WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:47.370 fast. Welcome to the emergency room. Welcome 00:00:47.370 --> 00:00:50.210 back to the deep dive. We are so glad you're 00:00:50.210 --> 00:00:52.270 here with us today. It's great to be here. We 00:00:52.270 --> 00:00:54.829 are stepping into what I honestly think is one 00:00:54.829 --> 00:00:57.399 of the most high stakes, high pressure, but I 00:00:57.399 --> 00:00:59.600 mean, ultimately rewarding environments in all 00:00:59.600 --> 00:01:02.179 of medicine. Oh, for sure. Imagine walking onto 00:01:02.179 --> 00:01:04.819 a pediatric unit. It's colorful, right? Yeah. 00:01:04.879 --> 00:01:06.480 Maybe there are cartoons on the wall. The nurses 00:01:06.480 --> 00:01:08.980 are wearing these fun scrubs. But underneath 00:01:08.980 --> 00:01:12.400 all that, that cheerful aesthetic, there is this 00:01:12.400 --> 00:01:15.280 incredible palpable tension. There is. Because 00:01:15.280 --> 00:01:17.879 kids, kids are not just small adults. That is 00:01:17.879 --> 00:01:20.719 the absolute first rule of pediatrics. Yes. It's 00:01:20.719 --> 00:01:23.280 the mantra. Yeah. If you walk in thinking a child 00:01:23.280 --> 00:01:25.500 is just a miniature version of a 40 -year -old, 00:01:25.680 --> 00:01:28.400 You're going to miss things. Big things. Vital 00:01:28.400 --> 00:01:31.379 things. They are an entirely different physiological 00:01:31.379 --> 00:01:33.900 species in many ways. I mean, their metabolic 00:01:33.900 --> 00:01:35.920 rates are different, their compensatory mechanisms 00:01:35.920 --> 00:01:39.480 are different, and the way they crash is really, 00:01:39.480 --> 00:01:41.459 really different. And that is exactly what makes 00:01:41.459 --> 00:01:44.459 the source material we are covering today. Chapter 00:01:44.459 --> 00:01:47.640 10, the pediatric health assessment. So incredibly 00:01:47.640 --> 00:01:49.930 daunting. It's a beast of a chapter. It really 00:01:49.930 --> 00:01:51.390 is. I was looking through the notes, the textbook 00:01:51.390 --> 00:01:53.450 excerpts, the lecture slides you send over, and 00:01:53.450 --> 00:01:56.010 it feels like an avalanche of disconnected details. 00:01:56.469 --> 00:02:01.409 You have to know growth charts and obscure reflexes, 00:02:01.629 --> 00:02:05.129 weird skin spots, specific timelines for fontanel 00:02:05.129 --> 00:02:07.329 closures, and somehow you have to do it all while 00:02:07.329 --> 00:02:09.490 a three -year -old is screaming at the top of 00:02:09.490 --> 00:02:12.449 their lungs and kicking you. It is the definition 00:02:12.449 --> 00:02:15.620 of information overload. And for a nursing student 00:02:15.620 --> 00:02:18.659 or, you know, a new grad, the risk is real. You 00:02:18.659 --> 00:02:21.280 get so bogged down in memorizing the circumference 00:02:21.280 --> 00:02:23.840 of a six -month -old's head, or the exact month 00:02:23.840 --> 00:02:26.080 a reflex disappears. Right. You get lost in the 00:02:26.080 --> 00:02:28.340 weeds. You do. Yeah. And you might miss the fact 00:02:28.340 --> 00:02:30.699 that the toddler across the room is in respiratory 00:02:30.699 --> 00:02:33.139 failure. You completely lose the forest for the 00:02:33.139 --> 00:02:35.860 trees. Exactly. So we are going to do something 00:02:35.860 --> 00:02:37.979 different today. We aren't just reading the chapter. 00:02:38.159 --> 00:02:41.120 No. We are applying the Pareto Principle. The 00:02:41.120 --> 00:02:43.439 80 -20 rule. Which is my favorite way to approach 00:02:43.439 --> 00:02:45.680 complex medical topics. It just cuts through 00:02:45.680 --> 00:02:48.500 the noise. It does. And the idea is simple. 20 00:02:48.500 --> 00:02:51.159 % of the information gives you 80 % of your results. 00:02:52.080 --> 00:02:55.139 And in the context of nursing, results mean two 00:02:55.139 --> 00:02:58.319 very specific things. First, passing your exams, 00:02:58.419 --> 00:03:00.300 because the test writers love to trap you on 00:03:00.300 --> 00:03:02.659 these specific developmental nuances. Oh, they 00:03:02.659 --> 00:03:04.620 love it. And second, honestly, the only one that 00:03:04.620 --> 00:03:06.439 really matters in the real world, keeping that 00:03:06.439 --> 00:03:08.860 child safe. That's the bottom line. So what we're 00:03:08.860 --> 00:03:12.080 going to do is separate the need to know, the 00:03:12.080 --> 00:03:14.719 safety critical high yield exam stuff, from the 00:03:14.719 --> 00:03:17.400 nice to know. The fluff. Yeah, the context and 00:03:17.400 --> 00:03:19.800 the fluff. We are turning this textbook into 00:03:19.800 --> 00:03:23.199 a survival guide. I love that, a survival guide. 00:03:23.620 --> 00:03:25.080 So we're going to walk through the assessment 00:03:25.080 --> 00:03:27.939 head to toe, but we're filtering every single 00:03:27.939 --> 00:03:30.479 step through the lens of exam traps and clinical 00:03:30.479 --> 00:03:32.680 red flags. Exactly. If you're a student cramming 00:03:32.680 --> 00:03:36.060 for a midterm or a new grad who's terrified of 00:03:36.060 --> 00:03:38.719 your first shift, this is your blueprint. Let's 00:03:38.719 --> 00:03:42.520 dive in. OK, so take us into the room. The source 00:03:42.520 --> 00:03:44.919 material starts with the general survey, but 00:03:44.919 --> 00:03:46.919 it makes a really interesting point immediately. 00:03:47.360 --> 00:03:49.860 It says the most important part of the assessment 00:03:49.860 --> 00:03:52.979 happens before you even say hello. Right. Before 00:03:52.979 --> 00:03:55.539 you even touch the patient. This is what we call 00:03:55.539 --> 00:03:58.699 the door handle observation. This is our first 00:03:58.699 --> 00:04:03.340 big need -to -know 80 -20 core concept. The door 00:04:03.340 --> 00:04:05.939 handle observation. It sounds like a spy novel 00:04:05.939 --> 00:04:09.099 technique. But tell us why this specific moment 00:04:09.099 --> 00:04:12.280 is so critical. It is critical because of, well... 00:04:12.280 --> 00:04:15.120 It's essentially the Heisenberg uncertainty principle 00:04:15.120 --> 00:04:16.519 of medicine. OK, you're going to have to break 00:04:16.519 --> 00:04:18.560 that down for me. The moment you walk into a 00:04:18.560 --> 00:04:21.379 room and engage with a child, you change the 00:04:21.379 --> 00:04:23.959 data. You change the dynamic. You're a variable. 00:04:24.139 --> 00:04:26.939 You're a huge variable. Yeah. If you rush in, 00:04:27.139 --> 00:04:29.360 they might start crying, which immediately changes 00:04:29.360 --> 00:04:31.139 their heart rate and their respiratory rate. 00:04:31.480 --> 00:04:34.139 Or they might perk up because of the stimulation, 00:04:34.620 --> 00:04:36.860 masking how lethargic they really were just a 00:04:36.860 --> 00:04:39.220 second ago. So you need the baseline. You need 00:04:39.220 --> 00:04:42.060 the unadulterated baseline. It literally means 00:04:42.060 --> 00:04:44.660 you pause with your hand on the door handle or 00:04:44.660 --> 00:04:47.220 just as you step inside the threshold and you 00:04:47.220 --> 00:04:49.860 look. Just look. You do not rush in with your 00:04:49.860 --> 00:04:51.819 stethoscope. You don't introduce yourself yet. 00:04:51.819 --> 00:04:55.019 You just observe. And what exactly are we scanning 00:04:55.019 --> 00:04:56.939 for in that split second? It can't be everything. 00:04:57.220 --> 00:05:00.220 No. It's very targeted. Yeah. You are looking 00:05:00.220 --> 00:05:03.339 for the pediatric assessment triangle. It's a 00:05:03.339 --> 00:05:06.160 rapid visual scan of three things. Appearance, 00:05:06.420 --> 00:05:08.939 work of breathing, and circulation to the skin. 00:05:09.500 --> 00:05:12.100 Appearance? work of breathing and circulation. 00:05:12.439 --> 00:05:14.500 This is your need -to -know foundation. Everything 00:05:14.500 --> 00:05:16.420 else is built on this. Okay, let's unpack those 00:05:16.420 --> 00:05:18.639 because appearance sounds a bit superficial. 00:05:19.100 --> 00:05:21.060 We aren't judging their outfit or if their hair 00:05:21.060 --> 00:05:23.980 is combed. No, not at all. Appearance in this 00:05:23.980 --> 00:05:26.560 context is entirely neurological. It's about 00:05:26.560 --> 00:05:29.699 tone, interactiveness, and consolability. So 00:05:29.699 --> 00:05:31.899 what does that look like from the doorway? Looks 00:05:31.899 --> 00:05:34.620 like? Is the child tracking you with their eyes 00:05:34.620 --> 00:05:37.339 as you walk in? Are they moving spontaneously? 00:05:37.600 --> 00:05:40.839 Or, this is a scary one, are they limp? Are they 00:05:40.839 --> 00:05:44.240 floppy? Like a ragdoll. Exactly. Yeah. Are they 00:05:44.240 --> 00:05:47.839 staring into space with a glazed look? If you 00:05:47.839 --> 00:05:50.660 see a floppy baby from the doorway, or a toddler 00:05:50.660 --> 00:05:53.199 who wasn't reacting to a stranger entering the 00:05:53.199 --> 00:05:55.639 room, you aren't doing a health history. No, 00:05:55.639 --> 00:05:58.060 you're intervening. You are calling a code or 00:05:58.060 --> 00:06:01.899 shouting for help. It's that serious. So, appearance 00:06:01.899 --> 00:06:06.319 equals brain profusion. Got it. What about work 00:06:06.319 --> 00:06:08.839 of breathing? You're looking for the struggle. 