A small compilation of nurse anesthesia care plans

These anesthesia care plans are meant to inspire nurse anesthesia residents when they are making their care plans. Always make sure you fully understand and "own" your care plan. Your plan must be specific for your patient and should always be with the most up-to-date information.

Asthma – Acute Obstructive disease (expiratory)

Affects: up to 22 million in the US

Reversible airflow obstruction unlike COPD - bronchoconstriction, airway inflammation, hyperirritability of tracheal tree

Symptoms

Wheezing, productive/nonproductive cough, dyspnea, chest discomfort that may lead to air hunger, tachypnea, prolonged expiratory phase, and fatigue. Eosinophilia (can be elevated).

Triggers

Allergens, pharmacologic agents (aspirin, beta-antagonists, some non-steroidal anti-inflammatory drugs, sulfiting agents, infections), exercise (mainly after), emotional stress.

Respiratory

Diagnose severity with flow volume measurements. The normal FEV1/FVC ratio is >80% in normal people, and FEV3/FVC is >95% in normal people. Asthma patients have higher lung volumes as they cannot "get rid" of the air, which is why FRC (Functional Residual Volume) is increased

Hyperreactive airway increases the risk of bronchospasm

Cessation of cigarette smoking 8 weeks before surgery is optimal

Optimal airway status - no acute infection

Anesthetic Considerations

Sedate to avoid anxiety

Anticholinergic drugs increase the viscosity of secretions, making them more challenging to remove. Propofol is used due to its relative broncho-dilating effect compared to Thiopental

Consider pretreatment with systemic corticosteroids

H2 blockers (Zantac/Tagamet) should be avoided as they have been associated with bronchospasm

Consider regional anesthesia if not contraindicated (avoid levels above T6)

Use laparoscopic procedures if possible

Mask and LMA preferred over ETT

Give Lidocaine to attenuate the effect of DL. Another option is to mask with a volatile agent (Sevoflurane, as it is less irritating to the airway) and deepen the anesthetic level prior to intubation.

Avoid nondepolarizing muscle blockers known for Histamine release (Atracurium). Histamine release has been attributed to Succinylcholine, but there is no evidence of increased airway resistance in asthmatic patients

Morphine and Meperidene can cause histamine release as well

Consider Fentanyl (2 mcg/kg low dose) for attenuation of DL/surgical incision

Ventilation: A slow inspiratory flow rate provides optimal ventilation distribution relative to perfusion. Sufficient time for exhalation to prevent air trapping (prolong inspiratory time?)

Avoid PEEP - may impair adequate exhalation in narrow airways

Liberal administration of fluids for hydration and less viscous airway secretions

Before extubation, consider giving IV Lidocaine or inhaled bronchodilator (beta-2-agonist) to prevent any bronchospasm   

Deep versus awake extubation

Treatment of intraoperative bronchospasm                             

Deepen the anesthetic level

100 % O2

Beta-2-agonist

Epinephrine IV or SQ

IV corticoids 2-4 mg/kg

Consider aminophylline drip for long-term post-op mechanical ventilation

If bronchospasm does not resolve, check for kinking of ETT, secretions, overinflated balloon, bronchial intubation, active expiratory efforts, pulmonary edema or embolism, and pneumothorax.