Nursing Care Plan (NCP) for Clubfoot

Understanding of Clubfoot:
- Gain knowledge about clubfoot, including its definition, causes, and the impact on a child’s musculoskeletal development.
Assessment Skills:
- Develop the ability to perform a comprehensive nursing assessment for clubfoot, including physical examination, imaging studies, and collaboration with other healthcare professionals.
Intervention Strategies:
- Learn evidence-based intervention strategies for clubfoot management, encompassing both non-surgical and surgical approaches.
Family Education:
- Acquire skills in educating parents and caregivers about the condition, treatment options, and the importance of ongoing care and follow-up for the child with clubfoot.
Monitoring and Evaluation:
- Understand the key parameters for monitoring the progress of clubfoot treatment and conducting regular evaluations to ensure optimal outcomes.

Pathophysiology of Clubfoot

Intrinsic Muscle Abnormalities:
- Clubfoot involves abnormalities in the muscles and tendons of the lower leg and foot, leading to an imbalance in muscle forces.
Connective Tissue Tightening:
- Tightening of connective tissues, such as ligaments and joint capsules, contributes to the characteristic deformities observed in clubfoot.
Bony Abnormalities:
- Clubfoot may involve malformations in the bones of the foot, including the talus, calcaneus, and metatarsals, affecting the overall structure.
Genetic Factors:
- Genetic factors play a role in the development of clubfoot, with certain gene mutations influencing the musculoskeletal development during fetal growth.
Intrauterine Positioning:
- The positioning of the fetus in the womb can contribute to the development of clubfoot, with abnormal pressure or constraint impacting the formation of the foot and ankle.
Neurological Factors:
- Consider neurological factors that may contribute to clubfoot, including abnormalities in the development or function of the nerves controlling lower limb muscles. Neurological issues can impact the coordination and balance of muscle forces, affecting foot positioning.
Vascular Insufficiency:
- Explore the role of vascular insufficiency in clubfoot development. Inadequate blood supply to specific regions of the developing foot may influence tissue growth and contribute to structural abnormalities observed in clubfoot.
Joint Dysplasia:
- Address joint dysplasia as a potential factor in clubfoot pathophysiology. Anomalies in joint development, particularly in the ankle and subtalar joints, can contribute to the misalignment and deformities seen in clubfoot

Etiology of Clubfoot

Genetic Factors:
- Clubfoot often has a genetic component, with a higher incidence in individuals with a family history of the condition. Specific gene mutations may contribute to the development of clubfoot.
Intrauterine Factors:
- Factors during fetal development, such as restricted space in the womb or abnormal positioning, can lead to the formation of clubfoot. Intrauterine crowding may affect the normal development of the foot.
Environmental Factors:
- Certain environmental factors, such as maternal smoking during pregnancy, have been associated with an increased risk of clubfoot. Exposure to teratogenic substances may contribute to its development.
Neurological Factors:
- Some cases of clubfoot may be associated with neurological conditions or abnormalities affecting the nerves that control muscle movement. Neurological factors can influence muscle tone and coordination.
Amniotic Band Syndrome:
- Clubfoot can be associated with amniotic band syndrome, where fibrous bands from the amniotic sac entangle fetal limbs, restricting normal development and leading to deformities like clubfoot.

Desired Outcome for Clubfoot

Correction of Foot Deformity:
- Achieve complete correction of the clubfoot deformity, restoring the foot to a normal position and alignment.
Normal Range of Motion:
- Attain a normal range of motion in the affected foot, allowing for flexibility, mobility, and functional use.
Optimal Muscle Strength:
- Develop optimal muscle strength in the affected leg and foot to support weight-bearing activities and ensure proper gait.
Pain-Free Functionality:
- Attain pain-free functionality in the corrected foot, allowing the individual to engage in activities without discomfort or pain.
Prevention of Recurrence:
- Implement measures to prevent the recurrence of clubfoot deformity through ongoing monitoring, orthotic interventions, and, if necessary, surgical correction.

