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.

Hypothyroidism

Decreased T3, T4, elevated TSH

The autoimmune disease destroys follicular epithelial cells. It cannot make thyroid hormones.

Seen in elderly patients

Symptoms

Cold intolerance (depression of BMR)

Decreased appetite and weight gain due to depression of BMR with low protein and fat metabolism

Decreased HR, pulse pressure

Edema (Myxedema)

  • Accumulation of protein - mucopolysaccharides under the skin, water in interstitial space

Cretinism

  • CNS development impaired; replace thyroid deficiency first few days to prevent long-term developmental side-effects

Myxedema Coma

Severe hypothyroidism with mortality >50%

Symptoms

Stupor or coma

Hypothermia

Hypoventilation with hypoxemia

Bradycardia HR 50-60

Hypotension

Apathy

Hoarseness

Hyponatremia

Treatment

Early intubation

Treat low BP cautiously with volume, inotropes, pacing

Passive warming if core temp <30 C

Specific treatment

L-Thyroxine (T4) or

Triiodothyronine (T3)

Hydrocortisone

Deceased TSH is the earliest sign of response to treatment

Anesthetic considerations

Ensure euthyroid state

  • Check core temp, HR, pulse pressure, and reflexes

Tracheal compression from large goiters can cause tracheal deviation, stridor

May see increased sensitivity to anesthetic agents and muscle relaxants

Decreased ventilatory response to increased CO2 and reduced O2

Bradydysrhythmias, diastolic HTN, decreased LV compliance, pericardial effusions

Addison's disease occurs in 5-10%

  • No aldosterone, no cortisol
    • May need steroids during surgery due to stress

Decreased BMR, temperature

May have joint pain, myalgia

Anemia, GI bleeding, constipation, ileus

Visualize vocal cords function before extubation

The ability to phonate "e" implies continued vocal cord function

Emergence

Risk of airway obstruction

  • Secondary to recurrent laryngeal nerve damage
    • Bilateral: the patient is unable to speak and requires reintubation
    • Unilateral: hoarseness

Tracheomalacia (weakness and floppiness of tracheal cartilage) or hematoma

  • Rapid intubation may be lifesaving
  • If hematoma, then reopen the incision and drain the blood

Acute hypo-parathyroid state (hypocalcemia)

  • Can present as laryngeal stridor 24-48 hrs postop
  • It may start with tingling of fingertips and lips, which, untreated, can progress to tetany and seizures
    • Give 1 amp of Ca++ gluconate iv over 20 min will usually alleviate symptoms