Action Cycle Three: Scenario templates
Inflammation of Croup – Orientation Overview
Impaired gas exchange R/T inflammation of croup
Debriefing/Guided Reflection Overview
(Simulation in Nursing Education)
Scenario Overview
AUT
S1 2014
Report to student
Croup is a common childhood illness in children
under the age of 5 and is characterised by a harsh,
barking cough.
Estimated scenario time: 15 minutes
Target group: year 3 nursing students
Guided reflection time: 15 minutes
Name: Dylan Afualo
Causes:
Croup is caused by a variety of viruses, often the
parainfluenza virus that may begin as what appears
to be a common cold. The barking cough that gives
croup its name is caused by inflammation of the
child’s windpipe and voice box (trachea and larynx)
that partially causes a blockage in the windpipe.
Children have very small airways to begin with, so
croup can cause air passages to narrow quite a bit.
Occasionally, croup is caused by a bacterial
infection, but this is not common.
LEARNING OBJECTIVES:
Hospital ID number: 322976
General:

Medications used include Paracetamol po,
dexamethasone IM, and adrenaline via nebuliser.
Brief summary:

Past history: healthy, reports a “few colds”

Signs and symptoms:

Affects children 6 months to 6 years

Stridor which often develops after a cold

May develop wheezing, grunting, tracheal
tug

Low-grade temperature

Hoarse voice and harsh barking cough
Paediatric Vital Sign Normal Ranges
Age
Group
Resp
Rate
Heart
Rate
Systolic
BP
New-born
30 - 50
120 160
50 - 70
Weight
in
kilos
Weight in
pounds
2-3
4.5 - 7
Infant (112
months)
20 - 30
80 140
70 100
4 - 10
9 - 22
Toddler
(1-3 yrs.)
20 - 30
80 130
80 110
10 - 14
22 - 31

Prenatal history—mother attended all clinics,
uncomplicated pregnancy

Born at 39 weeks; weight 3.6kg at birth. Parent
unsure of current weight.

Weight(kg)=age in months + 9/2
Children 1-5 yrs

Up-to-date on immunisations
o

Current medications: None

Breastfed; foods slowly being introduced
o

Weight(kg)=2x(age in yrs +5)
Children >5

Allergies: no known food or drug allergies

Weight(kg)=age x 4

Students should recognise what is normal/abnormal
in assessment of 9 month-old infant.

Students should be able to state the signs of infant
respiratory distress (i.e. nasal flaring, intercostal
retractions, tachypnoea, subcostal and intercostal indrawing, tracheal tug, mouth open in ‘air hunger.’

1% develop severe obstruction and require
intubation
Management of care—nursing interventions include:

Assessment for respiratory distress
(intercostal or subcostal recession,
tachypnoea, use of accessory muscles).
Students should review how to calculate medications
based on weight.
o For infants < 12 months
Scenario specific:

Student will demonstrate how to obtain a full set of
vital signs and know normal vital sign parameters for
9-month old child.

Students must demonstrate therapeutic
communication with the parent so as to decrease
stress of infant.

Students will obtain weight of child through weighing,
asking parent, or using formula for estimate.

Students must state the procedure of administering
an IM injection to an infant. Know landmarks and
safety consideration when holding to prevent
movement.

Students must demonstrate proper documentation of
medications administered, along with documentation
of vital signs.
Time: 0900
Recent medical history:
This case is a 9-month old male infant who presents to
an urgent care clinical with his parent. Dylan’s parent
reports that he had a “barking cough” throughout the
night. His parent states, “He still seems to be struggling
to get air.”
The mother notes that Dylan had a cold about a week
ago and she thought he was “over that.”
Student Roles:
1. Recorder and calling of ISBAR
2. Respiratory assessment, give medications
3. Vital signs and airway management
Preschooler
(3-5 yrs.)
20 - 30
80 120
80 110
14 - 18
31 - 40
School
Age (6-12
yrs.)
20 - 30
70 110
80 120
20 - 42
41 - 92
Adolesce
nt (13+
yrs.)
12 - 20
55 105
110 120
>50
>110

Identify any features of chronic respiratory
distress—runny nose, clubbing, barrelshaped chest.

Obtain a peak flow—useful to provide
objective evidence of severity of condition.
Cooperation is essential so can only be
obtained with children 5-6 years of age and
over

Inhaler/nebuliser: for severe cases use
1:1000 epinephrine ampoules at a dose of
0.5ml/kg/dose, max dose 5ml (make up to at
least 4ml with 0.9% normal saline).

Student will demonstrate ability to get swabs to test
for RSV and influenza.

