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 --> 00:00:46.890 fast. Welcome to the emergency room. Welcome 00:00:46.890 --> 00:00:50.810 back to The Deep Dive. Today we are tackling 00:00:50.810 --> 00:00:53.630 a beast, and I mean that quite literally and 00:00:53.630 --> 00:00:56.490 figuratively. We're looking at a massive stack 00:00:56.490 --> 00:00:59.210 of materials. I've got slides, textbook chapters, 00:00:59.469 --> 00:01:02.250 clinical charts, all centered around pediatric 00:01:02.250 --> 00:01:05.370 infectious diseases and infestations. It's a 00:01:05.370 --> 00:01:07.870 really dense topic. And we're looking primarily 00:01:07.870 --> 00:01:10.650 at Chapter 15, nursing care of the child with 00:01:10.650 --> 00:01:13.150 an infection, but also pulling from a whole host 00:01:13.150 --> 00:01:16.189 of other clinical guidelines. And yeah, just 00:01:16.189 --> 00:01:18.769 that the title alone sounds pretty exhausting 00:01:18.769 --> 00:01:21.049 if you're a nursing student. It does. And honestly, 00:01:21.209 --> 00:01:24.189 looking at this stack, it feels physically heavy. 00:01:24.280 --> 00:01:27.359 I mean, you've got everything in here from microscopic 00:01:27.359 --> 00:01:30.019 mites that burrow into the skin to bacteria that 00:01:30.019 --> 00:01:32.019 produce toxins strong enough to stop a heart. 00:01:32.439 --> 00:01:34.939 It just feels like chaos. It does. And our listener, 00:01:34.980 --> 00:01:36.900 who we call the learner, is probably staring 00:01:36.900 --> 00:01:39.400 at the same pile thinking, do I really need to 00:01:39.400 --> 00:01:41.659 memorize the incubation period of every single 00:01:41.659 --> 00:01:44.180 bug? Do I need to know the molecular weight of 00:01:44.180 --> 00:01:46.400 the pertussis toxin? And the short answer is 00:01:46.400 --> 00:01:50.219 no. Please, please don't do that. You will absolutely 00:01:50.219 --> 00:01:52.859 burn out before you even get to the exam. Exactly. 00:01:53.579 --> 00:01:57.560 mission today we are going to apply the Pareto 00:01:57.560 --> 00:02:00.260 principle you know the 80 -20 rule to all this 00:02:00.260 --> 00:02:02.900 material we are not going to memorize the encyclopedia 00:02:02.900 --> 00:02:05.540 right we are going to find the 20 % of the concepts 00:02:05.540 --> 00:02:08.110 that are going to help you answer 80 % of the 00:02:08.110 --> 00:02:10.530 exam questions. But I think more importantly, 00:02:10.889 --> 00:02:13.389 want to give you the clinical eyes to walk into 00:02:13.389 --> 00:02:16.370 a pediatric room and spot the kid who is in trouble. 00:02:16.389 --> 00:02:18.949 That's the key. Because in a clinical setting, 00:02:19.349 --> 00:02:21.729 safety is really about recognizing patterns. 00:02:22.169 --> 00:02:24.370 It's about spotting those can't miss signs before 00:02:24.370 --> 00:02:26.889 they become emergencies. It's about realizing 00:02:26.889 --> 00:02:29.689 that sometimes the quiet baby is actually much, 00:02:29.689 --> 00:02:31.629 much sicker than the one who is screaming. So 00:02:31.629 --> 00:02:33.430 I'm the student today. I'm the one with the highlighter 00:02:33.430 --> 00:02:35.949 out asking, what do I actually need to write 00:02:35.949 --> 00:02:38.289 down for the test. And I'll be the clinical voice 00:02:38.289 --> 00:02:40.830 of reason, trying to keep us grounded in the 00:02:40.830 --> 00:02:43.710 why. Why does this matter at the bedside? OK, 00:02:43.789 --> 00:02:45.490 great. We've got a roadmap. We're going to start 00:02:45.490 --> 00:02:47.590 with what we're calling a master map of these 00:02:47.590 --> 00:02:49.990 disease patterns. Then we'll go system by system 00:02:49.990 --> 00:02:53.969 respiratory, musculoskeletal, neuro, and finally, 00:02:54.490 --> 00:02:57.229 the creepy crawlies. And we absolutely cannot 00:02:57.229 --> 00:02:59.870 forget the developmental piece. For every single 00:02:59.870 --> 00:03:03.150 one of these we have to ask, so what? How does 00:03:03.150 --> 00:03:05.590 this infection, or even the treatment for it, 00:03:05.830 --> 00:03:08.810 affect a child's growth? Because, you know, treating 00:03:08.810 --> 00:03:10.909 a neonate with a cough is a completely different 00:03:10.909 --> 00:03:13.090 universe than treating a high school linebacker 00:03:13.090 --> 00:03:15.729 with a tick bite. Absolutely. Okay, let's unpack 00:03:15.729 --> 00:03:17.870 this. I want to start with part A, the master 00:03:17.870 --> 00:03:20.770 80 -20 map. Before we get into specific bugs, 00:03:21.000 --> 00:03:23.740 I'm seeing some recurring themes, some patterns 00:03:23.740 --> 00:03:26.259 in these slides, patterns of destruction, if 00:03:26.259 --> 00:03:28.199 you will. That's a great way to look at it, because 00:03:28.199 --> 00:03:31.020 if you can recognize the underlying pattern, 00:03:31.120 --> 00:03:33.699 you can often figure out the right nursing intervention, 00:03:33.699 --> 00:03:36.039 even if you for a second forget the specific 00:03:36.039 --> 00:03:38.460 name of the bacteria. The first pattern I'm seeing, 00:03:38.919 --> 00:03:42.060 and this one just screams emergency, is the airway 00:03:42.060 --> 00:03:44.400 threat. I'm looking at the slides for diphtheria 00:03:44.400 --> 00:03:46.800 and pertussis. Yes, this is your respiratory 00:03:46.800 --> 00:03:49.419 obstruction pattern. In pediatrics, the airway 00:03:49.419 --> 00:03:52.960 is king. It just is. Anatomically, a child's 00:03:52.960 --> 00:03:55.400 airway is shorter, it's narrower, and it's softer 00:03:55.400 --> 00:03:57.800 than an adult's. It's like a straw versus a pipe. 00:03:57.979 --> 00:04:00.460 So it clogs more easily. Much more easily. So 00:04:00.460 --> 00:04:03.120 if you see any question that mentions the throat, 00:04:03.400 --> 00:04:06.259 copious secretions, edema in the neck, or a membrane, 00:04:06.819 --> 00:04:09.120 your internal alarm bells should be ringing off 00:04:09.120 --> 00:04:12.020 the hook. So the can't miss concept here is obstruction. 00:04:12.219 --> 00:04:13.919 We're not just talking about a cold. Not at all. 00:04:13.919 --> 00:04:16.740 It's about air exchange. If air can't get in, 00:04:16.920 --> 00:04:19.759 nothing else you do matters. On an exam, you 00:04:19.759 --> 00:04:22.040 prioritize the airway above circulation, above 00:04:22.040 --> 00:04:24.379 comfort, above everything. Okay, clear enough. 00:04:24.660 --> 00:04:28.000 Pattern number two that jumps out, the neurotoxins. 00:04:28.360 --> 00:04:31.680 I'm seeing tetanus and botulism here. And it 00:04:31.680 --> 00:04:33.500 seems like a battle between too tight and too 00:04:33.500 --> 00:04:35.860 floppy. Precisely. That's a perfect way to frame 00:04:35.860 --> 00:04:38.420 it. These are diseases that attack muscle function 00:04:38.420 --> 00:04:41.079 right at the neurological level. One of them, 00:04:41.259 --> 00:04:44.420 tetanus, causes these rigid, unrelenting spasms. 00:04:44.500 --> 00:04:47.839 The other, botulism, causes a flaccid, profound 00:04:47.839 --> 00:04:50.279 weakness. But the outcome is the same. The can't 00:04:50.279 --> 00:04:52.680 miss connection is that your diaphragm is a muscle. 00:04:53.079 --> 00:04:54.920 It's the most important muscle for breathing. 00:04:55.079 --> 00:04:56.920 So whether that muscle is clamped tight and can't 00:04:56.920 --> 00:04:59.220 relax, or it's too weak and floppy to even move, 00:04:59.620 --> 00:05:02.500 the end result is the same. Respiratory failure. 00:05:02.720 --> 00:05:05.639 So again, it all circles back to breathing. Pattern 00:05:05.639 --> 00:05:08.540 three involves the skin. We have this rash plus 00:05:08.540 --> 00:05:11.600 fever complex. I'm seeing scarlet fever, Rocky 00:05:11.600 --> 00:05:14.430 Mountain spotted fever, Lyme. This is a tricky 00:05:14.430 --> 00:05:16.490 one for students because, let's be honest, kids 00:05:16.490 --> 00:05:18.850 get viral rashes all the time. It's a normal 00:05:18.850 --> 00:05:21.589 part of childhood. Right. The 80 -20 scale here 00:05:21.589 --> 00:05:24.069 is differentiating a simple viral rash, which 00:05:24.069 --> 00:05:26.589 is usually annoying, but self -limiting, from 00:05:26.589 --> 00:05:29.569 a bacterial or a vector -borne illness that requires 00:05:29.569 --> 00:05:32.569 antibiotics to prevent really serious permanent 00:05:32.569 --> 00:05:34.810 damage to organs like the heart or the kidneys. 