Anesthesia Care Plan
Written by: [Your Name]
I. Introduction
The Pre-operative Anesthesia Care Plan outlines the anesthesia procedures and considerations before surgery to ensure optimal patient safety and comfort during the perioperative period.
II. Patient Information
A. Demographics
Demographic | Details |
|---|
Name | [Patient's Name] |
Age | [Patient's Age] |
Gender | [Patient's Gender] |
Medical Record Number | [MRN] |
Date of Admission | [Date] |
B. Medical History
Past medical history: Hypertension, Diabetes
Current medications: Metformin 1000mg once daily, Lisinopril 10mg once daily
Allergies: None
III. Anesthesia Plan
A. Anesthetic Technique
B. Anesthetic Agents
Induction agents: Propofol 200mg
Maintenance agents: Sevoflurane 1-2%
Adjunct medications: Ondansetron 4mg IV
IV. Pre-operative Assessment
A. Physical Examination
Airway assessment: Mallampati score II, neck mobility normal
Cardiovascular assessment: Regular heart rate, palpable peripheral pulses
Respiratory assessment: Clear lung sounds, respiratory rate 16 breaths/min
B. Laboratory Investigations
Blood work: Normal complete blood count, electrolytes within normal range
Imaging studies: Normal chest X-ray, unremarkable ECG
C. Patient Preparation
Parameter | Target | Actual |
|---|
NPO Status | At least 8 hours | Met |
Medication Adjustment | Hold Metformin 24 hours pre-op | Adjusted |
IV Line Insertion | Established | Done |
V. Informed Consent
Discussion of risks, benefits, and alternatives of anesthesia
Documented patient consent for anesthesia administration
VI. Communication Plan
VII. Risk Management
Identifiable Risks: Risk of bleeding, risk of infection
Mitigation Strategies: Close monitoring of vital signs, prophylactic antibiotics
Emergency Contact: Emergency Department: (123) 456-7890
VIII. Emergency Protocols
IX. Follow-up Plan
X. Signatures
Anesthesia provider
Surgeon
Patient or legal representative
Plan Templates @ Template.net
