Welcome to the bed. We'll go ahead and give you
the story. This is all going to happen super
fast. Welcome to the emergency room. Welcome
back to the deep dive. We are so glad you're
here with us today. It's great to be here. We
are stepping into what I honestly think is one
of the most high stakes, high pressure, but I
mean, ultimately rewarding environments in all
of medicine. Oh, for sure. Imagine walking onto
a pediatric unit. It's colorful, right? Yeah.
Maybe there are cartoons on the wall. The nurses
are wearing these fun scrubs. But underneath
all that, that cheerful aesthetic, there is this
incredible palpable tension. There is. Because
kids, kids are not just small adults. That is
the absolute first rule of pediatrics. Yes. It's
the mantra. Yeah. If you walk in thinking a child
is just a miniature version of a 40 -year -old,
You're going to miss things. Big things. Vital
things. They are an entirely different physiological
species in many ways. I mean, their metabolic
rates are different, their compensatory mechanisms
are different, and the way they crash is really,
really different. And that is exactly what makes
the source material we are covering today. Chapter
10, the pediatric health assessment. So incredibly
daunting. It's a beast of a chapter. It really
is. I was looking through the notes, the textbook
excerpts, the lecture slides you send over, and
it feels like an avalanche of disconnected details.
You have to know growth charts and obscure reflexes,
weird skin spots, specific timelines for fontanel
closures, and somehow you have to do it all while
a three -year -old is screaming at the top of
their lungs and kicking you. It is the definition
of information overload. And for a nursing student
or, you know, a new grad, the risk is real. You
get so bogged down in memorizing the circumference
of a six -month -old's head, or the exact month
a reflex disappears. Right. You get lost in the
weeds. You do. Yeah. And you might miss the fact
that the toddler across the room is in respiratory
failure. You completely lose the forest for the
trees. Exactly. So we are going to do something
different today. We aren't just reading the chapter.
No. We are applying the Pareto Principle. The
80 -20 rule. Which is my favorite way to approach
complex medical topics. It just cuts through
the noise. It does. And the idea is simple. 20
% of the information gives you 80 % of your results.
And in the context of nursing, results mean two
very specific things. First, passing your exams,
because the test writers love to trap you on
these specific developmental nuances. Oh, they
love it. And second, honestly, the only one that
really matters in the real world, keeping that
child safe. That's the bottom line. So what we're
going to do is separate the need to know, the
safety critical high yield exam stuff, from the
nice to know. The fluff. Yeah, the context and
the fluff. We are turning this textbook into
a survival guide. I love that, a survival guide.
So we're going to walk through the assessment
head to toe, but we're filtering every single
step through the lens of exam traps and clinical
red flags. Exactly. If you're a student cramming
for a midterm or a new grad who's terrified of
your first shift, this is your blueprint. Let's
dive in. OK, so take us into the room. The source
material starts with the general survey, but
it makes a really interesting point immediately.
It says the most important part of the assessment
happens before you even say hello. Right. Before
you even touch the patient. This is what we call
the door handle observation. This is our first
big need -to -know 80 -20 core concept. The door
handle observation. It sounds like a spy novel
technique. But tell us why this specific moment
is so critical. It is critical because of, well...
It's essentially the Heisenberg uncertainty principle
of medicine. OK, you're going to have to break
that down for me. The moment you walk into a
room and engage with a child, you change the
data. You change the dynamic. You're a variable.
You're a huge variable. Yeah. If you rush in,
they might start crying, which immediately changes
their heart rate and their respiratory rate.
Or they might perk up because of the stimulation,
masking how lethargic they really were just a
second ago. So you need the baseline. You need
the unadulterated baseline. It literally means
you pause with your hand on the door handle or
just as you step inside the threshold and you
look. Just look. You do not rush in with your
stethoscope. You don't introduce yourself yet.
You just observe. And what exactly are we scanning
for in that split second? It can't be everything.
No. It's very targeted. Yeah. You are looking
for the pediatric assessment triangle. It's a
rapid visual scan of three things. Appearance,
work of breathing, and circulation to the skin.
Appearance? work of breathing and circulation.
This is your need -to -know foundation. Everything
else is built on this. Okay, let's unpack those
because appearance sounds a bit superficial.
We aren't judging their outfit or if their hair
is combed. No, not at all. Appearance in this
context is entirely neurological. It's about
tone, interactiveness, and consolability. So
what does that look like from the doorway? Looks
like? Is the child tracking you with their eyes
as you walk in? Are they moving spontaneously?
Or, this is a scary one, are they limp? Are they
floppy? Like a ragdoll. Exactly. Yeah. Are they
staring into space with a glazed look? If you
see a floppy baby from the doorway, or a toddler
who wasn't reacting to a stranger entering the
room, you aren't doing a health history. No,
you're intervening. You are calling a code or
shouting for help. It's that serious. So, appearance
equals brain profusion. Got it. What about work
of breathing? You're looking for the struggle.
Before you even think about putting a stethoscope
on their chest, can you see them breathing from
10 feet away? And what would that look like?
Is the chest heaving? Are they sitting in what
we call a tripod position, leaning forward with
their hands on their knees just to get air in?
I've seen that. Yeah. Are their nostrils flaring
with every breath? If you see the work, you know
there is pathology before you even hear the breath
sounds. And finally, circulation. This is color.
It's that simple. Are they pink? Or are they
pale? Are they mottled, which looks kind of like
a web -like, lacy pattern on the skin? Or are
they blue? And if you spot a problem in this
door handle phase... The routine exam is over.
It's done. You intervene immediately. Okay, so
assuming the door handle observation is stable,
the kid looks okay, they're breathing fine, we
move in. Now, I found... A massive exam trap
in the notes regarding the order of operations.
In adult nursing, we are trained to be robots
head to toe every time. Systematic. And if you
do that with a child, you will fail. You will
absolutely fail. Why? Why does the system just
completely break down? Because children are volatile.
Their mood is a ticking clock. The sources emphasize
that with kids, you have to be an opportunist.
It's another classic need to know. Be an opportunist.
Exactly. If you walk in and the infant or toddler
is sleeping or they're just quiet on the parent's
lap, what is the very first thing you do? My
adult nursing brain says, wake them up gently,
introduce myself, get a weight, get a height.
And that is how you fail the simulation and how
you make the next hour of your life miserable.
Brutal. OK, correct me. What's the right move?
If they are quiet, You listen, you get your stethoscope,
and you get your auscultation done, heart and
lungs, while they are calm. Because the moment
you wake them up to weigh them, or put them on
a cold scale, or look in their throat with a
tongue depressor, they will scream. And then
you can't hear anything. You can't hear anything.
And I defy anyone to hear a graded two heart
murmur through the chest wall of a screaming,
kicking toddler. Yeah. It's impossible. You've
lost your data. So the rule is, least invasive
to most invasive. Always. That is the core principle.
You listen first. You might touch the belly next.
That's usually okay. You save the ears, the throat,
and anything involving a needle or a probe for
the grand finale. Because once you lose their
trust... It's gone. You don't get it back in
that visit. You have to earn the right to do
the painful or scary stuff by doing the easy,
quiet stuff first. That actually leads us perfectly
into the developmental stages. The approach changes
completely depending on the age. The source material
highlights the no phase for toddlers. This is
ages, what, one to three? Yeah, one to three.
Toddlers are fascinating and so frustrating because
they are defined by egocentrism. That is the
developmental keyword you'll see on exams. Egocentrism.
They want autonomy. They just discover they are
separate people from their parents and their
favorite word is no. So if you ask a toddler,
Can I listen to your heart now, or is it okay
if I check your tummy? What is the answer always
gonna be? It's gonna be no. A very loud no. Even
if they aren't scared, they'll say no just to
exercise that power. They are testing their boundaries
with you. So how do you get consent without asking
a yes -no question? I mean, we can't just tackle
them. No, definitely not. You use what we call
forced choice or just direct statements. You
don't ask permission for the necessary things.
You say, cheerfully and firmly, I am going to
listen to your heart now. Just a statement of
fact. A statement of fact. Or if you want to
give them some control, which they crave, you
say, do you want me to listen to your heart first
or your teddy bear's heart first? That's clever.
You give them a choice, but neither option is
no, get away from me. Exactly. You frame the
interaction so that compliance is the only outcome,
but they still feel like they participated. They
got to make a decision. And location matters.
For a toddler, the exam table is lava. It's a
scary, cold, high up place. Do not put them up
there if you can avoid it. So where do you do
the exam? On the parent's lap. The parent is
their safety anchor, their home base. Use that
to your advantage. OK, moving up to preschoolers.
These are the three to five year olds. The notes
mention they have vivid imaginations, which sounds
cute, but in a hospital, it sounds terrified.
It is terrifying for them. Their cognitive development
is heavily based on magical thinking. Magical
thinking. Yeah. They don't understand cause and
effect properly yet. Right. They think thoughts
can cause reality. And the big fear here, and
this is a specific term in the literature you
need to know for your exams, is fear of mutilation.
Fear of mutilation. Wow, that sounds incredibly
intense for a four -year -old. It means they
have really poor body integrity concepts. They
view their skin as a balloon that holds everything
inside. OK. So if you give a preschooler a shot,
or if they get a cut, they genuinely worry that
all their insides, their blood, their guts, are
going to leak out through that one tiny hole.
Oh, wow. So that's why a tiny paper cut is the
end of the world. Exactly. And that's why band
-aids are like magic spells to them. It seals
the leak. It holds them together. So for the
exam, how do we mitigate that fear? You have
to demystify the equipment. Let them handle the
stethoscope. Let them press the button on the
thermometer. If they can play with it, it stops
being a weapon and starts being a toy. Make it
familiar. And you explain things in their language.
This is going to give your arm a big hug for
the blood pressure cuff. This is going to squeeze
you really tight. Language matters so much at
this age. Then we hit the adolescents. Teenagers,
the vibe shifts here completely. We aren't dealing
with fear of monsters anymore. We're dealing
with fear of judgment. The priority shifts to
privacy and body image. Adolescents are hyper
aware of their changing bodies, and they're mortified
by pretty much everything. The source material
says we should offer to have the parent step
out. That feels tricky if the parent is hovering
or insists on staying. It is tricky, but it's
necessary to offer it. You can say something
like, OK, for this part of the exam, I'm just
going to ask some routine questions. A lot of
teens prefer to do this part privately. Mom,
would you be comfortable stepping out for a few
minutes? And what if mom says no? You have to
respect that. But you document it, and you know
you're probably not getting honest answers. Adolescents
will not answer questions about substance use,
sexual activity, or depression, honestly, if
their mom is sitting right there. So you have
to try to create that safe space. You do. But.
And this is a huge legal and ethical need to
know. You have to establish the boundaries of
that privacy upfront. The safety limit. Right.
You cannot promise total secrecy. New nurses
often make this mistake. They say, I won't tell
anyone anything. I promise. And that's a problem
because if you do that and then the team tells
you they are suicidal, you are in a legal and
ethical bind. You have to break your promise.
So what's the script? What do you say? You have
to use the phrase. Everything we talk about is
private and confidential. Unless you tell me
someone is hurting you, you want to hurt someone
else or you want to hurt yourself. In those cases,
my job is to get you help and keep you safe.
That's the distinct line. You are a vault up
until lives are at risk. Correct. If you don't
say that disclaimer upfront... and then you have
to report them to protect them, they will feel
betrayed, and you've lost that therapeutic relationship
forever. Okay, that makes total sense. Before
we leave the general survey, let's hit a couple
of those nice -to -know supporting info points
from the notes. These are the things that make
the exam smoother but aren't necessarily life
or death. The art of the exam, not just the science.
Exactly. building rapport. The expert notes suggest
ignoring the child at first. That's so counterintuitive,
right? It does. I want to be friendly. I want
to say hi to the kid. But think about it from
the kid's perspective. You are a giant stranger
in a weird uniform. If you rush at them, you're
a threat. If you ignore them and talk calmly
to the parent, the child watches. They're observing
the interaction. They see the parent as calm,
they see the parent trust you. It's what we call
a social proxy. It's like when a dog looks at
its owner to see if a new person is okay. It
is the exact same mechanism. Once the kid sees
mom is cool with you, then you can slowly engage.
Get down on their eye level, don't tower over
them like a giant, and use a transition object.
A transition object? What's that? A puppet, a
toy, a light -up pen. Something to bridge the
gap between your scary medical world and their
world of play. You examine the puppet's heart
first. I like that. And lastly for this segment,
family history. The notes mention something called
a genogram. Right. A genogram is basically a
family tree, but for medical issues. In pediatrics,
we really want to go back three generations if
we can. Why three? We were looking for patterns,
early heart disease, genetic traits like sickle
cell or cystic fibrosis, sudden unexplained deaths.
It gives us the genetic context for the child
sitting in front of us. It's nice to know for
the immediate physical exam, but it becomes need
to know for the long -term plan of care. Got
it. OK, moving on to segment two, vital signs
and measurements. This seems straightforward,
numbers are numbers, but I feel like there are
some math traps here, specifically with blood
pressure. Oh, this is a huge one. This is our
next big need -to -know 80 -20 core. The blood
pressure cuff Goldilocks rule. I cannot stress
this enough. Okay, lay it on me. The Goldilocks
rule. Most people, you know, they just grab whatever
cuff is on the wall. A pediatric cuff, that looks
about right. That's so dangerous. The accuracy
depends entirely on cuff size relative to that
specific child's arm. So what's the rule? The
rule is the bladder width of the cuff, that's
the inflatable part inside, should be approximately
40 % of the circumference of the upper arm. 40%,
okay. That's very specific, but what happens
if we mess that up? This is the physics question
that always appears on tests. Right. So if the
cuff is too narrow, meaning it's too tight or
just too small for that arm, you will get a falsely
high GH reading. A falsely high. Why is that?
What's the mechanism? Think about the mechanics
of it. To stop the blood flow in a big artery
with a tiny little cuff, you have to pump it
up way harder to compress all the tissue deep
enough to pinch that artery shut. OK. The machine
reads all that extra effort, that extra pressure,
as higher blood pressure. That makes perfect
sense. So too small equals artificially high
pressure. And the opposite is also true. If the
cuff is too wide, too loose, or just too big,
you get a falsely low W reading. How does that
happen? It distributes the pressure too easily
over a larger surface area, so it stops the blood
flow with less pressure than is actually inside
the vessel. It's like trying to stop a river
with a bed sheet instead of a focused dam. Wow.
I can just see a new nurse panicking over a high
BP, calling the doctor, maybe even starting meds,
all because they used the standard pediatric
cuff on a chubby arm that really needed a small
adult cuff. It happens all the time. And conversely,
you could miss hypotension in a really sick,
shocky kid. because the cuff was too big, and
you think their pressure is fine when it's really
in the basement. The lesson is, always check
the cuff size before you treat the number. Always.
Let's talk pulse oximetry. We stick these on
kids all the time. Is there a trick to it? The
trick isn't the application, it's the validation.
This is a big need to know. Kids wiggle a lot.
True. If a child is waving their hand around,
the sensor's picking up motion. You might look
at the monitor and see a saturation of 85 % and
a heart rate of 60. But the kid looks pink and
happy and is breathing fine. So the monitor is
lying. The monitor is confused. You have to check
the waveform. You need to see a good, strong
plethe wave, that's the little squiggly line,
that matches the child's actual heart rate. So
you cross -reference. You have to. If the monitor
says the heart rate is 60, but you listen to
the chest and the heart is actually going 140,
that saturation number is garbage. It's artifact.
So the saying is true. Treat the patient, not
the machine. That should be tattooed on every
nurse's arm. Seriously. And one more thing on
pulse ox probes. The adhesive ones. You have
to rotate the sensor site every few hours. An
infant's skin is so fragile, you can cause a
pressure ulcer or a burn from that little red
light if you leave it in one spot for too long.
That's a great practical tip. Now, growth charts.
I remember seeing these. It's a lot of curves
and percentiles. It can be overwhelming. It can.
The need to know here is simple. A single point
in time is almost meaningless. We care about
the trend. Explain that. What does that mean
in practice? Okay, so a child comes in and they
are in the fifth percentile for weight. Is that
bad? It sounds low. My gut reaction is yes, that's
bad. It is low. But if they've been in the fifth
percentile since birth and their parents are
both very small, petite people, that is their
normal. They're growing along their own curve.
So it's about consistency. It's about their own
personal trajectory. That is likely their genetic
potential. We don't worry about that kid. So
when do we panic? When do we start the workup?
We panic at deviations. We worry when a child
who is tracking along the 50th percentile their
whole life suddenly at their two -year checkup
drops to the 10th percentile. That is called
falling off the growth curve. And that signals
a problem. That signals a big problem. That means
something is wrong. We start thinking failure
to thrive, malnutrition, or a chronic illness
that's just starting to show itself, like celiac
disease or cystic fibrosis. So it's the deviation,
not the destination. That's the red flag. Precisely.
Any quick nice -to -know points on measurement
logistics from the source material? Just a few
practical things. Weigh infants nude. A wet diaper
can weigh a significant amount relative to a
tiny baby. You don't want to document urine as
weight gain. That's a good point. And for height.
Yeah. Children under two? or those who can't
stand well are measured lying down. We call that
recumbent length. Once they can stand reliably,
usually after age two, we switch to standing
height and we measure head circumference until
age two or three to screen for things like hydrocephalus
or microcephaly. Okay, let's move to segment
three, the skin. This feels like detective work.
The skin is on the outside, but it tells us what's
happening on the inside. It's the billboard for
the body's systemic health. And the biggest scariest
need to know here is distinguishing between birthmarks
and abuse. This is a high stakes area. This is
crucial. The source mentions Mongolian spots.
Yes, the formal name now is congenital dermal
melanocytosis. These are dark, bluish pigmented
patches, and they usually show up on the lower
back, the buttocks, or the shoulders. And they're
common. Very common, but specifically in darker
skinned infants, so infants of black, Asian,
Hispanic, or Mediterranean descent. You don't
see them as much in fair -skinned babies. And
the problem is they look exactly like bruises.
They look exactly like deep old bruises. I have
personally seen parents get accused of abuse
by well -meaning but uneducated providers who
didn't know what these were. That is an absolute
nightmare scenario for a family. It is. The exam
trap and the clinical safety tip are the same.
If you are the admitting nurse, you must document
these immediately. Measure them, photograph them
if your policy allows, describe their location
and color. Why is that first documentation so
important? Because if you don't, and a different
provider sees them three days later, they will
assume they are new injuries acquired at home
or in the hospital. Your initial note protects
the family. So documentation is the shield. On
the flip side, what does actual abuse bruising
look like? We have a rhyme for this, and it's
grim, but it is very effective. Those who don't
cruise shouldn't bruise. Those who don't cruise
shouldn't bruise, meaning if the baby isn't walking
yet, they shouldn't have bruises. A two -month
-old cannot roll over and bump into a coffee
table. A four -month -old cannot fall off a swing
set. If you see echemosis, that's the medical
term for bruising on a non -mobile incident,
especially on the torso, the ears, or the neck.
That is a major red flag for non -accidental
trauma. A red flag that's waving violently. Exactly.
