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 --> 00:00:32.810 fast. Welcome to the emergency room. 45 minutes 00:00:32.810 --> 00:00:48.409 of CPR. We can stop CPR. Welcome back to the 00:00:48.409 --> 00:00:51.490 the deep dive today We are we're putting on our 00:00:51.490 --> 00:00:53.450 scrubs and stepping into what I think is probably 00:00:53.450 --> 00:00:55.729 one of most intimidating units in pediatric nursing 00:00:55.729 --> 00:00:57.770 Oh, absolutely. We are tackling the endocrine 00:00:57.770 --> 00:01:00.590 system. It is a beast. It's completely invisible 00:01:00.590 --> 00:01:03.689 It's all chemical and let's be honest. It scares 00:01:03.689 --> 00:01:07.849 a lot of nursing students, but it's also I like 00:01:07.849 --> 00:01:10.709 to call it the ultimate Goldilocks system Goldilocks 00:01:10.709 --> 00:01:13.870 like not too hot not too cold. Exactly Everything 00:01:13.870 --> 00:01:15.810 has to be just right. I mean, if you have too 00:01:15.810 --> 00:01:18.530 much hormone, you're in a crisis. Too little. 00:01:18.730 --> 00:01:21.230 A totally different crisis. And when we're talking 00:01:21.230 --> 00:01:24.430 about children, these aren't just metabolic inconveniences. 00:01:24.530 --> 00:01:27.689 They literally alter the entire trajectory of 00:01:27.689 --> 00:01:30.060 a child's growth and development. That sets the 00:01:30.060 --> 00:01:33.120 stage perfectly. And just to orient you, the 00:01:33.120 --> 00:01:35.340 listener, we are treating this deep death like 00:01:35.340 --> 00:01:37.260 a high yield coaching session today. You know, 00:01:37.540 --> 00:01:39.939 we're acting as your nursing educators. We've 00:01:39.939 --> 00:01:42.560 pulled a really specific, massive chapter on 00:01:42.560 --> 00:01:44.700 pediatric endocrine disorders. So we're covering 00:01:44.700 --> 00:01:47.260 the pituitary, thyroid, adrenal glands, and the 00:01:47.260 --> 00:01:50.750 parathyroid. Our mission here isn't to just read 00:01:50.750 --> 00:01:52.870 the textbook to you. That would be painfully 00:01:52.870 --> 00:01:55.629 boring. We are going to cross reference this 00:01:55.629 --> 00:01:59.069 material to extract the Pareto 80 -20. The 20 00:01:59.069 --> 00:02:01.250 % of the concepts that answer 80 % of your exam 00:02:01.250 --> 00:02:03.750 questions. Exactly. And more importantly, the 00:02:03.750 --> 00:02:05.930 stuff that prevents catastrophic errors at the 00:02:05.930 --> 00:02:08.389 bedside. Right. So fewer lists, more logic. Just 00:02:08.389 --> 00:02:09.969 a quick disclaimer before we jump in, though. 00:02:09.969 --> 00:02:12.569 This is an analysis of the provided text for 00:02:12.569 --> 00:02:15.189 educational purposes. We are here to help you 00:02:15.189 --> 00:02:17.930 learn, but always follow your specific hospital 00:02:17.930 --> 00:02:19.919 protocol. Should we dive into the map? Let's 00:02:19.919 --> 00:02:22.379 do it. So before we get into the specific diseases, 00:02:22.759 --> 00:02:25.560 you notice three really distinct patterns of 00:02:25.560 --> 00:02:28.039 pathology in the source material. These are the 00:02:28.039 --> 00:02:30.500 big buckets that exam writers just love. What's 00:02:30.500 --> 00:02:32.580 the first pattern? So the first pattern is what 00:02:32.580 --> 00:02:35.840 I call the growth velocity seesaw. In pediatrics, 00:02:36.139 --> 00:02:37.979 growth is basically a vital sign, right? Yeah. 00:02:38.240 --> 00:02:40.439 So you have diseases that just slam the brakes 00:02:40.439 --> 00:02:42.969 on growth. like growth hormone deficiency or 00:02:42.969 --> 00:02:46.650 hypothyroidism. And then on the exact opposite 00:02:46.650 --> 00:02:49.330 side of that seesaw, you have diseases that hit 00:02:49.330 --> 00:02:52.310 the accelerator way too hard. Like precocious 00:02:52.310 --> 00:02:55.530 puberty or hyperthyroidism. Precisely. So for 00:02:55.530 --> 00:02:59.669 the exam, your priority is recognizing those 00:02:59.669 --> 00:03:01.610 deviations on the girl chart. It's often the 00:03:01.610 --> 00:03:03.530 only red flag you get at first, right? It really 00:03:03.530 --> 00:03:05.909 is. Yeah. If a child falls off their percentile 00:03:05.909 --> 00:03:08.789 curve or if they are crossing percentiles upwards 00:03:08.789 --> 00:03:11.349 way too rapidly, That is your stop sign. You 00:03:11.349 --> 00:03:13.389 have to