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 --> 00:00:46.530 fast. Welcome to the emergency room. Welcome 00:00:46.530 --> 00:00:48.990 back to the deep dive. Today we are doing something 00:00:48.990 --> 00:00:52.429 a little different and frankly something I think 00:00:52.429 --> 00:00:54.570 a lot of our listeners have been secretly or 00:00:54.570 --> 00:00:58.100 not so secretly begging for. Usually we're taking 00:00:58.100 --> 00:01:00.859 a wide -angle lens to these big topics, you know, 00:01:01.000 --> 00:01:04.719 tech trends, history, societal shifts. But today... 00:01:04.719 --> 00:01:07.780 We're zooming in. We're zooming way in. Microscope 00:01:07.780 --> 00:01:10.159 level. We are looking at a stack of documents 00:01:10.159 --> 00:01:13.879 that I think terrifies a very specific segment 00:01:13.879 --> 00:01:16.000 of our audience. It's definitely a bit of a departure 00:01:16.000 --> 00:01:18.140 from our usual broad philosophy, isn't it? It 00:01:18.140 --> 00:01:20.200 is. Today we're not talking theory. We're looking 00:01:20.200 --> 00:01:23.540 at a massive stack of, well... Textbooks, lecture 00:01:23.540 --> 00:01:26.459 notes, clinical decision trees, the real nitty 00:01:26.459 --> 00:01:28.879 -gritty. A massive stack is an understatement. 00:01:28.939 --> 00:01:31.239 We're officially doing the pediatric nursing 00:01:31.239 --> 00:01:33.920 exam cram edition of the Deep Dive. I like it. 00:01:34.019 --> 00:01:36.219 We have pulled the heavy hitters, specifically 00:01:36.219 --> 00:01:39.640 Chapter 22, from the Wolter's Cluartex and PDA 00:01:39.640 --> 00:01:42.340 Chapter 22. We've got, I mean, lecture notes, 00:01:42.700 --> 00:01:45.659 charts on musculoskeletal and neuromuscular disorders. 00:01:45.980 --> 00:01:49.980 It is dense. It is dense? But it's also incredibly 00:01:49.980 --> 00:01:52.739 high stakes. Whether you are a nursing student 00:01:52.739 --> 00:01:55.959 sweating over an upcoming board exam, or you're 00:01:55.959 --> 00:01:57.819 a clinician who just wants to make sure you don't 00:01:57.819 --> 00:02:00.799 miss something critical at the bedside, this 00:02:00.799 --> 00:02:03.659 material is the absolute foundation. The foundation 00:02:03.659 --> 00:02:06.700 of what? Of keeping kids safe. Exactly. And our 00:02:06.700 --> 00:02:09.159 mission today is simple. We are not going to 00:02:09.159 --> 00:02:11.020 read the textbook to you. Please don't. No, that 00:02:11.020 --> 00:02:13.139 would be a cure for insomnia, not a study tool. 00:02:14.330 --> 00:02:16.849 we are going to apply the Pareto principle, the 00:02:16.849 --> 00:02:19.949 80 -20 rule, to this mountain of information. 00:02:19.990 --> 00:02:22.169 Okay. We want to find the 20 % of the material 00:02:22.169 --> 00:02:25.490 that answers 80 % of the exam questions and more 00:02:25.490 --> 00:02:27.830 importantly, prevents 80 % of the bad outcomes. 00:02:27.930 --> 00:02:30.509 I love that approach. It's about being strategic. 00:02:30.689 --> 00:02:32.330 We're going to act as your strategic coaches. 00:02:32.409 --> 00:02:34.870 So I'll play the role of the veteran clinical 00:02:34.870 --> 00:02:39.030 educator who's seen it all. And I could be the 00:02:39.030 --> 00:02:41.250 advocate for the stressed learner. Perfect. I'll 00:02:41.250 --> 00:02:43.530 be the one asking, do I really, really need to 00:02:43.530 --> 00:02:45.750 memorize this, or is it just a fluff? Because 00:02:45.750 --> 00:02:47.729 let's be honest, when you're staring at 1 ,000 00:02:47.729 --> 00:02:51.189 pages, everything looks like a priority. It does. 00:02:51.250 --> 00:02:54.580 And in pediatrics, the stakes are just... They're 00:02:54.580 --> 00:02:56.240 different. You aren't just treating a broken 00:02:56.240 --> 00:02:58.599 bone. You're treating a growing organism. The 00:02:58.599 --> 00:03:01.120 whole system is in flux. The physiology is different. 00:03:01.259 --> 00:03:03.259 The physiology is different. The psychology is 00:03:03.259 --> 00:03:05.919 different. And honestly, the way they break is 00:03:05.919 --> 00:03:08.360 different. If you treat a child like a mini adult, 00:03:08.639 --> 00:03:11.259 you're going to miss things, big things. OK, 00:03:11.360 --> 00:03:14.280 so here's our roadmap for this deep dive. We're 00:03:14.280 --> 00:03:16.580 breaking this into three distinct parts to keep 00:03:16.580 --> 00:03:19.379 it organized. First, we're going to lay out the 00:03:19.379 --> 00:03:22.879 Master 8020 map. The high yield patterns. Exactly. 00:03:22.979 --> 00:03:25.460 The patterns that show up across all these diseases. 00:03:25.800 --> 00:03:28.300 The idea is if you get the pattern, you can often 00:03:28.300 --> 00:03:30.639 guess the answer even if you forgot the specific 00:03:30.639 --> 00:03:33.099 pathology. That's the key to critical thinking 00:03:33.099 --> 00:03:35.319 right there. It's not about rote memorization. 00:03:35.400 --> 00:03:36.800 And then for the second part, we're going to 00:03:36.800 --> 00:03:39.080 do a condition by condition breakdown, the system 00:03:39.080 --> 00:03:41.740 by system lecture. We'll go from spina bifida 00:03:41.740 --> 00:03:44.819 to clubfoot and we'll specifically highlight 00:03:44.819 --> 00:03:48.479 need to know versus nice to know. I love that 00:03:48.479 --> 00:03:50.620 distinction. It helps you focus your energy. 00:03:50.830 --> 00:03:53.150 And finally, we'll hit the developmental cross 00:03:53.150 --> 00:03:55.949 -link, because in PEDS, you aren't just treating 00:03:55.949 --> 00:03:58.449 a bone, you're treating a growing kid. If you 00:03:58.449 --> 00:04:01.289 fix the hip, but you ruin their development because 00:04:01.289 --> 00:04:03.650 of isolation or trauma. You haven't done your 00:04:03.650 --> 00:04:06.169 job. That last part is so crucial. Holisticare 00:04:06.169 --> 00:04:08.110 isn't just a buzzword, it's the exam answer. 00:04:08.150 --> 00:04:10.270 It's the whole point. All right, let's unpack 00:04:10.270 --> 00:04:14.169 this. Part A, the master 80 -20 map. When you 00:04:14.169 --> 00:04:17.170 analyzed all these sources, I mean, from clubfoot 00:04:17.170 --> 00:04:20.870 to cerebral palsy, What are the big patterns 00:04:20.870 --> 00:04:23.529 these Xamriders are obsessed with? There are 00:04:23.529 --> 00:04:25.910 three main patterns. And if you recognize these, 00:04:25.970 --> 00:04:28.110 you can answer questions even if you've forgotten 00:04:28.110 --> 00:04:30.750 the specific pathophysiology. The first one is 00:04:30.750 --> 00:04:33.069 what I call the immobility trap. The immobility 00:04:33.069 --> 00:04:35.149 trap. OK, that sounds ominous. Break that down. 00:04:35.290 --> 00:04:37.470 This covers anything that stops a child from 00:04:37.470 --> 00:04:40.230 moving, whether it's a cast for a fracture, traction 00:04:40.230 --> 00:04:43.829 for a hip issue, or even paralysis from a neuromuscular 00:04:43.829 --> 00:04:46.589 disorder like spinal muscular atrophy. So anything 00:04:46.589 --> 00:04:48.870 that keeps them still. Anything that keeps them 00:04:48.870 --> 00:04:52.220 still. The exam question here is almost always 00:04:52.220 --> 00:04:54.660 about the complications of that immobility. And 00:04:54.660 --> 00:04:56.740 the king of all complications is compartment 00:04:56.740 --> 00:04:58.779 syndrome. I see this in the notes everywhere. 00:04:58.939 --> 00:05:01.420 It's in big, bold letters, highlighted in neon 00:05:01.420 --> 00:05:04.100 yellow. It seems like the exam writers really, 00:05:04.100 --> 00:05:06.540 really want us to know this. For very good reason. 00:05:06.540 --> 00:05:10.180 This is a need -to -know safety priority. Imagine 00:05:10.180 --> 00:05:13.819 the limb, the arm, or leg is like a turkey sandwich 00:05:13.819 --> 00:05:16.839 wrapped tightly in cling film. Okay, weird analogy, 00:05:16.920 --> 00:05:19.180 but I'm with you. Turkey sandwich. The muscles 00:05:19.180 --> 00:05:22.180 and blood vessels are the turkey. And the fascia, 00:05:22.360 --> 00:05:24.079 that's the connective tissue sheath holding it 00:05:24.079 --> 00:05:27.259 all together, is the cling film. Now, if the 00:05:27.259 --> 00:05:30.160 muscle swells due to trauma, or if the cast is 00:05:30.160 --> 00:05:32.079 applied too tightly, that pressure builds up 00:05:32.079 --> 00:05:35.360 inside. But the fascia, the cling film, it doesn't 00:05:35.360 --> 00:05:38.579 stretch. It's rigid. So the pressure has nowhere 00:05:38.579 --> 00:05:41.740 to go but inward. Oh, wow. It turns inward and 00:05:41.740 --> 00:05:44.279 crushes the blood vessel. Exactly. It compresses 00:05:44.279 --> 00:05:46.439 the arteries and the veins. It literally cuts 00:05:46.439 --> 00:05:48.980 off the oxygen supply to the muscles and nerves 00:05:48.980 --> 00:05:51.819 downstream. And that's bad. That is limb -threatening. 