SJHSNA NURS 517

1. Anesthesia Care Plan
“Plan A, Plan B, Plan C...”

3. That very sobering video
helps to illustrate why we
need to always be prepared
with a plan B and, possibly,
Plan C.
Patient safety requires
anesthesia providers to
remain prepared, humble and
open to suggestion.

4. 5 of our 11 Standards address care
planning.
Anesthesia is about planning and
preparation. This occurs even in the
most emergent cases.
An experienced provider intuitively
assesses and plans on a continuous
basis.

5. Standards for Nurse Anesthesia Practice
Standard I
Perform and document a thorough preanesthesia assessment and evaluation.
Standard II
Obtain and document informed consent for the planned anesthetic intervention
from the patient or legal guardian, or verify that informed consent has been obtained and
documented by a qualified professional.
Standard III
Formulate a patient-specific plan for anesthesia care.
Standard IV
Implement and adjust the anesthesia care plan based on the patient’s physiologic
status. Continuously assess the patient’s response to the anesthetic, surgical intervention,
or procedure. Intervene as required to maintain the patient in optimal physiologic
condition.
Standard X
Participate in the ongoing review and evaluation of anesthesia care to assess quality
and appropriateness.

6. One way in which a CRNAs
intuitive assessment and
planning is indoctrinated, begins
as a student by creating a written
care plan.

7. EVERY anesthesia provider formulates a
plan for EVERY case. As students you will
write your plan as a means of educating
yourself on various procedures,
techniques, positioning, drug interactions,
anesthetic implications of a case. This is
your opportunity to read, write and review
anesthesia care. The plans are evaluated
and critiqued by your supervisor for the
day and later by the program
administrators.

8. SRNA Written Care Plans
Care Plans are used to help students apply didactic knowledge
obtained from the classroom & independent study to plan
individualized nurse anesthesia care. The goal of written care plans is
to help in thinking about clinical anesthesia, individualize your
patient care, and document your preparation for the case.
1. A care plan template is used as a guideline.
2. Use a systematic approach to gathering information related to the patient.
3. Use a systematic approach to gathering information related to the planned
surgery.
4. Consider the anesthetic implications of the patient’s history and planned surgery.
5. Base your anesthetic technique on the patient and the surgical requirements.
6. Devise your prioritized care plan based on patient and surgical concerns.

9. The providers in the video appropriately
planned their care, and even resorted to
“plan B”, but failed to revise their plan
when it was needed. That fixation error
became the fatal flaw.
I devised the following method to help you
begin organizing your plan.

10. 3 Stages of Plan Development
Prior to Day of Surgery (DOS):
Patient / nursing completes a health assessment including
pre-anesthesia
Old medical records, including anesthesia, may be reviewed
Develop a care plan based on this information
DOS:
Conduct patient interview
Perform anesthesia physical assessment
Review current lab data
Revise the preliminary plan if needed
Intraoperative:
Provide vigilant care
Continually assess the plan and prepare to revise as needs arise

11. Anesthesia Care Plan Development:
Prior to DOS
 OR schedule – name, age, procedure, surgeon
 Medical Record – medical & surgical history, medications, lab info…
Room2
0730 Colagiovanni, S. MD Smith, John 64 Regional Cysto-u, Retros, laser
John Smith has a hx of hypertension on Atenolol 25 mg at bedtime, diet
controlled type 2 DM, and smokes 1 ppd. He weighs 225 lbs. and is 5’8”. He
has had multiple cystoscopies . EKG reads as sinus rhythm with non-specific
ST changes.

12. Example of
a systems
review
assessment
for
anesthesia
which is
best
completed
prior to
DOS

13. Medications
• Review all medications, prescribed and non-prescription
(OTC, herbal, recreational)
• Consider medications with anesthesia drug implications
and interactions
• Consider allergies
• Consider steroid usage

14. Medical and Surgical History
• Consider social history – tobacco, alcohol, illicit drugs
• Consider anesthetic history of pt and family
• Consider co-morbidities and the anesthetic
implications and interactions

15. Review current lab data
Routine diagnostic testing is longer a common acceptable
practice. Policies and practices vary as to what is “required”.
Generally:
An EKG for patients with a cardiac history or on antihypertensive
medications.
A pregnancy test for all menstruating females; possibly including
those who have had tubal ligation.
Type and screen for cases with large anticipated blood loss.
Blood sugar for diabetics.
Coagulation studies for patients on anticoagulants.

