LARYNGOTRACHEOBRONCHITIS

A Grand Case Presentation

Presented to the Faculty of St. Luke’s College of Nursing

In Partial Fulfillment of the Requirements

In Related Learning Experience for the

Degree of Bachelor of Science in Nursing

Submitted by:

2NU01/ Group 3

Quiaño, Elijah R.

October 2018

TABLE OF CONTENTS
 I. Objectives
A. General
B. Specific
II. Introduction
III. Patient’s Profile
A. Demographic Data
B. Chief Complaint
C. History of Present Illness
D. History of Past Illness
E. History of Family Illness
F. Social History
G. Allergies
H. Assessment
1. Physical Assessment
2. Gordon’s Functional Health Pattern
IV. Anatomy and Physiology
V. Pathophysiology
VI. Course in the Ward
VII. Diagnostic Procedures and Laboratory Examinations
VIII. Drug Study
IX. Nursing Theory
X. Nursing Care Management
XI. Discharge Plan

I. Objectives
A. General
 This case study for students, researchers and healthcare team who wants to expand
their knowledge towards the manifestation of Laryngotracheobronchitis.
B. Specific
● To understand the cause of Laryngotracheobronchitis and evaluate its signs and
symptoms.
● To be able to gain skills in order to apply appropriate action in the nursing process.
● To apply the appropriate protocol in order to deliver the right action towards the
patients recovery and rehabilitation.

II. Introduction
Croup, also known as Laryngotracheobronchitis, is the inflammation of the upper
respiratory tract. Mainly the larynx, trachea and bronchioles. It is commonly caused by an
infection, in most cases viral in nature which includes parainfluenza and influenza virus. It may
also be caused by bacterial infection, although it is rare.
A patient which has been admitted with croup manifest signs of a barking cough with
stridor accompanied with a hoarse voice. Fever and runny nose may manifest as well. The signs
and symptoms may be mild, moderate or at times severe. Many cases of croup are
preventable by immunizations. Croup is characterized by a "barking" cough, stridor, hoarseness,
and difficulty breathing which usually worsens at night. The "barking" cough is often described
as resembling the call of a seal or sea lion. The stridor is worsened by agitation or crying, and if
it can be heard at rest, it may indicate critical narrowing of the airways. As croup worsens,
stridor may decrease considerably. Other symptoms include fever, coryza (symptoms typical of
the common cold), and indrawing of the chest wall–known as Hoover's sign. Drooling or a very
sick appearance indicate other medical conditions, such as epiglottitis. Self-care measures at
home are usually sufficient to treat the majority of cases of croup. Medical treatment is rarely
required. Croup usually resolves on its own within three to six days.

III. Patient’s Profile

A. Demographic Data of the Patient
Name: J.S.S.
Age: 4Y8M21D
Sex: Male
Address: Blk 11 Lot 30 Sta. Elena village San Jose Antipolo, Rizal
Civil Status: Single
Occupation: Child
Nationality: Filipino
Religion: Roman Catholic

Date and Time of Admission: September 29,2018

Admitting Diagnosis: Laryngotracheobronchitis (Croup)

B. Chief Complaint

Barking cough

C. History of Present illness

Two weeks prior to the admission, the pt showed signs of colds. The mother of the pt
went to seek a pediatrician to for medication, on Sept 24, 2018. The physician’s advice was to
take oral fluids, chest clapping, pecof syrup ( 1 tsp, tid 7-1-7), cimex syrup 250mg (3.5ml, bid).
The pts cough weakened however still persisted in which the mother of pt decided to admit
the pt on september 29, 2018 with cold symptoms and nasal discharge.

F. History of Family Illness

The family is aware that they have prevalent diabetes mellitus.

I. Assessment

GENERAL APPEARANCE: Pt appears to be normal and

responsive with general difficulty
in breathing.
VITAL SIGNS: Hospital day:
PP: 125 PP: 121
RR: 31 RR: 33
T : 36.8 T : 36.8

SKIN: Skin appears to have some scabs

LYMPH NODES: There is swelling and easily palpabe

HEAD: Appears to be normal

EYES: Eyes are responsive and normal

EARS: Ears are normal no signs of

deformities

NOSE: Nose was flaring due to distress.

Small amounts of discharge would
come out.