00:05:52.199 --> 00:05:54.360 If you don't catch this within a few hours, we're 00:05:54.360 --> 00:05:56.680 talking usually four to six hours, the tissue 00:05:56.680 --> 00:06:00.060 dies. It's irreversible necrosis. You lose the 00:06:00.060 --> 00:06:02.300 limb. So this leads us to the famous five Ps. 00:06:02.439 --> 00:06:04.920 This is the safety priority assessment everyone 00:06:04.920 --> 00:06:08.519 talks about. The five Ps. Pain, pallor, pulselessness, 00:06:08.720 --> 00:06:11.319 paresthesia, and paralysis. But, and this is 00:06:11.319 --> 00:06:13.740 the massive need to know nuance that trips people 00:06:13.740 --> 00:06:16.620 up, you cannot wait for all five. If you wait 00:06:16.620 --> 00:06:19.259 for pulselessness. If you wait until you can't 00:06:19.259 --> 00:06:21.899 feel a pulse, you have likely already lost the 00:06:21.899 --> 00:06:25.360 limb. That is a very, very late sign. The damage 00:06:25.360 --> 00:06:27.639 is done. So which P is the canary in the coal 00:06:27.639 --> 00:06:29.839 mine? Which one do we need to spot first? Pain. 00:06:30.199 --> 00:06:33.319 But not just any pain, it is pain that is disproportionate 00:06:33.319 --> 00:06:35.500 to the injury. Give me a clinical picture of 00:06:35.500 --> 00:06:38.579 that because, I mean, kids cry when they break 00:06:38.579 --> 00:06:40.579 their arm. How do I know the difference between, 00:06:40.660 --> 00:06:43.920 ouch, my arm is broken and my arm is dying? Great 00:06:43.920 --> 00:06:45.920 question. So let's say you have a six -year -old 00:06:45.920 --> 00:06:48.360 with a forearm fracture. You've aligned it, you've 00:06:48.360 --> 00:06:50.079 casted it, and you've given them the ordered 00:06:50.079 --> 00:06:52.139 morphine or, you know, some other heavy -duty 00:06:52.139 --> 00:06:55.420 analgesic. Thirty minutes later... They are still 00:06:55.420 --> 00:06:58.060 screaming. They are agitated. They are saying 00:06:58.060 --> 00:07:01.100 their arm feels like it's on fire or it's asleep 00:07:01.100 --> 00:07:04.100 but in a painful way. So the rookie mistake is 00:07:04.100 --> 00:07:06.779 to think, well, they're a kid, they have a low 00:07:06.779 --> 00:07:09.519 pain tolerance, or maybe they're just scared. 00:07:09.819 --> 00:07:12.120 That is the fatal error. That's the one that 00:07:12.120 --> 00:07:14.779 ends up in a lawsuit. If the meds don't touch 00:07:14.779 --> 00:07:17.800 the pain, what we call intractable pain, or if 00:07:17.800 --> 00:07:19.839 moving their fingers passively, just wiggling 00:07:19.839 --> 00:07:23.279 them for them, causes screaming agony. Wow. That 00:07:23.279 --> 00:07:25.379 is compartment syndrome until proven otherwise. 00:07:25.620 --> 00:07:29.339 OK. That is a huge, huge red flag. Pain that 00:07:29.339 --> 00:07:32.779 meds don't touch. So say we see this. What is 00:07:32.779 --> 00:07:35.009 the first line action? You notify the provider 00:07:35.009 --> 00:07:37.250 immediately. This is a medical emergency. You 00:07:37.250 --> 00:07:39.730 do not, and I repeat, do not elevate the limb 00:07:39.730 --> 00:07:41.250 high above the heart. Oh, I thought you were 00:07:41.250 --> 00:07:43.329 supposed to elevate for swelling. Normally, yes. 00:07:43.589 --> 00:07:45.750 But here, that actually makes it harder for blood 00:07:45.750 --> 00:07:47.930 to get into the crushed area against gravity, 00:07:47.970 --> 00:07:49.810 so you keep it at heart level. OK, heart level. 00:07:49.829 --> 00:07:52.110 And if there is a tight cast, the intervention 00:07:52.110 --> 00:07:54.829 is to cut it. We call it bivalving, cutting it 00:07:54.829 --> 00:07:57.490 down both sides to relieve that external pressure. 00:07:57.709 --> 00:07:59.569 And if that doesn't work? Then they go to the 00:07:59.569 --> 00:08:01.680 operating room for a fasciotomy. That's where 00:08:01.680 --> 00:08:04.500 the surgeon literally slices open the fascia, 00:08:04.600 --> 00:08:07.199 the cling film, to let the muscle swell outward 00:08:07.199 --> 00:08:10.139 and get blood flow back. It's dramatic, but it 00:08:10.139 --> 00:08:13.560 saves the limb. Got it. So pattern one is immobility 00:08:13.560 --> 00:08:16.879 and the five P's. Catch the pain early. Don't 00:08:16.879 --> 00:08:20.199 wait. What is pattern two? Pattern two is the 00:08:20.199 --> 00:08:22.980 limping child. The exam writers absolutely love 00:08:22.980 --> 00:08:25.600 this because it forces you to filter the diagnosis 00:08:25.600 --> 00:08:28.639 through the child's age. A limp is not just a 00:08:28.639 --> 00:08:30.680 limp. Right. I saw this in the decision trees. 00:08:31.019 --> 00:08:33.240 It seems like the diagnosis shifts completely 00:08:33.240 --> 00:08:35.100 based on the birthday. It does. It's the most 00:08:35.100 --> 00:08:37.899 reliable filter you have. If you have an infant 00:08:37.899 --> 00:08:40.480 with a hip issue, it's almost always mechanical 00:08:40.480 --> 00:08:42.960 developmental dysplasia of the hip or DDH. Their 00:08:42.960 --> 00:08:45.299 hip socket just isn't formed right. OK. So infant 00:08:45.299 --> 00:08:48.350 equals DDH. Most likely. Now if you have a four 00:08:48.350 --> 00:08:50.049 to eight -year -old boy with a painless limp, 00:08:50.289 --> 00:08:53.250 it's likely a circulatory leg calvapirthus disease. 00:08:53.629 --> 00:08:55.929 Blood supply issue. But if you have an overweight 00:08:55.929 --> 00:08:58.730 adolescent with a painful limp, it's SCFE. Slipped 00:08:58.730 --> 00:09:01.669 capital femoral epicesis or SCFE and that one 00:09:01.669 --> 00:09:04.200 is an emergency. We will dive deep into the specifics 00:09:04.200 --> 00:09:06.080 of those later, but the can't miss safety item 00:09:06.080 --> 00:09:09.639 here is that SCFE in the teenager, right? Yes, 00:09:09.799 --> 00:09:12.539 absolutely. If you miss SCFE and treat it like 00:09:12.539 --> 00:09:14.740 a sprain, telling the kid to, you know, walk 00:09:14.740 --> 00:09:18.059 it off, the head of the femur can slip completely 00:09:18.059 --> 00:09:20.600 off a neck. The blood supply gets severed and 00:09:20.600 --> 00:09:23.340 the hip dies. It is a true surgical emergency. 00:09:23.639 --> 00:09:27.360 So the pattern is age plus symptom equals risk 00:09:27.360 --> 00:09:30.379 level. Exactly. And pattern three. Pattern three 00:09:30.379 --> 00:09:32.820 applies to the neuromuscular conditions, progressive 00:09:32.820 --> 00:09:35.320 versus non -progressive. This is the distinction 00:09:35.320 --> 00:09:38.519 between something like cerebral palsy and, say, 00:09:39.080 --> 00:09:41.399 muscular dystrophy. Right. The exam wants you 00:09:41.399 --> 00:09:44.000 to identify the trajectory of the disease. In 00:09:44.000 --> 00:09:46.100 cerebral palsy, the injury happened, usually 00:09:46.100 --> 00:09:48.360 around birth. It's done. The brain isn't getting 00:09:48.360 --> 00:09:50.419 more injured today than it was yesterday, so 00:09:50.419 --> 00:09:53.019 it's non -progressive. So the goal is to maximize 00:09:53.019 --> 00:09:55.559 potential. Right, and prevent complications like 00:09:55.559 --> 00:09:57.659 contractures. You're working with a fixed deficit. 00:09:57.899 --> 00:10:00.080 Whereas in muscular dystrophy, It's a tragedy 00:10:00.080 --> 00:10:04.000 in slow motion. The child was born healthy, seemingly 00:10:04.000 --> 00:10:07.779 normal, but they are losing ground. They are 00:10:07.779 --> 00:10:10.500 regressing. They used to walk. Now they stumble. 00:10:10.720 --> 00:10:12.659 Next year they won't walk. And eventually they 00:10:12.659 --> 00:10:14.899 won't be able to breathe on their own. So if 00:10:14.899 --> 00:10:17.559 it's progressive, we are managing decline and 00:10:17.559 --> 00:10:20.059 regression. If it's non -progressive, we are 00:10:20.059 --> 00:10:22.679 building on existing skills. Precisely. That 00:10:22.679 --> 00:10:24.879 distinction changes your entire nursing plan. 00:10:25.080 --> 00:10:27.580 how you set goals, and how you talk to the parents. 00:10:27.799 --> 00:10:30.159 It's fundamental. Okay, those are our three strategic 00:10:30.159 --> 00:10:32.820 maps. Yeah. The immobility trap, the limping 00:10:32.820 --> 00:10:35.620 child, and progressive versus non -progressive. 00:10:35.639 --> 00:10:38.059 Yeah. That's a great framework. Now, let's get 00:10:38.059 --> 00:10:40.940 into the weeds. Part B, the system -by -system 00:10:40.940 --> 00:10:42.879 breakdown. Let's do it. We have to start with 00:10:42.879 --> 00:10:45.669 the foundation. General pediatric anatomy and 00:10:45.669 --> 00:10:48.629 physiology. The sources make a huge deal about 00:10:48.629 --> 00:10:50.789 how kids are not just mini -adults. They really, 00:10:50.789 --> 00:10:53.190 really aren't. And there are three or four biological 00:10:53.190 --> 00:10:55.789 facts that explain almost every single orthopedic 00:10:55.789 --> 00:10:58.509 injury in kids. First, look at the periodosteum. 