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.

Tonsillectomy and Adenoidectomy

Etiology

The cause of obstructive sleep apnea (OSA) in children is usually due to enlarged adenoid and tonsillar tissues. However, nasal obstruction due to enlarged turbinates and jaw deformity can also be major contributors to developing OSA.

  • The primary treatment for OSA in children is adenoidectomy and tonsillectomy.

Children with OSA are at an increased risk for airway obstruction, respiratory distress, and the potential for apnea in the postoperative period.

Children hypoventilate and develop hypercarbia and arterial hypoxemia.

Preoperative Diagnosis

OSA, chronic tonsillitis and/or adenoiditis, tonsillar and adenoid hypertrophy, asymmetric enlargement of tonsils

Other symptoms are nasopharyngeal obstruction, obligatory mouth breathing, failure to thrive due to poor feeding, disturbances of speech and sleep

Chronic nasal obstruction may result in narrowing of the upper airway and dental and facial changes

May see airway obstruction, OSA, CO2 retention, and cor pulmonale

Sleep study

Apnea-hypopnea index - AHI (partial occlusion)

Pauses must be 10 seconds long to be significant; you might see a drop in O2 saturation

Respiratory disturbance index (RDI)

  • AHI 5-15 mild, 15-30 moderate (daytime sleepiness), >30 severe (cardiac risk)

Preoperative considerations

Surgery

The patient is supine, shoulders slightly elevated on shoulder roll, and a mouth gag is inserted. Tonsils are removed, and hemostasis is obtained using packs and suction electrocautery 

EBL

10 - 200 ml, monitor closely

Morbidity

Bleeding, aspiration, tooth damage

Pain Score

Adenoidectomy 3-5

Tonsillectomy 6-9

Age

2-8 yrs

Anesthetic Considerations

Monitor for any loose teeth. Advise parents that they may be dislodged with mouth gag/laryngoscopy manipulation

Oral airway to prevent airway obstruction on induction

An oral ray is placed midline to facilitate prompt placement of the mouth gag

  • Cuffed to minimize drainage to the abdomen, recheck bilateral breath sounds

If the throat pack is in place - ensure removal prior to extubation

Monitor the airway closely with manipulation of the mouth gag

The neck may be extended - evaluate pt for any neck issues/atlantoaxial subluxation

Risk of airway fire - decrease FiO2 as tolerated, should be less than 30% for procedures above the nipple line

Risk of blood in the stomach - N/V

Suction midline only

Careful with opioid dosing due to OSA (increases risk of hypoventilation)

Extubate when fully awake

  • There is a high risk of negative pulmonary edema due to previous obstruction to inhalations
  • Pt might continue to inspire with force

May give Decadron

May give Zofran

Lateral position to PACU