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Boni Avenue, Mandaluyong City College of Nursing
In partial fulfillment of the requirements in NCM 108: A CASE STUDY OF:
SUBMITTED BY: Taduran, Cayela Rosary T.
SUBMITTED TO: Prof. Ramon B. Espares RN, MAN
However. such as Loeys-Dietz Syndrome. some newborns have developed a twisted foot appearance due to intrauterine position. and the midfoot and forefoot are adducted and inverted. Some doctors have argued that club foot . this is commonly done as it is easily identified using an ultrasound scan. Most fetuses undergo a 20 weeks gestation fetal abnormality scan in which club foot is one of the abnormalities that can be picked up. A condition of the same name appears in animals.TEV occurs with some frequency in Ehlers Danlos Syndrome and some other connective tissue disorders. the hind foot is inverted. This temporary abnormality is called a pseudo-talipes disorder. Structural TEV (Talipes Equinovarus) is caused by genetic factors such as Edwards syndrome. A true clubfoot cannot be aligned properly without further intervention. Genetic influences increase dramatically with family history. this is countered by findings that TEV does not occur more frequently than usual when the intrauterine space is restricted. However. it is a congenital anomaly occurring at approximately 1 to 2 in every 1000 live births. This occurs in males more often than in females by a ratio of 2:1. Contractures of the soft tissues maintain the malalignments. Clubfoot or Talipes Equinovarus is a congenital anomaly in which the foot is plantar flexed at the ankle and subtalar joints. It was previously assumed that postural TEV could be caused by external influences in the final trimester such as intrauterine compression from oligohydramnios or from amniotic band syndrome. with manipulation the foot can be brought into a straight position. TEV may be associated with other birth defects such as spina bifida cystica. However. Talipes deformity could either be unilateral (affecting a single foot only) or bilateral (both feet are affected). Approximately 50% of cases of clubfoot are bilateral. particularly horses. In most cases it is an isolated dysmelia. There are different causes for clubfoot depending on what classification it is given. Growth arrests at roughly 9 weeks and compartment syndrome of the affected limb are also causes of Structural TEV.BACKGROUND/INTRODUCTION Talipes deformity is a disorder of ankle and foot. Screening for club foot prenatally is a debatable topic. Breech presentation is also another known cause. Regardless of which extremity is affected. a genetic defect with three copies of chromosome 18. Commonly called clubfoot. It comes from the Latin words TALUS meaning ankle and PES meaning foot.
If no syndromic association is found prenatally. 4. 3. most fetuses with club foot are born and can live a normal life with medical treatment Types of True Talipes Deformity 1. For example. Equinus (plantarflexion) Calcaneus (Dorsiflexion) Varus (foot turns inward) Valgus (foot turns outward) Some children with this deformity have a combination of the types listed. . a child who walks on the heel with the foot turning outwards has calcaneovalgus disorder while the child who tiptoes with the foot inverted has equinovarus deformity. 2.may occasionally be associated with a syndromic disease and should therefore be screened.
If the straightened foot does not move to a normal position. MANAGEMENT NON-SURGICAL: . cast and splint application (nonsurgical management) a. A small cut (about 3 mm) is made above the heel of the foot to lengthen the tendon.DIAGNOSTIC EVALUATION Physical Examination Twisted foot appearance should be assessed and gently manipulated. After the procedure final casting is done. Methods used are the following: 1. The reason for doing this is to loosen the foot. severing of Achilles tendon (tenotomy) is done before the final cast is applied. Ponseti Method – Applies certain techniques to reduce and correct the deformity to promote normal foot mobility and position. The procedure is usually done in a clinic where a local anesthetic is used.Slightly pivoting the bones and stretching the soft tissue 2. After the final cast is removed: . true clubfoot is present. Final cast is removed after 2-3 weeks when Achilles tendon is already healed. Manipulation . Placement of above the knee cast Frequency of changing the cast is every 5-7 days to accommodate the rapid growth during the first year of life.mild cases: manipulation. In most cases. Radiography Use of x-rays is definitive diagnosis for clubfoot as it determines abnormal bone anatomy and assesses the treatment efficiency.