00:10:58.590 --> 00:11:00.370 That's the sheath, the covering of the bone, 00:11:00.570 --> 00:11:03.789 right? Exactly. In adults, it's pretty thin, 00:11:03.929 --> 00:11:07.009 almost like paper. In kids, it is thick, it's 00:11:07.009 --> 00:11:09.789 rich in blood supply, and it is metabolically 00:11:09.789 --> 00:11:11.789 very, very active. And what does that mean in 00:11:11.789 --> 00:11:15.039 practice? It means kids heal incredibly fast. 00:11:15.600 --> 00:11:17.940 A fracture that might sideline an adult for 10 00:11:17.940 --> 00:11:20.519 or 12 weeks might heal in a child in just three 00:11:20.519 --> 00:11:22.879 or four weeks. Which sounds great. Fast healing 00:11:22.879 --> 00:11:25.700 is a superpower. But what's the downside of their 00:11:25.700 --> 00:11:28.039 bone structure? The downside is that the bones 00:11:28.039 --> 00:11:30.899 are more porous and flexible. They tend to bend 00:11:30.899 --> 00:11:33.179 before they break. That's why we see these green 00:11:33.179 --> 00:11:35.320 stick fractures. Like trying to snap a fresh 00:11:35.320 --> 00:11:37.659 twig from a tree. That's the perfect analogy. 00:11:37.799 --> 00:11:40.039 It splinters on one side, but stays connected 00:11:40.039 --> 00:11:42.759 on the other. You also see buckle fractures where 00:11:42.759 --> 00:11:44.779 the bone just kind of crumbles on itself instead 00:11:44.779 --> 00:11:47.379 of snapping clean. So you might not see a clean 00:11:47.379 --> 00:11:49.440 break on an x -ray, just a bend or a buckle. 00:11:49.779 --> 00:11:52.500 Exactly. But the biggest anatomical difference, 00:11:52.580 --> 00:11:55.340 and this is the biggest risk, is the epiphysis, 00:11:55.480 --> 00:11:57.320 or the growth plate. OK, the growth plate. This 00:11:57.320 --> 00:11:59.299 is the layer of cartilage at the end of long 00:11:59.299 --> 00:12:02.000 bones where all the actual growing happens. it 00:12:02.000 --> 00:12:04.139 is the weakest point in the entire pediatric 00:12:04.139 --> 00:12:06.860 skeleton. Weaker than the ligaments. Much weaker. 00:12:07.200 --> 00:12:09.720 In an adult, if you twist your ankle severely, 00:12:10.220 --> 00:12:12.559 the ligaments might tear. That's a sprain. In 00:12:12.559 --> 00:12:14.759 a child, the ligaments are stronger than the 00:12:14.759 --> 00:12:18.080 growth plate, so that same exact force won't 00:12:18.080 --> 00:12:20.000 tear the ligament. It'll fracture the growth 00:12:20.000 --> 00:12:21.679 plate. It will fracture the growth plate. It's 00:12:21.679 --> 00:12:23.639 called a Salter -Harris fracture. And if you 00:12:23.639 --> 00:12:25.740 break the growth plate, that's really bad. It 00:12:25.740 --> 00:12:28.480 can be catastrophic. You risk the bone -stopping 00:12:28.480 --> 00:12:31.039 growth altogether or growing crooked. That's 00:12:31.039 --> 00:12:33.919 why a sprained ankle in a kid often gets x -rayed 00:12:33.919 --> 00:12:37.019 immediately. We're terrified of missing growth 00:12:37.019 --> 00:12:41.720 plate damage. Okay, so need to know. Thick periosteum 00:12:41.720 --> 00:12:44.779 means fast healing. Growth plates are the weak 00:12:44.779 --> 00:12:47.139 spot. What about the nervous system side of things? 00:12:47.299 --> 00:12:50.559 The big concept here is myelinization. Nerves 00:12:50.559 --> 00:12:53.179 are like electrical wires, right? And myelin 00:12:53.179 --> 00:12:55.360 is the plastic insulation that lets the signal 00:12:55.360 --> 00:12:57.879 travel fast and efficiently. Got it. When a baby 00:12:57.879 --> 00:13:00.470 is born, that insulation isn't finished. The 00:13:00.470 --> 00:13:03.029 wires are still kind of bare. It finishes developing 00:13:03.029 --> 00:13:05.529 over the first two years of life. And it happens 00:13:05.529 --> 00:13:08.370 in a specific direction. I remember this. Cephalocodal. 00:13:08.570 --> 00:13:12.289 Head to toe. Head to toe. And proximodistal center 00:13:12.289 --> 00:13:15.169 to periphery. This explains the motor milestones 00:13:15.169 --> 00:13:17.269 we all memorize. It explains them perfectly. 00:13:17.669 --> 00:13:20.750 A baby gains control of their head. before they 00:13:20.750 --> 00:13:22.909 can sit up and control their trunk, and they 00:13:22.909 --> 00:13:24.950 sit before they can control their legs to walk, 00:13:25.190 --> 00:13:27.610 coddle. It's not a matter of strength. It's a 00:13:27.610 --> 00:13:30.289 matter of the nerves being insulated. So if an 00:13:30.289 --> 00:13:32.750 exam question asks why a three -month -old can 00:13:32.750 --> 00:13:35.210 hold their head up but can't stand, the answer 00:13:35.210 --> 00:13:38.289 isn't weak muscles. No, absolutely not. The answer 00:13:38.289 --> 00:13:41.509 is incomplete myelinization of the spinal cord. 00:13:41.710 --> 00:13:43.649 The wire isn't insulated all the way down to 00:13:43.649 --> 00:13:46.210 the legs yet. I love it. That makes so much sense. 00:13:46.610 --> 00:13:48.649 Okay, let's move to the specific disorders. First 00:13:48.649 --> 00:13:53.259 up... Neural tube defects. Spina bifida. Right, 00:13:53.299 --> 00:13:55.460 and this is a spectrum. On the mild end, you 00:13:55.460 --> 00:13:58.440 have spina bifida occulta. Occulta just means 00:13:58.440 --> 00:14:00.820 hidden. The vertebrae didn't fuse in the back, 00:14:00.879 --> 00:14:03.620 but the spinal cord itself is fine. And how would 00:14:03.620 --> 00:14:05.279 you even know it's there? You might just see 00:14:05.279 --> 00:14:07.299 a little dimple at the base of the spine, or 00:14:07.299 --> 00:14:10.059 maybe a tuft of hair, or a small birthmark. Usually 00:14:10.059 --> 00:14:12.700 there are no bad effects at all. It's an incidental 00:14:12.700 --> 00:14:14.500 finding. But on the other end of the spectrum, 00:14:14.679 --> 00:14:17.139 we have myelomeningocell. Right, and that's a 00:14:17.139 --> 00:14:19.600 whole different world. This is the severe one. 00:14:19.879 --> 00:14:22.460 The spine didn't close. And you have a visible 00:14:22.460 --> 00:14:25.139 sac protruding from the back that contains spinal 00:14:25.139 --> 00:14:28.200 fluid, meninges, and critically actual spinal 00:14:28.200 --> 00:14:32.179 nerves. Pathophysiology in plain language. It's 00:14:32.179 --> 00:14:34.120 a failure of the neural tube to close around 00:14:34.120 --> 00:14:37.100 three to four weeks gestation. And all the sources 00:14:37.100 --> 00:14:39.740 point to one specific nutritional deficiency. 00:14:40.120 --> 00:14:42.799 Folic acid. That's the big public health need 00:14:42.799 --> 00:14:45.340 to know. That's why prenatal vitamins are so 00:14:45.340 --> 00:14:47.730 important. All women of childbearing age need 00:14:47.730 --> 00:14:50.129 folic acid to prevent this. OK, let's say the 00:14:50.129 --> 00:14:53.029 baby is born with a sack. You are the nurse in 00:14:53.029 --> 00:14:56.809 the delivery room or the NICU. What is the absolute 00:14:56.809 --> 00:14:59.350 priority nursing action? The number one need 00:14:59.350 --> 00:15:02.250 to know. intervention. You have to protect that 00:15:02.250 --> 00:15:04.110 sac. That is your only job for the first few 00:15:04.110 --> 00:15:07.389 minutes. If that thin membrane ruptures, bacteria 00:15:07.389 --> 00:15:09.850 from the skin or from stool can get directly 00:15:09.850 --> 00:15:12.409 into the spinal fluid. And that causes meningitis. 00:15:12.710 --> 00:15:15.029 A devastating meningitis. So the intervention 00:15:15.029 --> 00:15:18.470 is all about positioning and protection. Prone. 00:15:18.850 --> 00:15:21.250 Belly down only. You cannot put this baby on 00:15:21.250 --> 00:15:23.610 their back, period. And you cover the sac with 00:15:23.610 --> 00:15:26.850 a sterile, saline -soaked, non -adhesive gauze. 00:15:27.129 --> 00:15:29.450 Okay, let's break that down. Why saline soaked? 00:15:29.639 --> 00:15:32.299 to keep the membrane moist. If it dries out, 00:15:32.379 --> 00:15:35.080 it gets brittle and can crack or tear much more 00:15:35.080 --> 00:15:37.500 easily. And non -aghesive. Because you don't 00:15:37.500 --> 00:15:39.620 want to rip the fragile tissue when you change 00:15:39.620 --> 00:15:42.039 the dressing. You have to be incredibly gentle. 00:15:42.600 --> 00:15:46.399 OK, sterile, wet, belly down. What else are we 00:15:46.399 --> 00:15:48.879 worried about? There are two major complications 00:15:48.879 --> 00:15:50.940 that are almost always associated with this. 00:15:51.279 --> 00:15:54.059 The first one is hydrocephalus. Water on the 00:15:54.059 --> 00:15:57.039 brain. Essentially, yes. Because of the defect 00:15:57.039 --> 00:16:00.000 in the spine, the normal flow of cerebrospinal 00:16:00.000 --> 00:16:02.899 fluid is often blocked. It builds up in the ventricles 00:16:02.899 --> 00:16:05.139 of the brain, causing pressure. So what's our 00:16:05.139 --> 00:16:06.960 assessment for that? You have to measure their 00:16:06.960 --> 00:16:09.419 head circumference daily. Any rapid increase 00:16:09.419 --> 00:16:12.200 is a huge red flag. You might also see bulging 00:16:12.200 --> 00:16:14.559 fontanels or setting sun eyes. And the second 00:16:14.559 --> 00:16:16.980 major complication is the bladder. Neurogenic 00:16:16.980 --> 00:16:19.179 bladder. The nerves that control the bladder 00:16:19.179 --> 00:16:21.500 are often damaged or non -existent because they 00:16:21.500 --> 00:16:23.840 were in that sack. The bladder doesn't empty 00:16:23.840 --> 00:16:26.320 properly. It retains urine, which can back up 00:16:26.320 --> 00:16:28.259 into the kidneys and destroy them. So these kids 00:16:28.259 --> 00:16:31.139 need catheterization. Often for life. We teach 00:16:31.139 --> 00:16:33.899 parents clean, intermittent catheterization. 