00:05:34.949 --> 00:05:37.170 OK, so it's about spotting the dangerous rash 00:05:37.170 --> 00:05:40.069 from the benign one. And finally, pattern four, 00:05:40.389 --> 00:05:44.639 the itch cycle. We've got lice. scabies, pinworms. 00:05:44.759 --> 00:05:47.300 This feels less like a true medical emergency 00:05:47.300 --> 00:05:50.639 and more like a social or hygiene crisis. It 00:05:50.639 --> 00:05:53.220 is on the surface, but it's also a skin integrity 00:05:53.220 --> 00:05:55.959 issue. The can't miss concept here is the secondary 00:05:55.959 --> 00:05:58.240 infection. If a child scratches until they bleed, 00:05:58.839 --> 00:06:00.980 they're basically opening a door and inviting 00:06:00.980 --> 00:06:03.699 staff or strep into their bloodstream. Yeah, 00:06:03.699 --> 00:06:06.220 and the other piece. And the other piece is transmission. 00:06:06.740 --> 00:06:09.779 With these, if one person in the house has it, 00:06:09.819 --> 00:06:12.220 You have to assume the whole house probably has 00:06:12.220 --> 00:06:14.560 it. You have to treat the environment, not just 00:06:14.560 --> 00:06:17.259 the patient. OK, that's a great map. Airway, 00:06:17.379 --> 00:06:20.259 neuro, rash, and itch. So now let's dive into 00:06:20.259 --> 00:06:22.720 the weeds. Part B, we're going system by system. 00:06:23.019 --> 00:06:24.759 And I want to start with the really scary stuff. 00:06:25.660 --> 00:06:29.019 Bacterial respiratory infections. The airway 00:06:29.019 --> 00:06:31.519 cluster. Let's start with diphtheria. OK, diphtheria. 00:06:31.600 --> 00:06:34.540 The one liner I've got for this is the bull neck 00:06:34.540 --> 00:06:37.319 airway blocker. That is a very vivid image, but 00:06:37.319 --> 00:06:38.980 it's completely accurate. If you look at the 00:06:38.980 --> 00:06:40.879 history books, this was often called the strangler 00:06:40.879 --> 00:06:43.420 of children. It was terrifying. The material 00:06:43.420 --> 00:06:46.379 mentions the bacteria, carinobacterium diphtheria. 00:06:47.079 --> 00:06:49.439 But the key patho here seems to be this pseudo 00:06:49.439 --> 00:06:52.420 membrane. It says it forms over the pharynx and 00:06:52.420 --> 00:06:54.829 uvula. Can you explain that in plain English? 00:06:54.949 --> 00:06:56.550 What is actually happening in the back of the 00:06:56.550 --> 00:06:58.589 throat? Yeah, it's really insidious. This bacteria 00:06:58.589 --> 00:07:00.709 implants itself in the upper respiratory tract 00:07:00.709 --> 00:07:04.189 and it starts releasing a potent toxin. This 00:07:04.189 --> 00:07:07.129 toxin causes necrosis. It literally kills the 00:07:07.129 --> 00:07:09.110 healthy tissue of the throat lining. So the tissue 00:07:09.110 --> 00:07:12.079 is dying. The tissue is dying. And that dead 00:07:12.079 --> 00:07:15.100 tissue, combined with white blood cells and fibrin 00:07:15.100 --> 00:07:17.939 from the inflammatory response, coagulates into 00:07:17.939 --> 00:07:21.660 this thick leathery gray coating. We call it 00:07:21.660 --> 00:07:23.839 a pseudomembrane, but I want you to imagine a 00:07:23.839 --> 00:07:26.680 layer of wet concrete forming over your tonsils 00:07:26.680 --> 00:07:28.720 and then hardening. And if you have a tiny pediatric 00:07:28.720 --> 00:07:31.120 airway and you coat the inside of it with a thick 00:07:31.120 --> 00:07:34.120 membrane, you have a complete physical obstruction. 00:07:34.439 --> 00:07:37.540 The child cannot breathe. And here is the really 00:07:37.540 --> 00:07:40.800 scary part. You can't just scrape it off. If 00:07:40.800 --> 00:07:43.339 you try to remove that membrane manually, it 00:07:43.339 --> 00:07:45.660 bleeds profusely because it's rooted deep into 00:07:45.660 --> 00:07:47.740 the tissue and that bleeding can actually cause 00:07:47.740 --> 00:07:49.959 even more swelling and make the obstruction worse. 00:07:50.220 --> 00:07:52.819 Wow, okay, this slide also mentions a bull's 00:07:52.819 --> 00:07:55.120 neck appearance. Is that just from swollen glands? 00:07:55.240 --> 00:07:58.180 It's lymphadenopathy on steroids. It's way beyond 00:07:58.180 --> 00:08:01.379 just swollen glands. The body is trying so hard 00:08:01.379 --> 00:08:03.740 to fight this toxin that the lymph nodes in the 00:08:03.740 --> 00:08:06.300 neck just explode in size and you get this massive 00:08:06.300 --> 00:08:08.560 edema fluid swelling in all the soft tissue. 00:08:08.959 --> 00:08:11.459 The neck literally expands outward, making it 00:08:11.459 --> 00:08:12.959 look like a bull's neck. And that's not just 00:08:12.959 --> 00:08:15.620 a cosmetic issue. No, you have to remember physics. 00:08:16.100 --> 00:08:18.740 If the neck is swelling out, it is also compressing 00:08:18.740 --> 00:08:21.500 in. It is squeezing the trachea shut from the 00:08:21.500 --> 00:08:23.860 outside while the membrane is blocking it from 00:08:23.860 --> 00:08:26.860 the inside. So for the need to know on the exam, 00:08:27.420 --> 00:08:29.560 if a question describes a child with a bull neck 00:08:29.560 --> 00:08:32.899 or a gray membrane in the throat, The priority 00:08:32.899 --> 00:08:36.039 is not giving antibiotics right away, it is managing 00:08:36.039 --> 00:08:39.220 the airway. 100%. Airway cart at the bedside, 00:08:39.460 --> 00:08:41.639 tracheostomy tray ready to go. The child goes 00:08:41.639 --> 00:08:43.759 on droplet precautions immediately because it 00:08:43.759 --> 00:08:46.360 is highly contagious. That is your first move. 00:08:46.720 --> 00:08:48.899 Now, speaking of treatment, the materials list 00:08:48.899 --> 00:08:52.080 antitoxin and then antibiotics like penicillin 00:08:52.080 --> 00:08:54.879 or erythromycin. Why do you need both? This is 00:08:54.879 --> 00:08:57.659 a crucial distinction and a favorite exam topic. 00:08:57.940 --> 00:09:00.220 The antibiotic kills the bacteria. It shuts down 00:09:00.220 --> 00:09:02.480 the factory that's producing the poison. But 00:09:02.480 --> 00:09:04.899 it does absolutely nothing about the poison, 00:09:05.100 --> 00:09:07.460 the toxin, that has already been shipped out 00:09:07.460 --> 00:09:10.340 and is circulating in the bloodstream. The anti 00:09:10.340 --> 00:09:13.059 -toxin is what's needed to neutralize that circulating 00:09:13.059 --> 00:09:15.340 toxin before it does permanent damage to other 00:09:15.340 --> 00:09:17.299 organs. And what kind of damage are we talking 00:09:17.299 --> 00:09:19.379 about? There's a detail here that really surprised 00:09:19.379 --> 00:09:23.450 me. It says telemetry observed for CHF. congestive 00:09:23.450 --> 00:09:26.090 heart failure from a sore throat. This is where 00:09:26.090 --> 00:09:29.289 diphtheria gets really dangerous. That toxin 00:09:29.289 --> 00:09:31.409 doesn't just stay in the throat. It has a high 00:09:31.409 --> 00:09:33.929 affinity, a special attraction for the heart 00:09:33.929 --> 00:09:36.549 muscle and the nervous system. It can cause a 00:09:36.549 --> 00:09:39.110 severe myocarditis inflammation of the heart 00:09:39.110 --> 00:09:42.179 muscle. So a kid with diphtheria needs a cardiac 00:09:42.179 --> 00:09:45.240 monitor. Absolutely. That is a classic exam trap. 00:09:45.419 --> 00:09:47.320 You might be focused on the respiratory system 00:09:47.320 --> 00:09:49.080 thinking, Oh, it's respiratory. I'll just watch 00:09:49.080 --> 00:09:52.000 O2 stats. No, you have to watch the heart rhythm 00:09:52.000 --> 00:09:54.600 because they can go into heart failure or develop 00:09:54.600 --> 00:09:57.360 a fatal arrhythmia days or even weeks after the 00:09:57.360 --> 00:10:00.320 throat starts to clear up. Wow. Okay. So airway 00:10:00.320 --> 00:10:02.899 first? Absolutely. But do not ignore the heart. 