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.

Chronic Obstructive Pulmonary Disease

Etiology

The most common pulmonary disorder

Prevalence increases with age

Strongly associated with smoking

Male predominance

Many are asymptomatic but show expiratory airflow obstruction upon PFTs

Chronic Bronchitis or emphysema, many have features of both

Chronic Bronchitis

Hypersecretion and inflammation

Productive cough most days for 2 years

Triggers: smoking, air pollutants, occupational dust exposure, recurrent pulmonary infections

Secretions and edema lead to obstruction

RV is increased in obstructive disease, intrapulmonary shunting (no perfusion), and hypoxemia common

Chronic hypoxemia leads to erythrocytosis (an increased circulating red blood cell mass resulting from a compensatory effort to meet reduced oxygen content), pulmonary hypertension, and eventually right ventricular failure (pumping against high resistance - cor pulmonale)

Pts develop CO2 retention, the ventilatory drive becomes less sensitive to arterial CO2 and may be depressed by O2 administration

Emphysema

Destruction of lung parenchyma

Reduced elastic recoil

Nearly always related to cigarette smoking

Early age: related to alpha1-antitrypsin deficiency (usually blocks elastase, so it doesn't break down lung elastic tissues) - if smoker then develops emphysema at an early age

Residual volume (RV), FRC, TLC, RV/TLC increased

Increased dead space

PaO2 and CO2 tension are usually normal

Purse lips to delay the closure of smaller airways

Anesthetic Considerations

Assess respiratory status - dyspnea, sputum, wheezing

Pulmonary function test

  •  FEV1 <50% of predicted = dyspnea on exertion
  •  FEV1 <25% = dyspnea minimal activity

Pre-operative goal:

  • Correcting hypoxemia, relieving bronchospasm, mobilizing and reducing secretions, treating infections

Discuss possible post-op ventilation with the surgeon and patient

Optimal: stopped smoking 6-8 weeks before surgery, but 24 hrs can help improve oxygen carrying capacity

Bronchodilator treatment (beta-2 agonist)

Consider digitalis treatment if pt has cor pulmonale with right ventricular failure

Regional: risk of high with decreased pulmonary function

Respiratory depression with anesthetics

Small TV, slow rates to avoid air trapping

Check ABG for accurate assessments

Risk of pneumothorax, especially with positive pressure ventilation