Ward management

Pain Management: Anaesthetic

• Childrens Pain Management Service (CPMS)

Most patients will require opioid infusion in the form of Patient Controlled Analgesia (PCA) or Nurse Controlled Analgesia. This is usually a morphine infusion.
Pain assessment is to be performed hourly with patient pain scores recorded at this time. This can be done using a visual analogue scale or tools such as Wong Baker faces. (See pain site)
NOTE: Pain that is out or proportion to the surgery performed should be reported immediately, as this may indicate the presence of Compartment Syndrome  which  is a medical emergency.

Neurovascular Observations:

Neurovascular observations at RCH are performed 30 minutely on return to the ward for the first 4 hours. They should then be performed hourly for the next 24 hours, and then four hourly until stable . Should there be any concern regarding a patient's neurovascular status, then the treating surgeon should be notified immediately.
This is also a good time to assess the footplate or toe slings for poor fit or any areas of pressure

Positioning of the limb:

Whilst elevation is important, the position of the limb is also something to concentrate on in the postoperative stage. It is suggested that the child rests in bed with the leg in full extension, with the knee cap pointing to the ceiling.

Physiotherapy / activity:

As soon as the patient is able to manage, it is important to encourage independence. This may involve them handling the frame, moving from bed to wheelchair, showering etc. Independence practised in hospital will make management at home much easier. It is importance that the child has practised transferring from chair to toilet, bed to chair and chair to bed with minimal assistance prior to discharge. This will make transport home much easier, and management at home with caregivers simpler. PRACTICE! PRACTICE! PRACTICE! Prior to discharge. Any aids required will also be identified prior to discharge.

Pin site care

Pin site care is to be performed on Days 1, 2 and 3.
It is important that the patient has adequate analgesia prior to beginning procedure. Should the child be extremely anxious, then a sedative such as Midazolam may be used. It is also often useful for another person to be available to distract the child. Large books or an easel may be helpful. It is suggested that you ascertain things that the child likes to do eg: reading stories, watching videos, Gameboys, computer games etc and to engage the child before commencing.
For days 1 and 2, the dressing is performed only to stage of the alcohol soaked gauze, pushing the stoppers down. On day 3, the dressings are bolstered, then left intact until follow up, which is usually approx. 10 days post surgery.

Medications

Most patients will cease their opioid infusion by approximately day 3. The patient is then given oral analgesia to manage their pain. The most common medications used at RCH are:
Paracetamol
Tramadol
Codeine
Oxycodone SR
Oxycodone

It is vital that a discharge script is provided to the family prior to discharge, with instruction to fill this prior to returning home.

Other medication that may be necessary may be some form of Laxative / stool softener. Unfortunately, as with other Orthopaedic surgery there is the very real risk of constipation. It is preferable that the child opens their bowels prior to leaving the hospital.

Orthosis

Toe slings

The elastic bands should be tight enough so the toes are in a straight line with the rest of the foot.

Toe slings should be removed every 4 hours for approximately 20 minutes. Check the toes and in-between them to make sure there isn't any skin breakdown.

Clean between the toes every night and put some powder between them to keep them dry. The toe slings can be worn overnight without needing to check them every 4 hours. Remove the toe slings and monitor the toes first thing in the morning.

Correction/ frame adjustment:

The surgeon or nurse must teach the family how to do the correction. The frame will be lablled prior to discharge from hospital. It is always preferable for the family to have the opportunity to demonstrate an adjustment prior to discharge, however in the case of adjustments beginning after discharge this is not possible.
The family must be able to verbalise that they understand where adjustment is to be made, how often and how much.
A turn chart is often helpful.