00:06:09.459 --> 00:06:11.660 Before you even think about putting a stethoscope 00:06:11.660 --> 00:06:14.139 on their chest, can you see them breathing from 00:06:14.139 --> 00:06:16.259 10 feet away? And what would that look like? 00:06:17.000 --> 00:06:19.339 Is the chest heaving? Are they sitting in what 00:06:19.339 --> 00:06:21.339 we call a tripod position, leaning forward with 00:06:21.339 --> 00:06:23.519 their hands on their knees just to get air in? 00:06:23.579 --> 00:06:26.160 I've seen that. Yeah. Are their nostrils flaring 00:06:26.160 --> 00:06:28.839 with every breath? If you see the work, you know 00:06:28.839 --> 00:06:30.939 there is pathology before you even hear the breath 00:06:30.939 --> 00:06:34.000 sounds. And finally, circulation. This is color. 00:06:34.399 --> 00:06:37.449 It's that simple. Are they pink? Or are they 00:06:37.449 --> 00:06:40.089 pale? Are they mottled, which looks kind of like 00:06:40.089 --> 00:06:43.810 a web -like, lacy pattern on the skin? Or are 00:06:43.810 --> 00:06:46.550 they blue? And if you spot a problem in this 00:06:46.550 --> 00:06:49.290 door handle phase... The routine exam is over. 00:06:49.550 --> 00:06:51.790 It's done. You intervene immediately. Okay, so 00:06:51.790 --> 00:06:54.050 assuming the door handle observation is stable, 00:06:54.329 --> 00:06:56.069 the kid looks okay, they're breathing fine, we 00:06:56.069 --> 00:07:00.889 move in. Now, I found... A massive exam trap 00:07:00.889 --> 00:07:03.110 in the notes regarding the order of operations. 00:07:03.750 --> 00:07:06.269 In adult nursing, we are trained to be robots 00:07:06.269 --> 00:07:10.329 head to toe every time. Systematic. And if you 00:07:10.329 --> 00:07:13.250 do that with a child, you will fail. You will 00:07:13.250 --> 00:07:15.750 absolutely fail. Why? Why does the system just 00:07:15.750 --> 00:07:18.389 completely break down? Because children are volatile. 00:07:18.750 --> 00:07:22.350 Their mood is a ticking clock. The sources emphasize 00:07:22.350 --> 00:07:24.850 that with kids, you have to be an opportunist. 00:07:25.129 --> 00:07:27.370 It's another classic need to know. Be an opportunist. 00:07:27.470 --> 00:07:30.329 Exactly. If you walk in and the infant or toddler 00:07:30.329 --> 00:07:32.610 is sleeping or they're just quiet on the parent's 00:07:32.610 --> 00:07:34.949 lap, what is the very first thing you do? My 00:07:34.949 --> 00:07:37.009 adult nursing brain says, wake them up gently, 00:07:37.250 --> 00:07:39.129 introduce myself, get a weight, get a height. 00:07:39.250 --> 00:07:42.189 And that is how you fail the simulation and how 00:07:42.189 --> 00:07:44.089 you make the next hour of your life miserable. 00:07:44.310 --> 00:07:46.649 Brutal. OK, correct me. What's the right move? 00:07:46.769 --> 00:07:50.389 If they are quiet, You listen, you get your stethoscope, 00:07:50.709 --> 00:07:52.589 and you get your auscultation done, heart and 00:07:52.589 --> 00:07:54.829 lungs, while they are calm. Because the moment 00:07:54.829 --> 00:07:56.769 you wake them up to weigh them, or put them on 00:07:56.769 --> 00:07:59.170 a cold scale, or look in their throat with a 00:07:59.170 --> 00:08:01.610 tongue depressor, they will scream. And then 00:08:01.610 --> 00:08:03.389 you can't hear anything. You can't hear anything. 00:08:03.670 --> 00:08:07.050 And I defy anyone to hear a graded two heart 00:08:07.050 --> 00:08:09.470 murmur through the chest wall of a screaming, 00:08:09.509 --> 00:08:12.149 kicking toddler. Yeah. It's impossible. You've 00:08:12.149 --> 00:08:15.970 lost your data. So the rule is, least invasive 00:08:15.970 --> 00:08:19.779 to most invasive. Always. That is the core principle. 00:08:20.199 --> 00:08:22.579 You listen first. You might touch the belly next. 00:08:22.660 --> 00:08:25.139 That's usually okay. You save the ears, the throat, 00:08:25.500 --> 00:08:27.519 and anything involving a needle or a probe for 00:08:27.519 --> 00:08:29.980 the grand finale. Because once you lose their 00:08:29.980 --> 00:08:32.000 trust... It's gone. You don't get it back in 00:08:32.000 --> 00:08:34.379 that visit. You have to earn the right to do 00:08:34.379 --> 00:08:37.220 the painful or scary stuff by doing the easy, 00:08:37.399 --> 00:08:40.220 quiet stuff first. That actually leads us perfectly 00:08:40.220 --> 00:08:42.840 into the developmental stages. The approach changes 00:08:42.840 --> 00:08:45.279 completely depending on the age. The source material 00:08:45.279 --> 00:08:47.759 highlights the no phase for toddlers. This is 00:08:47.759 --> 00:08:49.860 ages, what, one to three? Yeah, one to three. 00:08:50.279 --> 00:08:52.960 Toddlers are fascinating and so frustrating because 00:08:52.960 --> 00:08:55.460 they are defined by egocentrism. That is the 00:08:55.460 --> 00:08:58.299 developmental keyword you'll see on exams. Egocentrism. 00:08:58.519 --> 00:09:00.919 They want autonomy. They just discover they are 00:09:00.919 --> 00:09:02.820 separate people from their parents and their 00:09:02.820 --> 00:09:05.960 favorite word is no. So if you ask a toddler, 00:09:06.409 --> 00:09:09.269 Can I listen to your heart now, or is it okay 00:09:09.269 --> 00:09:15.230 if I check your tummy? What is the answer always 00:09:15.230 --> 00:09:18.870 gonna be? It's gonna be no. A very loud no. Even 00:09:18.870 --> 00:09:21.590 if they aren't scared, they'll say no just to 00:09:21.590 --> 00:09:24.610 exercise that power. They are testing their boundaries 00:09:24.610 --> 00:09:27.269 with you. So how do you get consent without asking 00:09:27.269 --> 00:09:29.370 a yes -no question? I mean, we can't just tackle 00:09:29.370 --> 00:09:31.730 them. No, definitely not. You use what we call 00:09:31.730 --> 00:09:34.049 forced choice or just direct statements. You 00:09:34.049 --> 00:09:35.529 don't ask permission for the necessary things. 00:09:35.669 --> 00:09:38.389 You say, cheerfully and firmly, I am going to 00:09:38.389 --> 00:09:40.549 listen to your heart now. Just a statement of 00:09:40.549 --> 00:09:43.250 fact. A statement of fact. Or if you want to 00:09:43.250 --> 00:09:45.470 give them some control, which they crave, you 00:09:45.470 --> 00:09:47.549 say, do you want me to listen to your heart first 00:09:47.549 --> 00:09:50.059 or your teddy bear's heart first? That's clever. 00:09:50.120 --> 00:09:52.240 You give them a choice, but neither option is 00:09:52.240 --> 00:09:54.879 no, get away from me. Exactly. You frame the 00:09:54.879 --> 00:09:57.539 interaction so that compliance is the only outcome, 00:09:57.539 --> 00:09:59.399 but they still feel like they participated. They 00:09:59.399 --> 00:10:01.940 got to make a decision. And location matters. 00:10:02.179 --> 00:10:05.759 For a toddler, the exam table is lava. It's a 00:10:05.759 --> 00:10:09.019 scary, cold, high up place. Do not put them up 00:10:09.019 --> 00:10:11.159 there if you can avoid it. So where do you do 00:10:11.159 --> 00:10:14.240 the exam? On the parent's lap. The parent is 00:10:14.240 --> 00:10:16.620 their safety anchor, their home base. Use that 00:10:16.620 --> 00:10:19.120 to your advantage. OK, moving up to preschoolers. 00:10:19.200 --> 00:10:21.480 These are the three to five year olds. The notes 00:10:21.480 --> 00:10:24.080 mention they have vivid imaginations, which sounds 00:10:24.080 --> 00:10:26.879 cute, but in a hospital, it sounds terrified. 00:10:27.039 --> 00:10:29.899 It is terrifying for them. Their cognitive development 00:10:29.899 --> 00:10:33.220 is heavily based on magical thinking. Magical 00:10:33.220 --> 00:10:35.600 thinking. Yeah. They don't understand cause and 00:10:35.600 --> 00:10:37.700 effect properly yet. Right. They think thoughts 00:10:37.700 --> 00:10:41.320 can cause reality. And the big fear here, and 00:10:41.320 --> 00:10:43.259 this is a specific term in the literature you 00:10:43.259 --> 00:10:45.899 need to know for your exams, is fear of mutilation. 00:10:46.169 --> 00:10:48.490 Fear of mutilation. Wow, that sounds incredibly 00:10:48.490 --> 00:10:50.009 intense for a four -year -old. It means they 00:10:50.009 --> 00:10:52.750 have really poor body integrity concepts. They 00:10:52.750 --> 00:10:54.990 view their skin as a balloon that holds everything 00:10:54.990 --> 00:10:57.549 inside. OK. So if you give a preschooler a shot, 00:10:57.730 --> 00:10:59.889 or if they get a cut, they genuinely worry that 00:10:59.889 --> 00:11:02.669 all their insides, their blood, their guts, are 00:11:02.669 --> 00:11:04.450 going to leak out through that one tiny hole. 00:11:04.789 --> 00:11:07.649 Oh, wow. So that's why a tiny paper cut is the 00:11:07.649 --> 00:11:09.750 end of the world. Exactly. And that's why band 00:11:09.750 --> 00:11:11.950 -aids are like magic spells to them. It seals 00:11:11.950 --> 00:11:14.460 the leak. It holds them together. So for the 00:11:14.460 --> 00:11:17.500 exam, how do we mitigate that fear? You have 00:11:17.500 --> 00:11:20.240 to demystify the equipment. Let them handle the 00:11:20.240 --> 00:11:22.720 stethoscope. Let them press the button on the 00:11:22.720 --> 00:11:25.139 thermometer. If they can play with it, it stops 00:11:25.139 --> 00:11:27.279 being a weapon and starts being a toy. Make it 00:11:27.279 --> 00:11:29.779 familiar. And you explain things in their language. 