USC Program of Nurse Anesthesia

Adult Care Plan

Date / / OR _______
Case # for day_______________ Age ______ Ht _______Wt_______ ASAClass___________
Procedure ________________________________________Estimated Surgical Time _____________
Position___________________ CRNA ________________ Anesthesiologist ___________________

Labs ------------------------ < >---------< EKG ________________________

CXR
Medications (include OTC and herbals):

Allergies (include reaction):

Previous Surgical History (including patient/family history of anesthetic complications):

Summary of Surgical Procedure:

Preoperative Vital Signs:

Airway Exam/Dental Concerns:

Pertinent Review of Systems/Prioritized Problem List:

Monitors: Special Equipment:

Primary Anesthetic Plan and Rationale Backup/Emergency Plan and Rationale
Pre-op Pre-op

Airway Management Airway Management

Induction Induction

Maintenance (including vent settings) Maintenance (including vent settings)

Emergence Emergence

Post-op Pain Management Post-op Pain Management

Perioperative Fluid Plan

EBV:___________ (cc/kg) ABL __________ (to HCT of______%) Estimated EBL__________
Type & Screen/Crossmatch No _______ Yes _______ for _______ units

Hour EBL Blood Colloid Crystalloid Crystalloid Crystalloid 3 Total

1:1 EBL 1:1 EBL EFD PFR X EBL
1st hour 1/2 =

2nd hour 1/4 =

3rd hour 1/4 =

4th hour

Medication Interactions:

Positioning Concerns:
Anticipated Problems Anesthetic Considerations Interventions
Pre-op:

Intra-op:

Post-op: