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

• Type of anesthesia: General

• Additional techniques: Peripheral nerve block
  

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

• Communication with surgical team regarding patient status and concerns

• Handoff communication between anesthesia providers during shift changes
  

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

• Management of intraoperative emergencies: Malignant hyperthermia protocol in place
  

• Activation of rapid response team or code blue procedures
  

IX. Follow-up Plan

• Post-operative pain management: Intravenous morphine PCA

• Post-anesthesia care unit (PACU) handoff: Report provided to PACU nurses
  

X. Signatures

Anesthesia provider

Surgeon

Patient or legal representative

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