00:10:03.340 --> 00:10:05.500 Now let's move to its cousin in the respiratory 00:10:05.500 --> 00:10:08.240 world, Pertussis. Whooping Cough. The Hundred 00:10:08.240 --> 00:10:09.899 Day Cough. Right. The Hundred Day Cough. Why 00:10:09.899 --> 00:10:11.419 do they call it that? Where does that name come 00:10:11.419 --> 00:10:14.840 from? It's because the bacteria, Bordetella pertussis, 00:10:15.100 --> 00:10:18.019 releases a toxin that damages the cilia in the 00:10:18.019 --> 00:10:20.820 lungs. Those are the tiny little hairs that are 00:10:20.820 --> 00:10:23.759 constantly sweeping mucus and debris out. The 00:10:23.759 --> 00:10:26.879 toxin paralyzes and kills them. It can take weeks, 00:10:26.919 --> 00:10:29.299 sometimes months, for those cilia to grow back. 00:10:29.460 --> 00:10:31.899 So even after the bacteria is gone? Exactly. 00:10:32.000 --> 00:10:33.799 Even after the antibiotics have killed all the 00:10:33.799 --> 00:10:35.899 bacteria, the child just keeps coughing because 00:10:35.899 --> 00:10:38.279 they have lost their natural mechanism for clearing 00:10:38.279 --> 00:10:41.759 their airway effectively. The slide lists paroxysmal 00:10:41.759 --> 00:10:45.059 cough and copious secretions as the key symptoms. 00:10:45.320 --> 00:10:47.940 Let's break down paroxysmal. It means a violent 00:10:47.940 --> 00:10:50.679 uncontrollable coughing fit. It's not a normal 00:10:50.679 --> 00:10:53.139 cough. The child coughs and coughs and coughs 00:10:53.139 --> 00:10:56.120 maybe 10 or 20 times in a row until they have 00:10:56.120 --> 00:10:58.320 physically emptied their lungs of every last 00:10:58.320 --> 00:11:01.539 bit of air. They turn red, then maybe even purple. 00:11:01.720 --> 00:11:03.879 And then the whoop. And then because they are 00:11:03.879 --> 00:11:06.539 absolutely starving for oxygen, they forcibly 00:11:06.539 --> 00:11:09.059 inhale against a narrowed glottis, which makes 00:11:09.059 --> 00:11:11.860 that high pitched whoop sound. It sounds absolutely 00:11:11.860 --> 00:11:14.899 exhausting. It is terrifyingly exhausting for 00:11:14.899 --> 00:11:18.039 the child and for the parents watching. Imagine 00:11:18.039 --> 00:11:20.820 running a full out sprint every single time you 00:11:20.820 --> 00:11:23.399 need to breathe. That's what it's like. And the 00:11:23.399 --> 00:11:26.320 material emphasizes copious secretions. Yes, 00:11:26.320 --> 00:11:29.259 and that is your nursing priority. These kids 00:11:29.259 --> 00:11:33.159 produce this thick, sticky, stringy mucus. They 00:11:33.159 --> 00:11:35.460 can't clear it because their cilia are damaged. 00:11:35.940 --> 00:11:38.320 So if diphtheria is about obstruction from a 00:11:38.320 --> 00:11:41.299 physical membrane, pertussis is often about obstruction 00:11:41.299 --> 00:11:43.360 from a mucus plug. So what's the intervention? 00:11:43.600 --> 00:11:46.320 Your best friend is the suction catheter. You 00:11:46.320 --> 00:11:48.340 have to be ready to suction that airway to clear 00:11:48.340 --> 00:11:50.279 the plug so they can breathe again after a coughing 00:11:50.279 --> 00:11:52.610 fit. Let's talk about the developmental impact 00:11:52.610 --> 00:11:55.129 here. The slide doesn't explicitly spell it out, 00:11:55.409 --> 00:11:58.269 but just imagine an infant with pertussis. This 00:11:58.269 --> 00:12:01.289 is a critical safety red flag for exams and for 00:12:01.289 --> 00:12:04.090 real life. In infants under six months, you typically 00:12:04.090 --> 00:12:07.250 do not hear the classic whoop. Their intercostal 00:12:07.250 --> 00:12:09.549 muscles just aren't strong enough to create that 00:12:09.549 --> 00:12:11.889 forceful inspiration. So what happens instead? 00:12:12.070 --> 00:12:13.669 Instead, they cough and cough, and then they 00:12:13.669 --> 00:12:16.250 just stop breathing. They go apneic. So a silent 00:12:16.250 --> 00:12:19.220 baby is a very bad sign. A silent baby after 00:12:19.220 --> 00:12:21.960 a coughing fit is a true emergency. They are 00:12:21.960 --> 00:12:24.559 hypoxic. And you also have to think about feeding. 00:12:24.919 --> 00:12:28.059 If you are having a coughing fit every 30 seconds... 00:12:28.039 --> 00:12:30.740 How do you possibly nurse? How do you take a 00:12:30.740 --> 00:12:32.899 bottle? You can't. You can't coordinate that 00:12:32.899 --> 00:12:35.559 suck, swallow, breathe pattern. Exactly. So they 00:12:35.559 --> 00:12:38.679 are a huge risk for severe dehydration and failure 00:12:38.679 --> 00:12:41.919 to thrive. A huge part of the nursing care involves 00:12:41.919 --> 00:12:45.320 maintaining nutrition, maybe giving small, very 00:12:45.320 --> 00:12:48.259 frequent feeds, or even placing an NG tube for 00:12:48.259 --> 00:12:50.090 feeding and clustering your care. What do you 00:12:50.090 --> 00:12:52.210 mean by clustering care? It means you do everything 00:12:52.210 --> 00:12:55.210 at once. You change the diaper, check the vitals, 00:12:55.370 --> 00:12:56.950 give the meds, and then you leave them alone 00:12:56.950 --> 00:12:59.570 to rest. If you wake them up every 15 minutes 00:12:59.570 --> 00:13:02.149 for a different task, you just trigger another 00:13:02.149 --> 00:13:04.250 coughing fit and they never get to recover. That 00:13:04.250 --> 00:13:07.129 makes sense. OK, let's jump over to our rash 00:13:07.129 --> 00:13:09.330 category for a moment, since it's also bacterial. 00:13:09.950 --> 00:13:13.120 Scarlet fever. Group A strip. This is basically 00:13:13.120 --> 00:13:15.460 strep throat's very angry cousin. The one -liner 00:13:15.460 --> 00:13:18.519 here is group A strip with a rash. The materials 00:13:18.519 --> 00:13:21.259 list a high fever, body aches, maybe some nausea 00:13:21.259 --> 00:13:23.740 and vomiting, and then a rash on the face, trunk, 00:13:23.960 --> 00:13:27.259 and extremities. Right. The bacteria produces 00:13:27.259 --> 00:13:30.440 what's called an erythrogenic toxin, which literally 00:13:30.440 --> 00:13:33.960 translates to red producing. The classic description 00:13:33.960 --> 00:13:37.000 you absolutely need to know for the exam is a 00:13:37.000 --> 00:13:39.919 sandpaper -like rash. If you run your hand over 00:13:39.919 --> 00:13:42.879 the child's trunk, it feels rough like fine grit 00:13:42.879 --> 00:13:45.759 sandpaper. And the strawberry tongue. I've seen 00:13:45.759 --> 00:13:48.279 that on practice questions. Yes. In the beginning, 00:13:48.419 --> 00:13:50.659 the tongue gets this thick white coating, but 00:13:50.659 --> 00:13:53.080 then the coating peels off after a day or two, 00:13:53.200 --> 00:13:56.279 leaving the tongue bright red and bumpy with 00:13:56.279 --> 00:13:59.080 very prominent papillae. It looks just like a 00:13:59.080 --> 00:14:01.700 strawberry. The transmission is droplets in contact 00:14:01.700 --> 00:14:04.100 with respiratory secretions. So again, we're 00:14:04.100 --> 00:14:06.679 looking at isolation procedures. Droplet precautions. 00:14:06.799 --> 00:14:08.779 They need to be isolated until they've been on 00:14:08.779 --> 00:14:11.600 antibiotics for a full 24 hours. After that, 00:14:11.659 --> 00:14:13.740 they're no longer considered contagious. The 00:14:13.740 --> 00:14:16.059 treatment is usually straightforward, penicillin 00:14:16.059 --> 00:14:19.360 or amoxy... Now, here's the big why. Why do we 00:14:19.360 --> 00:14:21.379 treat strep so aggressively? I mean, kids get 00:14:21.379 --> 00:14:23.539 sore throats all the time. Why are antibiotics 00:14:23.539 --> 00:14:26.200 so critical? We treat it to prevent the post 00:14:26.200 --> 00:14:30.000 -infectious complications. Group A strep is notorious 00:14:30.000 --> 00:14:32.639 for triggering these bizarre autoimmune responses. 