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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Fake Voyager Episode: Tuvok gets kidnapped and forced to compete in an arena where telepaths fight one another to the death for a shot at fortune and prestige. He was initially kidnapped as 'fodder' - the aliens who run the arena will grab any telepathic alien they can find regardless of skill and they're essentially just there to be killed by flashier veterans of the bloodsport.
The episode is mainly Tuvok showing off his tactical know-how and combat skills. We also get several flashbacks to him as a young man, learning how to fight both on Vulcan and in Starfleet. There's a concern that he will lose himself when forced into this seemingly endless battle, surrounded by violence, but in the end he prevails and manages to escape without killing a single person. He leaves the arena after giving a message of peace.
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Unnamed Goon: [Laughter] That puny 'Vuulcan' didn't land a single hit for all his bluster. Once I sealed his telepathic powers it was over! Huh huh huh… If I keep up this pace I should have him crushed beneath my fists in-
What...? I can't move...?
Tuvok: By now you have surely noticed it.
You are certainly a formidable opponent. Most would assume you to be a simple bruiser but that is not the case. You are a knowledgeable telepath - able to not only bolster your own physique but nullify the telepathic capabilities of your enemies.
However. You rely too much on one tactic and are too proud to allow yourself to look 'weak.' This was the ultimate cause of your ruination.
While you gleefully battered my body about the field I was able to locate twenty two out of twenty four 'kobat sfek' on your body - points which will render you immobile for approximately…four minutes. More than enough time. It was a shrewd precaution to nullify my telepathic ability.
However. I do not need them to best you in combat.
Even now, I am ten times stronger than you.
Unnamed Goon: T-Ten...TEN TIMES!?
[Imagining the sort of gruesome end that might await him, the unnamed Goon faints - leaving Tuvok the victor.]
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Black: Recall the worst insult you’ve ever received.
“Everything about you is perfect."
Normally, I don't get too worked up about what people say about me. Not even the blatant lies like this one. Maybe especially not the blatant lies. People lie all the time after all, every day, and for the smallest reasons. I've always thought the ability to tell stories is what really defines us from the animals around us. And a lie is just another story.
So lie to me! I don't mind! I'll lie back. We'll have some fun telling our stories and then we'll go our separate ways into the night carrying the memories of our elaborate fictions.
But coooome oooooooooon, ughhhhhh.
Fucking try, would you? Show some artistry! Make me suspend my disbelief for awhile. There's nothing worse than a boring, bad story.
And know your fucking audience.
I can't conceive of a worse insult than to tell someone who worships both the highs and lows of luck that she has no flaws.
Is my reaction to this worthy of an eye roll? Sure! Yeah! How like me to be annoyed at someone for saying a thing everyone knows is a compliment, right?
But that's the thing. The audience! Know the audience! Me! If you're going to lie to me– at least try to make it a good one. Tailor it to me. Show some creativity! Make it a fun lie. Make it one I might -want- to believe.
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