AnesthesiaCareplan2009.docVIP

WFUBMC Nurse Anesthesia Care Plan Date: Srna: Crna: MD: MRN: (circle) Age: M/F ASA: Allergies (rxn) Wt: (kg) ______ Ht: (cm) ______ (in) ______ Procedure/Surgeon: NPO: Yes No Time: _____ Pre-op: HR _______ BP _______ Brief Hx Present Illness: Anesthesia Hx: Tobacco: Alcohol: Other: Systems Review/Assessment Physical Exam Respiratory: orthopnea – # pillows ______ asthma COPD recent PNA/URI/cold cough other___________ Cardiovascular: exercise intol.(FOS) CP hx MI HTN valvular disease Type: _______ hx: rheumatic fever dysrythmias Type: _______ pacer/AICD other ________ Nervous System: seizures cerebral vasc insuff CVA Hepatic: hx: hepatitis other ________ GI/GU: GERD hiatal hernia renal disease HD _________ Hematologic: coagulation problems other _________ Eye/ENT: hoarseness other _________ Endocrine: diabetic thyroid adrenal pregnant other ____________ Musculoskeletal/ Integumentary: osteoarthritis rheumatoid arthritis other ____________ Airway Mallampati _____ TM distance ______ FBMO ______ lg. Tongue, deviated trach Neck FROM LROM short thick Chin receding protruding Teeth edentulous crowns/caps/bridges loose teeth poor dentition partial/dentures _________________ Lungs CTA diminished crackles/rales rhonchi wheezes CV RRR murmur Miscellaneous Prayer Sign _______ Last menstrual cycle (or HCG): _________ Other: ____________________ Significant Labs Other: PT _______