| Course | NU653 AGACNP Acute Care Diagnosis and Management Clinical II |
|---|---|
| Unit | Unit 4 |
| Paper type | Written plan defense |
| Length | About 1,110 words, 7 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NU653 Unit 4
Two Positions Held, One Conceded: A Written Plan Defense of Inpatient Insulin for a 61-Year-Old With Type 2 Diabetes and Influenza
[Student Name]
Purdue University Global
NU653: AGACNP Acute Care Diagnosis and Management Clinical II
Unit 4 Written Plan Defense
[Instructor Name]
[Date]
The patient is composite; doses, values and dates are bracketed, and the preceptor's challenges are paraphrased.
The Original Plan
Mr. [W.] is a [61]-year-old man admitted with influenza A, a cough and poor intake for [two] days. His A1c is [9.4] percent. His glucose on admission was [324] mg/dL and his creatinine [1.3] mg/dL, up from a usual [0.9]. He weighs [100] kg. His home regimen is two tablets: glipizide, [10 mg] each morning, and metformin, [1,000 mg] twice a day with food.
The plan written on admission:
1. Hold metformin and glipizide.
2. Start insulin glargine and mealtime insulin lispro at a total daily dose of [0.4] units per kg, [40] units, split evenly: glargine [20] units at bedtime and lispro [7] units before each meal.
3. Correction doses of lispro on a scale for glucose above [180] mg/dL.
4. Glucose target [140 to 180] mg/dL; checks before meals and at bedtime.
5. Hypoglycemia protocol, with a call to the team for any glucose below [70].
Challenge One: "Use Sliding Scale Alone Until He Is Eating"
The objection in its strongest form: he is eating poorly, basal insulin risks hypoglycemia if intake falls further, and sliding-scale insulin gives only what is needed.
The evidence on each side: in the RABBIT 2 trial, adults with type 2 diabetes admitted to medicine wards, none previously on insulin, were randomized to basal-bolus insulin or sliding-scale regular insulin. A glucose target below 140 mg/dL was reached in 66 percent with basal-bolus and 38 percent with sliding scale, 14 percent of the sliding-scale group stayed above 240 despite rising doses, and there was no difference in hypoglycemia (Umpierrez et al., 2007). Correction insulin used on its own is discouraged in the ADA hospital standards (American Diabetes Association Professional Practice Committee, 2025).
Verdict: the position holds. Sliding scale alone reacts to high glucose after it has happened and does little to prevent it, and his admission glucose was over 300 with an A1c of 9.4.
What changes: nothing in this part of the plan, though the concern about his intake returns in the third challenge.
Challenge Two: "Keep Metformin; It Is His Home Drug and Rarely Causes Hypoglycemia"
The objection in its strongest form: metformin does not cause hypoglycemia on its own, stopping it removes a drug he tolerates, and restarting it later risks being forgotten.
The evidence: metformin is generally held in hospitalized patients with acute illness, particularly when kidney function is falling or unstable, because of the risk of accumulation. Dehydration has pushed his creatinine up by about 40 percent, and influenza can worsen quickly. The ADA hospital standards prefer insulin for most hospitalized patients with hyperglycemia and advise caution with noninsulin agents during acute illness (American Diabetes Association Professional Practice Committee, 2025).
Verdict: the position holds, with a restart plan. Holding a drug is a decision that needs its own exit, so the plan now names the day and the creatinine at which metformin returns.
What changes: a line is added to restart metformin when he is eating, his creatinine is back near baseline and before discharge.
Challenge Three: "Forty Units Is Too Much for a Man Who Is Barely Eating"
The objection in its strongest form: RABBIT 2 enrolled patients who were eating, and Mr. [W.] ate less than half of each meal for [two] days; mealtime insulin given to someone who then does not eat is a direct route to hypoglycemia, and his kidney function is reduced.
