Hey so your post about pain management as a bedside nurse is so important to my own nursing practice that I've considered printing it out so I can have it to hand all the time. So thanks for that. Also, how do you deal with assignments that are busy enough that pain management is harder than it should be? I'm coming up on two years as a nurse and I feel like I take it personally when I am too busy to adequately manage my patients pain. I'm also coming from a newly unionized hospital where the ratios are still horrendous (I do 1:10 on med surg) and I'm hoping once we can enforce our staffing grids it'll be better but idk I'm burning out and I love my job so much and I really respect your nursing philosophy? I guess. Sorry for the word vomit it's been a crazy shift.
I've been trying to think of how to answer this since I got it. It's just such a horrendous ratio. With ten patients a shift, that's like six minutes an hour for each in a fantasy world where there's no charting and everything is exactly where you need it to be. I feel like I don't have great insight into this because the most med surg patients I've had assigned is five. Ten patients to one nurse is just a raw deal for everyone. Like christ no wonder you feel like you're burning out! I'll give you what thoughts I have and hopefully other people can chime in if they have suggestions. But that's such a hard patient load.
When I've been super swamped, I've found that's when being really explicit about your thinking with the patient helps. Like if I have to dash into a room and then dash back out, I'll make sure the board is updated with the next medication time and that the patient knows when the medication is going to kick in. I'll also provide call light parameters. I have a lot of success telling people, "the med should be doing something by 5:30. If I haven't checked in with you by then, and the pain is unchanged or barely changed, hit your call light and we'll try the next step. Also hit your call light if you feel any sudden change, like now you're nauseated or you have a headache or the type of pain changes or something just feels very wrong. Is there anything you need before I step out of the room?"
I like to be explicit about when to call me because I think there's two directions call light usage can go wrong: someone calls all the time, or someone never calls. With someone who calls all the time, I find that telling them when I'll be back and that I want them to call me if I'm not takes away some of that anxiety that can causes some people to call frequently. Often those patients are afraid that if they aren't on the call light, they're gonna get ignored.
For the other type of patient, the one that doesn't call, I want to make explicit that it's GOOD AND NORMAL TO CALL YOUR NURSE WHEN YOU HAVE SYMPTOMS. We've all had that patient at the end of shift who goes, "btw the gnawing pain in my leg is now a 10/10" and you're like "what gnawing pain sir?? you've literally never mentioned it before now?? I don't have any meds for that lemme page super quick????" These patients can get into pain crises easily because they don't ask for help until something is unbearable. In addition to pain crisis bad, it takes a lot more time to deal with something unbearable than it does to deal with something uncomfortable.
On that note, are you spending your very limited time efficiently? To me, that actually means spend more time talking with patients, at least up front. Manage expectations, make sure people know what to expect. Having conversations with patients that are like, "You just had surgery, it's not gonna happen that we get you completely painless. We want to get you to a manageable pain level that allows you to do whatever it is you most want to do this shift." (For me on nights, that's usually sleeping at least a little, but sometimes the realistic goal you make together is that you will feel at some point better than you feel right now.) "You have this medication scheduled, and you have this one available every X hours when your pain is severe. Is there anything you know that helps you deal with pain?"
Also establish if patients want to be woken up for certain prn medications or if they're sleeping, to let them sleep. With some patients, I will advise them to get woken up for pain medication because I know that they're going to need consistent control to avoid a crisis. (Crises take so much time!)
When I'm crunched for time, I'm fond of bringing in an ice pack and being like "if it works, great, if it doesn't, just take it off, either way here it is." Sometimes I'll do the same with a warm blanket. If I know my patient needs to take pills, I'll bring a cup of water with me into the room. If there's a basic prn like melatonin or tylenol that I think they might want, I'll pull them in advance. If the patient doesn't want them, I return them next time I'm in the med room. (Obviously, don't do this with controlled substances. It's super easy to forget to return them, and not returning opioids is one of those whoopsies people get fired over.)
Decision making takes time. Walking to go get stuff takes time. I want to save the time it takes to assess if the patient needs those things and then walk off to fetch them by just having the things already. If your tightest resource is time, be liberal with resources you can spare. If you're stuck with a patient, do you have anyone you can delegate a prn med pass to? Do you know how to do the absolute minimum charting you need to? Do you have flushes and alcohol wipes and whatever other most common things you need? And since you can't hoard time, if you've got some to spare, ask yourself if there is anything you can do now that will save you time later. If you have five free minutes now and an incontinent patient, getting them up to the bathroom now can save you from taking the time for incontinence care and a bed change later on when they've also sundowned and decide they hate everything but most of all you.
