University of New England Nurse Anesthesia Program Care Plan

SRNA:

CRNA:

Anesthesiologist:

Surgeon:

Patient:

Gender:

Age:

Diagnosis:

Procedure:

PS Status: 1 2 3 4 5 6 E

Ht:
Wt:
BMI:
NPO Status:

Surgical Time:

EBL:

Date:
Time:
Allergies:

Notes on Surgical Procedure

ABX:

Positioning (anesthesia considerations):

BP

Medical/Surgical History and Assessment

R
BS

Medications:

Labs (date): CBC:

Coags:

PMH:

PSH:

CV:

Problems With Anesthesia?

RESP:

Airway assessment:
Mallampati 1 2 3 4
TMD:
Other:
GI:

NEURO:

Musculoskeletal:

HEME:
Blood type:
T&S
T&C:
Other:

O2 Sat
Lytes:
Other:

GU:

EKG:
PCXR:

Anesthesia Technique
Plan A
o GA Mask
o GA LMA
o GETA
o Regional ___________
o MAC
o TIVA
Special Patient Concerns:

Fluids
Maintenance
NPO Deficit

Plan B
o GA Mask
o GA LMA
o GETA
o Regional SAB
o MAC
o TIVA

1st Hr

2nd Hr

Anesthesia Care Plan

Monitors/Equipment
NIBP
EKG- 3 lead /5 lead
(ST)
Pulse Ox
ETCO2
Temperature
Gas Analyzer
Nerve stimulator
IV:
OGT/NGT
3rd Hr

BairHugger- Upper/lower
Fluid/Blood Warmer
BIS
Esophageal/Precordial Steth
Vent Alarms
Back up ETT/LMA
Bite Block
Aline/CVP/PA
Foley Catheter

University of New England Nurse Anesthesia Program Care Plan

3rd Space loss
Pre-Op H/H:
EBV:
MABL:

EBLAirway Plan
ETT: _________
Hourly total
Total
Blade:
MAC _____
Miller _____
LMA : _______
Oral Airway: ____
Soft Bite block
Medication Other: Dose

INDUCTION
Medication/Gas
Dose

MAINTENANCE
Medication/Gas
Dose

EMERGENCE

Ventilation
Mode:
TV:
MV:
Rate:
Fio2:
I:E:
Other:

PRE-OP
with Rational
Dosages/Range

Plan with Rational

Dosages/Range

Plan with Rational

Dosages/Range

Plan with Rational

Plan

University of New England Nurse Anesthesia Program Care Plan

Medication/Gas

Dose

Problem

Dosages/Range

Prioritized Problem List

Anesthesia Implications
(pathophysiology, etc)

Anesthesia Interventions (actions)