate ventilation and oxygenation.
  • Maintain airway patency.
  • Demonstrate increased air exchange.
  • Adequate fluid intake.
  • Resume normal ADLs.
  • Become/remain afebrile.
  • Resume normal sleep patterns. 

The caregivers will: 

  • Verbalize/demonstrate effective coping mechanisms that reduce anxiety.
  • Utilize available support systems to aid in coping. 

Individual/Caregiver Education 

  • Discuss the disorder, underlying causes, diagnosis, and treatment.
  • Instruct on the prescribed drug therapy, including name, dosage, frequency, and duration of therapy.
  • Instruct the caregiver to keep the child hydrated with liquids such as water or electrolyte solutions such as Pedialyte®.
  • Instruct the caregiver on giving analgesics and antipyretics as directed.
  • Review the benefits of cool mist humidification, especially at night.
  • Instruct the caregiver to position the child over 12 months in an upright position. Infants can be placed in their infant seats.
  • Encourage restricted activity in a quiet, low stimuli environment; then, as tolerated.
  • Review what symptoms that the caregiver should seek immediate medical attention for:
    • Adverse effects of medications
    • Worsening signs and symptoms
    • Persistent fever, not responsive to antipyretics
    • Increasing respiratory distress
    • Signs of otitis media

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Additional Information

Content Release Date

4/1/2022

Content Expiration

12/31/2027

Course Contributor 

The content for this course was created by Stephanie L. Whitfield, B.S.N., R.N. Stephanie has over 15 years of clinical and teaching experience. Her areas of expertise are in neonatal intensive care, general pediatrics, home health, and children with medical complexities. She earned her Bachelor of Science in nursing from Chamberlain University in 2013. Her professional practice is guided by Jean Watson’s philosophy that, “Caring is the essence of nursing.” 

References 

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Stephanie L. Whitfield, B.S.N., R.N

Stephanie has over 15 years of clinical and teaching experience. Her areas of expertise are in neonatal intensive care, general pediatrics, home health, and children with medical complexities. She earned her Bachelor of Science in nursing from Chamberlain University in 2013. Her professional practice is guided by Jean Watson’s philosophy that, “Caring is the essence of nursing.”