| Course | NU648 Specialized Pharmacology for the AGACNP |
|---|---|
| Unit | Unit 4 |
| Paper type | Perioperative medication plan |
| Length | About 1,210 words, 7 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NU648 Unit 4
Continue, Hold, Adjust or Bridge: A Perioperative Medication Plan for a 74-Year-Old on Apixaban Before Open Sigmoid Colectomy
[Student Name]
Purdue University Global
NU648: Specialized Pharmacology for the AGACNP
Unit 4 Perioperative Medication Plan
[Instructor Name]
[Date]
The patient is composite; doses, dates and laboratory values are bracketed, and the plan follows the surgical team's stated conventions where the evidence is mixed.
Patient and Procedure
Mrs. [R.] is a [74]-year-old woman scheduled for an elective open sigmoid colectomy on [Day 0] for recurrent diverticulitis with a colovesical fistula. She weighs [68] kg, her creatinine is [1.1] mg/dL and her estimated creatinine clearance is [52] mL/min by Cockcroft-Gault. Her CHA2DS2-VASc score is [4] (age, sex, hypertension and diabetes), with no prior stroke. Her hemoglobin A1c is [7.4] percent. An open colectomy with an anastomosis and neuraxial analgesia counts as a high-bleeding-risk procedure, and that category drives the anticoagulant decision.
She brings six home medications: apixaban [5 mg] twice a day for atrial fibrillation; for blood pressure, lisinopril [20 mg] and metoprolol succinate [50 mg], each once a day; for diabetes, glargine [24] units each night plus metformin [1,000 mg] with breakfast and supper; and atorvastatin [40 mg] at night.
Each drug below is sorted by the risk it carries on each side of the decision. Stopping can cause harm and so can continuing, and naming both is what turns a list of instructions into a plan.
Apixaban: Hold Two Days, No Bridge, No Routine Level
Decision: last dose on the morning of [Day minus 3]; no doses on [Day minus 2] or [Day minus 1]; no apixaban on the day of surgery.
The tradeoff is bleeding against clotting. The PAUSE cohort tested a fixed interruption schedule in 3,007 patients with atrial fibrillation on a direct oral anticoagulant: two days off before a high-bleeding-risk procedure, resumption two to three days after, no heparin bridging and no preoperative coagulation testing (Douketis et al., 2019). In the apixaban group, the 30-day rate of arterial thromboembolism was 0.16 percent and the rate of major bleeding after high-bleeding-risk procedures was about 3 percent, which is low for major abdominal surgery. Her clearance of [52] mL/min is well above the level at which apixaban's clearance becomes a concern, so the standard interval applies to her.
No bridge is planned. A reader may expect heparin coverage for a woman with a CHA2DS2-VASc score of [4], so the plan states why. The BRIDGE trial randomized patients with atrial fibrillation who were interrupting warfarin to bridging with low-molecular-weight heparin or placebo; bridging did not lower the rate of arterial thromboembolism and roughly doubled major bleeding (Douketis et al., 2015). Apixaban leaves the body in days rather than a week, so the gap a bridge would fill is even shorter than in BRIDGE.
The two-day hold is set by the bleeding risk of the operation and her kidney function, not by how worried the team feels about her stroke risk.
Apixaban: Restart
Decision: prophylactic-dose anticoagulation per the surgical protocol from the evening of [Day 1] if hemostasis allows; full-dose apixaban [5 mg] twice daily from [Day 2 or Day 3], at 48 to 72 hours, once the surgeon confirms no bleeding concern.
Restart gets the same weight as the hold. Resumption is where postoperative plans most often lose track, because the order written before surgery is not always carried into the postoperative orders. The plan names who confirms the restart (the surgical team at morning rounds on [Day 2]) and what would delay it: a falling hemoglobin, drain output that looks like blood or a planned return to the operating room. An epidural catheter, if placed, must be removed before full-dose apixaban starts, following the anesthesia team's timing.
Metoprolol Succinate: Continue
Decision: take [50 mg] on the morning of surgery with a sip of water; continue after surgery, held only for a systolic pressure below [100] mm Hg or a heart rate below [55].
The tradeoff is rebound tachycardia and ischemia if stopped against hypotension and bradycardia if continued. Patients already on a beta-blocker should continue it through surgery (Thompson et al., 2024). The caution from POISE points the other way: starting high-dose metoprolol succinate in beta-blocker-naive patients just before surgery reduced myocardial infarction but increased stroke and death (POISE Study Group, 2008). The lesson is about starting a beta-blocker at surgery, not about stopping one she has taken for years, and the plan says so to avoid a misreading in either direction.
Lisinopril: Hold the Morning of Surgery
Decision: last dose on the morning of [Day minus 1]; no dose on the day of surgery; resume when she is eating, her creatinine is at baseline and her systolic pressure is above [110] mm Hg.
The evidence here is genuinely mixed. In the Stop-or-Not trial, 2,222 patients on renin-angiotensin system inhibitors were randomized to continue until surgery or stop 48 hours before; the rate of death and major complications at 28 days was 22 percent in both groups, but continuation increased intraoperative hypotension from 41 to 54 percent (Legrand et al., 2024). Neither strategy was better for outcomes, so the plan follows the surgical and anesthesia teams' stated convention of holding on the morning of surgery. A longer hold is not planned, because her hypertension has been hard to control.
Metformin: Hold the Day of Surgery
Decision: last dose with the evening meal on [Day minus 1]; none on the day of surgery; resume when she is eating and drinking and her kidney function is at baseline.
Metformin should be held on the day of surgery (American Diabetes Association Professional Practice Committee, 2025). The concern is less the drug itself than the day: she will be fasting, receiving contrast-free but fluid-shifting surgery and at some risk of acute kidney injury, which would raise her metformin exposure.
Insulin Glargine: Reduce the Evening Dose
Decision: [18] units the evening before surgery, which is 75 percent of her usual [24]; point-of-care glucose on arrival and every [two] hours during surgery; correctional insulin for glucose above [180] mg/dL; target 100 to 180 mg/dL.
The tradeoff is hypoglycemia while fasting against hyperglycemia, which raises infection risk after abdominal surgery. The American Diabetes Association recommends giving 75 to 80 percent of the usual long-acting basal dose before surgery (American Diabetes Association Professional Practice Committee, 2025). Her A1c of [7.4] percent does not suggest a need for more aggressive control, and a lower basal dose protects her through a fasting morning that may run long if the operating schedule slips.
Atorvastatin: Continue
Decision: continue without change, including the evening before surgery; restart with oral intake after surgery.
Patients already taking a statin should continue it through noncardiac surgery (Thompson et al., 2024). There is no bleeding, glucose or pressure tradeoff to weigh, so this is the one line of the plan without an argument.
Communication and Documentation
The plan will be sent to the surgeon, the anesthesia team and her primary care provider, and printed as a one-page calendar for Mrs. [R.] with each medication and its last date. Two points are marked for teach-back at the preoperative visit: the last apixaban dose date and the reduced glargine dose. Most perioperative medication errors happen at the handoffs between these people, not in the decisions themselves.
References
American Diabetes Association Professional Practice Committee. (2025). 16. Diabetes care in the hospital: Standards of care in diabetes 2025. Diabetes Care, 48(Suppl. 1), S321-S334. https://doi.org/10.2337/dc25-S016
Douketis, J. D., Spyropoulos, A. C., Duncan, J., Carrier, M., Le Gal, G., Tafur, A. J., Vanassche, T., Verhamme, P., Shivakumar, S., Gross, P. L., Lee, A. Y. Y., Yeo, E., Solymoss, S., Kassis, J., Le Templier, G., Kowalski, S., Blostein, M., Shah, V., MacKay, E., . . . Schulman, S. (2019). Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Internal Medicine, 179(11), 1469-1478. https://doi.org/10.1001/jamainternmed.2019.2431
Douketis, J. D., Spyropoulos, A. C., Kaatz, S., Becker, R. C., Caprini, J. A., Dunn, A. S., Garcia, D. A., Jacobson, A., Jaffer, A. K., Kong, D. F., Schulman, S., Turpie, A. G., Hasselblad, V., & Ortel, T. L. (2015). Perioperative bridging anticoagulation in patients with atrial fibrillation. New England Journal of Medicine, 373(9), 823-833. https://doi.org/10.1056/NEJMoa1501035
Legrand, M., Falcone, J., Cholley, B., Charbonneau, H., Delaporte, A., Lemoine, A., Garot, M., Joosten, A., Meistelman, C., Cheron-Leroy, D., Rives, J., Pastene, B., Dewitte, A., Sigaut, S., Danguy des Deserts, M., Truc, C., Boisson, M., Lasocki, S., Cuvillon, P., . . . Gayat, E. (2024). Continuation vs discontinuation of renin-angiotensin system inhibitors before major noncardiac surgery: The Stop-or-Not randomized clinical trial. JAMA, 332(12), 970-978. https://doi.org/10.1001/jama.2024.17123
POISE Study Group. (2008). Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): A randomised controlled trial. The Lancet, 371(9627), 1839-1847. https://doi.org/10.1016/S0140-6736(08)60601-7
Thompson, A., Fleischmann, K. E., Smilowitz, N. R., de las Fuentes, L., Mukherjee, D., Aggarwal, N. R., Ahmad, F. S., Allen, R. B., Altin, S. E., Auerbach, A., Berger, J. S., Chow, B., Dakik, H. A., Eisenstein, E. L., Gerhard-Herman, M., Ghadimi, K., Kachulis, B., Leclerc, J., Lee, C. S., . . . Williams, K. A. (2024). 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery. Circulation, 150(19), e351-e442. https://doi.org/10.1161/CIR.0000000000001285
Reading the NU 648 Unit 4 instructions
The Unit 4 assignment gives you a patient scheduled for surgery and a list of home medications, and asks for a plan that states what happens to each drug before and after the operation. For every medication you name the decision, the last preoperative dose, the restart timing and the evidence behind the choice. The bleeding risk of the procedure and the patient's kidney function usually set the anticoagulant timeline, so both need to appear early. Many sections ask you to address bridging directly, even when the answer is no. Expect three to five pages with current guidelines and trials, and write the plan so a surgical team could follow it.