16. Assign an ASA Classification
At the conclusion of the preanesthesia assessment
a score is assigned to each patient.
The “ASA” score was originally developed in the
1940’s and has been revised. The American Society
of Anesthesiologists Physical Status Classification
was devised as a means of communication amongst
anesthesia providers. It was not intended to
represent an estimate of anesthesia risk.
A consequence of its use is misclassification, either
overclassification or underclassification for billing or
statistical purposes.

17. “3 limits
activity”

18. “5 not likely to
survive”
Note: the “E” assignment
may be added to the
numeric value.
Ex. A healthy pt requiring
surgery for hemorrhagic
trauma is classified as a 1E.

19. Create “Plan A”
Consider the patients medications, medical and surgical history
review medical record
Consider the surgical procedure requirements
review textbooks
Consider the surgeons preferences
ask an experienced provider
Choose an appropriate anesthetic technique
general or regional or MAC (refer to text for guidance)
Choose anesthetic drugs based on all of the above
calculate all drug dosages
Decide how to manage fluids for the case
calculate fluid requirements
Decide on airway management for the case
calculate respiratory volumes, ET/LMA size
Decide how you will operationalize your plan
location of drugs and all required equipment
Decide on an alternate plan (and all of its requirements)
“Plan B”

20. SJHSNA Care Plan Template (front)

21. SJHSNA Care Plan Template (back)

22. Anesthesia Care Plan Development:
DOS
 Review current lab data
 Review medical & surgical history with the patient
 Perform physical assessment for anesthesia
 Discuss plan with supervisor
 Revise the plan as needed
 Discuss plan with patient and obtain consent

23. Review medical/surgical history with
the patient.
Anesthesia providers have limited contact
with the conscious patient. The interview is
an opportunity to create a rapport, in a
brief amount of time, with the patient who
may be anxious and is entrusting them self
to the providers care.
As experienced nursing caregivers,
creating rapport is a quality of CRNA’s.

24. During the interview:
Introduce yourself by name and status . “ I am Jamie Doe, a
Registered Nurse in the Anesthesia Program” (not as “a nurse
from anesthesia” )
Confirm the patients ID by hospital bracelet and verbally if
possible. Determine how the patient prefers being addressed.
Confirm the NPO status
Confirm the allergy status
Confirm the anesthesia history status
Review the medical record with the patient
Discuss the anesthesia plan with the patient. Verify/obtain
informed anesthesia consent.

25. Current acceptable fasting guidelines
Anesthesiology 2011;
114:495–511

26. A Preanesthesia Physical Assessment
• Airway
• BMI
• Cardiorespiratory Fitness/
Functional Capacity

27. Airway Examination- look for LEMONs
Look at pt for characteristics that cause difficult
ventilation, laryngoscopy or intubation
Evaluate 3-3-2
Mallampati
Obstruction
Neck Mobility

28. Look at characteristics
Difficult Mask Ventilation Predictors
Endentulous
people may
be difficult to
mask
ventilate
without an
oral airway
but are
generally
easier to
intubate.

29. One reason we assess for certain
characteristics is to help us line up the
3 axis (oral, pharyngeal & tracheal)
for the best intubation conditions.

30. Laryngoscopy
- align the 3 axis
With the head in a neutral position –
it’s difficult to view glottic opening
The head hyperextended & in sniffing
position aligns axis
Aligned axis eases intubation

31. Long
upper
incisors
Narrow
Inter-incisor
gap
Overbite Underbite
Difficult Laryngoscopy predictors for
the oral axis
Poor dentition

32. A normal anatomical view
At times this
is the view,
but it may be
difficult
aligning the
tube into the
glottis due to
abnormalities
with the oral
axis- teeth.

33. Difficult Laryngoscopy predictors
for the pharyngeal axis
Piercings
Micrognathia
or
Mandibular
hypoplasia
Large tongue,
short, thick neck >17”
Narrow palate

34. Difficult Laryngoscopy predictors
for tracheal axis
Prayer sign
Hoars
e
Voice
Prayer sign of
diabetes suggests
musculoskeletal
immoblity.
A hoarse voice in a pt
with rheumatoid
arthritis may indicate
cricoarytenoid arthritis.