So much of this answer I realize is investing as much time upfront as you can, which I realize is so hard when you are so busy. It sucks immensely that prepping takes much less time than not being prepared does when you don't always have time to prep. Plus when you invest that time to pain plan with patients and do small preventative interventions, I think it also provides some psychological comfort that helps with pain. You're letting them know you're invested and you care and you have a plan, even if you don't have all the time you'd like. That can mean better pain control, which can mean needing to spend less time in that room overall, meaning you can save six whole minutes at some point and maybe even, if we're feeling crazy, get a chance to indulge in that greatest of indulgences: just a real leisurely on-shift piss.
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Fluff alphabet for Nikolai? You’re one of the few who write for him and he’s my favorite character! Thank you so much!!
Hey there! Really? There aren't many people who write for him? That's such a shame, he's literally such a cool character and I adore him so much! Also, sorry I wrote this relatively late, but life got inbetween! But I wrote it now!
Fluff Alphabet for Nikolai
A ctivities - What do they like to do with their s/o? How do they spend their free time with them?
If it was up to him, then you’d be spending most of your days at home, within the safety of your walls. However, he loves doing whatever it is you love. You wanna go on a hike? You wanna have a boxing match with him? You wanna start a book club? Everything is game for him as long as you’re down for it, or make the suggestion. He is the adaptable sort of person who can do just about anything, especially if he gets to spend time with you and make you happy.
B eauty - What do they admire about their s/o? What do they think is beautiful about them?
The fact that you can stay with someone like him. Nikolai can be a very cocky man, he doesn’t particularly hide his occasional cruelty either. Sure, he is calm and collected as well, but he could see why you would want to leave him for someone more “proper”. You could likely get anyone in the world, and yet you decide to stay with him? He, who has killed the guilty and innocent alike? Who makes fun of the police whenever he can? It takes a special kind of crazy to want to be with someone like that. He can appreciate that.
C omfort - How would they help their s/o when they feel down/have a panic attack etc.?
Since one of his abilities is that he can stay calm under any circumstance, he would likely calmly talk to you, try to talk some sense into you as well. His voice can be rather calm too when he wants it to be. He’ll be your voice of reason while getting you away from whatever may be upsetting you, shielding you from onlookers. When you’re sad he’ll offer some advice, or maybe some distraction, whichever you say you need more at the moment. His advice is actually pretty solid too, he’s been through a lot and isn’t the youngest anymore either.
D reams - How do they picture their future with their s/o?
He has a small country house in the middle of nowhere in Russia, and he’d love living there with you. No more soldier or mercenary business, just you and him living together there, disturbed by no one aside from the occasional bird chirping here and there. He’d chop the wood while you make him a lovely pie. It doesn’t need to be fancy, as long as he gets to spend his future with you, winding down from all the adrenaline he gets on a regular basis, he’s happy.
E qual - Are they the dominant one in the relationship, or rather passive?
Surprisingly, he tends to be more passive in the relationship. Though, he could go either way, but normally he just goes along with whatever it is you want. Sure, he can and will flirt with you occasionally, and if you’re on the more passive side then he’ll take charge, but other than that he just goes with the flow and lets you decide. If you can’t decide for whatever reason, then he will. But whatever makes you happiest he’ll do.
F ight - Would they be easy to forgive their s/o? How are they fighting?
He would never raise his voice at you. It’s very hard to anger him in general, he usually believes he’s in the right anyway, which he usually is. He’s calm and collected at all times, but will be more factual with everything when he’s starting to get annoyed with you. However, he easily forgives, regardless of whether you apologize or not. Your relationship isn’t so weak that something like this should make it falter.
G ratitude - How grateful are they in general? Are they aware of what their s/o is doing for them?
Generally speaking, he knows what is and isn’t a given, and he knows to appreciate the things that aren’t. So yeah, he’s a pretty grateful man, even if it doesn’t seem like he’d show it very often. Nikolai knows that you cleaning the house from top to bottom, you cooking him a meal and giving him all the love he deserves and so much more isn’t a given, so he likes to show his gratitude through the small things, such as making sure to take in every new detail about you and always complimenting you, getting you the occasional gift as well. Something small but meaningful.
H onesty - Do they have secrets they hide from their s/o? Or do they share everything?
