Care Plans

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Care Plans

• Marianne Cosgrove, CRNA, DNAP, APRN

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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

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Pre-surgical Care Plan

• Assignment
• J. Doe, male, age 49
• Laparoscopic cholecystectomy
• General anesthetic
• Now what?

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Pre-surgical Care Plan, contd

• 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

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Pre-surgical Care Plan, contd

• 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
• smaller incision(s)
• reduced post-operative pain
• reduced incidence of ileus
• early ambulation
• shortened hospital stay
• earlier return to work and ADLs

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Laparoscopic Cholecystectomy, contd

• Synopsis contd
• 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
GoogleTM images
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Pre-surgical Care Plan, contd

• 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

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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, beta-blocked, pre-existing cardiac
  dz, etc

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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

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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), TS
• hypothermia from insufflation with cold gas
• actively warm ptfluid 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
• s/s
• increased ETCO2
• hypoxia/decreased SaO2
• hypotension (may be severe)
• mill-wheel murmur

Treatment -stop insufflation -head down, L
lateral decubitus position -FiO2 1.0 -support
with pressors
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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.

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Preliminary plan of anesthetic care

• What is your proposed plan?
• Rapid sequence induction (RSI) with GETA
• Rapid sequence induction
• Know the rationale/stepsadd 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!!!

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Preliminary plan of anesthetic care, contd

• 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/intubatio
  n
• Sevoflurane/O2/air for maintenance
• Rocuronium for ongoing relaxation
• Ondansetron 4 mg for PONV prophylaxis
• Neostigmine 0.04 mg/kg matched 11 with
  glycopyrrolate for reversal

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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

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Day of surgery

• Now what?
• Patient contact is made, chart review is done
• Wt 198 / 90 kg Ht 60
• 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

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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 inmakes it more
  personalized and meaningful
• will end up with a journal of anesthetic
  experiences

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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 airwayboth 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

SHOULD BE BULLETED!!
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After the case is finished, contd

• Smoking
• Cigarette smoke contains gt 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
• IE 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 ß-blockers

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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

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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

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POST-OP VISITS MANDATORY ON ALL PATIENTS!!
Use the bottom of the pre-anesthesia assessment
sheet to note the post-op visit
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Hints for success

• Save all of your co-morbidities and medications
  in a file folder on your computer
• may re-submit on future care planswork will
  already be done!
• do not trade with peers
• want to build your own library
• Ultimate goalto formulate a plan of care off of
  the top of your head

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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

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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