Wash hands and introduce self to parent

Identify patient name from ID band (DOB, hospital ID
number)
Inflammation of Croup – Resources
Equipment checklist
Equipment to have in the room for this scenario:

Sim infant (9 months old)
Proposed correct treatment (outline)
Potential nursing problems
Alteration in Respiratory function r/t inflammation
associated with croup

Standard precautions equipment

Paediatric stethoscope

Ask parent what prompted them to ring bell

Blood pressure cuff

Obtain BP, pulse, RR, Temp, SpO2

SpO2 monitor and probe

Do respiratory assessment of child
Defining characteristics:

Respiratory assessment abnormal

Changes in vital signs associated with audible
wheeze, stridor and/or barking cough.

Thermometer


ECG monitor and leads
Give IM injection of dexamethasone using proper
technique

Oxygen supply source

Nursing Diagnosis: Alteration in Respiratory function r/t
inflammation associated with croup

Oxygen delivery devices
Place child on Nebulised adrenaline with paediatric
mask (calculate proper dose based on weight)

Nebuliser cups for 9 month old baby along with
labelled adrenaline ampules (1:1000ml ampoules)

Reassess respiratory status and vitals every 2-5 min.

Call Registrar with ISBAR report at end of scenario

IM injection with labelled dexamethasone 4mg/ml
Medication and fluids:

IM injection of dexamethasone 0.6 mg/kg po or
IM with max dose of 12mg. Label the saline
ampules with “Dexamethasone 4mg/ml’

Nebulised
adrenaline
with pediatric mask
SIM Infant
settings
Patient/manikin actions
Lung sounds: stridor, barking cough
Initial(1:1000ml
state (0-3 ampoules
minutes) at a dose of 0.5ml/kg/dose
with max dose of 5ml (make up to at least
4ml wheeze
and audible
Heartwith
rate:0.9%
150/minute
saline).
Abdomen: abdominal retractions (if
Respiratory
rate:nebuliser
55/min.

Cool-mist
available)
BP:
100/70
Documentation
forms:

Doctors
SpO2:
88% instructions/DHB protocols Vocal sounds: barking cough, baby
groaning

Observation record, medication sheet,
nursing
Temp. 38.5 C
notes
Student interventions
Role member providing cue: patient

Introduce self to parent

Identify patient using armband
Cue: if student does not proceed to
assessing baby or taking vital signs,
mother can say,

Attend to ABCs, give oxygen mask

Obtain vital signs and report to
recorder

Assess respiratory status (lung
sounds, retractions, RR, colour,
pulse ox)

Check medications to see if anything
appropriate ordered

Take vital signs

Take vital signs, see trending in
respiratory status and reassess

Give Dexamethasone 0.6mg/kg IM
with max dose 12mg (5.4mg which in
4mg/ml=1.35ml as calculated dose)

Nebulised adrenalin given (1:1000
ampoules at a dose of
0.5ml/kg/dose. You need 4.5 ml and
make to 5ml with .9NS. Max dose
5ml (make up to at least 4ml with
0.9% saline)

Monitor child closely during and after
nebuliser treatment (if child is
relieved and remain well 3 hours
after nebuliser and steroids, they
may go home).
Diagnostic equipment:

Preparation of Sim NewB or infant

Location: Paediatric ward Starship

Baby cot or roll bed

Secure ID band with patient name, DOB, and
Vocal sounds: baby now grunting with
4-9 minutes
hospital ID number
perioral cyanosis present.
Respiratory
trend upward
Number of participants:

1 rate
nurse—recorder
ROLE sounds: grunting which proceeds
Heart
trend upward and calling ISBAR Vocal
to
respiratory arrest if student doesn’t

1 nurse—doing primary assessment, giving
HR: 170/min.
place child on nebuliser and give IM
medications
dexamethasone
Resp.
rate: 70/min. signs
with perioral

1 nurse—Vital
and airway management
cyanosis present (if available), wheezing,
and stridor
BP: 90/40
SpO2: to 85%
10-12 minutes
Heart rate: 150/min.
Vocal sounds (after saline bolus):
—“I feel a little better now.”
Resp. rate: 45/min.
BP: 100/50
Cue/prompt
Student should do the following:

Wear gloves

Communicate therapeutically with
parent

Monitor and record vital signs (BP,
AP, SpO2,) every 15 minutes until
stable

CALL ISBAR to physician requesting
further orders
SpO2: 93%
“What’s wrong with Dylan? He can’t
seem to get his air.”
Role member to provide cue: Mother
Cue:
“I’m worried, what are you going to do to
help Dylan? He can’t breathe!”
Role member to provide cue:
“Mother—so what is going to happen
now?”
Cue (final orders):

Call physician with ISBAR report of
events

Transfer to PICU for monitoring and
further evaluation