investigate. OK, got it. Pattern two. 00:03:13.629 --> 00:03:16.610 Pattern two is the salt and water extremes. This 00:03:16.610 --> 00:03:18.909 is honestly where students get mixed up the most. 00:03:19.210 --> 00:03:21.849 Oh, yeah. Electrolytes are tough. They are. So 00:03:21.849 --> 00:03:24.129 on one hand, you have diabetes insipidus, which 00:03:24.129 --> 00:03:28.349 is a dry, high sodium state. And you contrast 00:03:28.349 --> 00:03:31.870 that directly with congenital adrenal hyperplasia, 00:03:32.009 --> 00:03:35.250 or CAH, which almost always presents as a dehydrated, 00:03:35.569 --> 00:03:38.020 low sodium, high potassium state. I love that 00:03:38.020 --> 00:03:40.439 distinction. One keeps the salt, one loses the 00:03:40.439 --> 00:03:42.680 salt. And we're going to unpack that mechanism 00:03:42.680 --> 00:03:45.159 in a lot of detail in a bit. What is the third 00:03:45.159 --> 00:03:47.719 pattern? The sudden crash emergencies. Endocrine 00:03:47.719 --> 00:03:50.479 disorders can be really slow burns until they 00:03:50.479 --> 00:03:52.219 suddenly aren't. We're talking about thyroid 00:03:52.219 --> 00:03:56.680 storm, adrenal crisis, and the seizures or laryngeal 00:03:56.680 --> 00:03:59.199 spasm you get from hypocalcemia. The terrifying 00:03:59.199 --> 00:04:01.919 stuff. Right. These are the absolute can't miss 00:04:01.919 --> 00:04:04.400 signs where a patient can just collapse right 00:04:04.400 --> 00:04:06.300 in front of you. OK. Let's unpack this properly. 00:04:06.400 --> 00:04:08.280 We're going to go disease by disease applying 00:04:08.280 --> 00:04:11.259 that 80 -20 rule. Let's start with the pituitary 00:04:11.259 --> 00:04:14.819 gland and growth hormone deficiency. So hypopituitarism. 00:04:14.919 --> 00:04:16.959 Right. The one liner here is really simple. The 00:04:16.959 --> 00:04:20.240 tank is empty. The pituitary fails to secrete 00:04:20.240 --> 00:04:23.040 some atropin. So these kids are usually born 00:04:23.040 --> 00:04:25.540 at a normal weight, right? But then as they age, 00:04:25.779 --> 00:04:27.800 the fuel just isn't there to maintain the pace. 00:04:28.259 --> 00:04:31.360 Exactly. Looking at the pathology, it's an impaired 00:04:31.360 --> 00:04:35.120 metabolism of proteins, fats, and carbs. It could 00:04:35.120 --> 00:04:37.819 be a genetic defect, could be a tumor, or even 00:04:37.819 --> 00:04:39.740 trauma. But what does it actually look like when 00:04:39.740 --> 00:04:41.920 they walk into the clinic? Well, the age -specific 00:04:41.920 --> 00:04:43.920 presentation is the key here. At birth, they 00:04:43.920 --> 00:04:46.560 usually look completely normal. But later... 00:04:46.519 --> 00:04:48.579 You start seeing those falling percentiles we 00:04:48.579 --> 00:04:50.480 talked about. Right. The need to know findings 00:04:50.480 --> 00:04:53.699 are short stature, decreased muscle mass, and 00:04:53.699 --> 00:04:56.540 delayed tuberty. But here is the major nuance 00:04:56.540 --> 00:04:59.879 for exams. Their proportions are normal. So they 00:04:59.879 --> 00:05:01.800 aren't disproportionate. They just look like 00:05:01.800 --> 00:05:03.540 a much younger version of themselves. Exactly. 00:05:03.639 --> 00:05:05.759 They look like a perfectly proportioned younger 00:05:05.759 --> 00:05:08.120 child. And the intervention is pretty straightforward. 00:05:08.579 --> 00:05:11.319 We just replace the hormone. Yes. Subcutaneous 00:05:11.319 --> 00:05:13.579 growth hormone therapy. Usually some atropin. 00:05:13.740 --> 00:05:16.540 It's a daily injection. But here's the critical 00:05:16.540 --> 00:05:19.139 complication the text highlights, and exam writers 00:05:19.139 --> 00:05:22.279 absolutely love testing this one. You need to 00:05:22.279 --> 00:05:25.660 watch for painful hip or knee joints. Wait, hip 00:05:25.660 --> 00:05:28.680 pain? That seems totally random. Why hips? It's 00:05:28.680 --> 00:05:31.560 just physics, really. You are chemically forcing 00:05:31.560 --> 00:05:33.839 the bones to grow rapidly with the medication. 00:05:34.540 --> 00:05:37.300 If that growth happens too fast, the structural 00:05:37.300 --> 00:05:39.660 integrity of the hip joint can actually fail. 00:05:39.959 --> 00:05:43.379 Oh, wow. Yeah, the femoral head literally slips 00:05:43.379 --> 00:05:46.170 off the neck of the bone. It's called slipped 00:05:46.170 --> 00:05:50.209 capital femoral epithesis or SCFE. That sounds 00:05:50.209 --> 00:05:53.050 incredibly painful. It is. So if you have a parent 00:05:53.050 --> 00:05:54.550 calling the clinic saying, you know, he's doing 00:05:54.550 --> 00:05:56.529 great on the shots, but he's limping or his knee 00:05:56.529 --> 00:05:58.430 hurts. You don't just brush that off as growing 00:05:58.430 --> 00:06:01.949 pains. Never. That is not growing pains. That 00:06:01.949 --> 00:06:04.769 is a medical emergency. You stop the drug immediately 00:06:04.769 --> 00:06:07.730 and get an orthopedic consult. That is a massive 00:06:07.730 --> 00:06:11.480 safety tip. And developmentally, I imagine being 00:06:11.480 --> 00:06:13.959 much shorter than all your peers takes a huge 00:06:13.959 --> 00:06:17.100 toll. A huge impact. Self -esteem and body image 00:06:17.100 --> 00:06:19.560 are major nursing concerns here. You're treating 00:06:19.560 --> 00:06:22.240 the physical height, but you also have to aggressively 00:06:22.240 --> 00:06:24.399 support the child psychologically. Because they 00:06:24.399 --> 00:06:27.139 probably get babied a lot. All the time. By teachers, 00:06:27.259 --> 00:06:29.699 by peers, just because of their physical size, 00:06:29.779 --> 00:06:32.220 even though their cognitive development is perfectly 00:06:32.220 --> 00:06:34.680 age -appropriate. OK, let's flip the seesaw then. 00:06:34.920 --> 00:06:37.120 Let's talk about when the biological clock runs 00:06:37.120 --> 00:06:40.360 way too fast. precocious puberty. This is clinically 00:06:40.360 --> 00:06:43.060 defined as puberty starting before age 9 and 00:06:43.060 --> 00:06:46.120 boys or age 8 and girls. Which seems incredibly 00:06:46.120 --> 00:06:48.759 young to me. It is very young and here is the 00:06:48.759 --> 00:06:51.300 paradox that constantly trips people up on exams. 00:06:51.759 --> 00:06:53.899 These kids have a massive growth spurt early 00:06:53.899 --> 00:06:55.959 on so at age 7 they might be the tallest kid 00:06:55.959 --> 00:06:58.279 in their class by far. So parents might be thinking 00:06:58.279 --> 00:07:01.100 great he's gonna be an NBA player. Exactly. Yeah. 00:07:01.100 --> 00:07:03.839 But it's a trap because those early sex hormones 00:07:03.839 --> 00:07:07.500 trigger the growth plates in the bones to close 00:07:07.500 --> 00:07:10.620 or fuse way too early. Oh, I see. So they shoot 00:07:10.620 --> 00:07:13.360 up fast, fuse the bones, and then they stop growing 00:07:13.360 --> 00:07:15.860 completely at age 10 or 11. So the really tall 00:07:15.860 --> 00:07:19.240 seven year old becomes a very short adult. Precisely. 00:07:19.560 --> 00:07:21.740 If left untreated, they will have significant 00:07:21.740 --> 00:07:24.879 short stature as adults. The need -to -know findings 00:07:24.879 --> 00:07:28.019 here are premature pubic hair, breast development, 00:07:28.459 --> 00:07:30.740 and that advanced skeletal maturation you see 00:07:30.740 --> 00:07:32.899 on an x -ray. And what's the treatment? How do 00:07:32.899 --> 00:07:34.839 you stop it? You basically have to hit the pause 00:07:34.839 --> 00:07:36.939 button. If there's a tumor causing it, you remove 00:07:36.939 --> 00:07:39.920 it. If it's central precocious puberty, you use 00:07:39.920 --> 00:07:42.720 a GNRH agonist, something like luprolide. And 00:07:42.720 --> 00:07:45.000 that just tells the pituitary to calm down. Exactly. 00:07:45.100 --> 00:07:47.100 It tells the pituitary to stop shouting at the 00:07:47.100 --> 00:07:49.629 ovaries or the tests. Developmentally, this feels 00:07:49.629 --> 00:07:51.610 incredibly tricky. You have a seven -year -old 00:07:51.610 --> 00:07:55.329 girl who physically might look 14. That is the 00:07:55.329 --> 00:07:57.470 primary nursing challenge, honestly, outside 00:07:57.470 --> 00:08:00.329 of administering the meds. Her cognitive development 00:08:00.329 --> 00:08:02.209 is age -appropriate. She's playing with dolls. 00:08:02.290 --> 00:08:04.209 She thinks like a second grader. Yeah. But the 00:08:04.209 --> 00:08:06.410 outside world treats her like a teenager. Right. 00:08:06.589 --> 00:08:08.829 The risk of inappropriate social expectations 00:08:08.829 --> 00:08:12.459 and even sexualization is very real. We really 00:08:12.459 --> 00:08:14.480 have to coach the parents on that social mirror 00:08:14.480 --> 00:08:16.639 effect. That's a really powerful perspective. 