Clinical Case Study Guidelines
The very foundation of professional anesthesia practice involves evaluating/planning skills which evolves from
our didactic education into the physical performance of anesthesia care. The graduate student in nurse
anesthesiology must utilize critical thinking and understanding of the patient’s physical findings, their
pathophysiology, applied pharmacology, understand and apply perioperative care principles to establish a
plan of care. The clinical case studies in Practicum’s II and III expand the critical thinking and knowledge of a
plan of care to develop the skills and knowledge to progress and manage a greater complexity of patients and
procedures.
The purpose of the clinical case study is to complement didactic information and present actual patient
encounters. The following are recommended guidelines for the process and complemented by clinical case
study rubric for Practicum II and III.
1. The case study must utilized CHW standards and use APA Style 7th Edition for Student Papers.
a. APA Student Paper Checklist September 2021
b. APA Student Paper Setup Guide September 2021
2. The APA Style for Student Papers will include a title page, the body of the paper and
reference/bibliography page. An abstract is not included for this clinical case study.
3. Maximum of 12 pages, double spaced, which includes: Title page, Main Body and Reference page.
4. Title page for student papers includes title of case study, author’s name, institutional affiliation, course
number, instructor’s name and assignment due date. Page numbers initiated and “running head” is
not utilized.
5. Reference/Bibliography should include current anesthesia literature (within the past 5 years) as well as
currently utilized textbooks on anesthesia practice. In-text citations and references must follow APA Style 7th Edition 2020.
Sections
I. Patient Assessment: (10 points)
A. Patient Information:
Preoperative Diagnosis: __________________________________________________
Actual Surgical Procedure: ________________________________________________
Postoperative Diagnosis: ___________________________________________________
B. Physical Examination:
Blood Pressure range:____________ Pulse ______ Respirations ________ T°______
SaO2 ____on _____ ECG _________________ METS _________ APFEL _________
Height: ______cm Weight: _______kg. BMI _______kg/m2. Age ______ Gender _____
Allergies: _______________________ NPO status ____________STOPBang_________
C. Airway Assessment (Complete):
MP Class ____ TM distance ____ Lg Tongue ( ) Deviated Trachea ( )
Mouth Opening ____ Neck FROM ( ) Size Circumference _____ Short Neck ( )
Chin: Receding ( ) Protruding ( ) HX of Difficult Airway/Intubation ( )
Teeth: OK ( ) Edentulous ( ) Dentures ( ) Bridges ( ) Loose/Poor Dentition ( )
D. Social History:
Tobacco (Pack Years) ______Vaping ____ Alcohol (Quantity/Frequency) ________
Other Substance utilization __________________________
E. Anesthesia History (Which & When & Complications)
Patient: _____________________________________________________________
Family________________________________________________________________________________________________
F. Systems Assessment (as reflected from care plan):
Respiratory, Cardiovascular, Neurological (Psychiatric), Hepatic, Gastrointestinal, Urological,
Hematological, Eye/ENT, Endocrine, Musculoskeletal, Oncologic, and Infectious history (Covid,
MRSA, TB etc.)
Pregnancy: Gravida ____ Para____ Weeks Gestation _____FHTs___________
II. Preoperative Diagnostic Testing: (5 points)
1. Hematologic: Hematocrit & Hemoglobin, RBC, WBC, Platelets, and Coagulation function studies.
2. Electrolytes
3. Arterial Blood gases
4. Hepatic function studies
5. Renal function studies
6. Any additional laboratory studies: (Covid testing)
7. Cardiac testing: ECG (12 lead), Echocardiogram, etc.
8. Respiratory testing: Chest x-ray, PFTs etc.
9. Any other relevant radiological or other diagnostics and there relevance to your case study
· Document results (Proper value identifications K+ 3.9 mEq/L)
· Discuss relevance of results
· Please clarify why the diagnostic testing was performed and implication of the results in
your plan of care.
· Are there any additional diagnostics you would have liked to have seen (can you justifyindication)
III. Patient Comorbidities/Pathophysiology & Altered Physiology: (15 points)
A. As revealed with systems assessment.
B. What is the comorbidity? Your patient’s history,current status and treatment.
C. What is the relevance of these comorbidities in the development of your care plan?
D. What are the risks & implications for surgery and anesthesia relevant to your patient’s
comorbidities? (Preoperatively-Intraoperatively & Postoperatively)
· CV, Respiratory, Hematological, CNS, Hepatic, Renal, Endocrine, GI, GU,
Musculoskeletal, Psychiatric, Oncologic issues or any other pathology revealed.
· If pregnant discuss altered physiologic issues and discuss other issues with pregnancy as
indicated (Preeclampsia etc.)
· If Geriatric (>80 years), discuss physiologic alterations & concerns
IV. Patient Medications: (At home or intrahospital, OTC, not pre-medications)(5 points)
· What are these medications? Drug classification, MOA, & dosage
· What is the indication for the medications for your patient?
· When did patient last take medications. Which ones should be continued perioperatively?
· What are anesthesia implications? Any drug interactions?
· Herbal medications: relevance to surgery or anesthesia?
V. Surgical Procedure: (10 points)
· Is it an elective, urgent or emergency? (If emergency, why & how did it affect your
anesthetic plan))
· Explain or describe the surgical procedure? (Include actual events not 100% Jaffe)
· What are the perioperative risks of the procedure and anything specific that altered your
usual anesthetic plan?
· What are the anesthetic implications relevant to the surgical procedure?
VI. Surgical Positioning: (5 points)
· What was surgical positioning? (Need for specific table, equipment?)
· What are the physiologic changes or effects associated with the positioning?
· What are the potential risks and potential complications of the surgical positioning? (Did
any complications occur?)