Clubfoot Nursing Care Plan

Subjective Data:

Soreness of leg (post-treatment)

Objective Data:

Top of the foot is twisted downward
Foot twisted inward
Inability to walk properly

Nursing Assessment for Clubfoot

Physical Examination:
- Perform a thorough physical examination of the affected foot, assessing for the severity of deformity, range of motion, and muscle strength.
Family History:
- Obtain a detailed family history to identify any genetic predisposition or familial occurrences of clubfoot.
Maternal History:
- Explore maternal factors during pregnancy, such as exposure to teratogenic substances or conditions that might contribute to clubfoot.
Neurological Assessment:
- Evaluate the neurological status of the affected limb, assessing for any associated neuromuscular conditions.
Skin Integrity:
- Inspect the skin on and around the affected foot for any signs of irritation, pressure points, or breakdown.
Mobility and Gait Assessment:
- Observe the child’s mobility and gait to identify any compensatory movements or functional limitations related to the clubfoot.
Psychosocial Assessment:
- Assess the psychosocial impact of the clubfoot on the child and family, addressing any concerns or emotional needs.
Radiographic Studies:
- Collaborate with the healthcare team to review radiographic studies (X-rays) to further assess the skeletal structures and aid in treatment planning.
Foot Measurements:
- Take precise measurements of the affected foot, documenting key parameters such as length, width, and circumference. This information helps in tracking changes over time and assessing the effectiveness of interventions.
Joint Stability:
- Assess the stability of joints in the affected foot, focusing on the ankle, subtalar joint, and midfoot. Evaluate the ligaments and joint capsules for any laxity or restrictions that may impact the deformity.
Pain Assessment:
- Inquire about any pain or discomfort experienced by the child related to the clubfoot. Use age-appropriate pain assessment tools and encourage communication to address pain management strategies effectively.
Functional Impact:
- Evaluate the functional impact of clubfoot on daily activities, such as standing, walking, and participating in age-appropriate play. Assess any challenges faced by the child in performing routine tasks

Implementation for Clubfoot

Ponseti Method Education:
- Provide education to parents or caregivers about the Ponseti method, the most common non-surgical approach for treating clubfoot. Explain the process of casting and the importance of compliance.
Casting Application:
- Collaborate with the healthcare team to assist in the application of corrective casts using the Ponseti method. Ensure that the casts are applied correctly to gradually correct the foot deformity.
Teaching Home Care:
- Instruct parents on home care practices, including the importance of maintaining the cast, monitoring for signs of complications, and ensuring the child’s comfort during the casting phase.
Coordination of Multidisciplinary Care:
- Facilitate communication and coordination between different healthcare providers involved in the child’s care, such as orthopedic specialists, physical therapists, and pediatricians.
Psychosocial Support:
- Offer emotional support to both the child and family throughout the treatment process. Provide resources for support groups or counseling services to address any psychosocial challenges associated with clubfoot.

Nursing Interventions and Rationales

Nursing Intervention (ADPIE)	Rationale
Perform complete assessment, noting the severity of the defect	note: note inward vs outward. Severity of the foot. Color, calf size bilaterally.
Provide education to parents on condition	provide information from what the defect is, causes, and treatments. Helps alleviate any anxiety or worry they may have
Apply casting or braces as required for non-surgical treatment	This type of treatment (Ponseti method) helps realign the joints and stretch the tendons gradually over time. Ensure perfusion is intact distal to the cast/brace. Also assess for any skin breakdown (blisters/open sores) could could indicate an improper fit and need to be adjusted
Provide range of motion exercises routinely per protocol and treatment orders	Improve range of motion, flexibility, and prevent contractures.
Provide non-pharmacological methods of pain relief for older children experiencing leg pain	Massage Heat / cold Following treatment, the calf muscles will be smaller and may have pain and soreness with activity. Over time, this discomfort will lessen.

Provide pre- and post-operative care.	Maintain NPO status prior to surgery Initiate and maintain IV access Administer IV fluids and medications for nausea, sedation and pain appropriately Monitor vitals pre- and post-op Perform dressing changes and wraps per protocol and as needed
In cases of severe deformity and when other treatments have failed, corrective surgery may be the best option.	Ensure surgical sites remain clean, dry, and free from infection. Monitor for signs of post-op complications such as pneumonia, bleeding, and blood clots.