He runs a PMC, so naturally there are things he can’t tell you about. However, he does believe that secrecy kills a relationship. If it’s something he can talk about, he will. Although he won’t go into detail about how he tortured that man, he will give you constructive criticism on how you can improve your knitting. He’s not one for lying, you deserve to know just about everything. Isn’t the most open about his past, though.
I nspiration - Did their s/o change them somehow, or the other way around? Like trying out new things or helped them overcome personal problems?
I think Nikolai changed the most during his youth, so likely long before he met you. By the time you met he had already become who he is today. I don’t think anyone or anything could change him that significantly anymore, unless something truly terrible happened. He knows to take care of himself. However, I feel as though he could have become a bit kinder as a result of meeting you.
J ealousy - Do they get jealous easily? How do they deal with it?
He has faith in you to not leave him. Sure, he gets his spurts of jealousy, but he’s an adult, he doesn’t really act on it all that much. The only thing he really does when he’s jealous is talk over the other person to try and get your attention. He deals with it by either walking away from the situation or trying to get you away from the other person if he can. Again, he trusts you to not stray from him.
K iss - Are they a good kisser? What was the first kiss like?
He’s an attractive man, he likely had his fair share of lovers throughout his life, meaning he’s kissed plenty of times. When he was younger, he wasn’t a very good kisser, but he learned to adapt to the likes and dislikes of people. He could likely satisfy just about anyone with a few kisses these days. However, your first kiss with him would have beena a gentle one. He loved you even back then and was afraid of intimidating you. It was short, it was gentle, it was sweet.
L ove Confession - How would they confess to their s/o?
It wouldn’t be anything too fancy. He’d get you flowers, some chocolate or other sweets you like and invite you to a lake or something. And then he’d confess his feelings to you in a casual manner and ask you if you want to be with him. If you had said no then he would have made the offer of staying friends, at the very least.
M arriage - Do they want to get married? How do they propose? What would the marriage be like?
On the one hand, he does want to get married, on the other he doesn’t want to subject you to all the danger he’s usually part of. I think it would take him an eternity to propose and then it would be something simple as well. He’d test the waters by asking you if you want to marry him first, the ring comes later. Not much changes when you’re married to him. It still feels rather casual, but there’s always the fact you’re bound by your vows now. He’ll make it his goal to relive his honeymoon with you by going on a vacation with you every once in a while.
N icknames - What do they call their s/o?
Милый/милая (my dear, darling), Любимый/любимая (loved one) and Солнышко (sunshine) are his go to. He’s not overly creative, but he sometimes also calls you by the names of cute little animals. Again, he’s more casual when it comes to things like this. More often than not, he calls you by your name. However, he’s not above using terms of endearment in your native language as well. He knows eight languages, and if yours isn’t among them then he’ll simply learn it.
O n Cloud Nine - What are they like when they are in love? Is it obvious for others? How do they express their feelings?
It’s not obvious at all when he’s in love. Sure, he likes to spend more time with you, but he won’t prioritize you when he’s busy. Sometimes he’ll give you an expensive gift. Knowing fully well you’ll want to repay him, he’ll simply ask for your company and that you’ll pay for the coffee on your little date. He knows how to get what he wants, and if he wants a small outing with you then he’ll get it. He doesn’t express his feelings freely at first, but he’ll call and text you more often to check up on you. That’s about it, he has his feelings in check otherwise.
P DA - Are they upfront about their relationship? Do they brag with their s/o in front of others? Or are they rather shy to kiss etc. when others are watching?
He doesn’t really brag about his relationship. He only really mentions you here and there in front of his closest friends. The entire world doesn’t need to know about you, so he keeps you to himself for the most part. However, he doesn’t really mind PDA all that much. Sure, he won’t really initiate it, but if you really wanna kiss him, then you can just go for it. Same if you just wanna cuddle up to him under his jacket. He doesn’t really mind that sort of thing.
Q uirk - Some random ability they have that’s beneficial in a relationship.
The fact that he can stay cool under any circumstance. Even when you’re out to get on his nerves like no other he can stay almost completely neutral. It’s really hard to piss him off, and even then he thinks more rationally than he normally would. He really doesn’t let his emotions get the better of him when he’s in a negative situation. You’ll never have him yell at you, only tell you facts. He can also argue for you in case someone is being mean to you.
R omance - How romantic are they? What would they do to make their s/o happy? Cliché or rather creative?
He’s not really a romantic at heart. Sure, there’s the occasional gesture. He’ll gift you plushies, he’ll take you on a walk where you can watch the sunrise together, he’ll also cuddle you on the couch. However, he will also train you, he will take you to his shooting range, you will be sparring with him from time to time. Although it may not seem like much, that’s also another “romantic” aspect of his. He wants you to be able to defend yourself in an emergency, so he’ll make all of it seem more romantic than it really is. Will take you out for dinner, though. He can make some really mean pirozhki.