00:14:33.340 --> 00:14:35.919 If it's left untreated, weeks later, the child 00:14:35.919 --> 00:14:38.659 can develop rheumatic fever, which can permanently 00:14:38.659 --> 00:14:40.659 damage the heart valves. And it's not just the 00:14:40.659 --> 00:14:44.450 heart. Right. No, it can also cause acute glomerulonephritis, 00:14:44.769 --> 00:14:46.990 which attacks and can shut down the kidneys. 00:14:47.350 --> 00:14:49.490 So we aren't just treating a sore throat. We're 00:14:49.490 --> 00:14:51.769 giving that antibiotic to save the child's heart 00:14:51.769 --> 00:14:54.870 and kidneys down the road. Got it. OK, let's 00:14:54.870 --> 00:14:56.769 shift gears completely. We're leaving the airway 00:14:56.769 --> 00:15:00.330 now and going to the bones. Musculoskeletal infections. 00:15:00.470 --> 00:15:03.750 Yeah. Let's talk about osteomyelitis. Osteomyelitis. 00:15:03.850 --> 00:15:06.210 This is a bacterial infection of the bone itself 00:15:06.210 --> 00:15:08.730 and the soft tissue that surrounds it. The material 00:15:08.730 --> 00:15:12.039 says S. aureus staph. Aureus is the most common 00:15:12.039 --> 00:15:14.639 culprit. How does Staph even get into a bone? 00:15:14.720 --> 00:15:16.799 It's usually through the blood, what we call 00:15:16.799 --> 00:15:19.580 hematogenous spread. A kid scrapes their knee 00:15:19.580 --> 00:15:21.500 on the playground, gets a little skin infection, 00:15:21.639 --> 00:15:24.240 the bacteria enters the bloodstream. And because 00:15:24.240 --> 00:15:26.419 children's bones are still growing, they have 00:15:26.419 --> 00:15:29.179 these very rich vascular areas near the growth 00:15:29.179 --> 00:15:32.179 plates. The bacteria -filled blood slows down 00:15:32.179 --> 00:15:34.460 in those areas, and the bacteria just lands, 00:15:34.779 --> 00:15:37.000 sets up a colony, and starts to multiply. So 00:15:37.000 --> 00:15:40.940 how would this present? I'm seeing fever, irritability, 00:15:41.139 --> 00:15:44.080 lethargy listed, but the key physical finding 00:15:44.080 --> 00:15:47.440 seems to be decreased range of motion of affected 00:15:47.440 --> 00:15:50.559 extremity, swelling, warmth, and tenderness. 00:15:51.140 --> 00:15:53.799 Exactly. Picture a toddler. They can't always 00:15:53.799 --> 00:15:56.279 tell you, my leg hurts deep inside the femur. 00:15:56.360 --> 00:15:58.179 They don't have the vocabulary for that. So they 00:15:58.179 --> 00:16:00.100 show you instead. They show you. They just stop 00:16:00.100 --> 00:16:02.519 walking. Or they refuse to use one arm. They'll 00:16:02.519 --> 00:16:04.500 just hold it limp against their body. So that's 00:16:04.500 --> 00:16:06.919 the big can't miss assessment clue, right? Yes. 00:16:07.139 --> 00:16:09.820 That is the exam question right there. If a previously 00:16:09.820 --> 00:16:12.039 mobile child suddenly stops using a limb and 00:16:12.039 --> 00:16:14.559 they have a fever, your number one suspicion 00:16:14.559 --> 00:16:16.960 should be osteomyelitis until it's proven otherwise. 00:16:17.259 --> 00:16:19.340 You might see them guarding the limb or screaming 00:16:19.340 --> 00:16:21.700 when you try to change because just moving the 00:16:21.700 --> 00:16:24.320 leg is excruciating. The labs listed here are 00:16:24.320 --> 00:16:29.299 WBC, CRP, and ESR. Those are your big three inflammatory 00:16:29.299 --> 00:16:32.519 markers. White blood count, C -reactive protein, 00:16:32.740 --> 00:16:35.639 and erythrocyte sedimentation rate. Think of 00:16:35.639 --> 00:16:39.379 ESR and CRP as smoke detectors. They don't tell 00:16:39.379 --> 00:16:42.019 you where the fire is, but they are very sensitive, 00:16:42.200 --> 00:16:44.480 and they'll tell you that there is a fire inflammation 00:16:44.480 --> 00:16:46.860 somewhere in the body. So if they're high in 00:16:46.860 --> 00:16:49.200 a kid who won't walk... It points to the bone. 00:16:49.360 --> 00:16:51.700 It points very strongly to the bone. And the 00:16:51.700 --> 00:16:54.879 treatment. I'm seeing four to six week course 00:16:54.879 --> 00:16:58.600 of antibiotics. That seems really long. It is 00:16:58.600 --> 00:17:01.460 a huge deal. Four to six weeks. Antibiotics just 00:17:01.460 --> 00:17:04.119 do not penetrate bone tissue very easily. You 00:17:04.119 --> 00:17:06.779 need really high doses for a very long time to 00:17:06.779 --> 00:17:09.220 completely eradicate the infection. Let's talk 00:17:09.220 --> 00:17:11.319 about the developmental impact of that. You aren't 00:17:11.319 --> 00:17:12.980 going to keep a kid in the hospital for six weeks 00:17:12.980 --> 00:17:15.859 just for IV medicine. No, absolutely not. This 00:17:15.859 --> 00:17:18.980 almost always means a PICC line, a peripherally 00:17:18.980 --> 00:17:21.299 inserted central catheter is placed, and the 00:17:21.299 --> 00:17:23.740 child is sent home with home care nursing. So 00:17:23.740 --> 00:17:25.799 now you have a three -year -old whose developmental 00:17:25.799 --> 00:17:28.160 job is to run, jump, and explore, but they're 00:17:28.160 --> 00:17:30.259 now tethered to an IV pump for part of the day, 00:17:30.500 --> 00:17:32.460 or at least have this fragile line sticking out 00:17:32.460 --> 00:17:35.880 of their arm. So on an exam. if they ask about 00:17:35.880 --> 00:17:38.539 discharge planning for a child with osteomyelitis. 00:17:38.660 --> 00:17:41.160 It's all about central line care education for 00:17:41.160 --> 00:17:43.480 the parents. That's number one. And number two 00:17:43.480 --> 00:17:46.680 is finding quiet, developmentally appropriate 00:17:46.680 --> 00:17:50.019 activities. You have to get creative. How do 00:17:50.019 --> 00:17:52.480 you keep a preschooler entertained without them 00:17:52.480 --> 00:17:54.319 climbing the furniture and ripping out their 00:17:54.319 --> 00:17:56.940 5e? It's puzzles, coloring, stories, maybe some 00:17:56.940 --> 00:17:59.500 limited video games, things that keep them relatively 00:17:59.500 --> 00:18:02.119 stationary but still engaged and learning. Right, 00:18:02.259 --> 00:18:05.000 okay. Now briefly, let's touch on cat scratch 00:18:05.000 --> 00:18:07.299 disease. This one seems a little less intense. 00:18:07.700 --> 00:18:10.150 Yeah, Bartonella hensile. Usually from a kitten 00:18:10.150 --> 00:18:12.450 scratch or sometimes a bite, kittens are more 00:18:12.450 --> 00:18:15.029 likely to carry it than adult cats. The materials 00:18:15.029 --> 00:18:18.130 say painless non -puretic papule at the side, 00:18:18.569 --> 00:18:20.869 which is then followed by regional lymph adenitis. 00:18:21.109 --> 00:18:23.210 And that just means swollen lymph nodes in the 00:18:23.210 --> 00:18:25.630 area that drains the scratch. So if the kid gets 00:18:25.630 --> 00:18:28.390 scratched on the arm, you'll see a massive, tender 00:18:28.390 --> 00:18:30.710 lymph node pop up in their armpit, the axilla. 