| Course | NU652 AGACNP Acute Care Diagnosis and Management II |
|---|---|
| Unit | Unit 10 |
| Paper type | Management revision case study |
| Length | About 1,090 words, 6 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NU652 Unit 10
Three Plans in Ten Days: A Management Revision Case Study of Persistent Neutropenic Fever, Invasive Aspergillosis and Voriconazole Toxicity After Leukemia Induction
[Student Name]
Purdue University Global
NU652: AGACNP Acute Care Diagnosis and Management II
Unit 10 Management Revision Case Study
[Instructor Name]
[Date]
The patient is composite; doses, levels, days and times are bracketed.
Background
Mr. [E.] is a [64]-year-old man with newly diagnosed acute myeloid leukemia who completed [seven] days of induction chemotherapy on [Day minus 12]. He has a tunneled central venous catheter. He takes levofloxacin prophylaxis and acyclovir. On [Day 0], his temperature reached [101.8] F with an absolute neutrophil count of [100].
Plan One, Day 0: Empirical Therapy for Neutropenic Fever
Following the IDSA guideline for fever in neutropenic patients with cancer (Freifeld et al., 2011):
1. Blood cultures from each lumen of the catheter and from a peripheral vein; urine culture; chest radiograph.
2. Cefepime [2 g] every [eight] hours, started within one hour of the fever. Levofloxacin prophylaxis stopped.
3. No vancomycin, because he had no hypotension, catheter-site infection, skin infection, pneumonia or gram-positive bacteremia.
4. Reassess at [72 to 96] hours; continue cefepime while he remains neutropenic.
Blood and urine cultures were negative. His chest radiograph was clear.
Finding that ended plan one: on Day 4, temperature [102.2] F, neutrophils [100], cultures negative, and a new dry cough.
Revision One: What Does Persistent Fever Mean?
Persistent fever after four days of broad-spectrum antibiotics in a neutropenic patient raises three possibilities: a resistant bacterium, a hidden source such as the catheter or an abscess, or a fungus. The guideline recommends searching for invasive fungal infection in patients expected to remain neutropenic for more than seven days whose fever persists after four to seven days of antibiotics (Freifeld et al., 2011). Mr. [E.] was expected to remain neutropenic for at least [two] more weeks.
A resistant bacterium was less likely with negative cultures and no clinical deterioration. The catheter site was clean. A chest CT on Day 4 showed two nodules, [14] and [9] mm, in the right upper lobe, each surrounded by a halo of ground-glass opacity. Serum galactomannan returned an index of [1.8], above the positive threshold. A halo sign in a neutropenic patient with a positive galactomannan moves invasive aspergillosis from a possibility to the working diagnosis.
Plan Two, Day 4: Voriconazole
Following the IDSA aspergillosis guideline, which recommends voriconazole as primary therapy for invasive aspergillosis and therapeutic drug monitoring during treatment (Patterson et al., 2016):
1. Voriconazole [6 mg/kg] intravenously every [12] hours for two doses, then [4 mg/kg] every [12] hours.
2. Continue cefepime; no change to antibacterial coverage.
3. Bronchoscopy with lavage for galactomannan and culture if his condition allows.
4. Voriconazole trough level on Day [9], after steady state.
5. Daily liver tests; review of interacting drugs, since voriconazole inhibits several cytochrome enzymes.
His fever began to settle by Day [7], and his cough eased.
Finding that ended plan two: on Day 8, he reported seeing people in the corners of the room and flashes of light, and the Day 8 voriconazole trough was [7.2] mg/L.
Revision Two: Toxicity or Disease?
New hallucinations in a patient with a fungal infection could mean spread to the brain, a metabolic cause or drug toxicity. His neurologic examination was otherwise normal, his sodium, calcium and glucose were normal, and a brain MRI showed no lesions. Visual disturbances and hallucinations are known adverse effects of voriconazole, and they are more common at higher levels. In a study of therapeutic drug monitoring, troughs above 5.5 mg/L were associated with neurotoxicity, and troughs of 1 mg/L or below with treatment failure (Pascual et al., 2008). His trough of [7.2] fit toxicity.