00:11:30.299 --> 00:11:32.679 This is going to give your arm a big hug for 00:11:32.679 --> 00:11:34.700 the blood pressure cuff. This is going to squeeze 00:11:34.700 --> 00:11:37.159 you really tight. Language matters so much at 00:11:37.159 --> 00:11:41.220 this age. Then we hit the adolescents. Teenagers, 00:11:41.700 --> 00:11:44.019 the vibe shifts here completely. We aren't dealing 00:11:44.019 --> 00:11:46.120 with fear of monsters anymore. We're dealing 00:11:46.120 --> 00:11:49.000 with fear of judgment. The priority shifts to 00:11:49.000 --> 00:11:52.679 privacy and body image. Adolescents are hyper 00:11:52.679 --> 00:11:55.659 aware of their changing bodies, and they're mortified 00:11:55.659 --> 00:11:57.940 by pretty much everything. The source material 00:11:57.940 --> 00:11:59.860 says we should offer to have the parent step 00:11:59.860 --> 00:12:02.220 out. That feels tricky if the parent is hovering 00:12:02.220 --> 00:12:05.679 or insists on staying. It is tricky, but it's 00:12:05.679 --> 00:12:08.100 necessary to offer it. You can say something 00:12:08.100 --> 00:12:09.919 like, OK, for this part of the exam, I'm just 00:12:09.919 --> 00:12:12.279 going to ask some routine questions. A lot of 00:12:12.279 --> 00:12:15.399 teens prefer to do this part privately. Mom, 00:12:16.059 --> 00:12:17.759 would you be comfortable stepping out for a few 00:12:17.759 --> 00:12:19.860 minutes? And what if mom says no? You have to 00:12:19.860 --> 00:12:22.779 respect that. But you document it, and you know 00:12:22.779 --> 00:12:26.179 you're probably not getting honest answers. Adolescents 00:12:26.179 --> 00:12:28.259 will not answer questions about substance use, 00:12:28.559 --> 00:12:31.340 sexual activity, or depression, honestly, if 00:12:31.340 --> 00:12:33.340 their mom is sitting right there. So you have 00:12:33.340 --> 00:12:36.460 to try to create that safe space. You do. But. 00:12:36.559 --> 00:12:39.200 And this is a huge legal and ethical need to 00:12:39.200 --> 00:12:42.220 know. You have to establish the boundaries of 00:12:42.220 --> 00:12:44.779 that privacy upfront. The safety limit. Right. 00:12:44.919 --> 00:12:47.620 You cannot promise total secrecy. New nurses 00:12:47.620 --> 00:12:50.100 often make this mistake. They say, I won't tell 00:12:50.100 --> 00:12:52.059 anyone anything. I promise. And that's a problem 00:12:52.059 --> 00:12:54.659 because if you do that and then the team tells 00:12:54.659 --> 00:12:58.039 you they are suicidal, you are in a legal and 00:12:58.039 --> 00:13:00.639 ethical bind. You have to break your promise. 00:13:00.740 --> 00:13:02.700 So what's the script? What do you say? You have 00:13:02.700 --> 00:13:05.259 to use the phrase. Everything we talk about is 00:13:05.259 --> 00:13:07.559 private and confidential. Unless you tell me 00:13:07.559 --> 00:13:09.320 someone is hurting you, you want to hurt someone 00:13:09.320 --> 00:13:12.059 else or you want to hurt yourself. In those cases, 00:13:12.320 --> 00:13:14.980 my job is to get you help and keep you safe. 00:13:15.080 --> 00:13:17.679 That's the distinct line. You are a vault up 00:13:17.679 --> 00:13:20.980 until lives are at risk. Correct. If you don't 00:13:20.980 --> 00:13:22.919 say that disclaimer upfront... and then you have 00:13:22.919 --> 00:13:25.240 to report them to protect them, they will feel 00:13:25.240 --> 00:13:28.259 betrayed, and you've lost that therapeutic relationship 00:13:28.259 --> 00:13:31.139 forever. Okay, that makes total sense. Before 00:13:31.139 --> 00:13:33.159 we leave the general survey, let's hit a couple 00:13:33.159 --> 00:13:35.279 of those nice -to -know supporting info points 00:13:35.279 --> 00:13:37.539 from the notes. These are the things that make 00:13:37.539 --> 00:13:40.100 the exam smoother but aren't necessarily life 00:13:40.100 --> 00:13:42.919 or death. The art of the exam, not just the science. 00:13:43.120 --> 00:13:47.000 Exactly. building rapport. The expert notes suggest 00:13:47.000 --> 00:13:49.700 ignoring the child at first. That's so counterintuitive, 00:13:49.879 --> 00:13:51.600 right? It does. I want to be friendly. I want 00:13:51.600 --> 00:13:53.220 to say hi to the kid. But think about it from 00:13:53.220 --> 00:13:56.519 the kid's perspective. You are a giant stranger 00:13:56.519 --> 00:13:59.879 in a weird uniform. If you rush at them, you're 00:13:59.879 --> 00:14:03.279 a threat. If you ignore them and talk calmly 00:14:03.279 --> 00:14:06.200 to the parent, the child watches. They're observing 00:14:06.200 --> 00:14:08.639 the interaction. They see the parent as calm, 00:14:08.820 --> 00:14:10.899 they see the parent trust you. It's what we call 00:14:10.899 --> 00:14:13.120 a social proxy. It's like when a dog looks at 00:14:13.120 --> 00:14:15.159 its owner to see if a new person is okay. It 00:14:15.159 --> 00:14:18.340 is the exact same mechanism. Once the kid sees 00:14:18.340 --> 00:14:21.700 mom is cool with you, then you can slowly engage. 00:14:22.399 --> 00:14:24.879 Get down on their eye level, don't tower over 00:14:24.879 --> 00:14:28.139 them like a giant, and use a transition object. 00:14:28.379 --> 00:14:30.960 A transition object? What's that? A puppet, a 00:14:30.960 --> 00:14:34.360 toy, a light -up pen. Something to bridge the 00:14:34.360 --> 00:14:36.980 gap between your scary medical world and their 00:14:36.980 --> 00:14:39.279 world of play. You examine the puppet's heart 00:14:39.279 --> 00:14:42.899 first. I like that. And lastly for this segment, 00:14:43.220 --> 00:14:45.720 family history. The notes mention something called 00:14:45.720 --> 00:14:48.259 a genogram. Right. A genogram is basically a 00:14:48.259 --> 00:14:51.700 family tree, but for medical issues. In pediatrics, 00:14:51.759 --> 00:14:53.679 we really want to go back three generations if 00:14:53.679 --> 00:14:55.980 we can. Why three? We were looking for patterns, 00:14:56.379 --> 00:14:58.620 early heart disease, genetic traits like sickle 00:14:58.620 --> 00:15:01.679 cell or cystic fibrosis, sudden unexplained deaths. 00:15:02.179 --> 00:15:04.080 It gives us the genetic context for the child 00:15:04.080 --> 00:15:06.340 sitting in front of us. It's nice to know for 00:15:06.340 --> 00:15:08.759 the immediate physical exam, but it becomes need 00:15:08.759 --> 00:15:11.259 to know for the long -term plan of care. Got 00:15:11.259 --> 00:15:15.240 it. OK, moving on to segment two, vital signs 00:15:15.240 --> 00:15:17.639 and measurements. This seems straightforward, 00:15:17.820 --> 00:15:19.899 numbers are numbers, but I feel like there are 00:15:19.899 --> 00:15:22.120 some math traps here, specifically with blood 00:15:22.120 --> 00:15:24.200 pressure. Oh, this is a huge one. This is our 00:15:24.200 --> 00:15:27.559 next big need -to -know 80 -20 core. The blood 00:15:27.559 --> 00:15:31.259 pressure cuff Goldilocks rule. I cannot stress 00:15:31.259 --> 00:15:33.639 this enough. Okay, lay it on me. The Goldilocks 00:15:33.639 --> 00:15:35.840 rule. Most people, you know, they just grab whatever 00:15:35.840 --> 00:15:37.860 cuff is on the wall. A pediatric cuff, that looks 00:15:37.860 --> 00:15:40.399 about right. That's so dangerous. The accuracy 00:15:40.399 --> 00:15:43.600 depends entirely on cuff size relative to that 00:15:43.600 --> 00:15:46.259 specific child's arm. So what's the rule? The 00:15:46.259 --> 00:15:49.080 rule is the bladder width of the cuff, that's 00:15:49.080 --> 00:15:51.519 the inflatable part inside, should be approximately 00:15:51.519 --> 00:15:54.559 40 % of the circumference of the upper arm. 40%, 00:15:54.559 --> 00:15:56.539 okay. That's very specific, but what happens 00:15:56.539 --> 00:15:58.299 if we mess that up? This is the physics question 00:15:58.299 --> 00:16:01.200 that always appears on tests. Right. So if the 00:16:01.200 --> 00:16:03.759 cuff is too narrow, meaning it's too tight or 00:16:03.759 --> 00:16:06.720 just too small for that arm, you will get a falsely 00:16:06.720 --> 00:16:09.659 high GH reading. A falsely high. Why is that? 00:16:09.679 --> 00:16:11.860 What's the mechanism? Think about the mechanics 00:16:11.860 --> 00:16:14.210 of it. To stop the blood flow in a big artery 00:16:14.210 --> 00:16:16.570 with a tiny little cuff, you have to pump it 00:16:16.570 --> 00:16:19.049 up way harder to compress all the tissue deep 00:16:19.049 --> 00:16:22.090 enough to pinch that artery shut. OK. The machine 00:16:22.090 --> 00:16:24.929 reads all that extra effort, that extra pressure, 00:16:25.250 --> 00:16:27.009 as higher blood pressure. That makes perfect 00:16:27.009 --> 00:16:30.210 sense. So too small equals artificially high 00:16:30.210 --> 00:16:32.870 pressure. And the opposite is also true. If the 00:16:32.870 --> 00:16:36.210 cuff is too wide, too loose, or just too big, 00:16:36.690 --> 00:16:39.750 you get a falsely low W reading. How does that 00:16:39.750 --> 00:16:42.169 happen? It distributes the pressure too easily 00:16:42.169 --> 00:16:44.789 over a larger surface area, so it stops the blood 00:16:44.789 --> 00:16:46.870 flow with less pressure than is actually inside 00:16:46.870 --> 00:16:48.750 the vessel. It's like trying to stop a river 00:16:48.750 --> 00:16:51.309 with a bed sheet instead of a focused dam. Wow. 00:16:51.710 --> 00:16:54.409 I can just see a new nurse panicking over a high 00:16:54.409 --> 00:16:57.649 BP, calling the doctor, maybe even starting meds, 00:16:57.669 --> 00:16:59.950 all because they used the standard pediatric 00:16:59.950 --> 00:17:02.629 cuff on a chubby arm that really needed a small 00:17:02.629 --> 00:17:05.670 adult cuff. It happens all the time. And conversely, 00:17:05.670 --> 00:17:09.049 you could miss hypotension in a really sick, 00:17:09.190 --> 00:17:11.880 shocky kid. because the cuff was too big, and 00:17:11.880 --> 00:17:13.480 you think their pressure is fine when it's really 00:17:13.480 --> 00:17:16.839 in the basement. The lesson is, always check 00:17:16.839 --> 00:17:19.460 the cuff size before you treat the number. Always. 