00:18:31.130 --> 00:18:32.910 If they were scratched on the leg, it'll be in 00:18:32.910 --> 00:18:35.450 the groin. And the treatment, it says supportive, 00:18:35.990 --> 00:18:38.930 usually resolves in four to six weeks. antibiotics 00:18:38.930 --> 00:18:41.890 are only needed if the child is immunocompromised 00:18:41.890 --> 00:18:44.529 or if it persists for a long time. This is a 00:18:44.529 --> 00:18:47.170 great example of nice to know versus need to 00:18:47.170 --> 00:18:49.329 know. The need to know part is the history. Did 00:18:49.329 --> 00:18:52.130 you recently get a new kitten? And the physical 00:18:52.130 --> 00:18:55.609 finding of that one big swollen node, it almost 00:18:55.609 --> 00:18:58.390 always goes away on its own. The main job for 00:18:58.390 --> 00:19:00.650 the nurse is just reassuring the parents that 00:19:00.650 --> 00:19:03.470 it's not something scarier like lymphoma or cancer, 00:19:03.730 --> 00:19:05.390 which is often what they fear when they feel 00:19:05.390 --> 00:19:07.849 a huge lump on their child. OK, let's move to 00:19:07.849 --> 00:19:10.849 the neuromuscular toxins. This is the tight versus 00:19:10.849 --> 00:19:13.829 floppy showdown. I love this comparison because 00:19:13.829 --> 00:19:15.849 it really highlights how two different toxins 00:19:15.849 --> 00:19:18.390 can affect the exact same system in opposite 00:19:18.390 --> 00:19:21.690 ways. First up, tetanus. Lockjaw. This is the 00:19:21.690 --> 00:19:23.269 tight side of the coin, the muscle that won't 00:19:23.269 --> 00:19:25.730 let go. The material emphasizes prevention right 00:19:25.730 --> 00:19:27.950 at the very top. As it should, because once you 00:19:27.950 --> 00:19:30.369 have symptomatic tetanus, it is an absolute nightmare 00:19:30.369 --> 00:19:33.190 to treat. The mortality rate is high and the 00:19:33.190 --> 00:19:35.509 suffering is immense. Prevention through the 00:19:35.509 --> 00:19:38.490 vaccine, the DTaP, and Tdap is really the only 00:19:38.490 --> 00:19:41.579 effective strategy. The symptoms listed are headache, 00:19:42.079 --> 00:19:44.240 spasms, and cramping of the jaw, locked jaw. 00:19:44.359 --> 00:19:46.970 Right. The tetanus toxin gets into the motor 00:19:46.970 --> 00:19:49.509 nerves and it works by blocking the relaxed signal. 00:19:50.009 --> 00:19:52.509 Normally when you move a joint, one muscle contracts 00:19:52.509 --> 00:19:55.690 and the opposing muscle relaxes. Tetanus toxin 00:19:55.690 --> 00:19:58.049 stops the relaxation part from happening. So 00:19:58.049 --> 00:20:00.809 both muscles fire at once. Both muscles fire 00:20:00.809 --> 00:20:03.049 uncontrollably. It usually starts in the jaw 00:20:03.049 --> 00:20:06.349 that's lock jaw or trismus. But you also get 00:20:06.349 --> 00:20:10.230 this creepy fixed smile called rhesus sardonicus 00:20:10.230 --> 00:20:13.009 because the facial muscles are spasming. It sounds 00:20:13.009 --> 00:20:14.829 like something out of a horror movie. It honestly 00:20:14.829 --> 00:20:17.390 looks like it. The spasms then spread to the 00:20:17.390 --> 00:20:19.809 back, causing opus atnos, where the back arches 00:20:19.809 --> 00:20:22.250 so severely that the child is literally resting 00:20:22.250 --> 00:20:24.269 on just the back of their head and their heels. 00:20:24.789 --> 00:20:27.109 And these spasms are incredibly painful. They 00:20:27.109 --> 00:20:29.009 can be strong enough to fracture the child's 00:20:29.009 --> 00:20:32.109 own vertebrae. That's horrifying. OK, so management 00:20:32.109 --> 00:20:34.890 listed is clean wounds thoroughly. And here is 00:20:34.890 --> 00:20:37.930 the classic exam rule. If it has been more than 00:20:37.930 --> 00:20:40.650 five years since the last tetanus dose, a booster 00:20:40.650 --> 00:20:42.930 may be needed based on the type of injury. That 00:20:42.930 --> 00:20:45.730 is the classic NCLE -X question right there. 00:20:46.329 --> 00:20:48.150 A kid steps on a rusty nail in the backyard. 00:20:48.410 --> 00:20:50.529 The parent says, he had his shots, but the last 00:20:50.529 --> 00:20:52.970 one was six years ago. What do you do? You give 00:20:52.970 --> 00:20:55.130 the booster. You give the booster. Now what if 00:20:55.130 --> 00:20:56.910 the parent says, I don't know if he's ever had 00:20:56.910 --> 00:20:59.130 a shot. Then you'd give the booster A and D, 00:20:59.329 --> 00:21:02.140 the tetanus immune globulin. Exactly. The TIG 00:21:02.140 --> 00:21:05.220 gives immediate passive immunity to fight any 00:21:05.220 --> 00:21:07.539 toxin that might already be forming, while the 00:21:07.539 --> 00:21:09.920 booster shot stimulates their own long -term 00:21:09.920 --> 00:21:12.480 immunity. And what's a nursing priority for a 00:21:12.480 --> 00:21:15.359 child who's actually in the hospital with active 00:21:15.359 --> 00:21:19.359 tetanus? Low stimulation. A quiet, dark room. 00:21:20.039 --> 00:21:22.579 These spasms are triggered by external stimuli 00:21:22.579 --> 00:21:25.549 light sound, even touch. So you cluster your 00:21:25.549 --> 00:21:27.549 care, you minimize handling, you keep the room 00:21:27.549 --> 00:21:29.829 dark, because if you clap your hands loudly, 00:21:29.930 --> 00:21:31.930 you could trigger a full body spasm that causes 00:21:31.930 --> 00:21:33.970 them to stop breathing. Now let's contrast that 00:21:33.970 --> 00:21:36.750 with botulism, the other side of the coin. Botulism 00:21:36.750 --> 00:21:39.529 is the complete opposite. It causes a descending 00:21:39.529 --> 00:21:42.470 flatted paralysis, profound weakness. This is 00:21:42.470 --> 00:21:45.430 the floppy side. The patho in the slides explains. 00:21:46.089 --> 00:21:48.670 Toxin produced in the intestines of young children 00:21:48.670 --> 00:21:51.849 resulting from infection with Clostridium botulinum. 00:21:52.369 --> 00:21:55.549 And it specifically highlights immature intestines. 00:21:56.069 --> 00:21:58.470 Why is that important? This is a crucial distinction. 00:21:58.869 --> 00:22:01.109 In adults, botulism usually comes from eating 00:22:01.109 --> 00:22:03.690 preformed toxin, like from improperly canned 00:22:03.690 --> 00:22:06.509 food. But infants get it because they swallow 00:22:06.509 --> 00:22:08.930 the spores of the bacteria, most famously from 00:22:08.930 --> 00:22:11.009 honey, but also from environmental dust. Which 00:22:11.009 --> 00:22:13.390 is why we have the rule. No honey for any child 00:22:13.390 --> 00:22:15.869 under one year of age. Exactly. An adult's gut 00:22:15.869 --> 00:22:18.150 is very acidic, and it's full of mature, good 00:22:18.150 --> 00:22:20.450 bacteria that kill off any spores that come through. 00:22:20.730 --> 00:22:24.349 A baby's gut is like a pristine open field. The 00:22:24.349 --> 00:22:26.690 spores land, they germinate, they grow and they 00:22:26.690 --> 00:22:29.029 start producing the toxin inside the baby. The 00:22:29.029 --> 00:22:32.109 symptoms listed are constipation, poor feeding, 00:22:32.710 --> 00:22:35.150 listlessness, generalized weakness, and a weak 00:22:35.150 --> 00:22:38.190 cry. And constipation is very often the very 00:22:38.190 --> 00:22:40.400 first sign you'll see. The gut muscles are the 00:22:40.400 --> 00:22:42.220 first to get weak, so everything slows down. 00:22:42.640 --> 00:22:44.500 Then the weakness begins its classic descent 00:22:44.500 --> 00:22:46.960 from the head down. You'll notice a weak cry, 00:22:47.220 --> 00:22:49.579 a poor suck on the bottle. Then they lose head 00:22:49.579 --> 00:22:52.240 control, then trunk control. If you lift the 00:22:52.240 --> 00:22:54.180 baby up under their arms, they feel like a rag 00:22:54.180 --> 00:22:57.559 doll. Just floppy. And the treatment listed is 00:22:57.559 --> 00:23:01.359 botulinum immunoglobulin. Right. We call it Baby 00:23:01.359 --> 00:23:05.150 Big. It's an antitoxin that circulates and neutralizes 00:23:05.150 --> 00:23:07.450 the toxin. But again, just like with tetanus, 00:23:07.609 --> 00:23:10.269 the nursing priority is supportive care. This 00:23:10.269 --> 00:23:12.769 toxin also hits the respiratory muscles. But 00:23:12.769 --> 00:23:14.970 instead of clamping shut, the diaphragm becomes 00:23:14.970 --> 00:23:17.490 too weak and floppy to pull air in. So they need 00:23:17.490 --> 00:23:19.750 respiratory support. They often need to be intubated 00:23:19.750 --> 00:23:21.789 and put on a ventilator. And you have to provide 00:23:21.789 --> 00:23:24.369 nutrition, usually with an NG tube, until their 00:23:24.369 --> 00:23:26.970 nerves regenerate, which can take weeks or even 00:23:26.970 --> 00:23:29.109 months. So the developmental impact there is 00:23:29.109 --> 00:23:32.349 massive. It's huge. Failure to thrive is a major 00:23:32.349 --> 00:23:34.410 risk because they can't eat for a long time. 00:23:34.730 --> 00:23:36.710 And if they're on a ventilator for weeks, they're 00:23:36.710 --> 00:23:38.890 missing out on all that critical bonding, tummy 00:23:38.890 --> 00:23:41.630 time, and those early sensory experiences that 00:23:41.630 --> 00:23:44.309 build the brain. It's a long recovery. OK, let's 00:23:44.309 --> 00:23:47.250 move to the vector borne diseases, the bug bites. 