Transcript Care Plans - School of Nurse Anesthesia

Care Plans
Marianne Cosgrove, CRNA, DNAP, APRN
Care Plans
 Why?
To prepare for the case
 Delineates procedure
• How it is performed
• Pt position
• Anesthetic considerations and plan for that specific type of
surgery
• Anesthetic considerations for pt co-morbidities, meds
To prepare for testing/boards!
 The initial portion of the care plan is done when
you get your assignment → before the
procedure
Pre-surgical Care Plan
Assignment:
J. Doe, male, age 49
Laparoscopic cholecystectomy
General anesthetic
Now what?
Pre-surgical Care Plan, cont’d
 To be prepared for the AM of surgery:
 Planned procedure:
In a synopsized form, explain the procedure to be done.
Add details only if it directly impacts your anesthetic plan
of care.
 If you are doing multiples of the same case, one
cover sheet is acceptable for all cases
scheduled; write the actual number of cases
done that day on the cover sheet and attach
each pt done to the procedure sheet before
handing in
Pre-surgical Care Plan, cont’d
 Research the planned procedure
Synopsize lap chole:
 i.e. Laparoscopic approaches are applied to an increasing
number of procedures, including cholecystectomy, the
surgical excision of the gallbladder. Surgery is performed
for acute/chronic cholecystitis and/or cholelithiasis. Benefits
of the laparoscopic approach to cholecystectomy include:
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smaller incision(s)
reduced post-operative pain
reduced incidence of ileus
early ambulation
shortened hospital stay
earlier return to work and ADLs
Laparoscopic Cholecystectomy, cont’d
 Synopsis cont’d
 Operative technique
involves the intraperitoneal
insufflation of CO2 through
a needle inserted through a
small infraumbilical
incision. Patient
positioning in steep
Reverse Trendelenberg
with a left side-tilt facilitates
operative exposure of the
gallbladder.
Pictures are OK but not
necessary!! Check out Google
images
TM
Pre-surgical Care Plan, cont’d
 Anesthetic considerations for the
procedure:
 The most important part of your preparation
for the case
 “bullet” list format vs. paragraph may be easier
to follow

“chunking” of information allows the adult learner to
retain information better
Anesthetic implications for laparoscopic
cholecystectomy
 Hemodynamic changes associated with insufflation:
 increase in MAP and SVR with no effect on CO in healthy
patients
 a decrease in CO and hypotension in hypovolemic pts or
those with pre-existing cardiac disease
 absorption of CO2 across the peritoneum may result in
hypercarbia with SNS stimulation, increased BP, CO, HR,
and arrythmias
 controlled ventilation with cuffed ETT
 may note bradycardia due to vagal stimulation from peritoneal
stretching during initial insufflation
 pretreat with anticholinergic
 periods of hypotension may occur with the pt in steep
Reverse Trendelenburg, especially if hypovolemic, betablocked, pre-existing cardiac dz, etc
Anesthetic implications for laparoscopic
cholecystectomy
 Respiratory changes:
reduction in FRC from cephalad movement of
diaphragm, especially in Trendelenburg
atelectasis leading to hypoxia
need for PEEP if tolerated
decrease in abdominal and chest wall compliance
due to presence of pneumoperitoneum
increases in peak airway pressures
necessity for increased minute ventilation to offset
hypercarbia from insufflation with CO2
May want to avoid N2O; may insufflate bowels
making surgical exposure difficult; may add to
hypoxia, may cause PONV
Anesthetic implications for laparoscopic
cholecystectomy
Complications:
 vascular injury/hemorrhage from large vessel or organ penetration with
the Veres needle, trocars, or instruments
 larger bore IV (at least #18g), T&S
 hypothermia from insufflation with cold gas
 actively warm pt—fluid warmers, Upper body Bair
 brachial plexus injury from supine/Trendelenburg position
 secure arms
 increased incidence of emesis, PONV
 rapid sequence induction/intubation, antiemetics
 pneumomediastinum, pneumopericardium, or pneumothorax and
subcutaneous emphysema of the face and neck
 venous gas (CO2) embolism
Treatment:
 s/s
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increased ETCO2
hypoxia/decreased SaO2
hypotension (may be severe)
“mill-wheel” murmur
-stop insufflation
-head down, L lateral
decubitus position
-FiO2 1.0
-support with pressors
Your generalized plan of care for the
patient:
 GETA vs. general LMA, vs. regional vs. TIVA,
etc.
 No need to delineate each step used to perform the
type of anesthetic chosen; more important to know
why the specific type of anesthesia was chosen for
that case
 Could this be alternatively performed with regional or
MAC/TIVA?
 List drugs that you plan to use; be prepared
re: dosage ranges for the agents that you
have chosen.
Preliminary plan of anesthetic care
 What is your proposed plan?
 Rapid sequence induction (RSI) with GETA
 Rapid sequence induction
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Know the rationale/steps—add to plan of care if applicable i.e.
preoxygenate
HOB ↑ 30°
working suction at HOB
stylet in ETT
induction med followed by rapid-acting NMB without testing airway
cricoid pressure until intubation verified via ETCO2/auscultation
 Choose medications, why you want to use them, and KNOW YOUR
DOSAGES!