00:08:17.699 --> 00:08:20.160 Okay, let's move to pattern two, the salt and 00:08:20.160 --> 00:08:22.839 water games. This is usually the hardest section 00:08:22.839 --> 00:08:25.660 for nursing students to grasp. Let's start with 00:08:25.660 --> 00:08:28.839 the high and dry disorder, diabetes insipidus, 00:08:28.899 --> 00:08:33.139 or DI. Central DI. This is a lack of ADH antidiuretic 00:08:33.139 --> 00:08:34.919 hormone. I always tell my students to just call 00:08:34.919 --> 00:08:36.940 it the anti -peeing hormone. Because if you don't 00:08:36.940 --> 00:08:39.340 have the anti -peeing hormone... You pee. A lot. 00:08:39.600 --> 00:08:41.980 Massive amounts. Massive. The kidneys simply 00:08:41.980 --> 00:08:44.580 cannot concentrate the urine. So the core findings 00:08:44.580 --> 00:08:47.700 are polyuria, which is lots of urine, and polydipsia, 00:08:48.120 --> 00:08:51.019 and insatiable thirst. In a toilet -trained child, 00:08:51.440 --> 00:08:53.740 seeing them suddenly start wetting the bed, that 00:08:53.740 --> 00:08:56.919 anuresis is a classic warning sign. And the labs, 00:08:57.120 --> 00:08:59.980 because this is crucial for the exam. High serum 00:08:59.980 --> 00:09:04.860 sodium. Think high and dry. They are losing pure 00:09:04.860 --> 00:09:07.450 water. so the blood left behind becomes really 00:09:07.450 --> 00:09:10.309 salty. You get hypernatremia. And the urine. 00:09:10.629 --> 00:09:12.629 Because all that water is just dumping into the 00:09:12.629 --> 00:09:15.370 toilet, the urine is extremely dilute. It has 00:09:15.370 --> 00:09:17.710 a very low specific gravity, usually less than 00:09:17.710 --> 00:09:20.929 1 .005. It practically looks like tap water. 00:09:21.190 --> 00:09:23.929 Now, safety -wise, the text mentions a medical 00:09:23.929 --> 00:09:26.850 alert bracelet being mandatory. Absolutely mandatory. 00:09:27.210 --> 00:09:29.509 Think about it. If this child is in a car accident 00:09:29.509 --> 00:09:31.990 and is unconscious, they can't ask for water. 00:09:32.200 --> 00:09:35.100 But their body keeps dumping fluid anyway. They'll 00:09:35.100 --> 00:09:37.620 just dry out. They will dehydrate and seize from 00:09:37.620 --> 00:09:40.659 hypernatriony incredibly fast. The bracelet speaks 00:09:40.659 --> 00:09:42.960 for them when they can't. And for nursing care, 00:09:43.080 --> 00:09:45.320 we are obviously watching intake and output like 00:09:45.320 --> 00:09:48.080 a hawk. Now let's pivot to the adrenal glands. 00:09:48.399 --> 00:09:50.559 We talked about high and dry DI. Now we need 00:09:50.559 --> 00:09:52.759 to talk about congenital adrenal hyperplasia 00:09:52.759 --> 00:09:56.240 or CAH. This one always trips me up. It's complicated. 00:09:56.480 --> 00:09:58.259 But think of it as a broken factory assembly 00:09:58.259 --> 00:10:00.600 line. The adrenal gland is trying to make two 00:10:00.830 --> 00:10:04.230 critical end products, cortisol and aldosterone. 00:10:04.769 --> 00:10:07.870 But the factory is missing a worker, a specific 00:10:07.870 --> 00:10:11.210 enzyme, usually 21 -hydroxylase. So the factory 00:10:11.210 --> 00:10:14.090 can't make the final product. Right. But the 00:10:14.090 --> 00:10:16.809 brain doesn't know the factory is broken. It 00:10:16.809 --> 00:10:19.309 just senses low cortisol and screams, make more 00:10:19.309 --> 00:10:23.230 cortisol, by sending tons of ACTH. So the gland 00:10:23.230 --> 00:10:26.269 works over time? Yes. It gets huge. That's the 00:10:26.269 --> 00:10:28.769 hyperplasia. But it still can't make the cortisol. 00:10:28.970 --> 00:10:31.009 So where do all those hormone building blocks 00:10:31.009 --> 00:10:33.129 go? They get diverted down the only assembly 00:10:33.129 --> 00:10:35.350 line that's still open, which produces androgens, 00:10:35.610 --> 00:10:38.649 male sex hormones. So if you have a genetic female 00:10:38.649 --> 00:10:40.950 infant with this... She's born with ambiguous 00:10:40.950 --> 00:10:43.730 genitalia, an enlarged clitoris that might actually 00:10:43.730 --> 00:10:46.190 look like a penis, that is often your first assessment 00:10:46.190 --> 00:10:48.049 clue in the newborn nursery. But the real need 00:10:48.049 --> 00:10:50.350 -to -know crisis isn't the genitalia, it's the 00:10:50.350 --> 00:10:52.909 salt, right? Correct. Remember, they also can't 00:10:52.909 --> 00:10:54.909 make aldosterone, aldosterone your body's salt 00:10:54.909 --> 00:10:57.309 keeper. Without it, the kidneys just dump sodium 00:10:57.309 --> 00:11:00.690 into the urine. So these babies have hyponatremia, 00:11:01.149 --> 00:11:03.870 low sodium. Yes, and because sodium and potassium 00:11:03.870 --> 00:11:06.409 constantly trade places in the kidneys, they 00:11:06.409 --> 00:11:09.629 also develop hyperkalemia, high potassium. And 00:11:09.629 --> 00:11:12.259 they go into shock. They do. This is the adrenal 00:11:12.259 --> 00:11:15.679 crisis, dehydrated, low salt, high potassium, 00:11:15.879 --> 00:11:18.919 and tanking blood pressure. It is the exact physiological 00:11:18.919 --> 00:11:20.879 opposite of the DI patient we just talked about. 00:11:20.919 --> 00:11:22.980 And the treatment is lifelong replacement. You 00:11:22.980 --> 00:11:24.960 just have to give them what they're missing, 00:11:25.500 --> 00:11:28.600 leukocorticoids like hydrocortisone and mineralocorticoids 00:11:28.600 --> 00:11:30.919 like fludrocortisone. That's right. And there 00:11:30.919 --> 00:11:33.620 is a massive parent education point here that 00:11:33.620 --> 00:11:36.379 exam writers test constantly. It's called stress 00:11:36.379 --> 00:11:38.879 dosing. Tell me about that. This is the number 00:11:38.879 --> 00:11:42.139 one safety teaching point for CAH. Cortisol is 00:11:42.139 --> 00:11:45.059 our natural stress hormone. If a healthy person 00:11:45.059 --> 00:11:47.980 gets sick or breaks a leg or has surgery, our 00:11:47.980 --> 00:11:50.559 body naturally pumps out extra cortisol to keep 00:11:50.559 --> 00:11:52.919 our blood pressure up and manage the stress. 00:11:53.100 --> 00:11:55.220 But that these kids cannot do that. Exactly. 00:11:55.519 --> 00:11:57.120 So if they get something as simple as the flu, 00:11:57.279 --> 00:11:59.820 the parents must increase the dose. They have 00:11:59.820 --> 00:12:01.559 to. Sometimes double or triple it, depending 00:12:01.559 --> 00:12:04.539 on the protocol. If they don't, the child's body 00:12:04.539 --> 00:12:06.860 cannot handle the physical stress, they will 00:12:06.860 --> 00:12:09.500 go into vascular collapse, and they can die. 00:12:09.559 --> 00:12:12.600 That is a stark reality for a parent to manage. 00:12:12.960 --> 00:12:15.659 Just knowing my kid has a fever, I need to up 00:12:15.659 --> 00:12:17.840 the meds immediately or else. It saves lives. 00:12:18.080 --> 00:12:20.360 It's completely non -negotiable. OK, let's pivot 00:12:20.360 --> 00:12:22.399 to the thyroid. We have two sides of the coin 00:12:22.399 --> 00:12:26.120 here, congenital hypothyroidism and hyperthyroidism. 00:12:26.259 --> 00:12:29.080 Let's start with congenital hypo. This is a classic 00:12:29.080 --> 00:12:31.779 catch at early diagnosis. It is arguably the 00:12:31.779 --> 00:12:33.899 most critical endocrine screening we do in a 00:12:33.899 --> 00:12:36.970 newborn. The baby is born without enough thyroid 00:12:36.970 --> 00:12:39.389 hormone. What does that baby look like? The text 00:12:39.389 --> 00:12:41.990 describes a quote, quiet baby. Right. And that 00:12:41.990 --> 00:12:44.350 sounds really nice to a tired new parent. Oh, 00:12:44.389 --> 00:12:46.309 he's such a good baby. He sleeps all the time. 00:12:46.409 --> 00:12:49.490 He barely cries. But it's actually a huge danger 00:12:49.490 --> 00:12:53.750 sign. Lethargy, poor sucking, cool, dry skin. 00:12:53.830 --> 00:12:55.970 And there's a structural clue too, right? Yes. 00:12:56.549 --> 00:12:59.509 A very specific finding is a persistent open 00:12:59.509 --> 00:13:02.350 posterior fontanelle and an enlarged protruding 00:13:02.350 --> 00:13:04.899 tongue. Then why is it so critical to catch this 00:13:04.899 --> 00:13:07.720 early? Brain development. This is the ultimate 00:13:07.720 --> 00:13:11.220 80 -20 takeaway. Thyroid hormone is literally 00:13:11.220 --> 00:13:14.980 fuel for the developing brain. If you miss this 00:13:14.980 --> 00:13:17.879 and you don't start sodium levothyroxine immediately, 00:13:18.120 --> 00:13:20.879 It results in permanent intellectual disability. 00:13:21.120 --> 00:13:24.000 That is heavy. So the development impact is essentially 00:13:24.000 --> 00:13:27.139 saving their cognitive function. 100%. That's 00:13:27.139 --> 00:13:29.500 why we do the mandatory neonatal heel prick screen 00:13:29.500 --> 00:13:32.159 in all 50 states. We are specifically looking 00:13:32.159 --> 00:13:35.600 for low T4 and a high TSH. Now flip the coin. 00:13:36.600 --> 00:13:38.720 Hyperthyroidism. Graves' disease. The engine 00:13:38.720 --> 00:13:41.000 is running way too hot. This one usually hits 00:13:41.000 --> 00:13:43.860 an adolescence. Everything speeds up. Hyperactivity. 00:13:44.090 --> 00:13:45.610 weight loss, even though they're eating like 00:13:45.610 --> 00:13:48.789 a horse, heat intolerance, you'll see that classic 00:13:48.789 --> 00:13:51.789 exothelmos, the bulging eyes, and really velvety 00:13:51.789 --> 00:13:54.360 smooth skin. And the sudden crash we look out 00:13:54.360 --> 00:13:57.299 for here is the thyroid storm. This is an absolute 00:13:57.299 --> 00:13:59.720 life threat. It's an abrupt massive release of 00:13:59.720 --> 00:14:01.759 thyroid hormone, often triggered by stress or 00:14:01.759 --> 00:14:03.820 an infection. The patient becomes incredibly 00:14:03.820 --> 00:14:06.519 restless. They get a high fever, severe tachycardia, 00:14:06.559 --> 00:14:09.120 dipheresis. It's like the body is vibrating apart. 00:14:09.379 --> 00:14:11.419 It really is. You have to intervene immediately 00:14:11.419 --> 00:14:14.159 with beta blockers and anti -thyroid meds to 00:14:14.159 --> 00:14:16.980 slow the heart and block the hormone. Now, often 00:14:16.980 --> 00:14:19.080 they will treat this by removing the thyroid 00:14:19.080 --> 00:14:22.259 surgically. But the text warns about a very specific 00:14:22.259 --> 00:14:25.440 post -op complication. If you take out the thyroid, 00:14:25.960 --> 00:14:28.799 what else might you accidentally grab? The parathyroid 00:14:28.799 --> 00:14:30.980 glands, they sit right on top of the thyroid 00:14:30.980 --> 00:14:34.200 and they're tiny. If a surgeon accidentally nicks 00:14:34.200 --> 00:14:37.039 them or removes them, the body's calcium regulation 00:14:37.039 --> 00:14:39.639 just disappears. Which leads us perfectly into 00:14:39.639 --> 00:14:42.860 topic seven on our outline. hyperparathyroidism. 00:14:43.200 --> 00:14:45.600 Right. It's usually an accidental surgical complication. 00:14:46.000 --> 00:14:48.779 No parathyroid hormone means sudden hypocalcemia. 00:14:48.980 --> 00:14:51.120 And low calcium makes the nervous system, what, 00:14:51.379 --> 00:14:53.460 really twitchy? Extremely irritable. You get 00:14:53.460 --> 00:14:56.059 tetany. The classic nursing assessment here is 00:14:56.059 --> 00:14:58.620 the Schvostek sign. You tap the facial nerve 00:14:58.620 --> 00:15:00.700 right on the cheek, and the whole side of the 00:15:00.700 --> 00:15:03.309 face twitches. But the killer, the one that stops 00:15:03.309 --> 00:15:07.110 your breathing, is laryngospasm. Yes. The airway 00:15:07.110 --> 00:15:09.769 muscles literally cramp shut. So if you are caring 00:15:09.769 --> 00:15:13.250 for a kid post -thyroidectomy, you need a tracheostomy 00:15:13.250 --> 00:15:16.230 tray and IV calcium gluconate right at the bedside. 00:15:16.490 --> 00:15:19.090 You are watching that airway like a hawk. OK, 00:15:19.110 --> 00:15:21.370 we've covered the disease processes. Now let's 00:15:21.370 --> 00:15:23.529 move into the medication module. We've touched 00:15:23.529 --> 00:15:25.509 on a few of these, but let's drill down on the 00:15:25.509 --> 00:15:28.370 specific nursing pearls from the text. First 00:15:28.370 --> 00:15:32.889 up. growth hormone or somatropin. So administered 00:15:32.889 --> 00:15:35.570 subcutaneously. The penny pearl here is your 00:15:35.570 --> 00:15:37.649 monitoring. We already hammered home the hip 00:15:37.649 --> 00:15:40.129 and knee pain for the slipped epiphysis. Right, 00:15:40.230 --> 00:15:42.909 no growing pains. Exactly. But you also need 00:15:42.909 --> 00:15:45.110 to watch for rapid weight gain and increased 00:15:45.110 --> 00:15:47.730 thirst because growth hormone can actually mess 00:15:47.730 --> 00:15:50.450 with glucose metabolism and cause insulin resistance. 00:15:50.789 --> 00:15:53.870 Good to know. Med 2 is levothyroxine for the 00:15:53.870 --> 00:15:56.620 thyroid. I call this the picky eater of medications. 00:15:56.840 --> 00:15:59.200 It has to be given on an empty stomach. The text 00:15:59.200 --> 00:16:01.879 explicitly says to avoid giving it near food 00:16:01.879 --> 00:16:04.200 consumption because things like soy formula or 00:16:04.200 --> 00:16:06.720 calcium supplements completely block its absorption. 00:16:06.960 --> 00:16:09.299 And in an infant who eats every three hours, 00:16:09.340 --> 00:16:12.100 that is really tough timing. It's incredibly 00:16:12.100 --> 00:16:14.299 frustrating for parents, but you have to find 00:16:14.299 --> 00:16:17.250 that window. Because if the dose isn't absorbed, 00:16:17.350 --> 00:16:19.389 the brain doesn't develop. And you monitor the 00:16:19.389 --> 00:16:21.830 pulse with this one. Yes. If the resting heart 00:16:21.830 --> 00:16:24.590 rate goes too high, it usually means the levothyroxine 00:16:24.590 --> 00:16:27.730 dose is too high. You're pushing them into hyperthyroidism. 00:16:27.929 --> 00:16:32.110 Med 3, Desmopressin or DDAVP for diabetes insipidus. 00:16:32.350 --> 00:16:35.110 This comes as an intranasal stray, oral pill, 00:16:35.470 --> 00:16:38.370 or SQ injection. It works great. It stops the 00:16:38.370 --> 00:16:41.169 massive peeing. But here is the major safety 00:16:41.169 --> 00:16:44.490 alert. Water intoxication. Break that mechanism 00:16:44.490 --> 00:16:46.850 down for us. Think about the patient's routine. 00:16:47.470 --> 00:16:49.990 The child's been uncontrollably thirsty for weeks, 00:16:50.509 --> 00:16:52.850 drinking gallons of water every day. You give 00:16:52.850 --> 00:16:54.950 the med, and the kidneys suddenly stop making 00:16:54.950 --> 00:16:57.809 urine. OK. But out of sheer habit or psychological 00:16:57.809 --> 00:17:00.169 drive, the child keeps drinking those gallons 00:17:00.169 --> 00:17:02.649 of water. But now the water has nowhere to go. 00:17:02.870 --> 00:17:05.720 Exactly. It stays in the blood. It severely dilutes 00:17:05.720 --> 00:17:08.460 the sodium. You get rapid hyponutremia. The brain 00:17:08.460 --> 00:17:10.460 starts to swell and they seize. So you have to 00:17:10.460 --> 00:17:12.619 strict limit their fluids. You have to restrict 00:17:12.619 --> 00:17:15.059 fluids the moment that medication starts working. 00:17:15.640 --> 00:17:17.640 You can't let them drink like they used to. That 00:17:17.640 --> 00:17:21.200 is a critical balancing act. All right. Med four. 00:17:21.740 --> 00:17:24.259 Corticosteroids like hydrocortisone. We covered 00:17:24.259 --> 00:17:28.019 the big one here. Stress dosing. Never, ever 00:17:28.019 --> 00:17:31.339 skip a dose. And similar to growth hormone, long 00:17:31.339 --> 00:17:33.779 -term use of steroids can actually stunt growth 00:17:33.779 --> 00:17:35.859 velocity so we monitor their height closely. 00:17:36.119 --> 00:17:38.720 Finally, calcium gluconate. This is for that 00:17:38.720 --> 00:17:40.980 emergency hypocalcemia we talked about. The safety 00:17:40.980 --> 00:17:43.940 alert here is all about the IV line itself. Calcium 00:17:43.940 --> 00:17:46.440 is terrible for the veins. It's highly caustic. 00:17:46.500 --> 00:17:49.259 So if it leaks? If the IV infiltrates, meaning 00:17:49.259 --> 00:17:51.670 it goes into the surrounding... tissue instead 00:17:51.670 --> 00:17:54.170 of the vein. It causes extravasation. You get 00:17:54.170 --> 00:17:56.849 tissue necrosis and sleeping. The skin will literally 00:17:56.849 --> 00:17:59.529 die and peel off. Yes, it's a severe chemical 00:17:59.529 --> 00:18:02.470 burn. So you absolutely must check that IV site 00:18:02.470 --> 00:18:04.970 patency and get a good blood return before you 00:18:04.970 --> 00:18:08.289 push calcium every single time. Let's move to 00:18:08.289 --> 00:18:10.849 our cross -linking and synthesis section. We've 00:18:10.849 --> 00:18:12.950 been connecting dots as we go, but let's solidify 00:18:12.950 --> 00:18:15.730 a few key things. First, let's look at the developmental 00:18:15.730 --> 00:18:18.490 delays. We have the slow growers versus the fast 00:18:18.490 --> 00:18:21.740 growers. Right. GH deficiency and hypothyroidism 00:18:21.740 --> 00:18:24.960 are your slow growers. Precocious puberty and 00:18:24.960 --> 00:18:28.220 CAH are the fast growers. But here is the real 00:18:28.220 --> 00:18:32.440 kicker for pediatric nursing. All of them require 00:18:32.440 --> 00:18:35.900 hormonal manipulation to normalize their trajectory. 