00:16:34.320 --> 00:16:36.500 They have to drain the bladder with a catheter 00:16:36.500 --> 00:16:39.279 every three to four hours around the clock. Wow. 00:16:39.700 --> 00:16:41.799 Now here's an exam writer favorite I found in 00:16:41.799 --> 00:16:44.039 the notes. Feels like a random fact, but it's 00:16:44.039 --> 00:16:46.789 everywhere. The latex allergy. Oh, this is a 00:16:46.789 --> 00:16:49.929 classic NCLE X trap. Children with spina bifida 00:16:49.929 --> 00:16:52.850 have a massive exposure to medical products from 00:16:52.850 --> 00:16:56.149 day one. Catheters, gloves, shunts, multiple 00:16:56.149 --> 00:16:59.049 surgeries. They develop latex allergies at an 00:16:59.049 --> 00:17:01.769 incredibly high rate. So the rule is? What? The 00:17:01.769 --> 00:17:03.870 rule is you treat them as latex allergic from 00:17:03.870 --> 00:17:05.869 day one, even if they haven't had a reaction 00:17:05.869 --> 00:17:08.809 yet. It's a universal precaution for this population. 00:17:09.150 --> 00:17:11.869 No latex gloves, no balloons in the room. And 00:17:11.869 --> 00:17:14.329 functionally, be careful with foods that cross. 00:17:14.220 --> 00:17:16.940 react with latex, the latex fruit syndrome. Yes. 00:17:17.460 --> 00:17:18.799 You have to know that. Wait, what foods are we 00:17:18.799 --> 00:17:21.960 talking about? The big ones are bananas, avocados, 00:17:22.180 --> 00:17:24.680 kiwis, and chestnuts. The proteins in these foods 00:17:24.680 --> 00:17:27.539 look very similar to latex proteins to the immune 00:17:27.539 --> 00:17:31.259 system. That is wild. So if a spina bifida question 00:17:31.259 --> 00:17:33.900 mentions a child getting hives after eating guacamole. 00:17:34.140 --> 00:17:36.680 Think latex allergy immediately. That's the connection 00:17:36.680 --> 00:17:38.680 they want you to make. Okay, that is a fantastic 00:17:38.680 --> 00:17:43.400 tip. Moving on to cerebral palsy, or a CP. CP 00:17:43.400 --> 00:17:46.079 is the most common permanent physical disability 00:17:46.079 --> 00:17:48.819 in childhood. The one -liner here that you have 00:17:48.819 --> 00:17:52.019 to remember is a non -progressive brain injury 00:17:52.019 --> 00:17:55.019 affecting movement and posture. The non -progressive 00:17:55.019 --> 00:17:56.960 part is key, right? We talked about that in the 00:17:56.960 --> 00:17:59.519 patterns. It is absolutely vital. The brain injury 00:17:59.519 --> 00:18:01.880 happened, usually it was anoxic, meaning a lack 00:18:01.880 --> 00:18:04.539 of oxygen at birth or related to prematurity, 00:18:04.579 --> 00:18:07.240 and the injury itself doesn't spread or get worse. 00:18:07.619 --> 00:18:10.039 However, the symptoms and challenges can change 00:18:10.039 --> 00:18:12.869 as the child grows and tries to do more complex 00:18:12.869 --> 00:18:15.430 movements. The notes mention spastic CP is the 00:18:15.430 --> 00:18:18.609 most common type. By far, about 80 % have spastic 00:18:18.609 --> 00:18:21.309 CP. Their muscles are hypertonic. They're tight. 00:18:21.509 --> 00:18:23.509 They're stiff. They have increased muscle tone. 00:18:23.750 --> 00:18:26.170 How does this present in an infant? I saw a note 00:18:26.170 --> 00:18:28.930 about them pushing away. Yes, that's a classic 00:18:28.930 --> 00:18:32.369 sign. An infant who arches their back and stiffens 00:18:32.369 --> 00:18:34.430 when you try to cuddle them, it feels like they 00:18:34.430 --> 00:18:36.710 are fighting the cuddle, pushing away from you. 00:18:37.130 --> 00:18:39.569 What else would you see? You might also see scissoring 00:18:39.569 --> 00:18:41.670 of the legs, where the legs cross over each other 00:18:41.670 --> 00:18:43.970 when you lift them up because the adductor muscles 00:18:43.970 --> 00:18:46.910 in the thighs are so tight. And there's a red 00:18:46.910 --> 00:18:49.670 flag regarding hand dominance. This is a great 00:18:49.670 --> 00:18:52.829 one to know. Babies shouldn't pick a handedness, 00:18:52.910 --> 00:18:55.750 you know, being righty or lefty until closer 00:18:55.750 --> 00:18:58.170 to preschool age. They should use both hands 00:18:58.170 --> 00:19:00.829 pretty equally. So if you have a six month old 00:19:00.829 --> 00:19:03.250 who only ever reaches with their left hand and 00:19:03.250 --> 00:19:05.970 keeps the right hand in a tight fist, that is 00:19:05.970 --> 00:19:08.569 a huge red flag for hemiplegial paralysis on 00:19:08.569 --> 00:19:11.230 one side from CP. It means the right side is 00:19:11.230 --> 00:19:13.769 weak. That's a great clinical catch. What about 00:19:13.769 --> 00:19:16.410 need to know interventions? It's all about managing 00:19:16.410 --> 00:19:19.190 the spasticity. If muscles stay tight all the 00:19:19.190 --> 00:19:21.430 time, they shorten permanently. That's a contracture, 00:19:21.509 --> 00:19:24.089 and that leads to deformities. So we use baclofen. 00:19:24.309 --> 00:19:27.109 That's a muscle relaxant. It is. It can be a 00:19:27.109 --> 00:19:30.289 pill or, for severe cases, they can have a pump 00:19:30.289 --> 00:19:32.910 implanted under their skin that delivers it directly 00:19:32.910 --> 00:19:36.529 to the spinal fluid. We also use Botox injections 00:19:36.529 --> 00:19:39.150 directly into the muscle to paralyze it slightly 00:19:39.150 --> 00:19:41.539 and allow it to stretch. And nutrition seems 00:19:41.539 --> 00:19:45.099 to be a big exam theme here, too. Huge. Aspiration 00:19:45.099 --> 00:19:47.839 risk is massive. If the muscles in their jaw, 00:19:47.980 --> 00:19:50.819 tongue, and throat are spastic, they can't coordinate 00:19:50.819 --> 00:19:53.519 a safe swallow. So you might see jaw support 00:19:53.519 --> 00:19:56.160 feeding techniques, where the nurse or parent 00:19:56.160 --> 00:19:58.759 holds the jaw to help with swallowing, or even 00:19:58.759 --> 00:20:01.680 a G -tube for feeds if it's severe. OK, next 00:20:01.680 --> 00:20:05.240 topic, muscular dystrophy, specifically Duchenne 00:20:05.240 --> 00:20:08.980 or DMD. This is the heartbreak of pediatric neurology. 00:20:09.079 --> 00:20:11.259 It's an X -linked recessive disorder. Meaning 00:20:11.259 --> 00:20:14.119 the mother is a carrier, but it almost exclusively 00:20:14.119 --> 00:20:16.980 affects boys. Correct. And unlike CP, this is 00:20:16.980 --> 00:20:19.700 progressive. Tragically, yes. These boys are 00:20:19.700 --> 00:20:21.339 born seemingly normal. They might meet their 00:20:21.339 --> 00:20:23.700 early milestones, maybe a little delayed. But 00:20:23.700 --> 00:20:25.640 around age three to five, they start to stumble. 00:20:25.740 --> 00:20:27.579 They have trouble running or climbing stairs. 00:20:27.740 --> 00:20:30.259 And the path is predictable. It's a predictable, 00:20:30.740 --> 00:20:32.839 devastating decline. They lose the ability to 00:20:32.839 --> 00:20:35.839 walk, usually by age 12. Then they lose the ability 00:20:35.839 --> 00:20:38.819 to use their arms. And eventually, the muscles 00:20:38.819 --> 00:20:42.000 of respiration and the heart muscle fail. Patho, 00:20:42.319 --> 00:20:43.720 in plain language. What's actually happening? 00:20:43.779 --> 00:20:46.920 They are missing a critical protein called dystrophin. 00:20:47.339 --> 00:20:49.559 Think of dystrophin as the shock absorber for 00:20:49.559 --> 00:20:52.890 the muscle cell membrane. Without it, every single 00:20:52.890 --> 00:20:55.250 time the muscle contracts, the cell membrane 00:20:55.250 --> 00:20:58.089 pairs a little bit. The muscle cell dies. And 00:20:58.089 --> 00:21:00.450 the body replaces that dead muscle with fat. 00:21:00.589 --> 00:21:02.950 Exactly. It gets replaced by fat and connective 00:21:02.950 --> 00:21:05.430 tissue. This leads to something called pseudo 00:21:05.430 --> 00:21:08.029 -hypertrophy. False muscle growth. Right. You'll 00:21:08.029 --> 00:21:11.230 see a boy with these huge, bulky -looking calf 00:21:11.230 --> 00:21:13.609 muscles. It looks like he's a bodybuilder. But 00:21:13.609 --> 00:21:16.529 it's not muscle. It's fat infiltration. The muscle 00:21:16.529 --> 00:21:19.710 is actually incredibly weak. And there's a specific 00:21:19.710 --> 00:21:22.130 sign for how they get up from the floor, the 00:21:22.130 --> 00:21:24.849 Gower sign. The Gower sign is an exam staple. 00:21:25.329 --> 00:21:28.029 If you see this described, the answer is Duchenne. 00:21:28.190 --> 00:21:31.009 Because their hip and thigh muscles, the proximal 00:21:31.009 --> 00:21:33.470 muscles, are so weak, they can't just stand up. 00:21:33.470 --> 00:21:35.190 They have to get on their hands and knees and 00:21:35.190 --> 00:21:37.789 then literally walk their hands up their own 00:21:37.789 --> 00:21:39.869 legs, pushing on their shins, then their knees, 00:21:39.930 --> 00:21:43.089 then their thighs to force their torso upright. 00:21:43.569 --> 00:21:45.849 Walking up their own legs. If you see that phrase, 00:21:45.849 --> 00:21:49.130 it's Duchenne. every single time. What is the 00:21:49.130 --> 00:21:52.529 need to know for management? Is there a cure? 00:21:52.890 --> 00:21:56.250 There is no cure yet. The main treatment is steroids 00:21:56.250 --> 00:21:59.029 like prednisone. They can slow the progression 00:21:59.029 --> 00:22:00.789 and keep them walking for a couple more years, 00:22:01.029 --> 00:22:03.490 but they have all the nasty side effects like 00:22:03.490 --> 00:22:06.009 weight gain, mood changes, and bone thinning. 00:22:06.240 --> 00:22:08.480 So the nursing priority shifts over time? It 00:22:08.480 --> 00:22:10.980 does. Early on, it's about physical therapy and 00:22:10.980 --> 00:22:13.160 maintaining function. Later on, it's all about 00:22:13.160 --> 00:22:15.559 respiratory support, using a BiPAP machine at 00:22:15.559 --> 00:22:17.940 night, cough assist machines to clear secretions. 00:22:18.500 --> 00:22:20.400 The cause of death is usually cardiopulmonary 00:22:20.400 --> 00:22:22.880 failure in their early 20s. Let's contrast that 00:22:22.880 --> 00:22:26.640 with SMA, spinal muscular atrophy. SMA is also 00:22:26.640 --> 00:22:29.220 genetic and progressive, but the mechanism is 00:22:29.220 --> 00:22:31.759 different. It attacks the motor neurons in the 00:22:31.759 --> 00:22:33.900 spinal cord, The nerves that tell the muscles 00:22:33.900 --> 00:22:37.279 to move die off. This is the floppy baby. Yes. 00:22:37.680 --> 00:22:40.339 For type 1, the severe infantile form, which 00:22:40.339 --> 00:22:42.259 used to be called weird Nick Hoffman disease, 00:22:42.599 --> 00:22:45.720 you see extreme hypotonia. They lie in a frog 00:22:45.720 --> 00:22:48.319 leg position, totally limp. They have a weak 00:22:48.319 --> 00:22:51.000 cry, difficulty swallowing, and a belly breathing 00:22:51.000 --> 00:22:52.720 pattern because their intercostal muscles are 00:22:52.720 --> 00:22:55.519 too weak. It's the opposite of the stiff spastic 00:22:55.519 --> 00:22:58.319 CP baby. What's the need to know distinction 00:22:58.319 --> 00:23:01.039 regarding their mind? This is important. Vitally 00:23:01.039 --> 00:23:03.319 important. Just like in Duchenne, kids with SMA 00:23:03.319 --> 00:23:05.759 have normal, often bright cognitive function. 00:23:06.259 --> 00:23:08.500 They're smart, alert kids trapped in failing 00:23:08.500 --> 00:23:11.079 bodies. You must treat them as age -appropriate 00:23:11.079 --> 00:23:13.519 mentally, even if they can't move or speak clearly. 00:23:13.880 --> 00:23:15.720 That's so important for the developmental care 00:23:15.720 --> 00:23:17.579 piece. Okay, let's shift gears to the structural 00:23:17.579 --> 00:23:20.799 stuff. Bones and joints. Let's talk hips. Developmental 00:23:20.799 --> 00:23:23.960 dysplasia of the hip. DDH. Right. And I like 00:23:23.960 --> 00:23:26.490 to think of this as a plumbing problem. The ball 00:23:26.490 --> 00:23:28.950 of the femur isn't sitting tight in the socket, 00:23:29.089 --> 00:23:31.950 which is called the acetabulum. If it's loose 00:23:31.950 --> 00:23:34.910 or dislocated, the socket won't form a deep enough 00:23:34.910 --> 00:23:37.529 cup. We talked about the age -based diagnosis. 00:23:37.690 --> 00:23:39.970 Let's start with the infant. What are the screening 00:23:39.970 --> 00:23:42.369 tests we do in the nursery? The Ortolani and 00:23:42.369 --> 00:23:45.250 Barlow maneuvers. Every newborn gets this exam. 00:23:45.430 --> 00:23:47.589 Okay, break those down for me. The Ortolani is 00:23:47.589 --> 00:23:51.170 the reduction test. You gently abduct the hips, 00:23:51.349 --> 00:23:53.089 so you're moving the knees out like you're opening 00:23:53.089 --> 00:23:56.339 a book. If the hip was dislocated, you feel a 00:23:56.339 --> 00:23:59.240 distinct clunk as the head of the femur slides 00:23:59.240 --> 00:24:02.019 back into the socket. That's a positive Ortolani. 00:24:02.319 --> 00:24:06.079 So a clunk in is Ortolani and Barlow. Barlow 00:24:06.079 --> 00:24:09.019 is the stress test. You adduct, bring the knees 00:24:09.019 --> 00:24:11.460 together, and apply gentle posterior pressure 00:24:11.460 --> 00:24:13.460 to see if you can make the hip pop out of the 00:24:13.460 --> 00:24:15.900 socket. So clunk is the positive sign for both. 00:24:16.440 --> 00:24:18.640 What else do we look for in a baby just on inspection? 00:24:19.289 --> 00:24:21.650 Asymmetric gluteal folds. You turn the baby over 00:24:21.650 --> 00:24:23.549 onto their tummy and you look at the butt cheeks. 00:24:24.109 --> 00:24:26.890 The creases should be symmetrical. If one fold 00:24:26.890 --> 00:24:29.190 is higher than the other, that suggests that 00:24:29.190 --> 00:24:31.569 leg might be shorter because the hip is dislocated. 00:24:31.890 --> 00:24:34.450 Okay, we find it. What's the intervention for 00:24:34.450 --> 00:24:37.519 an infant under six months? The Pavlik harness. 00:24:38.079 --> 00:24:40.200 It looks like a little set of overalls made of 00:24:40.200 --> 00:24:43.279 soft straps. It holds the baby's legs in that 00:24:43.279 --> 00:24:46.140 frog position, flexed and abducted, to force 00:24:46.140 --> 00:24:48.740 the ball deep into the socket so the socket can 00:24:48.740 --> 00:24:50.700 develop properly around it. There are strict 00:24:50.700 --> 00:24:52.640 exam rules for the Pavlik harness, aren't there? 00:24:52.700 --> 00:24:55.559 Very strict. And they love to test these. Rule 00:24:55.559 --> 00:24:59.160 one, it is worn 23 to 24 hours a day. It basically 00:24:59.160 --> 00:25:01.339 never comes off, except maybe for a quick bath. 00:25:01.480 --> 00:25:04.259 OK. What's rule two? The parents do not adjust 00:25:04.259 --> 00:25:07.049 the straps. Ever. Only the orthopedic provider 00:25:07.049 --> 00:25:09.609 does. If parents mess with the straps and make 00:25:09.609 --> 00:25:11.829 them too tight, they can cut off blood supply 00:25:11.829 --> 00:25:13.750 to the hip or damage the femoral nerve. This 00:25:13.750 --> 00:25:17.230 is a huge safety point. Huge. Rule three, meticulous 00:25:17.230 --> 00:25:19.349 skin checks under the straps for any redness 00:25:19.349 --> 00:25:21.309 or breakdown. And rule four, the one everyone 00:25:21.309 --> 00:25:23.769 forgets, diapering. You put the diaper under 00:25:23.769 --> 00:25:26.589 the straps of the harness. Diaper under the straps. 00:25:26.809 --> 00:25:30.529 Got it. What if the kid is older, like a toddler 00:25:30.529 --> 00:25:32.609 who starts walking, and we discover it then? 00:25:32.859 --> 00:25:34.900 The harness won't work anymore, their muscles 00:25:34.900 --> 00:25:37.200 are too strong. Now you'll see a Trendelenburg 00:25:37.200 --> 00:25:40.339 gait. When they stand on the bad leg, the pelvis 00:25:40.339 --> 00:25:43.539 drops down on the good side because the hip abductor 00:25:43.539 --> 00:25:45.660 muscles can't hold it level. And the treatment 00:25:45.660 --> 00:25:48.680 is more invasive then? Much more. It usually 00:25:48.680 --> 00:25:50.920 involves a period of traction to stretch the 00:25:50.920 --> 00:25:53.400 muscles, followed by surgery to put the hip back 00:25:53.400 --> 00:25:56.359 in place, and then a spica cast. Spica casts 00:25:56.359 --> 00:25:59.019 are those huge full body casts. Yeah. From the 00:25:59.019 --> 00:26:01.299 chest all the way down one or both legs. Yes. 00:26:01.519 --> 00:26:04.140 And that brings massive nursing care challenges, 00:26:04.380 --> 00:26:07.359 especially around toileting and diapering. You 00:26:07.359 --> 00:26:10.079 have to be an absolute expert at tucking diapers 00:26:10.079 --> 00:26:12.440 in and using waterproof tape to keep that cast 00:26:12.440 --> 00:26:15.299 clean and dry. If urine soaks into the cast lining, 00:26:15.500 --> 00:26:17.440 the skin underneath will macerate and you'll 00:26:17.440 --> 00:26:19.980 get a terrible infection. Okay, moving down the 00:26:19.980 --> 00:26:25.099 leg. Clubfoot. The foot is twisted inward and 00:26:25.099 --> 00:26:26.660 downward. It literally looks like the head of 00:26:26.660 --> 00:26:28.759 a golf club. Is this just a positional thing, 00:26:29.200 --> 00:26:30.980 like the baby was just squished in the womb and 00:26:30.980 --> 00:26:34.079 the foot got stuck? No, and that's a common misconception 00:26:34.079 --> 00:26:38.480 parents have and a common exam distractor. Positional 00:26:38.480 --> 00:26:41.079 clubfoot is flexible and can be stretched out 00:26:41.079 --> 00:26:44.839 easily. True congenital clubfoot is a rigid bone 00:26:44.839 --> 00:26:47.869 deformity. The bones themselves are shaped wrong. 