MOUTH: No redness or inflammation

THROAT: Coughing is rough

NECK: Neck appears to be normal

BACK: Normal with no discoloration

THORAX: Breathing has stridor accompanied

with frequent cough

LUNGS: Breathing has stridor accompanied

with frequent cough
 BREAST: Normal

HEART: No signs of heart defects

ABDOMEN: Non distended abdomen

EXTREMITIES: Joints appeared to be normal and

responsive

MUSCULOSKELETAL: Joints appeared to be normal and

responsive

NEUROLOGIC: Normal posture is seen

2. Gordon’s Functional Health Pattern

Date: October 3, 2018

Temperature: 36. 8 Route: Auxiliary

Pulse Rate: 121 Site: Apical

Respiration Rate: 33

GORDON’S FUNCTIONAL HEALTH PATTERN

Before Hospitalization During Hospitalization

Health Perception and Management

Mother shows compliance by allowing

the nurse to administer medications

Nutritional and Metabolic

 The mother stated that the pt
receives a good nutritional balance of
meals

Elimination

The mother stated that the child

regularly passes stool and urinates

Activity and Exercise

The patient appears to be weak

although able to move his extremities
and able to move with ease

Sleep and Rest

The mother of the pt stated that the

pt would often sleep in the morning
d/t coughing in the evening

Cognitive - Perception

The pt is able to perceive objects and

sound

Role and Relationship

Son

Coping Stress Tolerance

N/A
 Value - Belief Pattern

N/A

IV. Anatomy and Physiology

The inflammatory response is complex sequence of events involving many of the

chemical mediation and cells of innate immunity. Tissue injury, regardless of the type, can
cause inflammation, trauma, burns, chemicals, or infections can damage tissue, resulting
inflammation. A bacterial infections is use here to illustrate an inflammatory response. The
bacteria, or damage to tissues, cause the release or activation of chemical mediators such as:

1. Histamine
2. Complement Kinins
3. Eicosanoids (Ex. Prostaglandins and Leucotriens)
The chemical mediators produce several effects:

1. Vasodilation, which increased blood flow and bring phagocytes and other white blood
cells to the area.
2. Chemotactic attraction of phagocytes, which leave the blood and enter the tissue.
3. Increase vascular permeability, which allows fibrinogen and complement to enter the
tissue from the blood. Fibrinogen is converted to fibrin, which prevent the spread of
infection by walling off the infected area. Complement further enhances the
inflammatory response and attracts additional phagocytes. The process of releasing
chemical mediators and attracting phagocytes and other white blood cells continues
until the bacteria are destroyed.
Lungs

The lungs are a pair of spongy, air-filled organs located on both sides of the chest, both
with different sizes. The left lung is smaller than the right. The right lung has 3 lobes, while the
left lobe only has 2 lobes. The lungs’ main function is to bring oxygen from air to the
bloodstream.

Trachea
 It is an integral part of the body’s airway and it is vital for respiration because it brings
air to and from the lungs. From its origin at the larynx, the trachea extends inferiorly into the
thorax. In the thorax, the trachea ends where it splits into the left and right bronchi. The
bronchioles eventually end up to be microscopic air sacs called alveoli.

Bronchioles

Bronchioles are the passageways by which air passes through the nose or mouth to the
alveoli (air sacs) of the lungs, in which branches no longer contain cartilage or glands in their
submucosa. They are branches of the bronchi, and are part of the conducting zone of the
respiratory system. The bronchioles divide further into smaller terminal bronchioles which are
still in the conducting zone and these then divide into the smaller respiratory bronchioles which
mark the beginning of the respiratory region.

Larynx

The larynx is an organ in the top of the neck of tetrapods involved in breathing,
producing sound, and protecting the trachea against food aspiration. The larynx houses the
vocal folds, and manipulates pitch and volume, which is essential for phonation. It is situated
just below where the tract of the pharynx splits into the trachea and the esophagus.

V. Pathophysiology

The infection causes inflammation of the larynx, trachea, bronchi, bronchioles, and lung
parenchyma. Obstruction caused by swelling and inflammatory exudates develops and
becomes pronounced in the subglottic region. Obstruction increases the work of breathing;
rarely, tiring results in hypercapnia. Atelectasis may occur concurrently if the bronchioles
become obstructed.