00:17:19.599 --> 00:17:21.579 Let's talk pulse oximetry. We stick these on 00:17:21.579 --> 00:17:24.619 kids all the time. Is there a trick to it? The 00:17:24.619 --> 00:17:26.859 trick isn't the application, it's the validation. 00:17:27.599 --> 00:17:30.940 This is a big need to know. Kids wiggle a lot. 00:17:31.059 --> 00:17:33.019 True. If a child is waving their hand around, 00:17:33.339 --> 00:17:35.480 the sensor's picking up motion. You might look 00:17:35.480 --> 00:17:38.559 at the monitor and see a saturation of 85 % and 00:17:38.559 --> 00:17:41.829 a heart rate of 60. But the kid looks pink and 00:17:41.829 --> 00:17:44.269 happy and is breathing fine. So the monitor is 00:17:44.269 --> 00:17:47.049 lying. The monitor is confused. You have to check 00:17:47.049 --> 00:17:49.890 the waveform. You need to see a good, strong 00:17:49.890 --> 00:17:51.970 plethe wave, that's the little squiggly line, 00:17:52.289 --> 00:17:54.890 that matches the child's actual heart rate. So 00:17:54.890 --> 00:17:57.390 you cross -reference. You have to. If the monitor 00:17:57.390 --> 00:17:59.650 says the heart rate is 60, but you listen to 00:17:59.650 --> 00:18:01.930 the chest and the heart is actually going 140, 00:18:02.309 --> 00:18:04.450 that saturation number is garbage. It's artifact. 00:18:04.609 --> 00:18:07.569 So the saying is true. Treat the patient, not 00:18:07.569 --> 00:18:09.799 the machine. That should be tattooed on every 00:18:09.799 --> 00:18:11.819 nurse's arm. Seriously. And one more thing on 00:18:11.819 --> 00:18:14.359 pulse ox probes. The adhesive ones. You have 00:18:14.359 --> 00:18:17.299 to rotate the sensor site every few hours. An 00:18:17.299 --> 00:18:19.720 infant's skin is so fragile, you can cause a 00:18:19.720 --> 00:18:22.000 pressure ulcer or a burn from that little red 00:18:22.000 --> 00:18:24.240 light if you leave it in one spot for too long. 00:18:24.460 --> 00:18:26.720 That's a great practical tip. Now, growth charts. 00:18:26.980 --> 00:18:29.380 I remember seeing these. It's a lot of curves 00:18:29.380 --> 00:18:32.039 and percentiles. It can be overwhelming. It can. 00:18:32.519 --> 00:18:35.339 The need to know here is simple. A single point 00:18:35.339 --> 00:18:38.859 in time is almost meaningless. We care about 00:18:38.859 --> 00:18:40.839 the trend. Explain that. What does that mean 00:18:40.839 --> 00:18:43.920 in practice? Okay, so a child comes in and they 00:18:43.920 --> 00:18:46.279 are in the fifth percentile for weight. Is that 00:18:46.279 --> 00:18:49.480 bad? It sounds low. My gut reaction is yes, that's 00:18:49.480 --> 00:18:52.059 bad. It is low. But if they've been in the fifth 00:18:52.059 --> 00:18:54.380 percentile since birth and their parents are 00:18:54.380 --> 00:18:57.200 both very small, petite people, that is their 00:18:57.200 --> 00:18:59.160 normal. They're growing along their own curve. 00:18:59.240 --> 00:19:01.259 So it's about consistency. It's about their own 00:19:01.259 --> 00:19:03.559 personal trajectory. That is likely their genetic 00:19:03.559 --> 00:19:05.559 potential. We don't worry about that kid. So 00:19:05.559 --> 00:19:07.940 when do we panic? When do we start the workup? 00:19:08.279 --> 00:19:11.680 We panic at deviations. We worry when a child 00:19:11.680 --> 00:19:14.559 who is tracking along the 50th percentile their 00:19:14.559 --> 00:19:17.700 whole life suddenly at their two -year checkup 00:19:17.700 --> 00:19:20.480 drops to the 10th percentile. That is called 00:19:20.480 --> 00:19:22.720 falling off the growth curve. And that signals 00:19:22.720 --> 00:19:25.640 a problem. That signals a big problem. That means 00:19:25.640 --> 00:19:27.900 something is wrong. We start thinking failure 00:19:27.900 --> 00:19:30.519 to thrive, malnutrition, or a chronic illness 00:19:30.519 --> 00:19:33.220 that's just starting to show itself, like celiac 00:19:33.220 --> 00:19:36.380 disease or cystic fibrosis. So it's the deviation, 00:19:36.599 --> 00:19:39.279 not the destination. That's the red flag. Precisely. 00:19:39.579 --> 00:19:41.460 Any quick nice -to -know points on measurement 00:19:41.460 --> 00:19:43.279 logistics from the source material? Just a few 00:19:43.279 --> 00:19:46.839 practical things. Weigh infants nude. A wet diaper 00:19:46.839 --> 00:19:49.140 can weigh a significant amount relative to a 00:19:49.140 --> 00:19:51.680 tiny baby. You don't want to document urine as 00:19:51.680 --> 00:19:53.680 weight gain. That's a good point. And for height. 00:19:53.680 --> 00:19:56.829 Yeah. Children under two? or those who can't 00:19:56.829 --> 00:19:59.210 stand well are measured lying down. We call that 00:19:59.210 --> 00:20:01.609 recumbent length. Once they can stand reliably, 00:20:02.009 --> 00:20:04.170 usually after age two, we switch to standing 00:20:04.170 --> 00:20:06.630 height and we measure head circumference until 00:20:06.630 --> 00:20:10.109 age two or three to screen for things like hydrocephalus 00:20:10.109 --> 00:20:12.210 or microcephaly. Okay, let's move to segment 00:20:12.210 --> 00:20:15.710 three, the skin. This feels like detective work. 00:20:16.210 --> 00:20:18.230 The skin is on the outside, but it tells us what's 00:20:18.230 --> 00:20:20.329 happening on the inside. It's the billboard for 00:20:20.329 --> 00:20:23.750 the body's systemic health. And the biggest scariest 00:20:23.750 --> 00:20:26.430 need to know here is distinguishing between birthmarks 00:20:26.430 --> 00:20:29.650 and abuse. This is a high stakes area. This is 00:20:29.650 --> 00:20:32.250 crucial. The source mentions Mongolian spots. 00:20:32.490 --> 00:20:34.970 Yes, the formal name now is congenital dermal 00:20:34.970 --> 00:20:38.930 melanocytosis. These are dark, bluish pigmented 00:20:38.930 --> 00:20:41.269 patches, and they usually show up on the lower 00:20:41.269 --> 00:20:43.829 back, the buttocks, or the shoulders. And they're 00:20:43.829 --> 00:20:46.529 common. Very common, but specifically in darker 00:20:46.529 --> 00:20:49.190 skinned infants, so infants of black, Asian, 00:20:49.509 --> 00:20:51.490 Hispanic, or Mediterranean descent. You don't 00:20:51.490 --> 00:20:53.549 see them as much in fair -skinned babies. And 00:20:53.549 --> 00:20:55.529 the problem is they look exactly like bruises. 00:20:55.650 --> 00:20:58.680 They look exactly like deep old bruises. I have 00:20:58.680 --> 00:21:00.900 personally seen parents get accused of abuse 00:21:00.900 --> 00:21:04.240 by well -meaning but uneducated providers who 00:21:04.240 --> 00:21:06.380 didn't know what these were. That is an absolute 00:21:06.380 --> 00:21:09.660 nightmare scenario for a family. It is. The exam 00:21:09.660 --> 00:21:11.779 trap and the clinical safety tip are the same. 00:21:12.039 --> 00:21:14.480 If you are the admitting nurse, you must document 00:21:14.480 --> 00:21:18.119 these immediately. Measure them, photograph them 00:21:18.119 --> 00:21:20.779 if your policy allows, describe their location 00:21:20.779 --> 00:21:23.359 and color. Why is that first documentation so 00:21:23.359 --> 00:21:26.539 important? Because if you don't, and a different 00:21:26.539 --> 00:21:29.099 provider sees them three days later, they will 00:21:29.099 --> 00:21:31.240 assume they are new injuries acquired at home 00:21:31.240 --> 00:21:33.859 or in the hospital. Your initial note protects 00:21:33.859 --> 00:21:37.200 the family. So documentation is the shield. On 00:21:37.200 --> 00:21:39.660 the flip side, what does actual abuse bruising 00:21:39.660 --> 00:21:41.839 look like? We have a rhyme for this, and it's 00:21:41.839 --> 00:21:44.779 grim, but it is very effective. Those who don't 00:21:44.779 --> 00:21:47.059 cruise shouldn't bruise. Those who don't cruise 00:21:47.059 --> 00:21:49.200 shouldn't bruise, meaning if the baby isn't walking 00:21:49.200 --> 00:21:51.609 yet, they shouldn't have bruises. A two -month 00:21:51.609 --> 00:21:53.470 -old cannot roll over and bump into a coffee 00:21:53.470 --> 00:21:55.869 table. A four -month -old cannot fall off a swing 00:21:55.869 --> 00:21:58.650 set. If you see echemosis, that's the medical 00:21:58.650 --> 00:22:00.789 term for bruising on a non -mobile incident, 00:22:00.970 --> 00:22:03.150 especially on the torso, the ears, or the neck. 00:22:03.650 --> 00:22:06.450 That is a major red flag for non -accidental 00:22:06.450 --> 00:22:09.289 trauma. A red flag that's waving violently. Exactly. 