Passive foot exercises (full range-of-motion) are executed by the primary caregiver to further maintain the position.1. Post-tenotomy management Observe for the following: Drainage on the cast Foul smelling odor from inside the cast. are used in this technique which are attached to metal pins and are inserted through the bone. A frame is individually made for each patient and weighs approximately 7 lbs. Ilizarov Technique – Method used for complex ankle-foot deformity. Denis Brown Splint b. Placement of the frame requires the administration of a general anesthetic and the procedure may last for several hours. Denis Brown Splints (shoes or boots attached to a bar) are used 23 hours each day for 3 months to maintain the normal foot alignment. . Ilizarov frames. redness and irritation at the distal portion of the cast. For the next 2-4 years the splint is fitted during naps and nighttime only. 2. High fever c. Swelling. the circular structure placed around the limb.
This then will give rise to a flat foot. redness and swelling distal from the cast and foul odor. assess the ankle and foot for a true talipes deformity by straightening the foot. passive foot exercises and Denis Brown splint). Tendon Transplant Done at 4-7 years of age when other corrective measures have been ineffective. Pseudo-talipes can be realigned to a normal position. surgery may be needed.g. Complications Rocker bottom Foot Vertical talus results from a forceful manipulation causing bone breakage. This is not usually done until the child is between four and eight months of age. Fever is the first sign of infection. The structures are then put back together in a lengthened position. Obtain a family and obstetric history for risk factors. Recurrent deformity The corrected foot may return to its deformed state if the parents or primary caregiver fails to apply the methods to further correct the position (e. Posteromedial Release The last option for a clubfoot is the release of all tight tendons and ligaments in the posterior and medial parts of the foot. . After delivery. 3. Monitor the infant’s temperature (for those who underwent tenotomy or surgery). 4.Ilizarov Technique SURGICAL: If cast treatment fails or the clubfoot is rigid. 2. For infants with cast assess for circulation. Nursing Interventions 1.
6. Risk for Impaired Parenting R/T maladaptive coping strategies secondary to diagnosis of talipes deformity 2.Administer analgesics as ordered for pain relief after a surgical correction. Acute pain R/T muscular and tissue damage secondary to surgery . wet diapers. Use a damp cloth and dry cleansers in wiping. 11. 9. Possible Nursing Diagnosis 1. Explain to the parents the importance of passive foot exercises after the final cast is removed.Assess coping mechanisms of family and resources available for long-term treatment. check and cleanse the pin sites frequently. Crying may mean hunger. Risk for Peripheral neurovascular dysfunction R/T mechanical compression (cast or brace) 3. 10. traction or surgery 4. abdominal pain or tingling sensation from a tight cast.Maintaining the aligned position after the cast application is essential to prevent reoccurrence. 7. Place a pillow or padding under the casted area to prevent cast damage and prevent sores from heel pressure. Risk for impaired skin integrity R/T cast application. 8. 12.5. Water and soap causes breakdown of cast particles. Cautiously evaluate crying. Keep the cast clean and dry by changing diapers frequently. For children with traction. Infants cannot voice out pain.
Movements. Talus: In equinus in the ankle mortise. The neck of the talus is medially deviated and plantar flexed. With growth. the cartilage is gradually replaced by bone except for joint surfaces. Forefoot: The forefoot is adducted and supinated. . Cuboid: The cuboid is medially subluxated over the calcaneal head. with the body of the talus being in external rotation.ANATOMY & PHYSIOLOGY The bones of the newborn’s foot are largely formed in cartilage. The joints of the foot move in many directions. Bone Tibia: Slight shortening is possible. severe cases also have cavus with a dropped first metatarsal. the body of the talus is extruded anterolaterally and is uncovered and can be palpated. All relationships of the talus to the surrounding bones are abnormal. Navicular: The navicular is medially subluxated over the talar head. which is less rigid and more easily moulded by external forces than bone. Os calcis: Medial rotation and an equinus and adduction deformity are present. Fibula: Shortening is common. It’s useful to consider a standard nomenclature for ankle and foot movements. Terminology can be confusing.