VI. Course in the ward

DATE PHYSICIAN’S ORDER NURSE’S ACTION

9/29/18 - Admit to pulmo ward - Carried out
1:45 AM - NPO temporarily
- Monitor vital signs Q4
and record
- Diagnotsics:
Neck x-ray anterior
- IVF: H20 .3 NaCl 480 cc
to 80 cc/hr x 6 hrs
- Therapeutics
- Epi-Neb PRN
- PNSS veb q4

10/1/18 - IVF to ff: D5 NaCl 1300 - carried out

cc Tw to 54 cc/hr x 24
12 PM
hrs

VII. Diagnostic Procedure and Laboratory Examination

TEST RESULTS - UNITS REFERENCE VALUES

WBC Count **21.27 -10^3/uL 5-10

RBC Count 5.30 -10^6/uL M: 4.6 - 6.2

F: 4.2 - 5.2

Hemoglobin **13.0 -g/dL M: 14.0 - 18.0

F: 12.0 - 16.0

Hematocrit 40.6 -% M: 40.0 - 54.0

F: 35.0 - 47.0

MCV **76.5 -fl 80.0 - 100.0

MCH **24.5 -pg 27.0 - 32.0

MCHC 32.0 -g/dL 32.0 - 36.0

Platelet count 395 10^3/uL 150 - 450

 Segmenters(%) **79.5 -% 40.0 - 60.0

Lymphocytes(%) 15.3 -% 20.0 - 40.0

Monocyte(%) 2.0 -% 2.0 - 8.0

Eosinophil(%) 2.6 -% 1.0 - 6.0

Basophil(%) 0.6 -% 0.1 - 1.0

The results was double checked by the registered medical technologist.
High WBC count may indicate an infection.
The low MCV value says that the erythrocytes are smaller than normal.
The low hemoglobin count indicates that there is acute respiratory tract infection.

VII. Drug Study

1. Epinephrine Neb Prn
DRUG MECHANIS INDICATIO CONTRAINDICATI ADVERSE NURSING
NAME: M OF N ON EFFECTS: RESPONSIBILITIE
ACTION: S

Date Epinephrin - Stridor - Allergy to - Headache - Assess patient

ordered e is a mixed Epinephrine - Nausea for infection
: α- and β- - Vomiting
- Obtain history
09/29/1 adrenergic - Nervousne
before initiation
8 agonist. ss
of therapy
Generic The α- - Dizziness
(obtain
name: adrenergic - shaking
specimens for
Epineph action is (tremor)
culture and
rine responsible - Trouble
sensitivity)
for sleeping
Princip
vasoconstri - Stomach - Reconstitute
en: Prn
ction and upset for IV use by
reduction - Sweating adding sterile
of airway - Dry mouth water for
edema. - Bad taste injection
- Cough
- Sore
throat
 2. Dexamethasone 10 mg
DRUG MECHANIS INDICATIO CONTRAINDICATI ADVERSE NURSING
NAME: M OF N ON EFFECTS: RESPONSIBILITIE
ACTION: S

Date Glucocortic General - Osteoporosis - Delayed 1.Determine

ordered oid Cerebral - Diabetes wound whether patient
: receptors edema - Hypertension healing is sensitive to
09/29/1 are found Allergic - Headache other
8 intracellula Inflammat - Euphoria corticosteroids
Generic rly in ory - Insomnia
2.Most adverse
name: almost all conditions - Vertigo
reactions to
Dexame tissues. Shock
corticosteroids
thasone Glucocortic
are dose-or
Classific oids enter
duration-
ation: cells
dependent.
Anti through
inflam passive 3.For better
matory diffusion results and less
Glucoco and form a toxicity, give
rticoid complex once daily dose
with a in morning.
receptor
protein. 4.Give oral dose
This with food when
complex possible. Patient
then may need drugs
undergoes to prevent GI
an irritation.
irreversible
activation
and enters
the cell
nucleus,
where it
binds to
DNA,
leading to
biological
effects
induced by
these
hormones,
including
increased
hepatic
gluconeoge
nesis,
increased
lipolysis,
muscle
catabolism,
and
inhibition
of
peripheral
glucose
uptake in
muscle and
adipose
tissue
3. Budesonide

DRUG MECHANIS INDICATIO CONTRAINDICATI ADVERSE NURSING

NAME: M OF N ON EFFECTS: RESPONSIBILITIE
ACTION: S

Date Anti- children > - Hypersensitivity - CNS: >WARNING:

ordered inflammato 6 yr and Headache,dizz Taper systemic
: ry effect; for iness, lethargy, steroids carefully
Date local patients fatigue, during transfer
ordered administrat requiring paresthesias, to inhalational
: ion into corticoster nervousness steroids; deaths
09/29/1 nasal oids for from adrenalin
8 passages asthma sufficiency have
Generic maximizes Inhalation occurred.>Arran
Name: beneficial suspensio ge for use of
budeso effects on n decongestant
nide these nose drops to
tissues,whil facilitate
Classific
e penetration if
ation:
decreasing edema,
Corticos
the excessive
teroid
likelihood secretions are
of adverse present.
effects
from
systemic
absorption

VIII Nursing Theory

The nursing theory used was of Faye Glenn abdellah, which focuses on the patient’s
problem. Shifting the focus on the patient will give a patient specific planning, intervention and
actions which will make the recovery of the patient hasten although in an orderly manner.