How this NU648 Unit 4 example is built
The example begins with the patient and procedure, including weight, creatinine clearance, CHA2DS2-VASc score and A1c, because each hold interval depends on them. Each drug then gets its own heading with the decision stated in one line, followed by the tradeoff in plain words, such as bleeding against clotting or hypotension against rebound. Apixaban is split into a hold section and a restart section, since resumption is where plans most often fail. The PAUSE cohort sets the interruption schedule, BRIDGE explains the absence of bridging, POISE is cited for starting beta-blockers rather than stopping them, and Stop-or-Not frames the lisinopril decision. The plan closes with communication, a one-page calendar for the patient and two points marked for teach-back at the preoperative visit.
Where the points sit in the NU648 Unit 4 rubric
Points in the Unit 4 rubric fall into the accuracy of each decision, the use of evidence, the handling of timing and the clarity of the plan. Accuracy is judged drug by drug, so one wrong interval can cost points even when the rest is sound. Evidence earns full credit when each decision cites a trial or guideline that actually tested it, such as PAUSE for direct oral anticoagulants. Timing is its own criterion; a plan that gives the last dose but not the restart date loses points. Clarity counts because a plan is a working document. Where the evidence is mixed, the rubric rewards saying so and naming whose convention the plan follows.
NU648 Unit 4 help from the desk
The costliest mistake is bridging a direct oral anticoagulant as though it were warfarin, which adds bleeding without benefit. Another is holding a long-term beta-blocker, a misreading of POISE that the paper corrects. Students often forget the restart, or give it without saying who confirms it and what would delay it. Diabetes medications are frequently left at full dose while the patient fasts. Some plans list decisions without reasons, and graders look for the tradeoff behind each one. Last, remember the patient: a calendar she can follow at home, with the last apixaban date marked, is part of a plan that works. Check the arithmetic of your dates as well; a hold counted from the wrong day is the kind of slip a grader catches first.
Get an NU648 Unit 4 example written to your instructions
Whatever the home list in your NU648 Unit 4 case, send it with the procedure, the patient data and the rubric. The plan sample, free the first time and delivered inside 24-48h, sorts each medication by the risk it carries around surgery, dates both the last dose and the restart, and attaches a source to every row. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
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NU648 Unit 4 questions, answered
What if the case uses warfarin instead of apixaban?
Warfarin changes the timeline and the monitoring. It is typically stopped about five days ahead with an INR check before surgery, and bridging becomes a genuine question for some patients, such as those with a mechanical mitral valve. The sample would cite the relevant guidance and apply the patient's thrombotic risk to the bridging decision.
Should herbal products and supplements appear in the plan?
If the patient takes any, yes. Several supplements affect bleeding or interact with anesthesia, and a complete home list includes them. The sample asks about them in the history, names any that should stop before surgery with the reason, and cites a recognized reference, since evidence for many products is limited.
Who actually decides which medications are held?
In practice, the surgical, anesthesia and prescribing teams within hospital policy. The coursework plan demonstrates the reasoning such a decision rests on, and its figures sit in brackets around an invented patient. It is not an order set, and no part of it applies to a real person without that team's review.
Where can I find a free NU648 Unit 4 sample paper?
The full NU648 Unit 4 perioperative medication plan is on this page, with all six home medications given a decision, a date and a source. If your patient takes warfarin or a different mix of drugs, request a free sample built on your own list.
Is heparin bridging needed for apixaban in NU648 Unit 4?
Usually not. The PAUSE cohort interrupted apixaban without bridging and saw low rates of stroke and major bleeding, and BRIDGE found that bridging warfarin patients with atrial fibrillation increased bleeding without preventing clots. The sample explains both before stating its decision.