Always have a contingency
plan!!!
Preliminary plan of anesthetic care, cont’d
 Plan: GETA with a rapid-sequence induction
Midazolam 1-2 mg IV for sedation
Fentanyl 50-100 mcg IV pre-induction
Glycopyrrolate 0.2 mg IV pre-induction
Propofol 2 mg/kg IV for induction
Succinylcholine 1 mg/kg for laryngoscopy/intubation
Sevoflurane/O2/air for maintenance
Rocuronium for ongoing relaxation
Ondansetron 4 mg for PONV prophylaxis
Neostigmine 0.04 mg/kg matched 1:1 with
glycopyrrolate for reversal
References
Must have at least two references
1 web reference is acceptable
Hurford, W.E. Clinical Anesthesia Procedures of the
Massachusetts General Hospital. Philadelphia,
Lippincott, Williams & Wilkins, 2002. pp 318-320
Roizen MF, Fleisher, LA. The Essence of
Anesthesia Practice. Philadelphia: W.B. Saunders
Company, 2002. pg 384
Day of surgery
Now what?
Patient contact is made, chart review is done
Wt 198# / 90 kg Ht 6’0”
Pt history remarkable for smoking, major depression,
OSA
Medications: Prozac, loratidine and percocet PRN,
nicotine patch
Labs all WNL
• transcribe all pertinent history onto care plan
During the case:
 note anesthetic technique used
 note medications/dosages used
at the end of the care plan, you will list these meds as
“actual”; note if there is a deviation from your original
plan
 jot down any interesting, unexpected, untoward
events (including mishaps!)
anecdotal information will be added to finalize the CP
before handing in—makes it more personalized and
meaningful
 will end up with a “journal” of anesthetic experiences
After the case is finished:
 Revisit the care plan to review and add
anesthetic implications for patient co-morbidities
and meds, i.e.
 OSA-obstructive sleep apnea-a disorder in which excessive soft tissue in
the upper airway intermittently obstructs the airway during sleep. Prevalence is
more common in obese pts. Pts report snoring, daytime somnolence, intellectual
impairment, repeated AM headaches. More serious cases may lead to RVH
from increases in pulmonary vascular resistance during apneic/hypoxic periods.
May lead to cor pulmonale and eventual L-sided heart failure. Other resultant
co-morbidities may include HTN, cardiac arrythmias, polycythemia, and vascular
disease.
 may be a difficult airway—both bag/mask ventilation,
laryngoscopy/intubation, and after extubation
• have a variety of airway implements on hand
• may use a nasal airway before extubation
 may be sensitive to the respiratory depressant effects of opioids
• use opioids/sedatives with caution
After the case is finished, cont’d:
 Smoking
 Cigarette smoke contains > 3000 identifiable constituents, many of which are
toxic (most notable are nicotine, CO, and cyanide). Smokers have:
 increased airway irritability and secretions, decreased ciliary activity;
potential for post-op pulmonary complications
• humidify gases
• lidocaine pre-intubation and extubation
• hydration
• ? use of anticholinergics
• ET suction before extubation
• ? deep extubation
 COPD
• I:E ratio which allows for longer expiratory phase
• watch PIP
 carboxyhemoglobinemia (COHb)
• Monitor SaO2
 ↑ incidence of HTN, CAD, PVD, from SNS stimulation from nicotine
• ? use of β-blockers
Medications
 Fluoxetine (Prozac)
 A selective inhibitor of serotonin reuptake used to treat major
depression, OCD, bulemia
 anesthetic considerations:
 pt may be ↑anxious
• use of benzodiazepenes
 pt may have extrapyramidal reactions
• avoid dopaminergic blockers (droperidol, metoclopramide)
• serotonin syndrome with concomitant use of MAOIs, tricyclics,
meperidine
 monitor temperature
 avoid use of meperidine
 SIADH
• watch U/O if applicable
 may inhibit cytochrome P-450 and potentiate the effects of
phenytoin, benzos, beta-blockers due to increased plasma levels of
these drugs
Finally…
Please complete these sections before
re-submitting to your preceptor for
signature
Post-op visit *If the pt is in STS, make an
attempt to re-connect before their
discharge to home; assess for pain,
PONV, untoward reaction to anesthesia,
etc.
extremely important
Use the
bottom of the
preanesthesia
assessment
sheet to note
the post-op
visit
Hints for success
Save all of your co-morbidities and
medications in a file folder on your
computer
may re-submit on future care plans—work will
already be done!
do not “trade” with peers
want to build your own library
Ultimate goal—to formulate a plan of care
off of the top of your head
Care Plan CHECKLIST
Keeps track of cases
Based on the CCNAs outline for boards
All case types not mandatory but will give
you an idea as to what needs to be
focused on for studying later
Mandatory to have 3 OB rotation (1 C/S, 1
co-morbidity, 1 laboring epidural/vaginal
delivery and 1 care plan/WEEK from
rotation sites
Care Plan CHECKLIST
Before graduation, you must have at least
one CP completed for each of the
categories listed
Will upload/submit to the school as an
electronic file, either separately or as a
component of your e-portfolio