00:22:09.369 --> 00:22:12.109 That requires an immediate, careful, and thorough 00:22:12.109 --> 00:22:14.789 investigation. That is a chilling rule, but very 00:22:14.789 --> 00:22:17.390 easy to remember. Let's talk about color changes 00:22:17.390 --> 00:22:20.089 as distress signals. We hear cyanosis and we 00:22:20.089 --> 00:22:23.470 think blue, but there are nuances here. Yes, 00:22:23.569 --> 00:22:26.529 we need to distinguish central cyanosis from 00:22:26.529 --> 00:22:29.730 acrocynosis. This is a classic exam question, 00:22:29.849 --> 00:22:32.049 a need to know for sure. OK, break it down for 00:22:32.049 --> 00:22:34.950 us. Central cyanosis is blue lips, a blue tongue, 00:22:35.170 --> 00:22:37.970 blue mucus membranes inside the mouth. This is 00:22:37.970 --> 00:22:40.509 the core of the body. It means the blood pumping 00:22:40.509 --> 00:22:42.450 out of the heart is not carrying enough oxygen. 00:22:42.710 --> 00:22:45.170 This is true hypoxia. It is an emergency. You 00:22:45.170 --> 00:22:48.569 run. Got it. Central is bad and acrocyanosis. 00:22:48.930 --> 00:22:50.950 Acrocyanosis is blueness of the hands and feet. 00:22:51.190 --> 00:22:53.990 The word acro means extremity. This is actually 00:22:53.990 --> 00:22:56.250 considered normal in newborns for the first 24 00:22:56.250 --> 00:22:59.049 to 48 hours. Normal. Blue hands are normal. That 00:22:59.049 --> 00:23:01.569 seems so counterintuitive. It does. But yes, 00:23:02.089 --> 00:23:04.589 their peripheral circulation is still very immature. 00:23:04.829 --> 00:23:07.369 The body is smart. It shunts the warm oxygenated 00:23:07.369 --> 00:23:09.849 blood to the vital organs, the brain, the heart, 00:23:10.049 --> 00:23:12.329 the kidneys, and it clamps down on the circulation 00:23:12.329 --> 00:23:14.250 to the hands and feet. So they're often cool 00:23:14.250 --> 00:23:16.890 and a little bit blue. So if a new mom frantically 00:23:16.890 --> 00:23:19.309 calls you over and says, my baby's hands are 00:23:19.309 --> 00:23:21.789 blue, you don't call a code blue. You don't. 00:23:21.970 --> 00:23:24.829 You calmly reassure her. You say, that's very 00:23:24.829 --> 00:23:27.190 normal for a new baby. Let's put some socks and 00:23:27.190 --> 00:23:30.190 mittens on him to warm him up. But if she says 00:23:30.190 --> 00:23:33.150 his lips are blue, you hit the emergency alarm. 00:23:33.430 --> 00:23:35.369 The location of the blue makes all the difference. 00:23:35.569 --> 00:23:37.950 What about jaundice? The yellowing of the skin. 00:23:38.250 --> 00:23:40.390 Jaundice is all about timing. It's a clock game. 00:23:40.549 --> 00:23:42.329 This is another core concept. The clock game, 00:23:42.329 --> 00:23:45.069 okay. If a baby turns yellow in the first 24 00:23:45.069 --> 00:23:48.069 hours of life on day one that is always considered 00:23:48.069 --> 00:23:51.569 pathological, that is bad. Why? What does that 00:23:51.569 --> 00:23:53.569 mean? It usually indicates a rapid destruction 00:23:53.569 --> 00:23:56.750 of red blood cells, maybe from a blood incompatibility 00:23:56.750 --> 00:23:59.990 between mom and baby, like an ABO or RH issue 00:23:59.990 --> 00:24:02.829 or a liver problem. That baby needs an immediate 00:24:02.829 --> 00:24:05.250 workout. And if the jaundice appears after 24 00:24:05.250 --> 00:24:09.029 hours? If it appears after 24 hours, so on day 00:24:09.029 --> 00:24:11.849 two or day three, it's much more likely to be 00:24:11.849 --> 00:24:14.849 physiologic jaundice. It's very common. It just 00:24:14.849 --> 00:24:17.150 means the newborn's liver is immature and can't 00:24:17.150 --> 00:24:19.750 process the breakdown of old fetal red blood 00:24:19.750 --> 00:24:22.849 cells fast enough. We monitor it. We might use 00:24:22.849 --> 00:24:25.309 phototherapy lights, but it's not the immediate 00:24:25.309 --> 00:24:28.329 crisis that day one jaundice is. So yellow on 00:24:28.329 --> 00:24:31.329 day one equals red flag. Yellow on day three 00:24:31.329 --> 00:24:34.289 equals watch and wait. You got it. Any quick? 00:24:34.509 --> 00:24:36.769 Nice to know points for skin from the chapter. 00:24:37.130 --> 00:24:39.250 Turgor. Yep. Turgor checks for hydration. In 00:24:39.250 --> 00:24:41.269 an adult, you usually pinch the skin on the back 00:24:41.269 --> 00:24:43.549 of the hand. In an infant, that's not reliable. 00:24:43.690 --> 00:24:45.690 You pinch the skin on the abdomen. On the belly. 00:24:45.849 --> 00:24:48.509 Right. If the skin tense, meaning it stays stuck 00:24:48.509 --> 00:24:50.930 up in a little tent shade after you let go, that's 00:24:50.930 --> 00:24:53.190 a sign of moderate to severe dehydration. And 00:24:53.190 --> 00:24:55.630 what about common benign lesions, the stuff parents 00:24:55.630 --> 00:24:58.750 ask about? Right. The, is this normal? Questions. 00:24:59.529 --> 00:25:01.730 Stork bites, those are the pink spots on the 00:25:01.730 --> 00:25:04.430 back of the neck or eyelids. Strawberry mangiomas, 00:25:04.509 --> 00:25:06.849 the bright red, raised marks that grow for a 00:25:06.849 --> 00:25:08.549 while and then usually shrink by school age. 00:25:09.049 --> 00:25:11.470 And Melia, those little white bumps on the nose. 00:25:12.109 --> 00:25:13.990 Tell parents not to pop the Melia, they're just 00:25:13.990 --> 00:25:15.630 clogged oil glands and they go away on their 00:25:15.630 --> 00:25:20.190 own. Segment four, heat. Head, eyes, ears, nose, 00:25:20.410 --> 00:25:23.180 throat. We have some heavy hitters in here. Let's 00:25:23.180 --> 00:25:25.400 start with the fontanels, the soft spots. The 00:25:25.400 --> 00:25:27.400 fontanels are brilliant design features, really. 00:25:27.500 --> 00:25:29.380 They allow the skull bones to overlap so the 00:25:29.380 --> 00:25:31.299 head can fit through the birth canal, and then 00:25:31.299 --> 00:25:33.440 they allow for the incredible brain growth that 00:25:33.440 --> 00:25:36.140 happens in the first year. But for us, clinically, 00:25:36.430 --> 00:25:38.910 They are windows into intracranial pressure. 00:25:39.170 --> 00:25:41.069 Windows into the brain. We have two main ones, 00:25:41.089 --> 00:25:42.869 right? Correct. The anterior fondinal, which 00:25:42.869 --> 00:25:44.730 is on the top of the head, and it's diamond shaped. 00:25:45.130 --> 00:25:46.970 And the posterior one, which is on the back of 00:25:46.970 --> 00:25:48.789 the head, and it's smaller, more triangular. 00:25:48.910 --> 00:25:51.210 And they close at different times. Vastly different 00:25:51.210 --> 00:25:54.170 times. This is a need to know. The posterior 00:25:54.170 --> 00:25:57.009 closes really fast, by about two months of age. 00:25:57.420 --> 00:26:00.339 but the anterior stays open much longer, usually 00:26:00.339 --> 00:26:02.960 until 12 to 18 months. So what are we feeling 00:26:02.960 --> 00:26:05.960 for when we touch that soft spot? We are feeling 00:26:05.960 --> 00:26:09.059 for pressure. We're assessing hydration and intracranial 00:26:09.059 --> 00:26:12.259 pressure. So if the fontanel is bulging, if it's 00:26:12.259 --> 00:26:15.079 tense hard and popping out above the skull, that 00:26:15.079 --> 00:26:17.380 indicates increased pressure inside the skull. 00:26:17.539 --> 00:26:19.920 And we should be thinking what? We think of scary 00:26:19.920 --> 00:26:23.019 things. Meningitis, hydrocephalus, maybe fluid 00:26:23.019 --> 00:26:25.660 overload from an IV. It's a sign of a serious 00:26:25.660 --> 00:26:28.079 problem. But the notes say crying affects this. 00:26:28.180 --> 00:26:30.500 That sounds like a huge exam trap. It is the 00:26:30.500 --> 00:26:32.859 trap. If a baby is screaming, they're performing 00:26:32.859 --> 00:26:35.819 a Valsalva maneuver, which increases their own 00:26:35.819 --> 00:26:38.140 intracranial pressure. The fontanel will bulge 00:26:38.140 --> 00:26:40.539 temporarily. So you can assess it. You cannot 00:26:40.539 --> 00:26:42.839 assess a fontanel accurately on a crying baby. 00:26:43.180 --> 00:26:44.980 You have to wait until they settle down, maybe 00:26:44.980 --> 00:26:48.279 give them pacifier, assess when calm. And if 00:26:48.279 --> 00:26:50.519 it's sunken, like a little crater in their head. 00:26:50.700 --> 00:26:52.640 Sunken means the tank is empty. It's a classic 00:26:52.640 --> 00:26:55.450 sign of dehydration. Got it. Let's talk about 00:26:55.450 --> 00:26:57.710 the eyes, the red reflex. I thought this was 00:26:57.710 --> 00:27:00.069 just for fixing photos in Photoshop. In nursing, 00:27:00.289 --> 00:27:02.470 it's a cancer screen. It's a need -to -know that 00:27:02.470 --> 00:27:05.490 saves lives. You take an ophthalmoscope, you 00:27:05.490 --> 00:27:07.470 stand at a distance, and you shine the light 00:27:07.470 --> 00:27:10.230 into the baby's eye. You should see a reddish 00:27:10.230 --> 00:27:13.450 -orange reflection from the retina, just like 00:27:13.450 --> 00:27:15.750 red eye in a photo. That's the normal result. 00:27:15.910 --> 00:27:18.230 So what's the abnormal, the red flag? If you 00:27:18.230 --> 00:27:21.440 see a white glow... The technical term is leukocoria. 