CLINICAL OBJECTIVES

LEVEL IV

	Date	Initials
1. Take client* history using structured and unstructured data collection tools to obtain physical, psychosocial, spiritual, cultural, familial, occupational, environmental information, risk factors, and client resources.
2. Perform assessment to identify health needs and monitor for change in health status.
3. Validate, report, and document assessment data using assessment tools.
4. Identify complex multi-system health care problems of clients.
5. Formulate nursing diagnoses based upon analysis of health data.
6. Perform health screening.
7. Analyze and interpret health data of clients.
8. Incorporate multiple determinants of health in clinical care when providing care for individuals and families.
9. Recognize that political, economic and societal forces affect the health of clients.
10. Identify short and long-term goals/outcomes, select interventions, and establish priorities for care in collaboration with the client.
11. Use current technology and evidence-based information to formulate and modify the nursing plan of care.
12. Contribute to the interdisciplinary plan of care.
13. Communicate plan of care to nurses and other interdisciplinary health care team members.
14. Initiate discharge planning in collaboration with interdisciplinary health care team.
15. Implement cost effective care.
16. Promote a safe, effective environment conducive to the optimal health and dignity of the client.
17. Implement plan of care to assist clients to meet physiological needs, including: circulation, nutrition, oxygenation, activity, elimination, comfort, pain management, rest and sleep.
18. Implement nursing care to promote health and manage acute and chronic health problems and disabilities.
19. Adjust priorities and implement nursing interventions in emergency situations.
20. Initiate nursing interventions to promote client’s psychosocial well-being.
21. Facilitate the development of client coping mechanisms during alterations in health status.
22. Perform therapeutic and preventive nursing measures and administer treatments and medications as authorized by law and determined by the BNE.
23. Evaluate, document, and report responses to medications, treatments, and procedures and communicate the same to other health care professionals clearly and accurately.
24. Collaborate with other health care providers with treatments and procedures.
25. Inform and support health care rights of clients.
26. Use interdisciplinary resources within the institution to address ethical and legal concerns.
27. Utilize therapeutic communication skills when interacting with clients.
28. Participate in peer review and quality improvement processes.
29. Use current technology to enhance client care.
30. Act as a role model in maintaining client confidentiality.
31. Assume accountability when using independent clinical judgment and established protocols.
32. Identify learning needs of clients related to health promotion, maintenance and risk reduction.
33. Collaborate with others to develop and modify individualized teaching plans based upon developmental and health care learning needs.
34. Individualize and implement established teaching plans.
35. Evaluate learning outcomes of the client receiving instruction.
36. Modify teaching methods to accommodate client differences.
37. Apply knowledge of how changes in clients’ personal behavior improve client’s health.
38. Serve as model & resource for health education & information.
39. Analyze client data to compare expected and achieved outcomes for client.
40. Identify and communicate reasons and rationales for deviation from plan of care to interdisciplinary health care team.
41. Modify plan of care and/or expected outcomes.
42. Evaluate and communicate quality and effectiveness of therapeutic interventions.
43. Use evaluation tools to measure processes and outcomes.
44. Identify priorities and make judgments concerning the needs of multiple clients in order to organize care.
45. Manage care for multiple clients.
46. Apply management concepts in assigning and/or delegating nursing care to other members of the nursing team.
47. Use critical thinking as a basis for decision-making in nursing practice.
48. Prioritize client care and follow-up on problems that warrant investigation.
49. Use knowledge of societal trends to identify and communicate client care problems.
50. Read and discuss relevant, current nursing practice journal articles and apply to practice.
51. Participate in the evaluation of care administered by the interdisciplinary health care team.
52. Consult with, utilize and make referrals to community agencies and health care resources to provide continuity of care.
53. Use organizational & management skills when utilizing resources to meet goals/outcomes, & enhance quality of nursing care and level of client satisfaction.
54. Use negotiation skills for the purpose of achieving positive client outcomes.
55. Participate in interdisciplinary health care team meetings/conferences.
56. Apply change strategies to achieve stated outcomes.
57. Work with client and interdisciplinary health care team for planning health care delivery to improve the quality of care across the life span.
58. Promote the effective coordination of client-centered health care.
59. Assess the adequacy of the support system of the client.
60. Identify providers and resources to meet the needs of clients.
61. Facilitate communication between client and institutional or community resources.
62. Advocate on behalf of the client with other members of the interdisciplinary health care team to procure resources for client care.
63. Identify and participate in activities to improve health care delivery within the work setting.
64. Report the need for corrective action within the organization.
65. Select human and material resources that are optimal, legal, and cost effective to achieve organizational goals.
66. Use basic management and leadership skills, act as a team leader, supervise and delegate care and contribute to shared goals.
67. Provide nursing care within limits of professional nursing knowledge, education, experience, and ethical/legal standards of care.
68. Provide holistic care that addresses the needs of diverse individuals across the life span.
69. Evaluate the learning needs of self, peers, or others and intervene to assure quality of care.
70. Promote accountability for quality nursing practice through participation on policy & procedure committees.
71. Delegate/assign to other health care providers within legal parameters and evaluate delivery of care.
72. Use communication techniques and management skills to maintain professional boundaries between clients and individual health care team members.
73. Support the client’s right of self-determination and choice even when these choices conflict with values of the individual professional.
74. Identify client’s unmet needs from a holistic perspective.
75. Advocate on behalf of the client with other members of the interdisciplinary health care team.
76. Participate on organizational committees, professional organizations and community groups to improve the quality of health care.
77. Serve as a member of voluntary health care and community teams to provide services to individuals and communities and unmet needs.
78. Promote collegiality among interdisciplinary health care team members.
79. Collaborate with members of nursing and other health care organizations to promote the profession of nursing.
80. Participate in activities individually or in groups through organizations that promote the profession of nursing.
81. Recognize roles of professional nursing organizations, regulatory agencies and organizational committees.
82. Practice within the RN role and Scope of Practice.
83. Serve as a positive role model for students, peers, and members of the interdisciplinary health care team.

* Client includes individual and family

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