00:18:36.039 --> 00:18:38.380 So it's not just about the numbers? Not at all. 00:18:38.559 --> 00:18:41.000 The goal of nursing care isn't just fixing the 00:18:41.000 --> 00:18:43.839 lab values. It is getting that child back onto 00:18:43.839 --> 00:18:46.460 the standard growth curve so they can hit those 00:18:46.460 --> 00:18:49.099 milestones, both physical and social, at the 00:18:49.099 --> 00:18:50.759 appropriate time. And then there's the fluid 00:18:50.759 --> 00:18:52.839 safety aspect. I want to reiterate this because 00:18:52.839 --> 00:18:55.519 it feels like the biggest trap for an exam or 00:18:55.519 --> 00:18:57.940 a real shift. It is the one that kills if you 00:18:57.940 --> 00:19:00.190 get it backwards. You have to know your patient's 00:19:00.190 --> 00:19:02.930 underlying disease. So if it's diabetes insipidus... 00:19:02.930 --> 00:19:05.309 They are dehydrated and hyponatremic. They have 00:19:05.309 --> 00:19:07.789 too much salt. They need free water fluids and 00:19:07.789 --> 00:19:11.049 DDAVP. But if it's an adrenal crisis from CAH... 00:19:11.049 --> 00:19:13.009 They are also dehydrated, but they are hyponatremic. 00:19:13.029 --> 00:19:15.410 They have no salt. So they need salt restoration, 00:19:15.970 --> 00:19:18.950 isotonic fluid resuscitation, and steroids. If 00:19:18.950 --> 00:19:20.609 you treat them the same just because they both 00:19:20.609 --> 00:19:22.690 look dehydrated? You will hurt them. You have 00:19:22.690 --> 00:19:24.900 to look at the sodium levels. That right there 00:19:24.900 --> 00:19:27.160 is the deep dive difference, understanding the 00:19:27.160 --> 00:19:29.440 why behind the dehydration. Exactly. All right, 00:19:29.440 --> 00:19:31.599 we have covered a massive amount of ground today. 00:19:31.640 --> 00:19:34.339 Let's wrap this up. If you are listening to this 00:19:34.339 --> 00:19:37.039 on your way to a big exam or your next clinical 00:19:37.039 --> 00:19:40.279 shift, what are the big three safety takeaways 00:19:40.279 --> 00:19:44.339 to keep in your pocket? Number one, stress dosing 00:19:44.339 --> 00:19:48.799 for CAH. Parents must know to increase the steroid 00:19:48.799 --> 00:19:51.400 dose during any illness to prevent shock. Got 00:19:51.400 --> 00:19:54.960 it. Number two, medical alert bracelets for diabetes 00:19:54.960 --> 00:19:57.740 insipidus. It speaks for the child when they 00:19:57.740 --> 00:20:00.119 physically can't ask for water. And number three, 00:20:00.299 --> 00:20:02.240 hip pain reporting for growth hormone therapy. 00:20:02.819 --> 00:20:05.119 Do not ignore a limping child on some atropine. 00:20:05.240 --> 00:20:07.519 Rule out that slipped epiphysis immediately. 00:20:07.799 --> 00:20:09.759 Perfect. And as we sign off, I want to leave 00:20:09.759 --> 00:20:11.380 you with a final thought to kind of mull over. 00:20:11.480 --> 00:20:13.559 We spent a lot of time talking about labs and 00:20:13.559 --> 00:20:16.069 hormones and IVs. But think about the social 00:20:16.069 --> 00:20:18.430 impact here. Right. I mean, imagine being that 00:20:18.430 --> 00:20:20.710 seven year old girl with precocious puberty. 00:20:21.049 --> 00:20:24.349 She is trying to navigate a grade school playground 00:20:24.349 --> 00:20:27.869 in a body that looks 14. She is dealing with 00:20:27.869 --> 00:20:30.779 social pressures from. older kids and adults 00:20:30.779 --> 00:20:34.200 that she just isn't cognitively ready for. Or 00:20:34.200 --> 00:20:36.759 the 10 -year -old boy with growth hormone deficiency 00:20:36.759 --> 00:20:39.299 who looks sick, constantly being patted on the 00:20:39.299 --> 00:20:41.539 head and treated like a toddler by his teachers. 00:20:41.640 --> 00:20:44.079 It's exhausting for them. The nursing role isn't 00:20:44.079 --> 00:20:47.279 just adjusting the hormone dose. It's protecting 00:20:47.279 --> 00:20:50.759 their childhood. It's advocating for them so 00:20:50.759 --> 00:20:52.599 that their physical appearance doesn't dictate 00:20:52.599 --> 00:20:54.579 their social worth or how they're treated in 00:20:54.579 --> 00:20:56.440 the hospital. Very well said. These patients 00:20:56.440 --> 00:20:58.839 aren't just lab values. They're children. on 00:20:58.839 --> 00:21:00.839 a disrupted growth curve and we are the ones 00:21:00.839 --> 00:21:02.880 helping them find their balance. Thanks for diving 00:21:02.880 --> 00:21:05.440 in with us today. Good luck on the exam and you 00:21:05.440 --> 00:21:06.960 know stay curious. See you next time.