00:27:21.759 --> 00:27:23.539 Or if you just see a black spot where the red 00:27:23.539 --> 00:27:26.279 should be, that is terrifying. Why? What could 00:27:26.279 --> 00:27:28.539 it be? It can mean congenital cataracts, which 00:27:28.539 --> 00:27:31.319 need to be removed to save vision. Or, and this 00:27:31.319 --> 00:27:33.440 is the emergent one, it can mean retinoblastoma. 00:27:33.460 --> 00:27:36.000 The tumor in the eye. A fast -growing cancer. 00:27:36.640 --> 00:27:39.019 If you miss that white reflex on a newborn exam, 00:27:39.660 --> 00:27:41.559 the child could lose their eye or even their 00:27:41.559 --> 00:27:44.740 life. So checking for that red eye is technically 00:27:44.740 --> 00:27:47.680 a life -saving maneuver. Wow. Okay, now for the 00:27:47.680 --> 00:27:50.259 classic exam question, the ear pull. I feel like 00:27:50.259 --> 00:27:51.740 I've heard this a thousand times, but I always 00:27:51.740 --> 00:27:54.059 mix it up. Everyone mixes it up because it's 00:27:54.059 --> 00:27:56.319 arbitrary, unless you know the anatomy behind 00:27:56.319 --> 00:27:59.019 it. The goal is to straighten the ear canal so 00:27:59.019 --> 00:28:01.480 you can get a clear view of the tympanic membrane, 00:28:01.700 --> 00:28:03.740 the eardrum. Okay, so what's the rule? It's based 00:28:03.740 --> 00:28:07.799 on age. For children under three years, the canal 00:28:07.799 --> 00:28:10.400 has a downward curve, so you have to pull the 00:28:10.400 --> 00:28:13.430 pinna that's the outer ear. Down and back. Down 00:28:13.430 --> 00:28:15.950 and back for the little ones. Correct. For children 00:28:15.950 --> 00:28:18.930 over three years, and for adults, the canal straightens 00:28:18.930 --> 00:28:21.289 out and moves up. So you pull the pin a U .P. 00:28:21.289 --> 00:28:23.670 and back. I used to have an mnemonic for this. 00:28:23.950 --> 00:28:26.269 Down for the kids because they are short, and 00:28:26.269 --> 00:28:28.009 up for the grown -ups because they are tall. 00:28:28.150 --> 00:28:30.750 That's a great one. Whatever works. Down for 00:28:30.750 --> 00:28:33.250 down low, up for tall. Just don't get it backward, 00:28:33.490 --> 00:28:35.630 or you'll be staring at the wall of the ear canal. 00:28:35.650 --> 00:28:37.730 You'll see nothing, and you might hurt the child. 00:28:38.309 --> 00:28:41.789 One more core point for heat. The nose, the obligate 00:28:41.789 --> 00:28:44.869 nose breather rule. This is so vital and so easy 00:28:44.869 --> 00:28:47.470 to forget. Infants, especially under about four 00:28:47.470 --> 00:28:50.349 weeks to a few months old, do not know how to 00:28:50.349 --> 00:28:52.730 breathe through their mouths automatically. It's 00:28:52.730 --> 00:28:54.690 not a reflex they have yet. They only breathe 00:28:54.690 --> 00:28:56.670 through their nose. They only breathe through 00:28:56.670 --> 00:28:58.849 their nose. It's an obligate function. So if 00:28:58.849 --> 00:29:01.109 they get a simple cold. It's a potential disaster. 00:29:01.710 --> 00:29:04.289 If an adult gets a stuffy nose, we just open 00:29:04.289 --> 00:29:07.329 our mouth and breathe. If a newborn gets a stuff 00:29:07.329 --> 00:29:10.319 nose from some mucus. They can't compensate. 00:29:10.480 --> 00:29:12.920 They can suffocate. Just from snot. Just from 00:29:12.920 --> 00:29:16.539 snot. They will exhibit severe respiratory distress. 00:29:17.079 --> 00:29:19.460 That's why we are obsessive about using that 00:29:19.460 --> 00:29:22.640 little blue bulb syringe to suction newborns 00:29:22.640 --> 00:29:25.960 before they eat or sleep. A clogged nose is a 00:29:25.960 --> 00:29:28.339 respiratory emergency in a neonate. Let's do 00:29:28.339 --> 00:29:31.380 a quick nice -to -know for heat. The notes mentioned 00:29:31.380 --> 00:29:34.299 ear alignment. Right. This is more of a screening 00:29:34.299 --> 00:29:36.940 tool for other issues. You imagine a line from 00:29:36.940 --> 00:29:38.759 the outer corner of the eye back to the top of 00:29:38.759 --> 00:29:41.180 the ear. The top of the pinna should touch across 00:29:41.180 --> 00:29:43.240 that line. And if it doesn't? If the ears are 00:29:43.240 --> 00:29:45.700 lower? If the ears are low set, positioned noticeably 00:29:45.700 --> 00:29:48.059 lower than the eyes, we start to think about 00:29:48.059 --> 00:29:50.420 chromosomal abnormalities like Down syndrome 00:29:50.420 --> 00:29:53.599 or renal anomalies. So kidney issues. Why kidneys? 00:29:53.700 --> 00:29:57.140 What's the connection? It's embryology. The ears 00:29:57.140 --> 00:29:59.259 and the kidneys develop at the exact same time 00:29:59.259 --> 00:30:01.980 in utero. So, there's a strong correlation that 00:30:01.980 --> 00:30:04.119 if one is malformed, the other one might be too. 00:30:04.900 --> 00:30:07.099 Low -set ears should trigger a thought about 00:30:07.099 --> 00:30:10.299 checking kidney function. Segment five, respiratory 00:30:10.299 --> 00:30:12.839 and cardiac. You mentioned earlier this is the 00:30:12.839 --> 00:30:16.259 big one. Why? Because this is how kids die. It 00:30:16.259 --> 00:30:18.839 sounds blunt, but it's true. Adults usually have 00:30:18.839 --> 00:30:21.960 primary cardiac events, heart attacks. Kids almost 00:30:21.960 --> 00:30:23.960 always have respiratory events that lead to cardiac 00:30:23.960 --> 00:30:26.140 arrest. So the heart stops because the lungs 00:30:26.140 --> 00:30:29.160 failed first. Exactly. So respiratory assessment 00:30:29.160 --> 00:30:31.059 is your number one safety tool. It's the most 00:30:31.059 --> 00:30:33.559 critical part of the whole exam. The source material 00:30:33.559 --> 00:30:36.599 has a great phrase, look before you listen. Yes. 00:30:36.940 --> 00:30:39.960 This is a core concept. You can diagnose respiratory 00:30:39.960 --> 00:30:42.259 distress from across the room just with your 00:30:42.259 --> 00:30:45.740 eyes. We look for three big signs, retractions, 00:30:46.140 --> 00:30:48.779 nasal flaring, and audible sounds like stridor. 00:30:49.059 --> 00:30:51.039 Let's talk retractions. That's when the skin 00:30:51.039 --> 00:30:54.089 sucks in. Exactly. A child's chest wall is very 00:30:54.089 --> 00:30:56.609 compliant. It's made of flexible cartilage, not 00:30:56.609 --> 00:30:58.970 rigid bone like an adult's. So when they have 00:30:58.970 --> 00:31:01.250 to pull really hard to get air and creating a 00:31:01.250 --> 00:31:04.109 lot of negative pressure, the chest wall actually 00:31:04.109 --> 00:31:06.799 collapses inward. you see the skin sucking in 00:31:06.799 --> 00:31:09.359 between or around the ribs. And does the location 00:31:09.359 --> 00:31:11.400 of the retraction matter? It matters immensely. 00:31:11.559 --> 00:31:14.140 This is a huge need to know. The higher up the 00:31:14.140 --> 00:31:16.400 retraction, the worse the distress. There's a 00:31:16.400 --> 00:31:18.640 clear hierarchy. Okay, explain that hierarchy. 00:31:19.079 --> 00:31:20.900 So intercostal retractions, that's between the 00:31:20.900 --> 00:31:23.460 ribs or subcostal, which is below the rib cage, 00:31:23.980 --> 00:31:27.450 indicate mild to moderate distress. But if you 00:31:27.450 --> 00:31:29.990 see super sternal retractions, where the skin 00:31:29.990 --> 00:31:32.450 is sucking in right at the little notch in the 00:31:32.450 --> 00:31:34.730 neck, above the sternum, or super collicular, 00:31:35.069 --> 00:31:38.190 above the collarbones, that is severe distress. 00:31:38.569 --> 00:31:40.690 It means they're using every single accessory 00:31:40.690 --> 00:31:43.569 muscle they have just to breathe. That kid is 00:31:43.569 --> 00:31:45.849 getting tired, and they're about to crash. And 00:31:45.849 --> 00:31:49.210 what about stridor? Stridor is that high -pitched, 00:31:49.509 --> 00:31:51.690 crowing musical sound you hear on inspiration. 00:31:52.269 --> 00:31:53.670 It means there's an upper airway obstruction. 00:31:54.049 --> 00:31:57.049 Think croup. or a piece of a hot dog stuck in 00:31:57.049 --> 00:32:00.150 the throat, or anaphylaxis closing the airway. 00:32:00.849 --> 00:32:03.150 It is the sound of air trying to squeeze through 00:32:03.150 --> 00:32:06.230 a tiny straw. It is always a medical emergency 00:32:06.230 --> 00:32:08.849 until proven otherwise. Moving to the heart. 00:32:09.289 --> 00:32:11.789 I found the PMI landmarking interesting. The 00:32:11.789 --> 00:32:14.849 point of maximum impulse. It moves. It moves 00:32:14.849 --> 00:32:17.930 as the child grows. The heart sits more horizontally 00:32:17.930 --> 00:32:20.690 in the chest in babies and young children. As 00:32:20.690 --> 00:32:22.670 they grow taller, the heart settles into a more 00:32:22.670 --> 00:32:24.869 vertical position. So where do we find it? Where 00:32:24.869 --> 00:32:26.849 do we listen? For children under seven years 00:32:26.849 --> 00:32:29.849 of age, the PMI is usually at the fourth intercostal 00:32:29.849 --> 00:32:32.549 space, and it's often larrowed to or outside 00:32:32.549 --> 00:32:35.029 of the mid -clavicular line. And after age seven? 00:32:35.210 --> 00:32:37.650 It drops down and moves in. it goes to the adult 00:32:37.650 --> 00:32:40.089 position, the fifth intercostal space, right 00:32:40.089 --> 00:32:41.890 through the mid -clavicular line. Exam writers 00:32:41.890 --> 00:32:44.150 would love that specificity. Under seven is fourth 00:32:44.150 --> 00:32:46.890 space. Over seven is fifth space. They absolutely 00:32:46.890 --> 00:32:49.470 do. If you are auscultating at the fifth space 00:32:49.470 --> 00:32:51.450 on a three -year -old, you're in the wrong spot, 00:32:51.490 --> 00:32:53.329 and you might miss the sounds you need to hear. 00:32:53.589 --> 00:32:55.809 Let's talk murmurs. I feel like every parent 00:32:55.809 --> 00:32:58.529 I know has at some point been told their kid 00:32:58.529 --> 00:33:01.529 has a murmur. They're incredibly common. Something 00:33:01.529 --> 00:33:03.589 like 50 % of all children will have a murmur 00:33:03.589 --> 00:33:06.009 at some point. Most of them are what we call 00:33:06.009 --> 00:33:08.250 innocent or functional murmurs. What makes it 00:33:08.250 --> 00:33:10.329 innocent? They're usually soft, maybe a grade 00:33:10.329 --> 00:33:13.009 one or two. They're often described as musical 00:33:13.009 --> 00:33:15.829 or vibratory and a key feature is that they often 00:33:15.829 --> 00:33:18.630 change or go away when the child sits up or changes 00:33:18.630 --> 00:33:21.490 position. They are just the sound of blood flowing 00:33:21.490 --> 00:33:23.930 normally through a small dynamic heart. So when 00:33:23.930 --> 00:33:27.230 do we worry? What are the red flags for a pathologic 00:33:27.230 --> 00:33:30.650 murmur? We worry about intensity and thrills. 00:33:31.190 --> 00:33:35.099 A grade four murmur or higher is loud. and it 00:33:35.099 --> 00:33:37.579 is almost always associated with a thrill. What 00:33:37.579 --> 00:33:40.200 a thrill? What's that? A thrill is a vibration 00:33:40.200 --> 00:33:42.359 you can actually feel with the palm of your hand 00:33:42.359 --> 00:33:44.819 on the chest. It feels like placing your hand 00:33:44.819 --> 00:33:47.180 on a purring cat. That's a great visual. I can 00:33:47.180 --> 00:33:49.779 feel that. If you feel a purr, that is not innocent. 00:33:50.140 --> 00:33:52.380 That is the feeling of turbulent blood flow caused 00:33:52.380 --> 00:33:55.039 by a structural defect, a hole in the heart, 00:33:55.039 --> 00:33:57.920 or a tight stenotic valve. That kid needs to 00:33:57.920 --> 00:34:00.539 see a cardiologist. Nice to know for this section. 00:34:00.700 --> 00:34:02.920 The notes mention chest shape. Yeah, just a quick 00:34:02.920 --> 00:34:05.349 point. Infants have a round chest. The front 00:34:05.349 --> 00:34:07.910 to back, or AP, diameter is equal to the side 00:34:07.910 --> 00:34:09.949 to side, or transverse diameter. It's a 1 .1 00:34:09.949 --> 00:34:12.769 ratio. And that changes. As they grow, it flattens 00:34:12.769 --> 00:34:14.829 out into the adult shape, where the chest is 00:34:14.829 --> 00:34:17.530 wider than it is deep. If a 10 -year -old still 00:34:17.530 --> 00:34:20.309 has a round, 1 .1 chest, that's called a barrel 00:34:20.309 --> 00:34:22.570 chest, and it's a sign of chronic air trapping 00:34:22.570 --> 00:34:24.989 from a lung disease like severe asthma or cystic 00:34:24.989 --> 00:34:28.429 fibrosis. Segment six, abdomen and genitourinary. 00:34:29.150 --> 00:34:31.710 We are moving down the body and we have another 00:34:31.710 --> 00:34:34.070 one of those order of operations traps here. 00:34:34.210 --> 00:34:37.159 Yes A big one. For the abdomen, the rule changes. 00:34:37.320 --> 00:34:39.420 The order is inspect, and then you auscultate. 00:34:39.559 --> 00:34:42.440 You listen second. You do not touch or palpate 00:34:42.440 --> 00:34:44.300 until after you have listened. Why is that so 00:34:44.300 --> 00:34:46.500 important? Because if you poke and prod the belly 00:34:46.500 --> 00:34:49.179 with your hands, you stir things up, you stimulate 00:34:49.179 --> 00:34:51.860 peristalsis, you might create bowel sounds that 00:34:51.860 --> 00:34:54.059 weren't there, or make them sound hyperactive 00:34:54.059 --> 00:34:56.179 when they were actually hypoactive. So you ruin 00:34:56.179 --> 00:34:58.639 the data. You completely ruin your auscultation 00:34:58.639 --> 00:35:01.380 data. You need to hear the baseline silence or 00:35:01.380 --> 00:35:03.599 activity before you disturb the peace. So it's, 00:35:03.880 --> 00:35:06.980 look. Listen, then feel. That's a solid rule. 00:35:07.159 --> 00:35:10.780 What about hernias? Umbilical hernias, the classic 00:35:10.780 --> 00:35:13.559 outy belly button, are super common in infants, 00:35:14.059 --> 00:35:16.539 especially premature infants. They usually resolve 00:35:16.539 --> 00:35:19.780 on their own by school age as the abdominal muscles 00:35:19.780 --> 00:35:22.280 strengthen. And the old advice to tape a coin 00:35:22.280 --> 00:35:24.380 over it? No, don't do that. That doesn't help. 00:35:24.599 --> 00:35:27.199 And can cause skin irritation. We just watch 00:35:27.199 --> 00:35:29.570 them. When are they dangerous? They're dangerous 00:35:29.570 --> 00:35:32.309 if they become hard, painful, or non -reducible. 00:35:32.710 --> 00:35:35.170 Non -reducible means you can't gently push the 00:35:35.170 --> 00:35:37.429 bulge back in with your finger. Then that means? 00:35:37.550 --> 00:35:40.110 That suggests the bowel has become trapped. We 00:35:40.110 --> 00:35:42.449 call that strangulated. That cuts off the blood 00:35:42.449 --> 00:35:45.269 supply. That is a surgical emergency. What about 00:35:45.269 --> 00:35:48.150 inguinal hernias? That's in the groin area. Those 00:35:48.150 --> 00:35:50.710 are different. They almost always require surgery. 00:35:50.869 --> 00:35:53.210 They don't fix themselves. And they have a much 00:35:53.210 --> 00:35:55.150 higher risk of getting stuck or strangulated. 00:35:55.389 --> 00:35:58.769 Now for the boys, the testicular exam, this seems 00:35:58.769 --> 00:36:02.010 fraught with difficulty. It is. The main thing 00:36:02.010 --> 00:36:04.650 we are checking for is cryptocarydism, which 00:36:04.650 --> 00:36:07.590 is the medical term for undescended tests. And 00:36:07.590 --> 00:36:10.090 why is that a problem? Well, the scrotum is designed 00:36:10.090 --> 00:36:12.150 to keep the testicles cooler than the core body 00:36:12.150 --> 00:36:14.710 temperature. If they don't drop down into the 00:36:14.710 --> 00:36:16.829 scrotum, the internal body temperature is too 00:36:16.829 --> 00:36:19.480 hot for them. It can kill the sperm cells leading 00:36:19.480 --> 00:36:21.980 to sterility, and it significantly increases 00:36:21.980 --> 00:36:24.219 the risk of testicular cancer later in life. 00:36:24.440 --> 00:36:26.679 But there's a reflex that makes this exam hard, 00:36:26.880 --> 00:36:28.940 right? Yes, the chromasteric reflex. It's an 00:36:28.940 --> 00:36:31.280 evolutionary protective mechanism. If you touch 00:36:31.280 --> 00:36:33.659 the inner thigh, or if your hands are cold, a 00:36:33.659 --> 00:36:35.699 muscle pulls the testicles up into the inguinal 00:36:35.699 --> 00:36:37.920 canal to protect them and keep them warm. So 00:36:37.920 --> 00:36:39.699 you look and it looks like they are missing, 00:36:39.780 --> 00:36:41.840 but really they are just hiding from your cold 00:36:41.840 --> 00:36:44.139 hands. Exactly. The parent might say, I see them 00:36:44.139 --> 00:36:46.469 in the warm bath. but not at the doctor's office. 00:36:46.570 --> 00:36:48.710 So how do we beat the reflex? How do we get an 00:36:48.710 --> 00:36:50.730 accurate exam? You have to trick the muscle. 00:36:51.170 --> 00:36:53.750 The best way is to have the child sit cross -legged 00:36:53.750 --> 00:36:57.349 like Indian style or in a tailor position. This 00:36:57.349 --> 00:37:00.250 gently stretches the inner thigh muscle and prevents 00:37:00.250 --> 00:37:03.670 the retraction. And for God's sakes, warm your 00:37:03.670 --> 00:37:06.949 hands first. Segment seven, neuro and musculoskeletal. 00:37:07.650 --> 00:37:09.889 We are in the home stretch now. Let's talk hips. 00:37:10.630 --> 00:37:13.440 This is a big one. Specifically in infants, we 00:37:13.440 --> 00:37:15.820 scream for something called developmental dysplasia 00:37:15.820 --> 00:37:18.699 of the hip or DDH. That's where the hip socket 00:37:18.699 --> 00:37:20.719 is too shallow, right? Exactly. The head of the 00:37:20.719 --> 00:37:23.420 femur, the ball, keeps popping out of the socket. 00:37:24.199 --> 00:37:26.800 We use two specific maneuvers to check for this. 00:37:27.300 --> 00:37:29.619 Ortolani and Barlow. Sounds like a fancy law 00:37:29.619 --> 00:37:31.699 firm. Ortolani and Barlow, what are we doing? 