00:23:47.910 --> 00:23:51.329 First up is Lyme disease. The great mimic, because 00:23:51.329 --> 00:23:53.490 its symptoms can look like so many other things. 00:23:53.769 --> 00:23:56.549 The symptoms are listed as, renal like rash at 00:23:56.549 --> 00:24:00.099 the site, fever. headache, malaise, fatigue, 00:24:00.619 --> 00:24:03.490 arthralgia which is joint pain. That ring -like 00:24:03.490 --> 00:24:06.289 rash, the erythema migrans, or the bullseye rash, 00:24:06.430 --> 00:24:09.509 is the Hallmark sign. But the problem is, not 00:24:09.509 --> 00:24:11.710 every kid gets it, or sometimes the parents miss 00:24:11.710 --> 00:24:13.529 it because it's on their scalp, under their hair, 00:24:13.549 --> 00:24:15.250 or on their back. So you have to look for the 00:24:15.250 --> 00:24:16.849 other signs. You have to look for the systemic 00:24:16.849 --> 00:24:19.069 signs, what looks like a summer flu. If a kid 00:24:19.069 --> 00:24:21.789 has flu -like symptoms in July or August, you 00:24:21.789 --> 00:24:24.130 need to be asking about ticks and outdoor activities. 00:24:24.349 --> 00:24:27.490 The materials also mention a really scary complication. 00:24:28.049 --> 00:24:31.049 Severe neurological complications, cranial nerve 00:24:31.049 --> 00:24:34.150 palsy. Yes, specifically Bell's palsy, which 00:24:34.150 --> 00:24:36.690 is a facial droop on one side. This is a big 00:24:36.690 --> 00:24:39.029 red flag. If a parent brings in their child in 00:24:39.029 --> 00:24:40.730 the summertime because their face started drooping 00:24:40.730 --> 00:24:42.150 on one side and they tell you they were just 00:24:42.150 --> 00:24:44.230 camping in the woods, you need to be testing 00:24:44.230 --> 00:24:46.650 for Lyme disease. Now, here's a very specific 00:24:46.650 --> 00:24:49.869 pharmacology rule in the notes. Doxycycline for 00:24:49.869 --> 00:24:52.329 children older than eight years and amoxicillin 00:24:52.329 --> 00:24:54.750 for children younger than eight years. This is 00:24:54.750 --> 00:24:58.390 a classic exam roll. Doxycycline is in the tetracycline 00:24:58.390 --> 00:25:01.049 family of antibiotics, and we generally avoid 00:25:01.049 --> 00:25:02.869 tetracyclines in children under eight because 00:25:02.869 --> 00:25:05.269 they bind to calcium in developing teeth. And 00:25:05.269 --> 00:25:07.329 that causes staining. You can cause permanent 00:25:07.329 --> 00:25:09.470 yellow or gray staining of the permanent teeth. 00:25:09.670 --> 00:25:12.269 So for Lyme disease, which is easily treatable 00:25:12.269 --> 00:25:14.829 with other drugs, we play it safe. Under eight, 00:25:15.130 --> 00:25:17.750 amoxicillin. Over eight, doxycycline is fine. 00:25:17.809 --> 00:25:19.809 But wait, I'm looking at the very next slide. 00:25:20.329 --> 00:25:23.940 Rocky Mountain Spotted Fever. or RMSF. Right. 00:25:24.339 --> 00:25:26.539 Another tick -borne disease, but a much more 00:25:26.539 --> 00:25:28.700 dangerous beast. The symptoms look similar at 00:25:28.700 --> 00:25:31.819 first. Fever, malaise, rash, myalgia, nausea, 00:25:32.039 --> 00:25:34.119 vomiting. But then I look at the management section, 00:25:34.220 --> 00:25:37.480 it just says, tetracycline. It doesn't give that 00:25:37.480 --> 00:25:40.180 age split. Why not? And that is a critical clinical 00:25:40.180 --> 00:25:43.700 nuance in a great exam question. RMSF is a vasculitis. 00:25:44.019 --> 00:25:45.980 It's an infection that attacks the lining of 00:25:45.980 --> 00:25:48.339 the blood vessels all over the body. It causes 00:25:48.339 --> 00:25:51.119 them to leak and bleed. The fatality rate is 00:25:51.119 --> 00:25:53.420 high if it's not treated quickly and correctly. 00:25:53.640 --> 00:25:55.900 And doxycycline is the best treatment. Doxycycline 00:25:55.900 --> 00:25:58.660 is the only high - That's it. And also, look 00:25:58.660 --> 00:26:01.799 at the rash. The lime rash is a bullseye. The 00:26:01.799 --> 00:26:04.900 RMSF rash is typically a patechial or macula 00:26:04.900 --> 00:26:07.059 papular rash that starts on the extremities, 00:26:07.319 --> 00:26:09.900 the wrists and ankles, and then spreads inward 00:26:09.900 --> 00:26:12.539 toward the trunk. That outside -in spread is 00:26:12.539 --> 00:26:14.900 a unique identifier. Got it. Okay, let's get 00:26:14.900 --> 00:26:17.140 itchy. We're moving to the parasitic and skin 00:26:17.140 --> 00:26:20.400 infestations, the school nurse specials. First 00:26:20.400 --> 00:26:24.839 up, pediculosis capitis. Head lice! The bane 00:26:24.839 --> 00:26:27.079 of every elementary school parent's existence. 00:26:27.460 --> 00:26:29.400 The clinical manifestations are pretty straightforward. 00:26:29.839 --> 00:26:32.480 Itching and observation of white eggs. The knits. 00:26:32.660 --> 00:26:34.420 And the key for assessment is distinguishing 00:26:34.420 --> 00:26:37.079 a knit from a piece of dandruff. Dandruff will 00:26:37.079 --> 00:26:39.279 flake right off when you flick it. Knits are 00:26:39.279 --> 00:26:41.180 cemented to the hair shaft with the specialized 00:26:41.180 --> 00:26:43.240 glue the last produces. You have to physically 00:26:43.240 --> 00:26:45.160 grab it and pull it all the way down the hair 00:26:45.160 --> 00:26:47.960 shaft to remove it. And the treatment. Permethrin 00:26:47.960 --> 00:26:51.250 and manual removal of knits. Right. The permethrin 00:26:51.250 --> 00:26:54.250 is a neurotoxin for the lice. It kills the live, 00:26:54.390 --> 00:26:57.150 crawling bugs. But it doesn't always penetrate 00:26:57.150 --> 00:26:59.789 the hard shell of the eggs, the nits. That's 00:26:59.789 --> 00:27:02.210 why the manual removal, the tedious nitpicking, 00:27:02.349 --> 00:27:04.750 is so important. If you miss just a few eggs, 00:27:04.890 --> 00:27:07.089 they'll hatch in seven to ten days and the whole 00:27:07.089 --> 00:27:09.230 cycle starts all over again. And for nursing 00:27:09.230 --> 00:27:12.819 care. Education regarding spread. This is a big 00:27:12.819 --> 00:27:15.000 one. You have to dispel the myths. Lice don't 00:27:15.000 --> 00:27:16.980 jump. They don't fly. They don't have wings and 00:27:16.980 --> 00:27:19.940 they don't have super legs. They crawl. So transmission 00:27:19.940 --> 00:27:22.759 is almost always from direct head -to -head contact 00:27:22.759 --> 00:27:25.579 or from sharing items that touch the head like 00:27:25.579 --> 00:27:28.480 brushes, hats, or bike helmets. What about the 00:27:28.480 --> 00:27:30.500 developmental or the social impact here? Oh, 00:27:30.559 --> 00:27:33.039 it's huge. The stigma is very real. Kids get 00:27:33.039 --> 00:27:35.579 teased relentlessly at school. Parents often 00:27:35.579 --> 00:27:37.460 feel ashamed, like it's a sign that their house 00:27:37.460 --> 00:27:40.180 is dirty or they're a bad parent. The nurse needs 00:27:40.180 --> 00:27:43.200 to provide a lot of reassurance. Lice actually 00:27:43.200 --> 00:27:45.619 prefer clean hair. It's easier for them to attach 00:27:45.619 --> 00:27:47.799 their eggs to a clean hair shaft than an oily 00:27:47.799 --> 00:27:50.420 one. This is not a hygiene failure. It's just 00:27:50.420 --> 00:27:53.279 really bad luck. OK, moving on to scabies. The 00:27:53.279 --> 00:27:56.579 mite that burrows. Sarcoptis scabii. A whole 00:27:56.579 --> 00:27:59.089 different level of itch. The manifestations here 00:27:59.089 --> 00:28:02.690 are inflammation with pruritus maculopapular 00:28:02.690 --> 00:28:05.269 lesions between digits. That location is the 00:28:05.269 --> 00:28:07.630 hallmark. The intra -digital spaces, the webs 00:28:07.630 --> 00:28:10.589 of the fingers, that's a classic spot. The groin, 00:28:10.789 --> 00:28:13.170 the armpits, and along the waistline are also 00:28:13.170 --> 00:28:16.069 very common. The female might literally burrows 00:28:16.069 --> 00:28:18.450 under the top layer of the epidermis to lay her 00:28:18.450 --> 00:28:22.150 eggs and, well, poop. And that leaves a visible 00:28:22.150 --> 00:28:25.130 linear track, like a tiny little pencil line 00:28:25.130 --> 00:28:27.900 under the skin. That is disgusting. and the itch. 00:28:28.119 --> 00:28:30.839 It's intense, overwhelming, and it's characteristically 00:28:30.839 --> 00:28:33.680 worse at night. And here's a key patho point 00:28:33.680 --> 00:28:36.119 for understanding this. The itch is actually 00:28:36.119 --> 00:28:38.500 an allergic reaction to the mites waste products. 