The ten steps to identify the patient's problems are:

1. Learn to know the patient

2. Sort out relevant and significant data

3. Make generalizations about available data in relation to similar nursing problems

presented by other patients

4. Identify the therapeutic plan

5. Test generalizations with the patient and make additional generalizations

6. Validate the patient's conclusions about his nursing problems

7. Continue to observe and evaluate the patient over a period of time to identify any

attitudes and clues affecting his behavior

8. Explore the patient's and family's reaction to the therapeutic plan and involve them in

the plan
9. Identify how the nurses feel about the patient's nursing problems

10. Discuss and develop a comprehensive nursing care plan

The eleven nursing skills in the theory are:

1. observation of health status

2. skills of communication

3. application of knowledge

4. teaching of patients and families

5. planning and organization of work

6. use of resource materials

7. use of personnel materials

8. problem-solving

9. direction of work of others

10. therapeutic use of the self

11. nursing procedure

IX Nursing Care Plan

CUES NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE FOR

DIAGNOSIS EXPLANATION EACH
OR INTERVENTION
BACKGROUND
Objectiv Ineffective Viral Goal: After 8
e: airway Infection/Bacte hrs shift of
-Cry clearance rial infection nursing
-Sharp r/t ↓ intervention
barking tracheobro tracheobronchi client’s
cough nchial al obstruction airway
-Audible obstruction ↓ patency will
stridor Ventilation improve.
(+) nasal perfusion (V/Q)
flaring mismatch Objectives:
- The client will 1.Position with 1. Open airway
↓
Intercoas be able: airway open allows adequate
Increase
tal 1.To be free (sniffing position ventilation.
secretion
retractio from if supine).
production
ns secretions or
↓ • Humidify • Help liquefy
- obstruction,
Ineffective oxygen or room secretions for ease
Producti easier work of
airway air and ensure in clearance
ve breathing,
clearance adequate fluid
cough(sh respiratory
intake
arp & and heart
(intravenous or
frequent rate within
oral). • Removal of
) parameters.
• Suction with secretions
bulb syringe or
via
nasopharyngeal
catheter as
• To avoid risk of
needed.
aspiration.
• If tachypneic,
maintain NPO
• To promote
status.
airway clearance.
• Encourage
expectoration of
sputum with
• To mobilize
coughing.
secretions
• Perform chest
with the assistance
physiotherapy if
of
ordered.
percussion or
vibration
accompanied by
postural drainage
•To avoid delay
should airway
 • Ensure become
emergency unmaintainable.
equipment is
readily available. 2. Produces
bronchodilation
2. Provide and exert a potent,
2. To take her patient optimal locally acting anti-
due patent airway inflammatory
medication with prescribed effect to decrease
(as bronchodilators the frequency and
prescribed) (racemic severity of attacks.
epinephrine
inhalant) and
corticosteroids
(betamethasone)
as ordered.
XI. Discharge Plan

Medication

- Emphasize that if complications reappear, that they should consult .

- Advise the parents to give their child medicines as directed by the physician, but also
keep eye on possible signs of adverse effect.

- Remind the patient to report to the nearest physician if any adverse effects occur.

Environment

- Encourage the family of the patient to provide a proper, health, clean and safe
environment at all times.

- Avoid smoking and polluted area as much as possible.

Treatment

- Discuss the purpose of the treatments to be done.

Health Teaching

- Encourage the patient to have an adequate rest periods to avoid further complications
and to avoid stress.

- Elaborate the importance of monitoring the pt breathing pattern because complication

can manifest even after discharge.

- Advise the parents to consider having the pt immunized to avoid the complication again.

Outpatient follow up

- Advice the pt and the mother to have regular check ups for prevention and maintenance
of optimum health
Diet

- Explain to the parent/caregiver importance of proper nutrition to maintain a

therapeutic lifestyle.

- Advise the parents to keep a healthy lifestyle and continue giving vitamins to boost up
the pt’s immune system.