S upport - Are they helping their s/o achieve their goals? Do they believe in them?
Naturally. He’s been through so much, he likely has some piece of advice for just about any situation. And even when he can’t give you any advice, he can help you out by either listening to your woes or by paying for whatever it is you need. He’ll always be there for you. Nikolai is a very loyal man once you’ve gotten on his good side. He would never let anyone he’s close with down, be it a friend or a lover. You can bet he’ll do just about anything for you.
T hrill - Do they need to try out new things to spice out your relationship? Or do they prefer a certain routine?
It entirely depends on what you want. He can honestly go either way. Sure, he might not want to spice his love life up by committing a murder with you every day, even if he could, but maybe going on a vacation every once in a while would be nice. While he may be down to try almost everything at least once, he doesn’t mind staying stagnant in that regard either. It’s really up to you. However, he will make you eat certain new foods he thinks you might like. He’s a great cook, his meals are always top notch.
U nderstanding - How good do they know their partner? Are they empathetic?
He’s not a very empathetic person. Sure, he can usually tell what someone is thinking, but that doesn’t mean he cares enough about most people to feel what they’re feeling. Even in a relationship he isn’t the most emphatic person, he barely has any empathy for anyone. However, he can easily take notice of even the smallest of changes in your behavior and act accordingly. To him, life is more logical than anything else, not so much emotional. So he will act in accordance with the signs you give him and do whatever he has learned works for you. Either that or he will listen to his intuition. His intuition is great.
V alue - How important is the relationship to them? What is it’s worth in comparison to other things in their life?
His relationship with you is on par with the friendship he has with Price and Laswell. He knows that you can’t live off of love and air your entire life, so he keeps close contact with both of them as well. While you could not bribe him out of the relationship if you tried, he does sometimes think about cutting ties with you to keep you safe. He wouldn’t go through with it, but he does value a lot of things in life. Any relationship is important to him, whether it be romantic or platonic. So yeah, you wanting him to cut ties with Price or Laswell would immediately raise a red flag with him. He wouldn’t give up either of them either, please understand that.
W ild Card - A random Fluff Headcanon.
He runs so very hot. Out of all the main characters, he has the highest body temperature. Nikolai is very comfortable to cuddle with in winter. He doesn’t mind cuddling with you either, if that’s what you want. But just so you know, he’s a tall man and could likely wrap himself around you almost entirely. He’s also very strong, so he could make you feel very protected as well. That’s one of his favorite things to do, making you feel safe and secure. The more you melt into him, the more you trust him to protect you, the better. He’s a nightmare to cuddle with in summer, though.
X OXO - Are they very affectionate? Do they love to kiss and cuddle?
On his own accord he’s kind of like a cat. He prefers to watch you and be in the same room as you to show affection. Once he’s figured out your style of affection, he’ll act in accordance to that. You wanna cuddle? Sure. You wanna be together in the same room? Naturally. You wanna be mushy together and exchange loving words? Yeah, he can do that too, even if he isn’t the most emotional person. Generally speaking, he likes kissing and cuddling, but he doesn’t need to be all over you all the time. The occasional kiss and cuddle is alright, but too much skin contact has the potential to annoy him.
Y earning - How will they cope when they’re missing their partner?
Since he knows that being distracted on the battlefield could lead to him never seeing you again, he tends to not think about you. However, once he has some downtime he likes to replay some of the moments he shared with you. The time you accidentally hurt yourself breaking a mug as he patched you up or when you fell asleep in his arms, he thinks about those moments more often than he’d like to admit. He doesn’t really keep a memento of you, you’re not even on his phone’s background, but he remembers you well. Your smiles, your tears, the way you’d hug him so tightly when he’d come home. He just thinks about you and those thoughts lull him to sleep.
Z eal - Are they willing to go to great lengths for the relationship? If so, what kind of?
I honestly wouldn’t be surprised if he has killed for you several times already. To answer the question, yes. He’s killed for you, he’s broken the law several times for you. He runs his own PMC, he could technically go to war for you as well. And he would if someone were to take you away from him. He could likely destroy a small nation for you. While he won’t do it if you ask him to, if someone were to kidnap you, he would not hesitate to fight for you. Your safety is a priority of his, so he will do what he can to make sure you’re by his side, forever and always.
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