Tibialis posterior flexes the ankle and supinates the foot. but the fibers are smaller in size. and flexor hallucis longus (FHL) are contracted. Muscles provide the power to make the foot joints move: Gastrosoleus flexes the ankle. The midtarsal joints include the talonavicular and calcaneocuboid joints. tibialis posterior. Joint capsules: Contractures of the posterior ankle capsule. Tendon sheaths: Thickening frequently is present. fibula and talus. Fascia: The plantar fascial contracture contributes to the cavus. Ankle movements are dorsiflexion and plantarflexion. and bifurcate ligaments. especially in the peroneal group. and talonavicular and calcaneocuboid joint capsules commonly are seen. especially of the tibialis posterior and peroneal sheaths. Muscles Atrophy of the leg muscles. Subtalar. Long toe flexors flex the ankle and toes. The calf is of a smaller size and remains so throughout life.Joints Ankle joint. ankle and midtarsal joints move together and result in foot supination and pronation. The number of fibers in the muscles is normal. This lies between the tibia. Subtalar joint lies between the talus and calcaneus. . flexor digitorum longus (FDL). In patient with clubfoot. Peroneals flex the ankle and pronate the foot. Ligaments Stability of the foot is provided by ligaments. Ligaments are strong fibrous bands that connect bones and allow limited motion. The triceps surae. as does contracture of fascial planes in the foot. Tibialis anterior extends the ankle and supinates the foot. subtalar capsule. Long toe extensors extend the ankle and toes. talofibular. contractures are seen in the calcaneofibular. is seen in clubfeet. (ankle) deltoid. even following successful long-lasting correction of the feet. spring. long and short plantar.
DRUG STUDY Drug Nam e Ibupr ofen Classif Dosa ication ge Mechanis m of Action Antiinflammatory . nauseavomiting CNS: nerveroot lesion. bron erosion. Considerat ion Administer in the morning with a full glass of water. asthenia CV: Angina Patient must stay upright for 60min GI: after taking gastric/eso the tablet to phagealulc avoid ers. during myalgia. salicylates. 25ml Relief of mild to moderate pain Fever reduction *Post surgery* Headache &musculoskele tal pain Advanced kidney and liver disease Asthma Active GI bleeding C/I with allergy to ibuprofen. and antipyretic activities largely related to inhibition of prostagl andin synthesis. Inhibits both cyclooxyge nase(COX) 1 and Slightly more selective for COX1 Indication Contraindic Side ation Effects Adverse Effects Nsg. and after joint pain therapy. nasal polyps) CNS: headache. potentially serious RESPI: esophageal URTI. dyspepsia. chitis. analgesic. NSAID Age 6 mos23 mos: 50 mg/1. abdomina l pain. Analge sic. dizziness. vertigo CV: Hypertensi on GI: diarrhea. or other NSA IDS (more common in patients with rhinitis. MUSCUL pneumonia M o n i t o OSKELE r serm TAl: calcium Back levels befor pain. asthma. insomnia. e. Ensure adequat e intake of Vitamin D and calcium Encour age frequent small meals if GI effects are uncomfo rtable . chronic urticaria.
Combined use predisposes the child to experience adverse renal effects. Exercise Execution of passive foot exercises several times a day for several months to maintain the corrected foot alignment. Do not use Tylenol with NSAIDs or salicylates.DISCHARGE PLAN Medication Acetaminophen (Tylenol) is an analgesic and antipyretic given for pain relief after traction or tenotomy. This can cause damage to the bones. she should be at the infant’s side most of the time. For older infants. . Spiritual The mother or the primary caregiver is the significant person for the infant. Convey expression of parents towards the child’s condition. introduction of solid foods must have the interval of 5-7 days. therefore. Use dry cleanser in wiping the cast. Never forcibly evert or pronate the foot during clubfoot casting. Ongoing Assessment Assess the circulation of casted foot. Diet Breastfeeding for infants younger than 4-6 months. Treatment Cast application Physiotherapy Surgery (last option) Health Teaching Cast care: Frequently change the infant’s diaper to prevent soiling of the cast.
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