The evidence: the Basal Plus trial compared basal-bolus insulin with basal insulin plus correction doses in general medical and surgical patients with type 2 diabetes. Mean glucose improved similarly with both regimens, both were better than sliding scale alone, and glucose below 70 occurred in 16 percent with basal-bolus against 13 percent with basal plus correction (Umpierrez et al., 2013). The ADA standards suggest basal-plus-correction insulin for patients with poor oral intake (American Diabetes Association Professional Practice Committee, 2025), and the Endocrine Society guideline suggests lower starting doses for patients with reduced kidney function (Umpierrez et al., 2012).
Verdict: the challenge is correct, and the defense concedes it. The original plan applied a regimen designed for patients who eat to a patient who was not eating, and it ignored his reduced kidney function in choosing the dose.
What changes:
1. Total daily dose reduced to [0.3] units per kg, [30] units.
2. Glargine [15] units at bedtime; scheduled mealtime lispro stopped.
3. Correction lispro before meals only if he eats at least half the meal, on the same scale.
4. Scheduled mealtime doses of [5] units restart when he eats most of his meals for a full day.
The Revised Plan
1. Metformin and glipizide held; metformin restarts when eating and creatinine is near baseline, glipizide reconsidered at discharge.
2. Glargine [15] units at bedtime.
3. Correction lispro before meals, given only if at least half the meal is eaten.
4. Target [140 to 180] mg/dL; checks before meals and at bedtime.
5. Scheduled mealtime insulin restarts on a stated condition.
6. Hypoglycemia protocol unchanged.
How the Revised Plan Will Be Judged
A defense that changes a plan should also say how the change will be tested. Three measures will show whether the revised plan works. First, the share of glucose readings between [140] and [180] mg/dL over the next [48] hours; the aim is more than half. Second, any reading below [70], which would prompt a further reduction in glargine. Third, his intake, recorded as a percentage of each meal, since the return of scheduled mealtime insulin depends on it. If his readings stay above [240] despite correction doses, the basal dose rises by [10 to 20] percent. These rules are written into the orders so the night team does not have to reopen the argument.
What the Defense Shows
Defending a plan is not the same as refusing to change it. The two positions that held rested on trials and guidelines that fit the patient. The one that fell rested on a trial that did not fit him, because it studied patients who were eating. Conceding that point improved the plan, and saying so plainly is part of a defense that can be trusted on the points where it holds. A preceptor who sees a student concede a good point is more likely to accept the points the student defends.
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
Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G. A., Montori, V. M., Seley, J. J., & Van den Berghe, G. (2012). Management of hyperglycemia in hospitalized patients in non-critical care setting: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 97(1), 16-38. https://doi.org/10.1210/jc.2011-2098
Umpierrez, G. E., Smiley, D., Hermayer, K., Khan, A., Olson, D. E., Newton, C., Jacobs, S., Rizzo, M., Peng, L., Reyes, D., Pinzon, I., Fereira, M. E., Hunt, V., Gore, A., Toyoshima, M. T., & Fonseca, V. A. (2013). Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: Basal Plus trial. Diabetes Care, 36(8), 2169-2174. https://doi.org/10.2337/dc12-1988
Umpierrez, G. E., Smiley, D., Zisman, A., Prieto, L. M., Palacio, A., Ceron, M., Puig, A., & Mejia, R. (2007). Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care, 30(9), 2181-2186. https://doi.org/10.2337/dc07-0295
NU653 Unit 4 instructions, in plain terms
The Unit 4 assignment asks you to defend a management plan against challenges from a preceptor or instructor. You present the original plan, restate each challenge in its strongest form, weigh the evidence on each side, give a verdict and state what changes in the plan. Most prompts set two to four challenges and five pages. A good defense is willing to concede a point when the evidence supports the challenge, and the rubric often rewards a reasoned concession. The revised plan should appear at the end, complete, so a reader can see the final result of the defense. Keep the original plan visible, since the defense is judged against it.
