Nursing Assessment
Assessment of a child with clubfoot include:
 History. Seek a detailed family history of
clubfoot or neuromuscular disorders, and
perform a general examination to identify
any other abnormalities.
 Physical exam. Examine the feet with the
child prone, with the plantar aspect of the
feet visualized, and supine to evaluate
internal rotation and varus; if the child can
stand, determine whether the foot is
plantigrade, whether the heel is bearing
weight, and whether it is in varus, valgus, or
neutral.
Nursing Diagnosis
Based on the assessment data, the major nursing
diagnoses are:
 Disturbed body image related to permanent
alteration in structure and/or function.
 Deficient knowledge related to the condition,
prognosis, treatment, self-care, and
discharge needs.
 Risk for peripheral neurovascular
dysfunction related to mechanical
compression (cast or brace).
 Risk for impaired skin integrity related to
cast application, traction or surgery.
 Risk for impaired parenting related to
maladaptive coping strategies secondary to
diagnosis of talipes deformity.
Nursing Care Planning and Goals
The major nursing care planning goals for patients
with congenital talipes equinovarus (clubfoot) are:
 Parents verbalize acceptance of self in the
situation
 Family/SO discuss about situation and
changes that would have occurred.
 Parents develop realistic goals/plans for the
future.
 Parents explain disease state, recognizes
the need for medications and understands
treatments.
 Parents demonstrate how to incorporate
new health regimen into lifestyle.
 Parents exhibit ability to deal with health
situation and remain in control of life.
 Parents demonstrate an understanding of
plan to heal tissue and prevent injury.
 Parents describe measures to protect and
heal the tissue, including wound care.
Nursing Interventions
Nursing interventions for the child are:
 Protect skin integrity. Monitor site of
impaired tissue integrity at least once daily
for color changes, redness, swelling,
warmth, pain, or other signs of infection;
monitor patient’s skin care practices, noting
type of soap or other cleansing agents
used, temperature of water, and frequency
of skin cleansing; and provide gloves or clip
the nails if necessary to avoid damaging the
skin with scratches.
 Promote acceptance of body image.
Acknowledge and accept an expression of
feelings of frustration, dependency, anger,
grief, and hostility; support verbalization of
positive or negative feelings about the
actual or perceived loss; and be realistic
and positive during treatments, in health
teaching, and in setting goals within
limitations.
 Provide health education. Include the
parents in creating the teaching plan,
beginning with establishing objectives and
goals for learning at the beginning of the
session; provide clear, thorough, and
understandable explanations and
demonstrations; and render positive,
constructive reinforcement of learning.
Evaluation
Goals are met as evidenced by:
 Parents verbalized acceptance of self in
situation
 Family/SO discussed about situation and
changes that would have occurred.
 Parents developed realistic goals/plans for
the future.
 Parents explained disease state, recognizes
need for medications, and understands
treatments.
 Parents demonstrated how to incorporate
new health regimen into lifestyle.
 Parents exhibited ability to deal with health
situation and remain in control of life.
 Parents demonstrated an understanding of
plan to heal tissue and prevent injury.
 Parents described measures to protect and
heal the tissue, including wound care.