· Were there or what are the anesthesia issues or implications relevant to the surgical
positioning?
VII. The Patient’s ASA classification was: (5 points)
· The assigned class was ________
· What was the reasoning for the given classification? (It was based upon…..)
· Was it elective, ASAP or emergency (Why?)
VIII. Anesthesia Plan (Case Summary): (15 points)
A. Preoperative Preparation:
· What medications were given (anesthesia or surgeon) and dosages and why?
· Where there any therapeutic interventions specific to your patient?
· What lines, IV’s, IV solutions utilized.
· Any regional anesthetics initiated in preop? Which ones and why? Local anesthetics
administered. Ultrasound? Results of Intervention.
B. Anesthetic Technique chosen (General Anesthesia, MAC procedure with sedation, Neuraxial or
Peripheral Nerve Block) Describe procedures
· Why did you choose the specific technique(s)?
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· Discuss process (ex. RSI or SAB etc.)
· Airway management and results
· Anticipated risks of the chosen technique based upon the surgical procedure and the
patient’s comorbidities?
· Was there a discussion of an alternative anesthesia plan?
C. Anesthetic Monitoring utilized for your case:
· Which ones were utilized and why (Standard ASA?AANA)
· Any specific invasive monitoring techniques and why?
· Any non-standard monitoring techniques selected (i.e. BIS)
· Was there any non-anesthesia monitoring techniques (Neurophysiologic monitoring)
and how did they affect your anesthetic plan?
D. Pharmacologic plan utilized and your reasoning:
· Discuss dosages used for each drug utilized
· What is mechanism of action for the drugs utilized?
o Induction
o Intubation (Neuromuscular blocking agents for both intubation and paralytic
maintenance)
o Maintenance phase (Unconsciousness, analgesia, amnesia, muscle relaxants),
Enhanced Recovery After Surgery Protocol [ERAS])
§ MAC (Sedation utilized, conscious level & LA utilized per surgeon)
o Local anesthetics & adjuncts for regional anesthetic utilized
o Resuscitative drugs if utilized (Hemodynamic Stability)
E. Emergence Phase:
· Pharmacologic intervention utilized for emergence
· Sequence of events
· Complications and how managed
F. Fluid Management:
· Predetermined: EBV, ABL30, maintenance, deficit & third spacing fluid calculations
· Identifies case length for fluid management
· Actual case management: actual blood loss, total fluids, blood, blood components &
colloids administered
· Urine output (if measured)
· Any relevant issues or problems associated with fluid & blood management
IX. Perioperative Case Management: (10 points)
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How was your anesthesia plan implemented and results?
· Discuss utilized ERAS pre-, intra-, and postoperatively
· Discuss relevant anesthetic & patient events, etiology, treatment & results of interventions
· Discuss any surgical issues which affected your anesthesia management.
X. Postoperative Handoff (5 points)
What was or would be your process for postoperative handoff? SBAR mnemonic
What information did or should you have given to PACU/ICU staff!
· S- Situation: Patient, procedure, anesthetic & current status
· B- Background: History, diagnosis, co-morbidities & status, allergies, airway
management/concerns
· A- Assessment: IV’s, Invasive lines, I & O,EBL, vital sign history, temperature issues,
medications, last paralytic, last narcotic, reversal, status of regional technique, multimodal
pain mgt. plan, ERAS provisions, anesthetic problems, neurologic status, labs (last profile,
ABG, Glucose)
· R- Recommendations: PONV, pain management, evaluate respiratory/hemodynamic
concerns, patient co-morbidity evaluation, airway recommendations, repeat labs, need for
x-ray, follow up issues.
XI. Multimodal Pain Management Regimen & PO outcomes (5 points)
· Discuss pain management plan(Neuraxial, Peripheral, Systemic, Local)
· Surgeon provision; LA, how much and where injected
· Outcome/status pain regimen
· PO visit and any identified PO problems 24-48 hours post anesthesia
XII. Bibliography/References: (5 points)
· Utilizing APA 7th Ed Style
· Properly produce the bibliography utilized in the writing of this case study.
· References less than 5 years old (Unless approved by faculty)
XIII. Writing Skills: (5 points)
· If needing assistance check with Barry Learning Center – writing lab
· Sentence structure, Grammar, Spelling and proper utilization of all abbreviations (Accepted
abbreviations & defined prior to usage)
· Proper identification/labeling of all laboratory values
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· All based upon 7th Ed APA Style for Student Papers
Case Study Grading
Section Points
I. Patient Assessment 10
II. Preoperative Diagnostic Testing 5
III. Patient Comorbidities/Altered Physiology. 15
IV. Patient Medications 5
V. Surgical Procedure 10
VI. Surgical Positioning 5
VII. ASA Classification 5
VIII. Anesthesia Plan – Case Summary 15
IX. Perioperative Case Management 10
X. Post-anesthesia Handoff (SBAR) 5
XI. Multimodal Pain Regimen & PO outcomes 5
XII. Bibliography/References 5
XIII. Writing Skills 5
Total 100
Text Assistance:
1. Jaffe’s Anesthesiologist’s Manual of Surgical Procedures 6th Edition
a. Appendices
· A. Preoperative Considerations
· B. Standard Adult Anesthetic Protocols
· C. Multimodal Perioperative Pain Management
· F. Tables of Drug Interactions & Recommendations for Pre-Op MGT
· K. Enhanced Recovery After Surgery (ERAS)
2. ERAS:
· Nagelhout Nurse Anesthesia 7th Ed, Pages 388,389 & 821 & 822
· AANA Practice Considerations – Enhanced Recovery after Surgery
I have Added two examples to use, plus the books needed.