00:28:38.920 --> 00:28:41.000 So the first time a kid gets scabies, they might 00:28:41.000 --> 00:28:43.160 not even itch for several weeks until their immune 00:28:43.160 --> 00:28:45.099 system sensitizes to the mite. Oh, that's important. 00:28:45.319 --> 00:28:47.990 OK, treatment, scabicide, permethrin. But the 00:28:47.990 --> 00:28:49.930 instructions here are different. Leave on for 00:28:49.930 --> 00:28:53.190 8 -14 hours. Right. For scabies, you apply the 00:28:53.190 --> 00:28:55.430 cream from the neck down. You have to cover every 00:28:55.430 --> 00:28:57.130 single inch of the body, and the person sleeps 00:28:57.130 --> 00:28:59.009 in it, then washes it off in the morning. And 00:28:59.009 --> 00:29:01.890 here's the kicker, prophylactic therapy for household 00:29:01.890 --> 00:29:04.990 members. This is the biggest exam trap for stabies. 00:29:05.410 --> 00:29:07.730 If one kid in the house has scabies, you must 00:29:07.730 --> 00:29:09.809 treat everyone who lives in that house at the 00:29:09.809 --> 00:29:12.170 exact same time, even if they aren't itching. 00:29:12.710 --> 00:29:15.349 Remember, the itch can take weeks to show up. 00:29:15.450 --> 00:29:18.509 If you only treat the one itchy patient, their 00:29:18.509 --> 00:29:21.109 asymptomatic brother or parent will just give 00:29:21.109 --> 00:29:23.930 it right back to them next week. Okay, and finally, 00:29:24.230 --> 00:29:27.269 pinworms. The last of the itchy bunch. The most 00:29:27.269 --> 00:29:29.609 common worm infection in the United States, believe 00:29:29.609 --> 00:29:32.369 it or not. The symptoms are listed as anal itching 00:29:32.369 --> 00:29:36.109 and restlessness. Specifically, itching at night. 00:29:36.589 --> 00:29:38.930 The female worm lives up in the cecum, but at 00:29:38.930 --> 00:29:41.549 night she migrates all the way down and crawls 00:29:41.549 --> 00:29:43.869 out of the anus to lay her eggs on the perinatal 00:29:43.869 --> 00:29:46.549 skin. The glue she uses to stick the eggs there 00:29:46.549 --> 00:29:49.390 is very irritating. It causes an intense localized 00:29:49.390 --> 00:29:51.650 itching. So the kid scratches. The kid scratches 00:29:51.650 --> 00:29:53.690 in their sleep, gets the microscopic eggs under 00:29:53.690 --> 00:29:55.589 their fingernails, and then the next day puts 00:29:55.589 --> 00:29:57.750 their fingers in their mouth or touches a toy 00:29:57.750 --> 00:30:00.210 that another kid then touches, and the oral -fecal 00:30:00.210 --> 00:30:02.710 cycle continues. And the diagnosis is the tape 00:30:02.710 --> 00:30:06.369 test. Yes. It's very low tech, but very high 00:30:06.369 --> 00:30:09.009 yield. You take a piece of clear scotch tape, 00:30:09.309 --> 00:30:11.730 sticky side out, wrapped around a tongue depressor, 00:30:11.990 --> 00:30:13.630 first thing in the morning before the child uses 00:30:13.630 --> 00:30:16.349 the bathroom or takes a bath. You press the tape 00:30:16.349 --> 00:30:19.210 firmly against the skin around the anus. The 00:30:19.210 --> 00:30:21.529 eggs stick to the tape. You then put the tape 00:30:21.529 --> 00:30:24.089 on a glass slide and send it to the lab to be 00:30:24.089 --> 00:30:27.230 looked at under a microscope. Treatment is mubendazole 00:30:27.230 --> 00:30:29.890 or parenteral pomode. Yes, and again, you treat 00:30:29.890 --> 00:30:32.029 the whole household. And you have to watch all 00:30:32.029 --> 00:30:34.109 the bedding in pajamas and hot water to kill 00:30:34.109 --> 00:30:36.990 any eggs in the environment. It's usually one 00:30:36.990 --> 00:30:39.269 dose now and then a second dose in two weeks 00:30:39.269 --> 00:30:41.809 to kill any worms that hatched from eggs that 00:30:41.809 --> 00:30:44.210 were swallowed later. Okay, we've covered the 00:30:44.210 --> 00:30:46.569 bugs. Now let's pull back and talk about the 00:30:46.569 --> 00:30:48.509 nursing interventions that apply across many 00:30:48.509 --> 00:30:51.269 of these conditions. Part C. I'm looking at the 00:30:51.269 --> 00:30:53.549 material on nursing interventions to promote 00:30:53.549 --> 00:30:56.390 comfort. Because regardless of the specific bug, 00:30:56.609 --> 00:30:58.990 whether it's chicken pox, scabies, or measles, 00:30:59.430 --> 00:31:02.430 the child is miserable and uncomfortable. And 00:31:02.430 --> 00:31:04.450 an uncomfortable child doesn't eat, doesn't sleep, 00:31:04.509 --> 00:31:06.910 and doesn't heal as well. The first one is straightforward. 00:31:07.549 --> 00:31:12.240 Assess pain. Administer analgesics and antipyridics. 00:31:12.619 --> 00:31:15.240 Antipyridics just means anti -itch, right? Yes. 00:31:15.680 --> 00:31:18.680 Medications like diphenhydramine, benadryl, or 00:31:18.680 --> 00:31:21.359 hydroxazine, these help with the itch directly, 00:31:21.539 --> 00:31:23.460 but they also have a helpful sedative effect, 00:31:23.539 --> 00:31:25.339 which can be a blessing for a kid who has been 00:31:25.339 --> 00:31:28.079 scratching all night and can't sleep. Apply cool 00:31:28.079 --> 00:31:31.099 compresses or baths to areas of pruritus. Why 00:31:31.099 --> 00:31:35.190 cool? It's basic physics. Heat causes vasodilation. 00:31:35.450 --> 00:31:37.849 It opens up the blood vessels. That brings more 00:31:37.849 --> 00:31:40.009 histamine and inflammatory cells to the skin, 00:31:40.069 --> 00:31:42.710 which actually makes the itching worse. Cool 00:31:42.710 --> 00:31:45.150 water, on the other hand, causes vasoconstriction. 00:31:45.470 --> 00:31:48.089 It calms the inflammation and temporarily numbs 00:31:48.089 --> 00:31:51.349 the nerve endings. So never hot baths for itchy 00:31:51.349 --> 00:31:55.079 kids. Tepid or cool is the way to go. OK. provide 00:31:55.079 --> 00:31:57.500 cool mishumidification. This is more for those 00:31:57.500 --> 00:32:00.019 respiratory kids, the ones with perticis, diphtheria, 00:32:00.059 --> 00:32:02.519 or even just a bad case of croup. It helps keep 00:32:02.519 --> 00:32:04.799 the mucus and secretions in their airway loose 00:32:04.799 --> 00:32:06.799 and thin so they can cough them up more easily. 00:32:06.940 --> 00:32:08.680 And here's one parents get wrong all the time. 00:32:09.319 --> 00:32:11.559 Dress the child in light clothing of febrile. 