Evaluation for Clubfoot

Assessment of Corrective Progress:
- Regularly evaluate the progress of the corrective measures, including the degree of correction achieved through casting or other interventions. Use visual inspection and imaging studies as needed.
Functional Mobility and Development:
- Assess the child’s functional mobility and developmental milestones to ensure that the correction of clubfoot does not hinder normal motor development. Evaluate gait, balance, and overall motor skills.
Complication Monitoring:
- Monitor for any potential complications associated with the treatment, such as skin issues under the cast, neurovascular compromise, or signs of infection. Promptly address and manage any identified complications.
Parental Compliance:
- Evaluate parental or caregiver compliance with the prescribed treatment plan, including the use of corrective devices, attendance at follow-up appointments, and adherence to home care instructions.
Psychosocial Impact:
- Assess the psychosocial impact of the clubfoot treatment on both the child and family. Identify any emotional or social challenges and provide appropriate support or referrals to address these aspects of care.

References

https://www.mayoclinic.org/diseases-conditions/clubfoot/symptoms-causes/syc-20350860
https://my.clevelandclinic.org/health/diseases/16889-clubfoot
https://orthoinfo.aaos.org/en/diseases–conditions/clubfoot/

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Transcript

Hi everyone. Today, we are going to be creating a nursing care plan for clubfoot. Let’s get started. We’re going to go over the pathophysiology of clubfoot. Clubfoot is a congenital deformity of shortened tendons causing the foot to twist inward while it’s not painful during infancy. If left untreated, it can cause permanent damage and an inability to walk. Some nursing considerations: you want to do a full assessment, range of motion exercises, monitor skin breakdown from the braces or the casting, non-pharmacological pain relief methods, and pre and post-surgical care. Desired outcome: the patient will have optimal function of the foot, or their feet will have adequate mobility.

And here’s a picture for you guys to see what clubfoot looks like. You’re going to see here in the picture that the foot is turned inward. See how these are inward. And the top of the foot is kind of pushed downward this way. This would be what it looks like in an infant.

So, we’re going to go ahead and go into the care plan. We’re going to be writing down some subjective data and some objective data. So, what are we going to see with these patients? So, the main thing you’re going to notice is the foot being twisted inward, and that inability to walk. Other things you’re going to see they’re going to complain of some soreness of the leg that’s usually post-treatment. And that top foot is twisted downward.

So, in the interventions, we want to do a complete assessment. So, we’re going to assess, making sure that we’re going to be noting the severity of the defect. We’re going to see inward versus outward. We want to make sure we’re checking the color, maybe the size, the calf size bilaterally, another intervention that we’re going to do, we’re going to do some range of motion. So, whether that is active range of motion or passive range of motion, we’re going to do both of those and try to get the flexibility and prevent any sort of contracture forming. Another invention that we’re going to be doing is applying caste and or brace. This type of treatment, which is known as Ponseti Method helps realign the joints and it stretches those tendons gradually over time, ensuring perfusion. You want to make sure that there’s perfusion intact at the distal part of that cast and the brace. You also want to assess for any sort of skin breakdown, such as blisters or open sores that could indicate that there’s an improper fit of that cast or brace that may need to be adjusted. Another intervention is any sort of non-pharmaceutical pain are ways of relieving pain, and that’s usually massaging or heat or cold therapy, especially after doing any of those range of motion exercises. Those muscles will be sore with that activity. Another intervention we want to do is that we want to make sure that if any of those treatments we’ve tried with the patient has failed, surgery may be needed. So, we’re going to get the patient ready for surgery. We want to make sure we’re maintaining them on NPO status. We want to initiate starting an IV for IV access for fluids or medications that may be needed such as for nausea, sedation, and pain. We want to make sure we’re monitoring vital signs pre and post-surgery. And we want to make sure that we’re doing those dressing changes post-surgery – you’ll do that per protocol as needed.

Okay, now we have that complete care plan. We’re going to go over some of the key points here. So, pathophysiology, congenital deformity of the shortened tendons that causes the foot to twist inwards. The exact cause is unknown, but it appears to be a genetic disorder. Some risk factors are smoking during pregnancy, maternal recreational drug use, and any maternal infections. Some subjective and objective data that you will see with these patients. They’ll have soreness of the leg. The top of the foot that’s twisted downward, will be twisted inward, which is very, very classic. The inability to walk properly. You want to provide those range of motion exercises. So that’s going to be your active range of motion and that passive range of motion. You want to apply the braces and the casting and assessing for any sort of skin breakdown, pain, and surgery. You want to make sure you’re providing any sort of nonpharmacological methods of pain relief, such as heat or cold compress and massages. You want to prepare and educate the family on surgery if all the other treatments fail. Awesome job.

We love you guys. Go out, be your best self today, and as always happy nursing.