35. Evaluate 3-3-2
Interincisor
Gap- 2-3
fingers or
40 mm
Evaluate neck extension
and tissue compliance
Hyomental
Minimum of
3 fingers or
>6.5cm
Thyrohyoid
Minimum of
2 fingers
Laryngoscopy
requires the
ability to
insert the
blade and
displace the
tongue. If the
space or
distance is too
small, the
glottis is
difficult to
visualize.
If the tissue or
neck is
immovable
the glottis is
difficult to
visualize.

36. Mallampati-
assessed with the pt
sitting upright, head in
neutral position, mouth
maximally open,
tongue maximally
protruded,
no phonation.
Class 3 & 4
predict
difficulty. As a
stand alone test
is poorly
predictive.

37. Obstruction
Visualized and
non-visualized
enlarged tonsils
Obvious and subtle
severe
obstructions
Ludwig’s Angina

38. An inspiratory wheeze may equate
with an upper airway obstruction.
An expiratory wheeze may equate
with a lower airway / thoracic
obstruction.

39. Neck Mobility
Burns/radiation scarringacromegaly arthritis

40. Neck or tissue
immobility
generally requires
awake fiberoptic
intubation

41. Airway Characteristics Evaluation video

42. BMI
(IBW) Ideal Body weight
Some drug dosages and endotracheal tube
sizing are based on IBW and not actual weight.

43. Cardiorespiratory Fitness
Assess heart & lung sounds
Assess exercise tolerance
METs* Equivalent Level of exercise
1 Eating, dressing, sitting
3 Walking 1-2 blocks on flat ground
5 Climbing 1 flight of stairs, dancing, cycling
7 Playing singles tennis
9 Jumping rope slowly, moderate cycling
11 Cross country skiing, full court basketball
*1 MET = O2 consumption of 3.5 mL/min/kg
< 4-5 METs increases risk for periop complications

44. Anesthesia Care Plan Development:
DOS
Review medical & surgical history with the patient
Review current lab data
Perform physical assessment
Discuss plan with supervisor
Revise the plan as needed
Discuss plan with patient and obtain consent
Ex. Mallampati 3, TM distance 3 fingers, edentulous, heart regular, lungs
clear, no SOB with 2 flights of stairs
Ex. FBS 132, NPO since 12 noon yesterday
Ex. Strong history of PONV and motion sickness
Ex. The supervisor disagrees with your valid plan for MAC anesthesia because the
surgeon won’t like it

45. Example of
Assessment
to be
completed
DOS
This portion is a
concise version
with specific
info pertinent to
the immediate
case.

46. It is the anesthetists
responsibility to either obtain
or verify informed anesthesia
consent.

47. Example of an Anesthesia Consent Form

48. Anesthesia Care Plan Development:
Intraoperative
Be prepared to continually adjust a plan.
Be prepared to abandon a plan and replace with
a safer plan.
Be prepared to stick with a safe but “unpopular”
plan.

49. Postanesthesia Evaluation
Standard X requires all providers review and evaluate
anesthesia care. The postanesthesia evaluation is a
way for each provider to improve their practice. It is a
key part of our care plan.
Areas evaluated may include:
Vital signs
Respiratory status
Pain level
Postoperative nausea/vomiting
Intraoperative awareness
Satisfaction with the anesthesia care
Adverse outcomes (positioning injuries, sore throat…)

50. Anesthesia Specific Emergencies
Can’t Ventilate, Can’t Intubate
OR/Airway Fire
MH
3 very rare, but very deadly, events
particularly if they become fixation events.

51. Flexibility & Humility
2 key characteristics which may
have been missing from the
providers in the opening video

52. Care Plan Class
Evaluation Assignment
Using the distributed template,
create a care plan with the provided
information. Each student will
submit the handwritten care plan by
1pm next Weds.

53. The 2nd Exam
The 2nd exam will be an essay style open book exam.
Each student will receive 3 questions and a care plan to
complete.
No breaks are allowed during the 3 hour exam.
The focus is not on memorization or test taking ability
but learning through reading, writing and eventually
applying to practice.