Two options were considered: reduce the voriconazole dose and recheck the level, or change to another agent. Dose reduction would take several days to confirm a safe level while the hallucinations continued, and his levels had already shown how variable voriconazole can be.
Plan Three, Day 8: Isavuconazole
1. Stop voriconazole.
2. Start isavuconazole, [372 mg] of isavuconazonium sulfate every [eight] hours for six doses, then once daily.
3. Continue cefepime while neutropenic.
4. Repeat chest CT at [two] weeks; galactomannan weekly.
5. Monitor for resolution of hallucinations; delirium precautions in the meantime.
Isavuconazole was chosen because in the SECURE trial it was noninferior to voriconazole for invasive mold disease, with all-cause mortality at day 42 of 19 against 20 percent, and it had fewer drug-related adverse events, including fewer hepatobiliary, eye and skin disorders (Maertens et al., 2016). The IDSA guideline lists it as an alternative primary therapy.
His hallucinations resolved within [72] hours. His fever did not return, and his neutrophils recovered on Day [21]. The repeat CT at [two] weeks showed the nodules smaller.
What Did Not Change, and Why
Three orders stayed the same through all three plans, and each was a decision rather than inertia. Cefepime continued throughout, because the guideline advises keeping empirical antibacterial coverage in place while a febrile patient remains neutropenic, even after a fungal diagnosis is made. The catheter stayed in, because there was no sign of catheter infection and removing it would have meant new access in a patient with low platelets. And no second antifungal was added at any point: combination therapy was considered on Day 4 and set aside, since he was improving on a single agent and adding a drug would have made the later toxicity harder to attribute.
The patient and his wife were told at each revision what had changed and why. The second revision was the harder conversation, because the hallucinations had frightened them both, and they needed to hear that the cause was the medicine, that it would pass, and that the new drug treats the same infection. Explaining a plan change to the patient is part of the revision, not an afterthought.
What the Revisions Show
Each revision began with a specific finding, and each was answered by asking what the finding meant before changing the plan. The first revision did not add antibiotics for a persistent fever; it looked for a fungus because the guideline and his expected duration of neutropenia said to. The second did not assume that new confusion meant a spreading infection; it checked a drug level and found toxicity. A plan that changes only when a named finding requires it, and says why, is easier for the next team to follow and easier to reverse if the finding turns out to be wrong.
References
Freifeld, A. G., Bow, E. J., Sepkowitz, K. A., Boeckh, M. J., Ito, J. I., Mullen, C. A., Raad, I. I., Rolston, K. V., Young, J.-A. H., & Wingard, J. R. (2011). Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 52(4), e56-e93. https://doi.org/10.1093/cid/cir073
Maertens, J. A., Raad, I. I., Marr, K. A., Patterson, T. F., Kontoyiannis, D. P., Cornely, O. A., Bow, E. J., Rahav, G., Neofytos, D., Aoun, M., Baddley, J. W., Giladi, M., Heinz, W. J., Herbrecht, R., Hope, W., Karthaus, M., Lee, D.-G., Lortholary, O., Morrison, V. A., . . . Ullmann, A. J. (2016). Isavuconazole versus voriconazole for primary treatment of invasive mould disease caused by Aspergillus and other filamentous fungi (SECURE): A phase 3, randomised-controlled, non-inferiority trial. The Lancet, 387(10020), 760-769. https://doi.org/10.1016/S0140-6736(15)01159-9
Pascual, A., Calandra, T., Bolay, S., Buclin, T., Bille, J., & Marchetti, O. (2008). Voriconazole therapeutic drug monitoring in patients with invasive mycoses improves efficacy and safety outcomes. Clinical Infectious Diseases, 46(2), 201-211. https://doi.org/10.1086/524669
Patterson, T. F., Thompson, G. R., III, Denning, D. W., Fishman, J. A., Hadley, S., Herbrecht, R., Kontoyiannis, D. P., Marr, K. A., Morrison, V. A., Nguyen, M. H., Segal, B. H., Steinbach, W. J., Stevens, D. A., Walsh, T. J., Wingard, J. R., Young, J.-A. H., & Bennett, J. E. (2016). Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 63(4), e1-e60. https://doi.org/10.1093/cid/ciw326
NU652 Unit 10 instructions, in plain terms
The Unit 10 assignment asks you to present a case in which management was revised as new findings emerged. You describe each plan as it was written, the finding that ended it, how that finding was interpreted and the revised plan, with evidence for each decision. The earlier plans must stay visible, since the assignment is about revision. Most prompts expect at least two revisions and six to eight pages. Orders that did not change should also be explained, because continuing a treatment is a decision. Communication with the patient about each change is often part of the rubric. Each revision should begin with the finding that forced it.