00:37:31.940 --> 00:37:35.079 With the baby on their back, we are gently abducting 00:37:35.079 --> 00:37:37.699 and abducting the hips, rotating them out and 00:37:37.699 --> 00:37:41.469 in. You are feeling for a clunk. A clunk. The 00:37:41.469 --> 00:37:44.230 notes emphasize not a click. Right. A soft click 00:37:44.230 --> 00:37:46.570 is common, and usually just a ligament snapping 00:37:46.570 --> 00:37:50.110 like cracking your knuckles. It's benign. A clunk 00:37:50.110 --> 00:37:53.389 is a distinct, deep feeling. It feels like the 00:37:53.389 --> 00:37:55.469 bone physically dislocating and then popping 00:37:55.469 --> 00:37:57.949 back into the socket. If you feel that clunk, 00:37:58.210 --> 00:38:00.559 the hip is unstable. Are there any visual clues 00:38:00.559 --> 00:38:03.420 we can look for? Yes. This is a great tip for 00:38:03.420 --> 00:38:05.699 parents, too. Look at the baby's legs from the 00:38:05.699 --> 00:38:07.460 back when they're on their tummy. Look at the 00:38:07.460 --> 00:38:09.539 gluteal folds, the fat rolls in the back of the 00:38:09.539 --> 00:38:11.519 thighs. OK, what are we looking for? They should 00:38:11.519 --> 00:38:14.860 be symmetrical. If one side has more rolls, or 00:38:14.860 --> 00:38:16.739 if the rolls are higher up than on the other 00:38:16.739 --> 00:38:19.599 side, that suggests one leg is shorter than the 00:38:19.599 --> 00:38:21.679 other. And it's shorter because? Because the 00:38:21.679 --> 00:38:24.860 hip is dislocated upwards and backwards. Asymmetrical 00:38:24.860 --> 00:38:27.900 gluteal folds is a classic sign of hip dysplasia. 00:38:28.030 --> 00:38:30.090 That's a great visual check you could do during 00:38:30.090 --> 00:38:32.170 a diaper change. Okay. Let's talk about primitive 00:38:32.170 --> 00:38:33.849 reflexes. These are the ones babies are born 00:38:33.849 --> 00:38:36.650 with. Right. The Morkodia, or startle reflex. 00:38:36.869 --> 00:38:38.949 The rooting reflex, where they turn toward a 00:38:38.949 --> 00:38:41.530 touch on the cheek to find food. Yeah. The Babinski 00:38:41.530 --> 00:38:43.969 reflex, where the toes fan out. The need to know 00:38:43.969 --> 00:38:46.010 here isn't just that they exist, but that they 00:38:46.010 --> 00:38:48.769 have to leave. Yes. That is the key point. They 00:38:48.769 --> 00:38:51.630 must disappear. These are reflexes controlled 00:38:51.630 --> 00:38:54.599 by the lower brainstem. As the brain matures 00:38:54.599 --> 00:38:57.420 and the nerves get their myelin sheath, the higher 00:38:57.420 --> 00:39:00.340 brain, the cortex, takes over and suppresses 00:39:00.340 --> 00:39:02.280 these primitive movements. So if they stick around 00:39:02.280 --> 00:39:04.619 for too long? If a primitive reflex persists 00:39:04.619 --> 00:39:07.440 past its expiration date, for example, if a two 00:39:07.440 --> 00:39:09.460 -year -old who is walking still has a positive 00:39:09.460 --> 00:39:11.739 Babinski reflex where their toes fan out when 00:39:11.739 --> 00:39:14.900 you stroke their foot, that is a major red flag. 00:39:15.099 --> 00:39:17.480 What does it indicate? It indicates a neurological 00:39:17.480 --> 00:39:21.139 lesion or an upper motor neuron problem. We think 00:39:21.139 --> 00:39:24.280 of things like cerebral palsy. It means the brain 00:39:24.280 --> 00:39:26.820 isn't maturing and developing correctly. So, 00:39:27.199 --> 00:39:30.579 reflexes. Good in babies, bad in toddlers. Exactly. 00:39:31.079 --> 00:39:33.559 Their presence is normal, but their persistence 00:39:33.559 --> 00:39:36.800 is pathological. Nice to know for legs. The notes 00:39:36.800 --> 00:39:39.340 distinguish knock knees from bull legs. This 00:39:39.340 --> 00:39:41.780 confuses parents all the time. It's a normal 00:39:41.780 --> 00:39:44.159 developmental progression. Toddlers are often 00:39:44.159 --> 00:39:47.670 bull leg. The medical term is genuvarum. Their 00:39:47.670 --> 00:39:50.130 legs are apart like a little cowboy. That's normal 00:39:50.130 --> 00:39:52.090 for new walkers as they find their center of 00:39:52.090 --> 00:39:53.989 gravity. And then what happens? As they get a 00:39:53.989 --> 00:39:55.690 little older, around preschool age, their legs 00:39:55.690 --> 00:39:58.170 swing the other way. They tend to become knock 00:39:58.170 --> 00:40:01.130 -kneed, or genuvalgum, where their knees touch 00:40:01.130 --> 00:40:03.469 when they stand straight. There is a great mnemonic 00:40:03.469 --> 00:40:05.730 for this in the notes. I love this one. Gum. 00:40:06.630 --> 00:40:08.989 Genuvalgum. Gum makes your knees stick together. 00:40:09.130 --> 00:40:12.329 That's perfect. I'll never forget that now. Genuvalgum 00:40:12.329 --> 00:40:15.300 equals gum equals sticky knees. And finally, 00:40:15.400 --> 00:40:17.599 a quick note on cerebellar function, which is 00:40:17.599 --> 00:40:20.829 balance and coordination. For older kids, the 00:40:20.829 --> 00:40:23.050 school -aged kids and teens, we can do tests 00:40:23.050 --> 00:40:25.110 like the finger -to -nose test or the heel -to 00:40:25.110 --> 00:40:27.690 -shin test. It looks a lot like a roadside sobriety 00:40:27.690 --> 00:40:30.409 test, but it's a great quick screen for coordination 00:40:30.409 --> 00:40:32.650 problems. Wow. We just ran through the entire 00:40:32.650 --> 00:40:34.849 body from head to toe. That was intense. It is 00:40:34.849 --> 00:40:37.510 a lot of information, but if you focus on those 00:40:37.510 --> 00:40:40.269 key safety triggers, those knee -to -nose, it 00:40:40.269 --> 00:40:42.349 becomes manageable. So let's wrap this up. We've 00:40:42.349 --> 00:40:45.110 covered a ton of ground. If our listener is driving 00:40:45.110 --> 00:40:46.929 into their clinical shift right now or cramming 00:40:46.929 --> 00:40:50.039 for an exam, what are the absolute must -haves 00:40:50.039 --> 00:40:51.559 they should keep in their pocket from today. 00:40:51.800 --> 00:40:55.519 Okay, three things. Number one, safety first. 00:40:55.900 --> 00:40:58.739 Know your respiratory distress hierarchy. Blue 00:40:58.739 --> 00:41:01.719 hands are okay, blue lips are not, intercostal 00:41:01.719 --> 00:41:04.179 retractions are bad, super sternal retractions 00:41:04.179 --> 00:41:06.980 mean you need help right now. Number two. Number 00:41:06.980 --> 00:41:09.739 two, accuracy matters. Don't fake the numbers. 00:41:10.079 --> 00:41:12.780 Use the right BP cuff, that 40 % rule. Pull the 00:41:12.780 --> 00:41:15.139 ear the correct way down and back for small kids, 00:41:15.440 --> 00:41:18.639 up and back for bigger kids. Bad data leads to 00:41:18.639 --> 00:41:22.639 bad treatment. And the third. Number three, differentiation. 00:41:23.840 --> 00:41:26.480 Know the difference between a bruise and a Mongolian 00:41:26.480 --> 00:41:29.380 spot. Know the difference between a normal toddler 00:41:29.380 --> 00:41:32.980 fall and signs of abuse. Your documentation is 00:41:32.980 --> 00:41:35.500 your defense, and more importantly, it's the 00:41:35.500 --> 00:41:38.619 child's protection. That is the core 20 % right 00:41:38.619 --> 00:41:40.820 there. It really is. If you nail those things, 00:41:41.079 --> 00:41:43.380 you're on your way. No, I want to leave everyone 00:41:43.380 --> 00:41:45.380 with a final thought. We talked about a lot of 00:41:45.380 --> 00:41:48.300 data today. Charts, numbers, maneuvers, reflexes. 00:41:48.579 --> 00:41:50.480 But you had a really interesting point in our 00:41:50.480 --> 00:41:53.219 pre -show notes about the invisible assessment. 00:41:53.500 --> 00:41:55.989 Yes. This is Sort of the art that comes after 00:41:55.989 --> 00:41:57.869 the science. We can teach you the science. You 00:41:57.869 --> 00:42:00.570 can memorize the entire chapter. But the best 00:42:00.570 --> 00:42:03.130 pediatric nurses, the ones who really save lives, 00:42:03.630 --> 00:42:05.510 have an extra sense. What is that? They walk 00:42:05.510 --> 00:42:07.550 into a room and they feel the vibe before they 00:42:07.550 --> 00:42:09.690 even look at the patient. The vibe. What do you 00:42:09.690 --> 00:42:11.849 mean by that? They sense the anxiety in the room. 00:42:12.610 --> 00:42:14.750 How is the parent holding the child? Are they 00:42:14.750 --> 00:42:17.190 holding them loosely or with a death grip? Is 00:42:17.190 --> 00:42:19.329 the parent terrified? Is the parent disengaged 00:42:19.329 --> 00:42:22.139 and on their phone? because children are emotional 00:42:22.139 --> 00:42:25.199 mirrors. So the parent's state affects the child's 00:42:25.199 --> 00:42:28.460 vitals. Directly. If the parent is terrified, 00:42:28.840 --> 00:42:31.300 the child's heart rate goes up. The child's breathing 00:42:31.300 --> 00:42:34.900 pattern changes. The data we collect is profoundly 00:42:34.900 --> 00:42:37.219 influenced by the emotion in the room. So the 00:42:37.219 --> 00:42:39.760 assessment isn't just biological, it's emotional, 00:42:39.960 --> 00:42:42.860 it's relational. Exactly. The art behind the 00:42:42.860 --> 00:42:46.079 science is knowing that you are treating a family 00:42:46.079 --> 00:42:49.519 unit, not just a little body in a bed. And sometimes, 00:42:49.539 --> 00:42:51.719 if you can calm the parent down, you might just 00:42:51.719 --> 00:42:54.179 cure the tachycardia you were about to document. 00:42:54.920 --> 00:42:56.659 Sometimes the most important intervention you 00:42:56.659 --> 00:42:58.219 can do is just put a hand on a mom's shoulder 00:42:58.219 --> 00:43:00.460 and say, you're doing a really good job, we're 00:43:00.460 --> 00:43:02.280 going to figure this out together. That is a 00:43:02.280 --> 00:43:05.340 powerful place to end. Listeners, take a deep 00:43:05.340 --> 00:43:07.820 breath. You know more than you think you do. 00:43:08.159 --> 00:43:10.579 Trust your gut, watch for those red flags, and 00:43:10.579 --> 00:43:13.199 always, always check the cuff size. Stay curious. 00:43:13.800 --> 00:43:15.320 We'll see you on the next Deep Dive.