00:32:11.839 --> 00:32:15.079 Yes. Don't bundle up a feverish kid. The old 00:32:15.079 --> 00:32:17.960 wisdom was to sweat it out. But in pediatrics, 00:32:18.039 --> 00:32:20.339 all that does is raise the child's core temperature 00:32:20.339 --> 00:32:23.079 even higher and increases their risk of a febrile 00:32:23.079 --> 00:32:26.470 seizure. You want the heat to escape? A single 00:32:26.470 --> 00:32:29.509 layer of light cotton pajamas is perfect. Use 00:32:29.509 --> 00:32:31.970 diversional activities and distraction. This 00:32:31.970 --> 00:32:34.210 links right back to development. Play is the 00:32:34.210 --> 00:32:37.049 work of the child. Even sick kids need to play. 00:32:37.529 --> 00:32:40.410 Absolutely. And distraction is an incredibly 00:32:40.410 --> 00:32:43.869 powerful non -pharmacologic painkiller. For a 00:32:43.869 --> 00:32:46.650 toddler, blowing bubbles can completely distract 00:32:46.650 --> 00:32:49.329 them from the poke of an injection. For a school 00:32:49.329 --> 00:32:51.309 -age kid, an engaging video game can make them 00:32:51.309 --> 00:32:53.009 forget about the itch of their chicken pox for 00:32:53.009 --> 00:32:55.269 an hour. Okay, now let's focus on promoting skin 00:32:55.269 --> 00:32:57.730 integrity, first point. Keep child's fingernails 00:32:57.730 --> 00:33:00.450 short. This is so critical and so simple. Sure, 00:33:00.650 --> 00:33:02.430 clean nails prevent them from breaking the skin 00:33:02.430 --> 00:33:04.269 when they inevitably scratch. If they break the 00:33:04.269 --> 00:33:06.210 skin, they create a portal of entry for bacteria 00:33:06.210 --> 00:33:08.990 and they end up with impetigo or ocellulitis, 00:33:09.490 --> 00:33:11.849 a nasty secondary bacterial infection on top 00:33:11.849 --> 00:33:14.170 of their original problem. Encourage child to 00:33:14.170 --> 00:33:17.130 press on rather than scratch. Yeah, press. Don't 00:33:17.130 --> 00:33:19.859 scratch. It's a great little mantra to teach 00:33:19.859 --> 00:33:23.259 kids and parents. Applying firm pressure or rubbing 00:33:23.259 --> 00:33:25.539 the itchy spot with the palm of your hand can 00:33:25.539 --> 00:33:28.460 confuse the nerve endings and relieve that itch 00:33:28.460 --> 00:33:30.920 sensation without actually pairing the epidermis. 00:33:31.180 --> 00:33:32.900 Finally, let's talk about key teaching points. 00:33:33.799 --> 00:33:35.779 This is where we prevent kids from bouncing right 00:33:35.779 --> 00:33:39.490 back to the ER. First point. Assess child and 00:33:39.490 --> 00:33:41.890 family's willingness to learn. You have to read 00:33:41.890 --> 00:33:44.049 the room. If the parent is panicked, they aren't 00:33:44.049 --> 00:33:46.329 listening. If a mother is terrified that her 00:33:46.329 --> 00:33:48.450 child is going to stop breathing from pertussis, 00:33:48.730 --> 00:33:51.509 she cannot hear your detailed lecture on antibiotic 00:33:51.509 --> 00:33:53.930 schedules. You have to calm them down first. 00:33:54.269 --> 00:33:56.390 Acknowledge their fear. Say, this is really scary. 00:33:56.450 --> 00:33:58.970 I understand. Let's take a breath. Here is what 00:33:58.970 --> 00:34:01.250 we are going to do first. Repeat information. 00:34:01.789 --> 00:34:04.250 Teach in short sessions. This is the rule of 00:34:04.250 --> 00:34:07.000 repetition. Parents in a stressful hospital environment 00:34:07.000 --> 00:34:09.699 are basically sleep -deprived zombies. They probably 00:34:09.699 --> 00:34:11.980 retain about 10 % of what you say the first time, 00:34:12.000 --> 00:34:14.280 so you have to write it down, say it again, and 00:34:14.280 --> 00:34:16.400 then have them teach it back to you. Show me 00:34:16.400 --> 00:34:18.360 how you are going to measure that Tylenol. And 00:34:18.360 --> 00:34:21.559 lastly, gear teaching to the level of understanding 00:34:21.559 --> 00:34:24.739 of the child. Don't ignore the kid. They are 00:34:24.739 --> 00:34:27.949 the patient. You need their cooperation. Explain 00:34:27.949 --> 00:34:29.690 to the five -year -old why they have to take 00:34:29.690 --> 00:34:32.489 the yucky tasting medicine. This pink stuff is 00:34:32.489 --> 00:34:34.250 going to fight the bad bugs in your throat so 00:34:34.250 --> 00:34:37.070 you can go back to playing soccer again? Use 00:34:37.070 --> 00:34:39.730 simple, empowering terms. These are the good 00:34:39.730 --> 00:34:42.650 soldiers fighting the bad germs. So we've mapped 00:34:42.650 --> 00:34:45.110 it out. We've gone system by system. We've looked 00:34:45.110 --> 00:34:47.409 at the big nursing interventions. What does this 00:34:47.409 --> 00:34:49.170 all mean for the learner who is getting ready 00:34:49.170 --> 00:34:51.489 to take their exam? Let's try to summarize the 00:34:51.489 --> 00:34:53.610 master keys. I think it means you need to filter 00:34:53.769 --> 00:34:56.070 every single question you read through the dual 00:34:56.070 --> 00:34:59.409 lens of safety and development. First, safety. 00:34:59.949 --> 00:35:03.809 One, airway. Is there a membrane like in diphtheria 00:35:03.809 --> 00:35:06.210 or a ton of secretions like in pertussis that's 00:35:06.210 --> 00:35:08.789 blocking the pipe? If yes, that is always your 00:35:08.789 --> 00:35:12.449 priority. Two, neuro. Is the muscle too tight 00:35:12.449 --> 00:35:14.909 like in tetanus or too weak and floppy like in 00:35:14.909 --> 00:35:18.030 botulism? Both of those paths lead to respiratory 00:35:18.030 --> 00:35:22.070 failure. Three, rash. Is this a simple viral 00:35:22.070 --> 00:35:24.670 rash where we can watch and wait? Or is it bacterial 00:35:24.670 --> 00:35:26.889 or vector -borne, where we need to give antibiotics 00:35:26.889 --> 00:35:29.409 immediately to save the heart or kidneys? Four, 00:35:29.849 --> 00:35:32.369 itch. Are we doing everything we can to prevent 00:35:32.369 --> 00:35:34.250 secondary infection from scratching, and are 00:35:34.250 --> 00:35:36.250 we remembering to treat the entire household, 00:35:36.349 --> 00:35:38.070 not just the one patient? And the developmental 00:35:38.070 --> 00:35:40.489 takeaways seem to be. For infants, you're always 00:35:40.489 --> 00:35:42.989 watching for apnea and feeding failure. For toddlers, 00:35:43.349 --> 00:35:45.409 you're watching for regression and mobility issues 00:35:45.409 --> 00:35:48.130 like refusing to walk in osteomyelitis. And for 00:35:48.130 --> 00:35:50.369 school -age kids and teens, you have to be aware 00:35:50.369 --> 00:35:52.369 of the body image issues and the social stigma 00:35:52.369 --> 00:35:54.429 that comes with things like lice or a lime rash. 00:35:54.909 --> 00:35:57.309 Precisely. If you view the question through those 00:35:57.309 --> 00:36:00.010 lenses, you will land on the right answer 80 00:36:00.010 --> 00:36:03.010 % of the time, probably more. I want to end with 00:36:03.010 --> 00:36:04.809 a thought on one of the first slides in this 00:36:04.809 --> 00:36:07.449 deck. It lists methods of preventing infectious 00:36:07.449 --> 00:36:11.619 diseases. The second bullet point is simply adequate 00:36:11.619 --> 00:36:14.400 immunization. Mm -hmm. This is the elephant in 00:36:14.400 --> 00:36:16.900 the room, isn't it? diphtheria, pertussis tetanus, 00:36:17.159 --> 00:36:20.480 measles, rubella. We just spent a lot of time 00:36:20.480 --> 00:36:23.659 talking about how truly horrific these diseases 00:36:23.659 --> 00:36:27.750 are. The bull neck, the lock jaw. The 100 -day 00:36:27.750 --> 00:36:30.130 cough. It's easy for us to forget that for a 00:36:30.130 --> 00:36:32.030 long, long time we just didn't see these diseases 00:36:32.030 --> 00:36:34.110 because the vaccines were so effective. And as 00:36:34.110 --> 00:36:36.070 vaccination rates fluctuate in different communities, 00:36:36.349 --> 00:36:38.550 we are seeing them return. We are seeing major 00:36:38.550 --> 00:36:40.489 pertussis outbreaks. We're seeing measles come 00:36:40.489 --> 00:36:42.809 back. The nurse is on the front line of education. 00:36:43.030 --> 00:36:45.289 And when you truly understand the pathology, 00:36:45.329 --> 00:36:47.210 when you can picture in your mind what tetanus 00:36:47.210 --> 00:36:50.150 can do to a child's spine, you become a much 00:36:50.150 --> 00:36:52.849 more powerful and effective advocate for that 00:36:52.849 --> 00:36:55.230 DTaP vaccine. It's not just checking a box on 00:36:55.230 --> 00:36:57.550 a form. No. It's about preventing an absolute 00:36:57.550 --> 00:37:00.489 nightmare. That is a very powerful place to leave 00:37:00.489 --> 00:37:03.630 it. This knowledge isn't just to pass an exam. 00:37:04.030 --> 00:37:06.329 It's for the protection of these kids. Well said. 00:37:06.429 --> 00:37:08.929 To the learner. Take a deep breath. You do not 00:37:08.929 --> 00:37:10.949 need to know every single detail. Focus on the 00:37:10.949 --> 00:37:13.250 patterns. Focus on the airway. Focus on safety. 00:37:13.590 --> 00:37:15.030 You've got this. Go crush that exam.