Anesthesia Care Plan
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