That requires an immediate, careful, and thorough
investigation. That is a chilling rule, but very
easy to remember. Let's talk about color changes
as distress signals. We hear cyanosis and we
think blue, but there are nuances here. Yes,
we need to distinguish central cyanosis from
acrocynosis. This is a classic exam question,
a need to know for sure. OK, break it down for
us. Central cyanosis is blue lips, a blue tongue,
blue mucus membranes inside the mouth. This is
the core of the body. It means the blood pumping
out of the heart is not carrying enough oxygen.
This is true hypoxia. It is an emergency. You
run. Got it. Central is bad and acrocyanosis.
Acrocyanosis is blueness of the hands and feet.
The word acro means extremity. This is actually
considered normal in newborns for the first 24
to 48 hours. Normal. Blue hands are normal. That
seems so counterintuitive. It does. But yes,
their peripheral circulation is still very immature.
The body is smart. It shunts the warm oxygenated
blood to the vital organs, the brain, the heart,
the kidneys, and it clamps down on the circulation
to the hands and feet. So they're often cool
and a little bit blue. So if a new mom frantically
calls you over and says, my baby's hands are
blue, you don't call a code blue. You don't.
You calmly reassure her. You say, that's very
normal for a new baby. Let's put some socks and
mittens on him to warm him up. But if she says
his lips are blue, you hit the emergency alarm.
The location of the blue makes all the difference.
What about jaundice? The yellowing of the skin.
Jaundice is all about timing. It's a clock game.
This is another core concept. The clock game,
okay. If a baby turns yellow in the first 24
hours of life on day one that is always considered
pathological, that is bad. Why? What does that
mean? It usually indicates a rapid destruction
of red blood cells, maybe from a blood incompatibility
between mom and baby, like an ABO or RH issue
or a liver problem. That baby needs an immediate
workout. And if the jaundice appears after 24
hours? If it appears after 24 hours, so on day
two or day three, it's much more likely to be
physiologic jaundice. It's very common. It just
means the newborn's liver is immature and can't
process the breakdown of old fetal red blood
cells fast enough. We monitor it. We might use
phototherapy lights, but it's not the immediate
crisis that day one jaundice is. So yellow on
day one equals red flag. Yellow on day three
equals watch and wait. You got it. Any quick?
Nice to know points for skin from the chapter.
Turgor. Yep. Turgor checks for hydration. In
an adult, you usually pinch the skin on the back
of the hand. In an infant, that's not reliable.
You pinch the skin on the abdomen. On the belly.
Right. If the skin tense, meaning it stays stuck
up in a little tent shade after you let go, that's
a sign of moderate to severe dehydration. And
what about common benign lesions, the stuff parents
ask about? Right. The, is this normal? Questions.
Stork bites, those are the pink spots on the
back of the neck or eyelids. Strawberry mangiomas,
the bright red, raised marks that grow for a
while and then usually shrink by school age.
And Melia, those little white bumps on the nose.
Tell parents not to pop the Melia, they're just
clogged oil glands and they go away on their
own. Segment four, heat. Head, eyes, ears, nose,
throat. We have some heavy hitters in here. Let's
start with the fontanels, the soft spots. The
fontanels are brilliant design features, really.
They allow the skull bones to overlap so the
head can fit through the birth canal, and then
they allow for the incredible brain growth that
happens in the first year. But for us, clinically,
They are windows into intracranial pressure.
Windows into the brain. We have two main ones,
right? Correct. The anterior fondinal, which
is on the top of the head, and it's diamond shaped.
And the posterior one, which is on the back of
the head, and it's smaller, more triangular.
And they close at different times. Vastly different
times. This is a need to know. The posterior
closes really fast, by about two months of age.
but the anterior stays open much longer, usually
until 12 to 18 months. So what are we feeling
for when we touch that soft spot? We are feeling
for pressure. We're assessing hydration and intracranial
pressure. So if the fontanel is bulging, if it's
tense hard and popping out above the skull, that
indicates increased pressure inside the skull.
And we should be thinking what? We think of scary
things. Meningitis, hydrocephalus, maybe fluid
overload from an IV. It's a sign of a serious
problem. But the notes say crying affects this.
That sounds like a huge exam trap. It is the
trap. If a baby is screaming, they're performing
a Valsalva maneuver, which increases their own
intracranial pressure. The fontanel will bulge
temporarily. So you can assess it. You cannot
assess a fontanel accurately on a crying baby.
You have to wait until they settle down, maybe
give them pacifier, assess when calm. And if
it's sunken, like a little crater in their head.
Sunken means the tank is empty. It's a classic
sign of dehydration. Got it. Let's talk about
the eyes, the red reflex. I thought this was
just for fixing photos in Photoshop. In nursing,
it's a cancer screen. It's a need -to -know that
saves lives. You take an ophthalmoscope, you
stand at a distance, and you shine the light
into the baby's eye. You should see a reddish
-orange reflection from the retina, just like
red eye in a photo. That's the normal result.
So what's the abnormal, the red flag? If you
see a white glow... The technical term is leukocoria.
Or if you just see a black spot where the red
should be, that is terrifying. Why? What could
it be? It can mean congenital cataracts, which
need to be removed to save vision. Or, and this
is the emergent one, it can mean retinoblastoma.
