Patient Information



KUMC NURSE ANESTHESIA EDUCATIONANESTHESIA CARE PLANClinical Practicum NURA 801Student: FORMTEXT ????? Instructor: FORMTEXT ????? Date: FORMTEXT ?????Age FORMTEXT ????Gender FORMDROPDOWN Weight (kg) FORMTEXT ?????Height FORMTEXT ?????ASA FORMTEXT ?????Mallampati Score FORMTEXT ?????Allergies / Reactions: FORMTEXT ?????Surgical Procedure: FORMTEXT ?????Previous Anesthetics/Complications FORMTEXT ?????EKG / Chest X-ray: FORMTEXT ?????Labs: FORMTEXT ?????Current medicationsDrug classificationDosagePeak actionElimination half lifeAnesthesia interactions/Considerations FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Co-existing diseasesEtiologySymptomsAnesthetic considerations FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Anesthesia PlanChoose One: FORMDROPDOWN Airway: ETT (size) FORMTEXT ?????oral / nasal FORMTEXT ?????LMA (size) FORMTEXT ?????Choose One: FORMDROPDOWN FORMTEXT ?????Induction drugs / dosage: FORMTEXT ?????Muscle relaxant / dosage: FORMTEXT ?????Narcotic / dosage: FORMTEXT ?????Inhalation agent: FORMTEXT ?????Ventilator settings: FORMTEXT ?????Antiemetic / dosage: FORMTEXT ?????Antibiotic / dosage: FORMTEXT ?????Anesthesia Care Plan Part II -- CALCULATION WORKSHEETFluid Balance and Body Weight Calculations:Ideal body weight (IBW) = 105 lb + 6 lb for each inch > 5 feet for males = 100 lb + 5 lb for each inch > 5 feet for femalesIdeal body weight (IBW) = FORMTEXT ????? kgObese Calculated Weight / Adjusted Body Weight (ABW) = FORMTEXT ????? kg0.3 (actual weight - ideal weight) + ideal weight = adjusted body weightMaintenance fluid:First 10 kg: 4 ml/kg/hrSecond 10 kg: add 2ml/kg/hr>20 kg: add 1ml/kg/hr Maintenance fluid = FORMTEXT ????? ml/hrNPO deficit = FORMTEXT ????? ml (hourly maintenance x number of NPO hours)3rd space loss – please choose one: FORMDROPDOWN 3rd Space loss = FORMTEXT ????? mlEstimated blood volume FORMTEXT ????? mlNeonates: Preterm 95 ml/kg, term 85 ml/kg; infants 80 ml/kg; Adult Male 75 ml/kg, Adult female 65 ml/kgAllowable blood loss FORMTEXT ????? ml = (HCT start - HCT allow) x EBV / HCT startStarting HCT FORMTEXT ?????Allowable HCT FORMTEXT ?????1st hour2nd hour3rd hour4th hourNPO FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Maintenance FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3rd space FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????EBL FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Total FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PediatricsEndotracheal tube size (mm) FORMTEXT ????? Choose One: FORMDROPDOWN Children older than 2 yrs (age/4 + 4 = ETT); generally children < 10 yrs old get uncuffed ETTLength of ETT insertion (oral) FORMTEXT ????? cm(under 1 yr: 6 + wt (kg); over 2 yrs: 12 + age/2)Reservoir bag (circuit) size FORMTEXT ?????(newborn 0.5 L; 1-3 yrs 1.0 L; 3-5 yrs 2.0 L; >5 yrs 3.0 L)Care Plan Resources (APA format): FORMTEXT ????? ................
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