00:26:48.150 --> 00:26:50.869 You cannot passively stretch it to a normal position. 00:26:51.109 --> 00:26:53.049 So what's the fix if you can't just stretch it? 00:26:53.329 --> 00:26:55.670 The gold standard is the Ponsetti method. It 00:26:55.670 --> 00:26:59.210 involves serial casting. Serial, meaning a series 00:26:59.210 --> 00:27:03.190 of casts. Exactly. We start immediately, usually 00:27:03.190 --> 00:27:04.970 in the first week of life when the bones are 00:27:04.970 --> 00:27:07.609 softest. We gently stretch the foot as far as 00:27:07.609 --> 00:27:09.849 it will go, and we put a cast on to hold it there. 00:27:10.359 --> 00:27:12.559 A week later, they come back, we take the cast 00:27:12.559 --> 00:27:15.319 off, stretch the foot a tiny bit more, and put 00:27:15.319 --> 00:27:17.279 a new cast on. And you just repeat that over 00:27:17.279 --> 00:27:19.599 and over. We do this weekly for about six to 00:27:19.599 --> 00:27:22.259 eight weeks to slowly reshape the bones and ligaments. 00:27:22.420 --> 00:27:24.980 So for the exam, if a parent asks, can we just 00:27:24.980 --> 00:27:28.839 do physical therapy? The answer is no. It requires 00:27:28.839 --> 00:27:31.640 this specific casting method. Correct. And it 00:27:31.640 --> 00:27:33.900 usually ends with a small outpatient surgery 00:27:33.900 --> 00:27:36.220 to lengthen the Achilles tendon, followed by 00:27:36.220 --> 00:27:38.500 a final cast and then special bracing for a few 00:27:38.500 --> 00:27:42.369 years to prevent relapse. Next up, osteogenesis 00:27:42.369 --> 00:27:46.690 imperfecta, or OI, brittle bone disease. This 00:27:46.690 --> 00:27:49.730 is a genetic defect in collagen. Collagen is 00:27:49.730 --> 00:27:53.210 the rebar, the scaffolding of your bones. Without 00:27:53.210 --> 00:27:55.690 good collagen, the bones are incredibly brittle, 00:27:56.089 --> 00:27:58.670 like dry chalk. These kids can fracture from 00:27:58.670 --> 00:28:01.049 just being handled normally. What is the classic 00:28:01.049 --> 00:28:03.950 assessment sign that screams OI? Blue sclera. 00:28:04.200 --> 00:28:06.960 The whites of the eyes have a distinct blue or 00:28:06.960 --> 00:28:09.519 grayish tint. Why is that? What does collagen 00:28:09.519 --> 00:28:11.880 have to do with the eyes? Because the sclera, 00:28:12.019 --> 00:28:14.180 the white part of the eye, is also made of collagen. 00:28:14.660 --> 00:28:17.140 In OY, it's so thin that you are actually seeing 00:28:17.140 --> 00:28:19.720 the color of the veins in the layer underneath 00:28:19.720 --> 00:28:22.619 the choroid shining through. That's fascinating. 00:28:22.829 --> 00:28:25.089 And the safety priority here is all about handling. 00:28:25.269 --> 00:28:27.430 This is huge. This is life or death for these 00:28:27.430 --> 00:28:29.549 kids' quality of life. You have to be terrified 00:28:29.549 --> 00:28:31.849 of causing a fracture during routine care. Need 00:28:31.849 --> 00:28:34.569 to know, never ever pull a baby's legs up by 00:28:34.569 --> 00:28:36.849 the ankles to change a diaper. That lever force. 00:28:36.950 --> 00:28:39.349 It can snap both femurs. You have to lift gently 00:28:39.349 --> 00:28:41.710 from the hips or buttocks. Support the limbs 00:28:41.710 --> 00:28:44.410 fully. And what about blood pressure? Avoid automatic 00:28:44.410 --> 00:28:46.950 blood pressure cuffs if possible. The squeeze 00:28:46.950 --> 00:28:49.630 can easily fracture a humerus. You have to use 00:28:49.630 --> 00:28:52.950 manual cuffs and be extremely careful. That is 00:28:52.950 --> 00:28:56.250 intense. Now, let's tackle the hip pain showdown. 00:28:56.630 --> 00:28:59.869 Leg Calvi Perthas versus SCFE. We mentioned the 00:28:59.869 --> 00:29:02.450 ages in part A, but let's dig a little deeper 00:29:02.450 --> 00:29:05.230 into the presentation. Okay, let's do it. Leg 00:29:05.230 --> 00:29:09.059 Calvi Perthas or LCP. This is a vascular necrosis 00:29:09.059 --> 00:29:11.880 of the femoral head. For some unknown reason, 00:29:12.039 --> 00:29:13.839 the blood supply to the ball of the hip just 00:29:13.839 --> 00:29:16.720 stops for a while. The bone softens and dies, 00:29:16.880 --> 00:29:19.119 then eventually blood flow returns and the body 00:29:19.119 --> 00:29:21.759 starts to regrow it. And who is the typical patient? 00:29:21.900 --> 00:29:24.200 The classic patient is a boy, usually between 00:29:24.200 --> 00:29:26.299 the ages of four and eight, he's active, running 00:29:26.299 --> 00:29:29.640 around. And what are the symptoms? Often a painless 00:29:29.640 --> 00:29:32.559 limp, or maybe some mild pain in the hip or groin 00:29:32.559 --> 00:29:34.579 that comes and goes. He just starts favoring 00:29:34.579 --> 00:29:36.759 a leg. And the treatment? It's often containment. 00:29:36.960 --> 00:29:39.700 We want to keep the ball of the femur inside 00:29:39.700 --> 00:29:42.079 the socket while it's soft and healing so it 00:29:42.079 --> 00:29:44.640 doesn't grow back flat or square. It is self 00:29:44.640 --> 00:29:47.339 -limiting. It heals on its own over several years. 00:29:48.039 --> 00:29:51.119 We use NSAIDs for inflammation, maybe bracing 00:29:51.119 --> 00:29:54.259 or casting, and critically, activity limitation. 00:29:54.839 --> 00:29:58.000 No jumping, no running, no impact sports. Now 00:29:58.000 --> 00:30:01.690 contrast that with SCFE. Slipped capital femoral 00:30:01.690 --> 00:30:04.289 epiphysis. SCFE is a total different beast. It's 00:30:04.289 --> 00:30:07.109 a mechanical failure. The femoral head literally 00:30:07.109 --> 00:30:09.430 slides off the neck of the femur right through 00:30:09.430 --> 00:30:11.849 the growth plate. Think of a scoop of ice cream 00:30:11.849 --> 00:30:13.890 slipping off a cone. Great visual. The femoral 00:30:13.890 --> 00:30:15.990 head is the ice cream. And the neck of the femur 00:30:15.990 --> 00:30:18.309 is the cone. The growth plate is the weak spot 00:30:18.309 --> 00:30:20.130 where it shears off. And the patient profile 00:30:20.130 --> 00:30:23.089 here. Older. In adolescent, usually between 10 00:30:23.089 --> 00:30:25.670 and 16, it often happens during a rapid growth 00:30:25.670 --> 00:30:28.230 spurt. And statistically, the patient is often 00:30:28.230 --> 00:30:31.049 overweight or obese. The extra weight puts more 00:30:31.049 --> 00:30:33.029 sheer force on that vulnerable growth plate. 00:30:33.089 --> 00:30:36.029 And the symptoms? Pain, hip pain, groin pain, 00:30:36.250 --> 00:30:39.049 or, and this is the absolute classic exam trap 00:30:39.049 --> 00:30:40.630 knee pain. Wait a minute, the hip is slipping, 00:30:40.690 --> 00:30:43.990 but the knee hurts. It's referred pain. The obturator 00:30:43.990 --> 00:30:46.250 nerve serves both the hip joint and the knee, 00:30:46.470 --> 00:30:48.809 so the brain gets confused and interprets the 00:30:48.809 --> 00:30:51.809 signal as coming from the knee. That is a It 00:30:51.809 --> 00:30:54.049 catches people every single time. The take -home 00:30:54.049 --> 00:30:56.490 message is, if an overweight teenager comes in 00:30:56.490 --> 00:30:58.650 complaining of knee pain, you must examine their 00:30:58.650 --> 00:31:01.190 hip. You'll also see that their leg is usually 00:31:01.190 --> 00:31:03.329 externally rotated, turned out, and they can't 00:31:03.329 --> 00:31:05.569 turn it inward. And the need -to -know action? 00:31:06.069 --> 00:31:09.309 Absolute non -weight -bearing. Immediately. The 00:31:09.309 --> 00:31:12.309 second you suspect SCFE, that kid should not 00:31:12.309 --> 00:31:14.720 take another step. Get them a wheelchair. If 00:31:14.720 --> 00:31:17.400 they keep walking on it, the ice cream slides 00:31:17.400 --> 00:31:20.059 further off the cone, the blood vessels that 00:31:20.059 --> 00:31:22.779 feed the femoral head get kinked and torn, and 00:31:22.779 --> 00:31:26.420 the hip dies. So, LCP equals rest and wait. SEFE 00:31:26.420 --> 00:31:28.380 equals get off your feet right now and go to 00:31:28.380 --> 00:31:30.539 surgery for pinning. You got it. It's a surgical 00:31:30.539 --> 00:31:34.960 emergency. Next up, scoliosis. Lateral or sideways 00:31:34.960 --> 00:31:37.480 curvature of the spine. The screening is the 00:31:37.480 --> 00:31:40.440 Adams forward bend test. Right. The child bends 00:31:40.440 --> 00:31:42.839 at the waist, lets their arms hang down. And 00:31:42.839 --> 00:31:44.539 what you're looking for isn't just the curve 00:31:44.539 --> 00:31:47.299 of the spine itself. You are looking for asymmetry, 00:31:47.619 --> 00:31:50.160 specifically a rib hump. One side of the rib 00:31:50.160 --> 00:31:52.000 cage will be higher than the other because the 00:31:52.000 --> 00:31:54.859 curve also involves rotation. And treatment depends 00:31:54.859 --> 00:31:57.079 on the degrees of the curve. Exactly. It's a 00:31:57.079 --> 00:32:00.339 continuum. Mild, which is less than 25 degrees. 