The tumor in the eye. A fast -growing cancer.
If you miss that white reflex on a newborn exam,
the child could lose their eye or even their
life. So checking for that red eye is technically
a life -saving maneuver. Wow. Okay, now for the
classic exam question, the ear pull. I feel like
I've heard this a thousand times, but I always
mix it up. Everyone mixes it up because it's
arbitrary, unless you know the anatomy behind
it. The goal is to straighten the ear canal so
you can get a clear view of the tympanic membrane,
the eardrum. Okay, so what's the rule? It's based
on age. For children under three years, the canal
has a downward curve, so you have to pull the
pinna that's the outer ear. Down and back. Down
and back for the little ones. Correct. For children
over three years, and for adults, the canal straightens
out and moves up. So you pull the pin a U .P.
and back. I used to have an mnemonic for this.
Down for the kids because they are short, and
up for the grown -ups because they are tall.
That's a great one. Whatever works. Down for
down low, up for tall. Just don't get it backward,
or you'll be staring at the wall of the ear canal.
You'll see nothing, and you might hurt the child.
One more core point for heat. The nose, the obligate
nose breather rule. This is so vital and so easy
to forget. Infants, especially under about four
weeks to a few months old, do not know how to
breathe through their mouths automatically. It's
not a reflex they have yet. They only breathe
through their nose. They only breathe through
their nose. It's an obligate function. So if
they get a simple cold. It's a potential disaster.
If an adult gets a stuffy nose, we just open
our mouth and breathe. If a newborn gets a stuff
nose from some mucus. They can't compensate.
They can suffocate. Just from snot. Just from
snot. They will exhibit severe respiratory distress.
That's why we are obsessive about using that
little blue bulb syringe to suction newborns
before they eat or sleep. A clogged nose is a
respiratory emergency in a neonate. Let's do
a quick nice -to -know for heat. The notes mentioned
ear alignment. Right. This is more of a screening
tool for other issues. You imagine a line from
the outer corner of the eye back to the top of
the ear. The top of the pinna should touch across
that line. And if it doesn't? If the ears are
lower? If the ears are low set, positioned noticeably
lower than the eyes, we start to think about
chromosomal abnormalities like Down syndrome
or renal anomalies. So kidney issues. Why kidneys?
What's the connection? It's embryology. The ears
and the kidneys develop at the exact same time
in utero. So, there's a strong correlation that
if one is malformed, the other one might be too.
Low -set ears should trigger a thought about
checking kidney function. Segment five, respiratory
and cardiac. You mentioned earlier this is the
big one. Why? Because this is how kids die. It
sounds blunt, but it's true. Adults usually have
primary cardiac events, heart attacks. Kids almost
always have respiratory events that lead to cardiac
arrest. So the heart stops because the lungs
failed first. Exactly. So respiratory assessment
is your number one safety tool. It's the most
critical part of the whole exam. The source material
has a great phrase, look before you listen. Yes.
This is a core concept. You can diagnose respiratory
distress from across the room just with your
eyes. We look for three big signs, retractions,
nasal flaring, and audible sounds like stridor.
Let's talk retractions. That's when the skin
sucks in. Exactly. A child's chest wall is very
compliant. It's made of flexible cartilage, not
rigid bone like an adult's. So when they have
to pull really hard to get air and creating a
lot of negative pressure, the chest wall actually
collapses inward. you see the skin sucking in
between or around the ribs. And does the location
of the retraction matter? It matters immensely.
This is a huge need to know. The higher up the
retraction, the worse the distress. There's a
clear hierarchy. Okay, explain that hierarchy.
So intercostal retractions, that's between the
ribs or subcostal, which is below the rib cage,
indicate mild to moderate distress. But if you
see super sternal retractions, where the skin
is sucking in right at the little notch in the
neck, above the sternum, or super collicular,
above the collarbones, that is severe distress.
It means they're using every single accessory
muscle they have just to breathe. That kid is
getting tired, and they're about to crash. And
what about stridor? Stridor is that high -pitched,
crowing musical sound you hear on inspiration.
It means there's an upper airway obstruction.
Think croup. or a piece of a hot dog stuck in
the throat, or anaphylaxis closing the airway.
It is the sound of air trying to squeeze through
a tiny straw. It is always a medical emergency
until proven otherwise. Moving to the heart.
I found the PMI landmarking interesting. The
point of maximum impulse. It moves. It moves
as the child grows. The heart sits more horizontally
in the chest in babies and young children. As
they grow taller, the heart settles into a more
vertical position. So where do we find it? Where
do we listen? For children under seven years
of age, the PMI is usually at the fourth intercostal
space, and it's often larrowed to or outside
of the mid -clavicular line. And after age seven?
It drops down and moves in. it goes to the adult
position, the fifth intercostal space, right
through the mid -clavicular line. Exam writers
would love that specificity. Under seven is fourth
space. Over seven is fifth space. They absolutely
do. If you are auscultating at the fifth space
on a three -year -old, you're in the wrong spot,
and you might miss the sounds you need to hear.
Let's talk murmurs. I feel like every parent
I know has at some point been told their kid
has a murmur. They're incredibly common. Something
like 50 % of all children will have a murmur
at some point. Most of them are what we call
innocent or functional murmurs. What makes it
innocent? They're usually soft, maybe a grade
one or two. They're often described as musical
or vibratory and a key feature is that they often
change or go away when the child sits up or changes
position. They are just the sound of blood flowing
normally through a small dynamic heart. So when
do we worry? What are the red flags for a pathologic
murmur? We worry about intensity and thrills.
A grade four murmur or higher is loud. and it
is almost always associated with a thrill. What
a thrill? What's that? A thrill is a vibration
you can actually feel with the palm of your hand
on the chest. It feels like placing your hand
on a purring cat. That's a great visual. I can
feel that. If you feel a purr, that is not innocent.
That is the feeling of turbulent blood flow caused
by a structural defect, a hole in the heart,
or a tight stenotic valve. That kid needs to
see a cardiologist. Nice to know for this section.
The notes mention chest shape. Yeah, just a quick
point. Infants have a round chest. The front
to back, or AP, diameter is equal to the side
to side, or transverse diameter. It's a 1 .1
ratio. And that changes. As they grow, it flattens
out into the adult shape, where the chest is
wider than it is deep. If a 10 -year -old still
has a round, 1 .1 chest, that's called a barrel
chest, and it's a sign of chronic air trapping
from a lung disease like severe asthma or cystic
fibrosis. Segment six, abdomen and genitourinary.
We are moving down the body and we have another
one of those order of operations traps here.
Yes A big one. For the abdomen, the rule changes.
The order is inspect, and then you auscultate.
You listen second. You do not touch or palpate
until after you have listened. Why is that so
important? Because if you poke and prod the belly
with your hands, you stir things up, you stimulate
peristalsis, you might create bowel sounds that
weren't there, or make them sound hyperactive
when they were actually hypoactive. So you ruin
the data. You completely ruin your auscultation
data. You need to hear the baseline silence or
activity before you disturb the peace. So it's,
look. Listen, then feel. That's a solid rule.
What about hernias? Umbilical hernias, the classic
outy belly button, are super common in infants,
especially premature infants. They usually resolve
on their own by school age as the abdominal muscles
strengthen. And the old advice to tape a coin
over it? No, don't do that. That doesn't help.
And can cause skin irritation. We just watch
them. When are they dangerous? They're dangerous
if they become hard, painful, or non -reducible.
Non -reducible means you can't gently push the
bulge back in with your finger. Then that means?
That suggests the bowel has become trapped. We
call that strangulated. That cuts off the blood
supply. That is a surgical emergency. What about
inguinal hernias? That's in the groin area. Those
are different. They almost always require surgery.
They don't fix themselves. And they have a much
higher risk of getting stuck or strangulated.
Now for the boys, the testicular exam, this seems
fraught with difficulty. It is. The main thing
we are checking for is cryptocarydism, which
is the medical term for undescended tests. And
why is that a problem? Well, the scrotum is designed
to keep the testicles cooler than the core body
temperature. If they don't drop down into the
scrotum, the internal body temperature is too
hot for them. It can kill the sperm cells leading
to sterility, and it significantly increases
the risk of testicular cancer later in life.
But there's a reflex that makes this exam hard,
right? Yes, the chromasteric reflex. It's an
evolutionary protective mechanism. If you touch
the inner thigh, or if your hands are cold, a
muscle pulls the testicles up into the inguinal
canal to protect them and keep them warm. So
you look and it looks like they are missing,
but really they are just hiding from your cold
hands. Exactly. The parent might say, I see them
in the warm bath. but not at the doctor's office.
So how do we beat the reflex? How do we get an
accurate exam? You have to trick the muscle.
The best way is to have the child sit cross -legged
like Indian style or in a tailor position. This
gently stretches the inner thigh muscle and prevents
the retraction. And for God's sakes, warm your
hands first. Segment seven, neuro and musculoskeletal.
We are in the home stretch now. Let's talk hips.
This is a big one. Specifically in infants, we
scream for something called developmental dysplasia
of the hip or DDH. That's where the hip socket
is too shallow, right? Exactly. The head of the
femur, the ball, keeps popping out of the socket.
We use two specific maneuvers to check for this.
Ortolani and Barlow. Sounds like a fancy law
firm. Ortolani and Barlow, what are we doing?