Inside the NU652 Unit 10 example
The example is arranged as three dated plans, each followed by the finding that ended it. Plan one follows the IDSA guideline for fever and neutropenia. The first revision works through the three causes of persistent fever and explains why the CT and galactomannan point to aspergillosis. Plan two follows the IDSA aspergillosis guideline, including drug monitoring. The second revision asks whether hallucinations mean toxicity or disease and answers with an examination, MRI and a trough level. Plan three explains the switch with SECURE data. A section on what did not change and a closing section on the method complete it. Each plan lists what continued as well as what changed.
Reading the NU652 Unit 10 grading rubric
The Unit 10 rubric looks at the presentation of each plan, the interpretation of each new finding, the evidence for each change, the handling of adverse events and the overall reasoning. Each plan earns credit when it is complete and specific. Interpretation is weighted heavily; the rubric rewards considering alternatives before changing the plan, such as excluding brain involvement before blaming the drug. Evidence should be cited at each decision point. Adverse event management counts when a level or test confirms the cause. Overall reasoning is judged on whether each revision follows from a named finding. Dating each plan also makes the sequence easy for the grader to follow.
NU652 Unit 10 help: mistakes that cost points
The most common mistake is presenting only the final plan, which hides the reasoning the assignment is testing. Another is changing management without naming the finding that required it. Students often add antibiotics for persistent neutropenic fever instead of looking for a fungus. Toxicity is sometimes assumed without a drug level or other causes being ruled out. Unchanged orders are rarely explained. Communication with the patient is often left out. And a case study that lists changes without dates makes it impossible for the reader to follow the sequence of events. Keep each revision anchored to a date and a single finding, so the reader never has to guess why the plan changed.
Get an NU652 Unit 10 example written to your instructions
Final-unit cases vary by section, from a single patient supplied in the prompt to one the student constructs. Either kind works: share the case or its outline, how many revisions are expected, and the rubric. A first case study at no cost, returned within 24-48h, preserves each earlier plan intact beside the finding that ended it. 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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NU652 Unit 10 questions, answered
Why keep the earlier plans instead of presenting only the final one?
Because the assignment is about revision. What was believed at each point, and what changed it, has to stay visible; a final plan alone hides the reasoning. The sample preserves every plan as written on its date and places the ending finding beneath it, which is also how an acute care chart ideally reads when a diagnosis evolves.
Is isavuconazole the only alternative to voriconazole?
No. [Liposomal amphotericin B] and posaconazole both appear in current guidance as alternatives, each with its own toxicity and interaction profile. Isavuconazole is chosen for this composite because of the SECURE trial data and its milder adverse event profile, but your case, its drug interactions and the local formulary may point to a different agent.
How many revisions should the case contain?
Whatever your prompt specifies; two is common. Each revision should follow a distinct finding rather than a gradual adjustment of the same plan. The sample's two rewrites respond to different kinds of problem, a new diagnosis and then a drug toxicity, which lets it show two different reasoning moves in one admission instead of repeating the first.
Where can I find a free NU652 Unit 10 sample paper?
The full NU652 Unit 10 management revision case study is on this page, with three dated plans, the findings that ended each and the evidence for every change. For a case with different revisions, a free case study can be written from your details.
Why switch from voriconazole in NU652 Unit 10?
Because his hallucinations matched voriconazole neurotoxicity, his trough of 7.2 mg/L was above the level linked to toxicity, and brain imaging showed no spread. Isavuconazole was noninferior in the SECURE trial with fewer drug-related adverse events.