00:32:00.460 --> 00:32:03.900 We just observe. We watch and wait. Moderate, 00:32:04.000 --> 00:32:06.619 which is 25 to 45 degrees. That's when we use 00:32:06.619 --> 00:32:11.049 bracing. And severe. Over 45 to 50 degrees, that 00:32:11.049 --> 00:32:13.490 usually requires spinal fusion surgery. Let's 00:32:13.490 --> 00:32:15.829 talk about the brace, usually a Boston brace 00:32:15.829 --> 00:32:19.400 or a TLSO. The number one exam rule for bracing 00:32:19.400 --> 00:32:22.319 is compliance. To work, it has to be worn for 00:32:22.319 --> 00:32:25.059 23 hours a day. It only comes off for showering. 00:32:25.279 --> 00:32:27.079 Does it cure the curve? Does it straighten the 00:32:27.079 --> 00:32:30.119 spine? No. And that is a crucial parent and patient 00:32:30.119 --> 00:32:33.039 education point. The brace prevents the curve 00:32:33.039 --> 00:32:35.140 from getting worse while the child is still growing. 00:32:35.599 --> 00:32:37.359 It does not straighten the spine back to normal. 00:32:37.519 --> 00:32:39.779 It just holds the line. That's got to be a tough 00:32:39.779 --> 00:32:42.200 sell for a 14 -year -old girl. It's a developmental 00:32:42.200 --> 00:32:44.640 nightmare. Body image is everything at that age. 00:32:45.140 --> 00:32:47.839 Hiding this bulky plastic shell under your clothes 00:32:47.839 --> 00:32:50.819 is mortifying. Compliance is the single biggest 00:32:50.819 --> 00:32:53.480 hurdle we face. If they do end up needing surgery, 00:32:53.759 --> 00:32:57.839 the spinal fusion, what is the key post -op nursing 00:32:57.839 --> 00:33:01.619 priority? Log rolling. You have to move the patient 00:33:01.619 --> 00:33:04.859 as a single solid unit, like a log, to prevent 00:33:04.859 --> 00:33:08.400 any twisting of that newly -fused spine, and 00:33:08.400 --> 00:33:10.940 frequent meticulous neurovascular checks of the 00:33:10.940 --> 00:33:12.740 legs, making sure they can wiggle their toes, 00:33:13.119 --> 00:33:15.180 feel you touching them, to ensure the surgery 00:33:15.180 --> 00:33:17.680 didn't damage the spinal cord. Okay, last big 00:33:17.680 --> 00:33:20.500 section in Part B, trauma and cast care. We already 00:33:20.500 --> 00:33:22.319 hammered compartment syndrome. Let's talk about 00:33:22.319 --> 00:33:24.680 traction. Okay, two main types you need to know. 00:33:24.940 --> 00:33:27.680 Skin traction, like bucks or bryants, and skeletal 00:33:27.680 --> 00:33:30.150 traction. Skin traction involves... Straps and 00:33:30.150 --> 00:33:33.049 boots. Yes, exactly. Foam boots or adhesive straps 00:33:33.049 --> 00:33:34.970 are applied to the skin and the pulling force 00:33:34.970 --> 00:33:37.130 is on the skin. It's for temporary stabilization 00:33:37.130 --> 00:33:39.529 or for conditions that don't require a lot of 00:33:39.529 --> 00:33:41.789 weight. No pins go into the body. And skeletal 00:33:41.789 --> 00:33:44.329 traction. That's the heavy -duty version. Pins 00:33:44.329 --> 00:33:46.609 or wires are surgically drilled through the bone 00:33:46.609 --> 00:33:48.890 and the traction pulls directly on the skeleton. 00:33:49.329 --> 00:33:51.390 This allows for much heavier weight and for a 00:33:51.390 --> 00:33:53.289 longer duration. What are the need -to -know 00:33:53.289 --> 00:33:56.599 traction rules for the exam? Rule one. The weights 00:33:56.599 --> 00:33:59.059 must hang freely at all times. They cannot be 00:33:59.059 --> 00:34:01.400 resting on the floor or on the bed frame. If 00:34:01.400 --> 00:34:03.579 they aren't hanging, there is no traction force 00:34:03.579 --> 00:34:06.480 being applied. OK, that's a big one. Huge. Rule 00:34:06.480 --> 00:34:10.300 two, never ever lift the weights to help the 00:34:10.300 --> 00:34:12.920 patient move up in bed. Releasing that traction 00:34:12.920 --> 00:34:15.219 force suddenly causes intense pain and muscle 00:34:15.219 --> 00:34:17.719 spasms and can undo the alignment. So you have 00:34:17.719 --> 00:34:19.440 to move the patient with the weights in place. 00:34:19.519 --> 00:34:23.469 You do. And rule three, pin care. The sites where 00:34:23.469 --> 00:34:26.070 the metal enters the skin are a direct line for 00:34:26.070 --> 00:34:28.570 bacteria to get to the bone. That's osteomyelitis. 00:34:28.869 --> 00:34:30.530 You have to clean them meticulously according 00:34:30.530 --> 00:34:32.929 to the hospital's protocol, usually with chlorhexidine 00:34:32.929 --> 00:34:35.449 or saline. You have to get the crusts off. One 00:34:35.449 --> 00:34:37.750 specific cast complication I saw in the notes 00:34:37.750 --> 00:34:41.309 that seems really scary. Cast syndrome. Yes, 00:34:42.050 --> 00:34:44.940 superior mesenteric artery syndrome. This happens 00:34:44.940 --> 00:34:48.239 with those big spica body casts. If the cast 00:34:48.239 --> 00:34:50.599 is too tight around the abdomen, it can compress 00:34:50.599 --> 00:34:53.420 the superior mesenteric artery against the spine. 00:34:53.480 --> 00:34:55.380 And what are the symptoms of that? Abdominal 00:34:55.380 --> 00:34:58.820 pain, bloating, nausea, and vomiting, especially 00:34:58.820 --> 00:35:01.380 after eating. It's essentially a bowel obstruction 00:35:01.380 --> 00:35:03.719 caused by the cast. It's an emergency. What's 00:35:03.719 --> 00:35:06.340 the fix? You have to cut a window in the abdominal 00:35:06.340 --> 00:35:08.420 part of the cast immediately to relieve that 00:35:08.420 --> 00:35:11.400 pressure, or the bowel can become ischemic and 00:35:11.400 --> 00:35:14.349 die. Wow. Okay, we have covered a ton of conditions. 00:35:15.130 --> 00:35:18.070 Now, let's move to part C, crosslinking and synthesis. 00:35:18.369 --> 00:35:20.210 Let's build that mental decision tree for the 00:35:20.210 --> 00:35:21.969 listener. Let's do the limping child decision 00:35:21.969 --> 00:35:25.110 tree. Imagine you are in the ER triage. This 00:35:25.110 --> 00:35:27.309 is how you should think. Okay, I'm ready. A mom 00:35:27.309 --> 00:35:29.929 walks in. Her 18 -month -old just started walking 00:35:29.929 --> 00:35:32.869 and is walking funny. Okay, first question. Is 00:35:32.869 --> 00:35:36.369 there pain? Is the child crying? No pain. Seems 00:35:36.369 --> 00:35:38.679 happy, just waddles. Check the gate. When they 00:35:38.679 --> 00:35:41.000 stand on one leg, does the pelvis on the opposite 00:35:41.000 --> 00:35:43.900 side drop? Yes. The Trendelenburg sign is positive. 00:35:44.280 --> 00:35:47.280 That's likely missed, DDH. Developmental dysplasia 00:35:47.280 --> 00:35:49.940 of the hip. Get an x -ray. Okay, next patient. 00:35:50.400 --> 00:35:53.059 Six -year -old boy. Mom says he's been limping 00:35:53.059 --> 00:35:55.460 for a few weeks, especially after he plays. Says 00:35:55.460 --> 00:35:58.079 he's faking it to get out of gym class. Check 00:35:58.079 --> 00:36:00.820 his hip's range of motion. Is it limited? Especially 00:36:00.820 --> 00:36:03.920 internal rotation. Mildly. And it hurts a little 00:36:03.920 --> 00:36:05.920 at the end of the range of motion. That's the 00:36:05.920 --> 00:36:09.139 classic picture for leg calvae perthas. Prescribed 00:36:09.139 --> 00:36:13.000 rest, NSAIDs, and a referral to ortho. Next up, 00:36:13.280 --> 00:36:15.980 13 -year -old football island big guy. Complains 00:36:15.980 --> 00:36:17.920 of knee pain after practice for the last month. 00:36:18.059 --> 00:36:20.539 Wait. Knee pain, you said. Yeah, his knee hurts. 00:36:20.539 --> 00:36:22.260 He's pointing to his knee. This is the trap. 00:36:22.579 --> 00:36:25.340 Hip pathology in adolescents almost always refers 00:36:25.340 --> 00:36:27.579 pain to the knee. You ignore the knee for a second 00:36:27.579 --> 00:36:29.880 and check the hip. Is it painful to rotate the 00:36:29.880 --> 00:36:31.940 hip inward? Is the leg stuck turned out? Yes, 00:36:32.059 --> 00:36:34.059 very. He can't turn it in at all. Stop walking 00:36:34.059 --> 00:36:37.400 immediately. Get a wheelchair. It is SCFE until 00:36:37.400 --> 00:36:40.480 proven otherwise. Surgical emergency. That knee 00:36:40.480 --> 00:36:42.820 pain referral is the sneakiest exam trick. It 00:36:42.820 --> 00:36:45.300 catches people every single time. Knee pain in 00:36:45.300 --> 00:36:48.539 an adolescent is a hip exam first, always. Now 00:36:48.539 --> 00:36:50.800 let's look at the floppy versus weak overlap. 00:36:51.380 --> 00:36:54.079 How do we distinguish spina bifida versus CP 00:36:54.079 --> 00:36:56.679 versus muscular dystrophy on the floor? Okay, 00:36:57.039 --> 00:36:59.519 spina bifida. You can usually see the physical 00:36:59.519 --> 00:37:01.519 defect on the back or at least the surgical scar. 00:37:01.760 --> 00:37:04.960 And critically, they have sensory loss. They 00:37:04.960 --> 00:37:07.280 can't feel their legs below the level of the 00:37:07.280 --> 00:37:10.760 lesion. OK, so sensation is a key differentiator. 