With the baby on their back, we are gently abducting
and abducting the hips, rotating them out and
in. You are feeling for a clunk. A clunk. The
notes emphasize not a click. Right. A soft click
is common, and usually just a ligament snapping
like cracking your knuckles. It's benign. A clunk
is a distinct, deep feeling. It feels like the
bone physically dislocating and then popping
back into the socket. If you feel that clunk,
the hip is unstable. Are there any visual clues
we can look for? Yes. This is a great tip for
parents, too. Look at the baby's legs from the
back when they're on their tummy. Look at the
gluteal folds, the fat rolls in the back of the
thighs. OK, what are we looking for? They should
be symmetrical. If one side has more rolls, or
if the rolls are higher up than on the other
side, that suggests one leg is shorter than the
other. And it's shorter because? Because the
hip is dislocated upwards and backwards. Asymmetrical
gluteal folds is a classic sign of hip dysplasia.
That's a great visual check you could do during
a diaper change. Okay. Let's talk about primitive
reflexes. These are the ones babies are born
with. Right. The Morkodia, or startle reflex.
The rooting reflex, where they turn toward a
touch on the cheek to find food. Yeah. The Babinski
reflex, where the toes fan out. The need to know
here isn't just that they exist, but that they
have to leave. Yes. That is the key point. They
must disappear. These are reflexes controlled
by the lower brainstem. As the brain matures
and the nerves get their myelin sheath, the higher
brain, the cortex, takes over and suppresses
these primitive movements. So if they stick around
for too long? If a primitive reflex persists
past its expiration date, for example, if a two
-year -old who is walking still has a positive
Babinski reflex where their toes fan out when
you stroke their foot, that is a major red flag.
What does it indicate? It indicates a neurological
lesion or an upper motor neuron problem. We think
of things like cerebral palsy. It means the brain
isn't maturing and developing correctly. So,
reflexes. Good in babies, bad in toddlers. Exactly.
Their presence is normal, but their persistence
is pathological. Nice to know for legs. The notes
distinguish knock knees from bull legs. This
confuses parents all the time. It's a normal
developmental progression. Toddlers are often
bull leg. The medical term is genuvarum. Their
legs are apart like a little cowboy. That's normal
for new walkers as they find their center of
gravity. And then what happens? As they get a
little older, around preschool age, their legs
swing the other way. They tend to become knock
-kneed, or genuvalgum, where their knees touch
when they stand straight. There is a great mnemonic
for this in the notes. I love this one. Gum.
Genuvalgum. Gum makes your knees stick together.
That's perfect. I'll never forget that now. Genuvalgum
equals gum equals sticky knees. And finally,
a quick note on cerebellar function, which is
balance and coordination. For older kids, the
school -aged kids and teens, we can do tests
like the finger -to -nose test or the heel -to
-shin test. It looks a lot like a roadside sobriety
test, but it's a great quick screen for coordination
problems. Wow. We just ran through the entire
body from head to toe. That was intense. It is
a lot of information, but if you focus on those
key safety triggers, those knee -to -nose, it
becomes manageable. So let's wrap this up. We've
covered a ton of ground. If our listener is driving
into their clinical shift right now or cramming
for an exam, what are the absolute must -haves
they should keep in their pocket from today.
Okay, three things. Number one, safety first.
Know your respiratory distress hierarchy. Blue
hands are okay, blue lips are not, intercostal
retractions are bad, super sternal retractions
mean you need help right now. Number two. Number
two, accuracy matters. Don't fake the numbers.
Use the right BP cuff, that 40 % rule. Pull the
ear the correct way down and back for small kids,
up and back for bigger kids. Bad data leads to
bad treatment. And the third. Number three, differentiation.
Know the difference between a bruise and a Mongolian
spot. Know the difference between a normal toddler
fall and signs of abuse. Your documentation is
your defense, and more importantly, it's the
child's protection. That is the core 20 % right
there. It really is. If you nail those things,
you're on your way. No, I want to leave everyone
with a final thought. We talked about a lot of
data today. Charts, numbers, maneuvers, reflexes.
But you had a really interesting point in our
pre -show notes about the invisible assessment.
Yes. This is Sort of the art that comes after
the science. We can teach you the science. You
can memorize the entire chapter. But the best
pediatric nurses, the ones who really save lives,
have an extra sense. What is that? They walk
into a room and they feel the vibe before they
even look at the patient. The vibe. What do you
mean by that? They sense the anxiety in the room.
How is the parent holding the child? Are they
holding them loosely or with a death grip? Is
the parent terrified? Is the parent disengaged
and on their phone? because children are emotional
mirrors. So the parent's state affects the child's
vitals. Directly. If the parent is terrified,
the child's heart rate goes up. The child's breathing
pattern changes. The data we collect is profoundly
influenced by the emotion in the room. So the
assessment isn't just biological, it's emotional,
it's relational. Exactly. The art behind the
science is knowing that you are treating a family
unit, not just a little body in a bed. And sometimes,
if you can calm the parent down, you might just
cure the tachycardia you were about to document.
Sometimes the most important intervention you
can do is just put a hand on a mom's shoulder
and say, you're doing a really good job, we're
going to figure this out together. That is a
powerful place to end. Listeners, take a deep
breath. You know more than you think you do.
Trust your gut, watch for those red flags, and
always, always check the cuff size. Stay curious.
We'll see you on the next Deep Dive.