NU657 Unit 1 Clinical Objectives for a Medical ICU Example

Objectives Written Around the Census: A Clinical Objectives Statement for an AGACNP Rotation in a 20-Bed Medical ICU

[Student Name]

Purdue University Global

NU657: AGACNP Critical Care Management Clinical

Unit 1 Clinical Objectives Statement

[Instructor Name]

[Date]

The site is composite; its census figures, volumes and review dates are bracketed. The preceptor agreement lines are left blank.

The Site and What It Admits

The rotation is based on the medical intensive care unit of a [340]-bed community teaching hospital, [20] beds in all. Its admission pattern over the last year, as the unit's nurse manager described it, sets the limits of what this rotation can offer. Roughly [60] percent of admissions are sepsis and shock, usually from pneumonia, urinary sources or the abdomen. About [20] percent are respiratory failure, including chronic obstructive pulmonary disease, pneumonia and a small number of ARDS cases, perhaps [two] a month. The remaining [20] percent are spread across acute kidney injury, gastrointestinal bleeding, diabetic emergencies, overdoses and neurologic emergencies that do not need neurosurgery. Family meetings about goals of care happen about [twice] a month, and continuous dialysis is started [three or four] times a month.

Two consequences follow. First, sepsis will be the setting for most of my practice, so my objectives use it wherever possible. Second, an objective that depends on rare events, such as leading the management of an ARDS patient from intubation to extubation, would be a wish rather than a plan. Where the census is thin I have narrowed the objective to a skill I can practice on any patient.

How the Objectives Are Written

Each objective follows the same pattern: an action I will perform, the condition under which I will perform it, a standard that can be counted or checked, and a point in the course when my preceptor and I will review it. This is the SMART structure, applied without naming it at every line. For each objective I also name the organ failure it serves, so that the list stays tied to the subject of NU657, and the evidence that will show progress. Quantities are bracketed, because the site sets the volume and my preceptor may adjust them.

The Five Objectives

Objective 1. Shock typing on rounds. Action and condition: for every patient on a vasopressor whom I present, I will state the shock type, the bedside and echocardiographic findings that support it, and the target for the day, before proposing any change in the vasopressor. Organ failure: circulatory. Evidence: [15] presentations over the rotation, with my preceptor noting whether the type was supported by findings. Review: Unit 5 and Unit 10.

Objective 2. Ventilator orders drafted and reviewed before entry. Action and condition: for every intubated patient on my list, I will draft the day's ventilator orders on paper, including the predicted body weight calculation, tidal volume per kilogram, plateau and driving pressure, and the criteria for a breathing trial, and review them with my preceptor before any order is entered. Organ failure: respiratory. Evidence: [20] drafts, with the number that needed correction recorded and expected to fall by the second half of the rotation. Review: Unit 5 and Unit 10.

Objective 3. KDIGO staging for every new kidney injury. Action and condition: when a patient on my list has a new rise in creatinine or a fall in urine output, I will stage the injury by both KDIGO criteria (Khwaja, 2012), name the most likely cause and write a plan that states the thresholds for renal replacement therapy. Organ failure: renal. Evidence: [eight] staged cases, each with both criteria calculated. Review: Unit 10.

Objective 4. Daily delirium screening with a written plan. Action and condition: for every patient on my list, I will complete the CAM-ICU, a screening tool validated in ventilated patients (Ely et al., 2001), each day with the bedside nurse, and for each positive screen I will write a plan that addresses sedation, sleep, mobility, medications that may be contributing, and family presence, the elements of the ABCDEF bundle, whose fuller use was linked to lower mortality and less delirium in a large collaborative (Pun et al., 2019). Organ failure: neurologic. Evidence: screens and plans for all patients on my list, with [ten] plans reviewed by my preceptor. Review: Unit 5 and Unit 10.

Objective 5. Rounds presentations under three minutes. Action and condition: I will present each patient on morning rounds in a fixed system order, with overnight events first and one question for the attending at the end, in no more than [three] minutes. Organ failure: all systems. Evidence: timed presentations, with my preceptor recording the time and whether the question was clear, for at least [20] presentations. Review: Unit 3, Unit 5 and Unit 10.

Why These Five

These objectives reflect the AGACNP role as it plays out in this unit: diagnosing and managing adults whose organs are failing, and coordinating the team around them. Shock, respiratory failure, kidney injury and delirium are the four organ failures I will see most in this census, and presentation is the skill through which every other skill is judged on rounds. I have deliberately left out procedures as a separate objective, because procedures depend on who is admitted and what the attending allows, and I will record them in my log instead.

An objective about managing ARDS in a unit that admits two cases a month is a wish; an objective about drafting ventilator orders for every intubated patient is a plan.

What I Cannot Yet Do

I have managed septic patients on a medical floor and in a step-down unit, but I have not written vasopressor or ventilator orders in an intensive care unit. My confidence with bedside echocardiography is limited to recognizing a large pericardial effusion and a severely reduced ejection fraction. I have never led a family meeting. These gaps are the reason for Objectives 1, 2 and 4 and for my plan to observe [two] family meetings before taking part in one. The number of hours I complete and the count of each activity will come from my own clinical log, which my preceptor will verify; this statement sets the targets but does not record them.

Preceptor Agreement

Preceptor name and credentials: ______________________

Date reviewed: ______________________

Changes agreed: ______________________

References

Ely, E. W., Inouye, S. K., Bernard, G. R., Gordon, S., Francis, J., May, L., Truman, B., Speroff, T., Gautam, S., Margolin, R., Hart, R. P., & Dittus, R. (2001). Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA, 286(21), 2703-2710. https://doi.org/10.1001/jama.286.21.2703

Khwaja, A. (2012). KDIGO clinical practice guidelines for acute kidney injury. Nephron Clinical Practice, 120(4), c179-c184. https://doi.org/10.1159/000339789

Pun, B. T., Balas, M. C., Barnes-Daly, M. A., Thompson, J. L., Aldrich, J. M., Barr, J., Byrum, D., Carson, S. S., Devlin, J. W., Engel, H. J., Esbrook, C. L., Hargett, K. D., Harmon, L., Hielsberg, C., Jackson, J. C., Kelly, T. L., Kumar, V., Millner, L., Morse, A., . . . Ely, E. W. (2019). Caring for critically ill patients with the ABCDEF bundle: Results of the ICU Liberation Collaborative in over 15,000 adults. Critical Care Medicine, 47(1), 3-14. https://doi.org/10.1097/CCM.0000000000003482