00:37:10.840 --> 00:37:14.039 Key. Now, CP, they have sensation. Their muscles 00:37:14.039 --> 00:37:16.940 are usually spastic or tight, not floppy, though 00:37:16.940 --> 00:37:19.739 there is a rare atonic type. And you'll have 00:37:19.739 --> 00:37:22.000 a history of prematurity or birth trauma. And 00:37:22.000 --> 00:37:24.039 muscular dystrophy. They were normal. And now 00:37:24.039 --> 00:37:26.420 they are getting weaker. It's a history of regression. 00:37:26.699 --> 00:37:29.420 And they have the classic physical signs, like 00:37:29.420 --> 00:37:31.539 the pseudo hypertrophy of the calves. and the 00:37:31.539 --> 00:37:34.260 Gower sign. That helps clarify it. Now, the safety 00:37:34.260 --> 00:37:36.400 addendum. Let's talk about the terrible differential. 00:37:36.840 --> 00:37:40.079 Child abuse versus osteogenesis imperfecta, OI. 00:37:40.239 --> 00:37:42.079 This is one of the toughest calls in medicine. 00:37:42.460 --> 00:37:44.440 If a child comes in with multiple fractures, 00:37:44.440 --> 00:37:46.159 you have to have abuse at the top of your list. 00:37:46.159 --> 00:37:48.619 But you also have to rule out OI. So what are 00:37:48.619 --> 00:37:51.159 the clues for OI? You look at the eyes for the 00:37:51.159 --> 00:37:53.380 blue sclera. You look at the teeth, which are 00:37:53.380 --> 00:37:56.099 often brittle and discolored. You check the family 00:37:56.099 --> 00:37:59.139 history. And for abuse, what are the fracture 00:37:59.139 --> 00:38:02.050 patterns that are really concerning? Spiral fractures 00:38:02.050 --> 00:38:05.010 in non -walking infants. A baby who can't walk 00:38:05.010 --> 00:38:07.150 shouldn't have a twisting fracture of their femur. 00:38:07.650 --> 00:38:09.889 That requires a significant rotational force 00:38:09.889 --> 00:38:12.530 that they can't generate on their own. Also, 00:38:12.789 --> 00:38:14.610 fractures in different stages of healing on the 00:38:14.610 --> 00:38:18.230 skeletal survey is a classic sign. Exactly. Though, 00:38:18.329 --> 00:38:20.750 to be fair, OI can sometimes present that way 00:38:20.750 --> 00:38:23.150 too, so genetic testing is often the definitive 00:38:23.150 --> 00:38:25.889 answer. But your suspicion has to be high for 00:38:25.889 --> 00:38:28.809 abuse. Okay. Part D, developmental impact. The 00:38:28.809 --> 00:38:31.150 so -what factor. We've touched on this throughout, 00:38:31.289 --> 00:38:33.289 but let's map it to Erickson's stages really 00:38:33.289 --> 00:38:34.929 quickly. This feels like a high -yield way to 00:38:34.929 --> 00:38:36.909 think about it. It is. Let's start with the infant. 00:38:37.710 --> 00:38:40.730 Erickson's stages trust versus mistrust. They 00:38:40.730 --> 00:38:45.130 need consistent, loving care and bonding. Immobilization, 00:38:45.409 --> 00:38:47.809 like being in a Pavlik harness or a Spika cast, 00:38:48.329 --> 00:38:50.730 terrifies parents. They become afraid. to hold 00:38:50.730 --> 00:38:53.170 their baby. And that interrupts bonding terribly. 00:38:53.469 --> 00:38:55.730 So the nursing action is to actively teach and 00:38:55.730 --> 00:38:57.809 encourage parents to hold the child with the 00:38:57.809 --> 00:39:00.610 harness or cast on. We show them how to adapt 00:39:00.610 --> 00:39:03.409 breastfeeding positions. Skin to skin is still 00:39:03.409 --> 00:39:06.659 vital. Toddler. Autonomy versus shame and doubt. 00:39:06.860 --> 00:39:09.619 Toddlers need to move to learn. Their whole world 00:39:09.619 --> 00:39:13.300 is exploration. A spike a cast is a prison. They 00:39:13.300 --> 00:39:15.500 can't cruise the furniture. They can't run. They 00:39:15.500 --> 00:39:17.159 lose their autonomy. This is a nursing action. 00:39:17.380 --> 00:39:20.760 You have to adapt. Use a special wagon or a modified 00:39:20.760 --> 00:39:23.099 stroller so they can still be mobile. Bring the 00:39:23.099 --> 00:39:25.559 world to them. Give them choices wherever possible. 00:39:25.860 --> 00:39:28.320 Do you want the red sticker or the blue sticker 00:39:28.320 --> 00:39:31.260 on your cast? It gives them back a tiny piece 00:39:31.260 --> 00:39:34.199 of control. Preschool. Initiative versus guilt. 00:39:34.349 --> 00:39:36.730 This is the magical thinking age. They connect 00:39:36.730 --> 00:39:38.829 unrelated events. They think, I hit my brother 00:39:38.829 --> 00:39:41.130 yesterday, so now my leg is broken as a punishment. 00:39:41.550 --> 00:39:43.610 They internalize it as their fault. And the nursing 00:39:43.610 --> 00:39:45.670 action is to fight that. Constantly. You have 00:39:45.670 --> 00:39:47.829 to reassure them frequently and in simple terms. 00:39:48.050 --> 00:39:50.050 You did nothing wrong. This is not a punishment. 00:39:50.469 --> 00:39:52.590 Your leg is sick and we are helping it get better. 00:39:52.989 --> 00:39:56.130 School age. Industry versus inferiority. They 00:39:56.130 --> 00:39:58.349 want to achieve. They want to be good at things 00:39:58.349 --> 00:40:00.650 to keep up with their friends at school. Being 00:40:00.650 --> 00:40:02.550 stuck in a hospital bed while their friends are 00:40:02.550 --> 00:40:04.849 playing soccer is boring and makes them feel 00:40:04.849 --> 00:40:08.590 incompetent and inferior. So what do we do? Schoolwork 00:40:08.590 --> 00:40:10.889 is actually therapeutic here. It gives them a 00:40:10.889 --> 00:40:14.190 job, a sense of industry, and maintaining peer 00:40:14.190 --> 00:40:17.469 connection is vital FaceTime, visits from friends. 00:40:18.050 --> 00:40:21.250 And finally, the adolescent. Identity versus 00:40:21.250 --> 00:40:24.210 role confusion. This is by far the hardest group. 00:40:24.440 --> 00:40:28.039 A scoliosis brace or a wheelchair devastatingly 00:40:28.039 --> 00:40:30.039 impacts their ability to fit in. They just want 00:40:30.039 --> 00:40:32.159 to be like everyone else, and their medical condition 00:40:32.159 --> 00:40:35.059 makes them feel like an outcast. So our priority 00:40:35.059 --> 00:40:37.920 is their social health. It has to be. We can 00:40:37.920 --> 00:40:40.000 introduce them to peers with the same condition 00:40:40.000 --> 00:40:42.880 through support groups, and we negotiate treatment 00:40:42.880 --> 00:40:44.940 to fit their social life as much as is safely 00:40:44.940 --> 00:40:48.159 possible. We might say, OK, the rule is 23 hours 00:40:48.159 --> 00:40:50.380 in the brace. You can take it off for the one 00:40:50.380 --> 00:40:53.079 hour you are at the school dance. That compromise 00:40:53.079 --> 00:40:55.130 can make the difference between compliance and 00:40:55.130 --> 00:40:58.250 non -compliance. Brilliant. Okay, we have covered 00:40:58.250 --> 00:41:01.210 a marathon of material. Let's hit the outro and 00:41:01.210 --> 00:41:04.349 wrap this up. To recap, if you walk away with 00:41:04.349 --> 00:41:06.809 nothing else from this deep dive, remember the 00:41:06.809 --> 00:41:10.610 big three. Number one, safety first. Neurovascular 00:41:10.610 --> 00:41:14.130 checks, the five P's. On everything that is restricted, 00:41:14.329 --> 00:41:17.889 be it a cast or traction, do not ignore disproportionate 00:41:17.889 --> 00:41:21.539 pain. Number two. Age matters. A limp means completely 00:41:21.539 --> 00:41:23.579 different things at age two, age six, and age 00:41:23.579 --> 00:41:26.719 12. Let the child's age guide your thinking. 00:41:27.000 --> 00:41:29.760 And number three. Development. Treat the child, 00:41:29.820 --> 00:41:31.900 not just the bone. Always ask yourself how this 00:41:31.900 --> 00:41:34.579 condition, this caste, this hospitalization is 00:41:34.579 --> 00:41:36.739 impacting their growth and development and what 00:41:36.739 --> 00:41:39.300 you can do to support it. And our provocative 00:41:39.300 --> 00:41:41.800 thought for the day to leave everyone with. Well, 00:41:41.800 --> 00:41:44.280 we talked about Duchenne and SMA as these tragic, 00:41:44.380 --> 00:41:47.199 fatal diseases, but the textbook is already becoming 00:41:47.199 --> 00:41:50.219 outdated as we speak. Gene therapies are emerging, 00:41:50.320 --> 00:41:53.900 things like zolgensma for SMA, exon -skipping 00:41:53.900 --> 00:41:56.639 drugs for Duchenne. We are on the cusp of turning 00:41:56.639 --> 00:41:59.280 these fatal diseases into chronic, manageable 00:41:59.280 --> 00:42:01.719 conditions. That's a huge shift. It's a paradigm 00:42:01.719 --> 00:42:04.500 shift. The nurse of the future won't just be 00:42:04.500 --> 00:42:07.079 managing respiratory failure and providing palliative 00:42:07.079 --> 00:42:09.500 care. They might be managing the rehabilitation 00:42:09.500 --> 00:42:12.039 of a child whose muscles are actually recovering. 00:42:12.679 --> 00:42:15.699 The focus will shift from palliative to rehabilitative. 00:42:16.280 --> 00:42:18.260 It's an incredible time to be in this field. 00:42:18.480 --> 00:42:21.000 That is a very hopeful note to end on. It is. 00:42:21.099 --> 00:42:23.420 The science is moving incredibly fast. You've 00:42:23.420 --> 00:42:27.000 got the 80 -20. Now go ace that exam. Thanks 00:42:27.000 --> 00:42:29.699 for listening to the Deep Dive. Stay curious.