Last line of defense, first line of offense: the perianesthesia nurse as goalkeeper

Abstract

WOMEN’S SOCCER IS big in the Hooper household, and as my almost 10-year-old daughter is the goalkeeper for a local traveling soccer team, needless to say, we are watching the Women’s World Cup and the games leading up to it with excitement and awe. For those of you who are unfamiliar with soccer, the keeper or goalie is affectionately considered the “last line of defense, and the first line of offense.” The keeper is the last person that can stop the other team from scoring; they are the last line of defense. Keepers are often also the first person to launch their team’s counterattack as they put the ball back into play. I believe that nurses, particularly perianesthesia nurses, function in a similar role as a soccer team’s goalkeeper. Our role is to function as our patient’s “last line of defense,” as we do all that we can to protect the patient from harm. We are also the patient’s “first line of offense,” as it is our job to always advocate for the patient and be proactive on his or her behalf. So what are some issues that we should be aware of as we train for this critical position on the health care team? What can we do to get in shape and contribute to the team? The primary role of defenders in a soccer game is to prevent the other team from moving the ball forward to their goal and scoring (an adverse event). The keeper is the last person that stands between the ball and that goal. He or she has to react to the situation or play as it develops and quickly, but calmly intervene to prevent the score. The perianesthesia nurse, in all areas and at all times, is always poised to calmly intervene and prevent the adverse event. We must react to the developing play, the patient’s signs and symptoms, and intervene to prevent disaster. The preadmission testing nurse functions as a last line of defense on a daily basis. It is the role of the preadmission testing nurse to pick up on those subtle hints and nuances that may indicate a larger problem. This month’s article, “Screening High-Risk Patients for the Ambulatory Setting,” illustrates 2 instances in which the preadmission testing nurse picked up on subtle signs and symptoms, reacted, intervened, and avoided disaster in the form of an adverse surgical or anesthesia event. The PACU nurse also functions as the last line of defense in many situations. The PACU nurse must react quickly and definitively to the patient teetering on the edge of disaster. Respiratory distress, hypotension, postoperative bleeding, and malignant hyperthermia are all examples of PACU emergencies that require rapid response on the part of the PACU nurse to “defend” the patient against disaster. The PACU nurse should also “defend” the patient from an early discharge to the floor or Day Surgery (DS) when there are issues that still need to be resolved. If bleeding or inadequate anesthesia recovery is suspected, it is the role of the PACU nurse to protect the patient and resolve the issue before transfer. We have the greatest access to both the surgeon and the anesthesia provider. Although we are all pushed to move patients quickly from one level of care to another, it is your role to resolve outstanding issues before transport to defend against disasters in DS or on the floor. The DS nurse is also charged with defending the patient against disaster. DS nurses are also pushed to get the patient home, and to do that as quickly as possible. At times, we may actually roll the patient out the door with unresolved postoperative pain or nausea and vomiting. This month’s Original Research article by Kathy Horvath indicates that even though a patient may have adequate pain control on discharge from DS, his or her pain levels often increase to a moderate to severe level later in the day of discharge. This indicates that even those patients discharged with adequate pain control will experience unacceptable pain levels after discharge. A patient that is discharged with an unacceptable pain level may very well be a disaster waiting to happen as pain levels at home may escalate to the severe level, requiring a visit to the Emergency Department and possible readmission. It is the role of the DS nurse to defend against such events by assuring adequate symptom control before discharge. All nurses must act defensively in their daily practice to protect themselves from further liabilities. One of the best ways to defend your own practice is to chart thoroughly and clearly. The chart is a legal record and will be pulled as such if any medical-legal issues ever arise. If you look back on your charting from last week, can you get a full picture of the care that you provided to your patient? Were all identified issues clearly resolved before discharge? Is an outcome charted for every intervention that you initiated? Can you ascertain the patient’s condition on both arrival and discharge from your unit? Did you create a clear picture of your patient’s stay in your unit? If not, re-evaluate your charting style and improve it. The role of offensive players in a game is to be proactive. They are to attack and move the ball forward and score. The keeper serves as the first line of offense as he or she punts, throws, or kicks the ball to a strategic area or player, thus facilitating forward movement of the ball toward a scoring opportunity for the team. The perianesthesia nurse also has to act proactively and strategically put plays or interventions into action to assure a positive outcome (or goal) for the patient. Preadmission testing nurses react proactively by initiating a thorough preoperative assessment and teaching plan. Preoperative and discharge teaching begin at first contact with the patient and serve to proactively prepare the patient for a successful surgical/anesthesia experience and recovery. If the patient knows what to expect and how to prepare, he or she is able to plan and is more likely to experience a positive outcome, both from a surgical and personal perspective. PACU nurses act proactively through their thorough assessment of each and every patient for whom they care. Proactive assessment enables the nurse to pick up on problems early and intervene before disaster strikes. The PACU nurse must also take the offensive with pain control. ASPAN is leading the way with the publication of the Pain and Comfort Clinical Guideline (Journal of PeriAnesthesia Nursing, August 2003).1American Society of PeriAnesthesia NursesPain and comfort clinical guideline.J PeriAnesth Nurs. 2003; 18: 232-236Abstract Full Text Full Text PDF Google Scholar Postoperative pain should be aggressively assessed and managed. Patient-controlled analgesia and patient-controlled epidural analgesia pumps for pain control must be initiated in the PACU. The PACU nurse is the “keeper,” or the first line of offense in postoperative pain assessment and intervention. The DS nurse is also charged with acting proactively to effect positive outcomes. Much of this action, like the preadmission testing area, falls back to the implementation of a clear and thorough postoperative teaching plan. Patients and their families must be taught what to expect when they go home. They must have an understanding of how long that it will “really” take them to recover and return to their normal activities. They must also have a clear understanding of how to take their medications and effectively manage their postoperative pain. Proactive actions by the DS surgery nurse prevent postoperative complications and lay the path for a smooth and rapid recovery in the home setting. All nurses must also take personal responsibility to serve as their own “first line of offense.” Professional nurses must stay current in both clinical and professional issues affecting their practice. They must be aware of, and familiar with the content of national and state regulations, professional practice standards, and current clinical guidelines. Nurses should maintain membership in their professional organizations and obtain certification as offered for their particular nursing specialty. These actions protect nurses in the legal system should they ever be identified as part of a medical-legal action. These activities, more importantly, also armor nurses with current information and knowledge, thus enabling them to provide the best care possible for their patients. Nurses are the “keepers” of the system. We are there to both defend and attack on our patient’s behalf. This position is one of the most demanding on the health care team. To be successful, all keepers must “be brave, athletic, calm, and above all, intelligent.”2Bampton C. Superguides Soccer. Dorling Kindersley Ltd, London, England2000: 18Google Scholar Are you up to the challenge? The World Cup is coming, now is the time to prepare!