Inside the NU653 Unit 4 example
The example sets out the original plan in full, with weight, A1c, creatinine and doses, so every challenge can be measured against it. Each challenge follows the same four steps: the objection in its strongest form, the evidence, the verdict and what changes. RABBIT 2 and the ADA hospital standards answer sliding scale alone. The metformin challenge is held with a named restart condition. The third challenge is conceded with the Basal Plus trial and the Endocrine Society guideline, and the revised dose is worked out. A section on how the revised plan will be judged and a closing reflection complete the defense.
NU653 Unit 4 rubric: what earns full points
The Unit 4 rubric generally weighs the presentation of the original plan, the fairness of each challenge, the use of evidence, the verdicts and the revised plan. Fairness earns credit when each objection is restated in its strongest form. Evidence is judged on whether the trials fit the patient; the rubric rewards noticing when they do not. Verdicts count when they follow from the evidence rather than from loyalty to the first plan. The revised plan must be complete and specific. A defense that concedes a point with a clear reason often scores higher than one that defends everything.
Common NU653 Unit 4 mistakes, and how to avoid them
The most common mistake is answering a weakened version of the challenge, which persuades no one. Another is defending every point, even when a trial's population does not match the patient. Students often cite RABBIT 2 without noticing that its patients were eating. Holding a drug without a restart plan is frequent. Some defenses change the plan in the text but never write out the revised version. And a defense that treats the preceptor as an opponent, rather than a colleague testing the reasoning, reads poorly. Also check that the concession changes the written plan, not only the argument. A reader should be able to find the new dose in the revised plan without rereading the challenge. Finally, keep the tone collegial throughout; a defense is a conversation with a colleague about evidence.
Get an NU653 Unit 4 example written to your instructions
Plan defenses rely on the challenges a preceptor actually raised, and those belong to the rotation and to the student. Summarize the plan and the kinds of questions posed, de-identified, and include the rubric. The sample, free on a first order and returned inside 24-48h, shows how each challenge can be held or conceded with a cited reason. 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.
More NU653 papers and MSN samples
- NU653 Unit 1: Re-Presenting a Changed Diagnosis
- NU653 Unit 2: Serial Progress Notes, Encephalitis
- NU653 Unit 3: Revised Case Presentation, DRESS
- NU653 Unit 5: Seminar Reflection
- NU653 Unit 6: Family Update Summary
- NU653 Unit 7: Case Conference Review
- NU653 Unit 8: Consultation Note
- NU653 Unit 9: Reflective Narrative
- NU653 Unit 10: Learning Objectives Update
- NU652 Unit 4: Diagnostic Error Review, Ischemic Bowel
- NU651 Unit 4: I-PASS Handoff, Febrile Neutropenia
- NU650 Unit 4: NEWS2 Early Warning Score Exercise
- NU648 Unit 4: Perioperative Medication Plan
NU653 Unit 4 questions, answered
Are the preceptor challenges in the sample real?
No. They are composed to resemble questions preceptors commonly ask about a plan like this one. The exchange you had with your own preceptor, and anything your preceptor signs or evaluates, is yours alone. The sample demonstrates the structure of a response, fair restatement, evidence, verdict and consequence, so you can apply it to the questions you were actually asked.
Does conceding a point lower the grade?
Not when the concession is reasoned. Instructors often read a well-argued concession as evidence of judgment, especially if it improves the plan. What tends to lower the grade is conceding without explanation, or conceding a point the evidence actually supports holding. The sample concedes once, cites the trial that justified it and shows the revised plan.
How many challenges should the defense answer?
Your prompt usually sets the number; two or three is common. More challenges mean less depth for each, so a defense answering five objections in five pages often reads as rushed. The sample answers three, giving each roughly a page with the objection, the evidence, the verdict and the change it produces.
Where can I find a free NU653 Unit 4 sample paper?
This page holds the complete NU653 Unit 4 written plan defense, with the original plan, three challenges, the evidence, two positions held, one conceded and the revised plan. For a defense of a different plan, a free sample can be drafted from your case.
Is sliding-scale insulin alone acceptable in NU653 Unit 4?
The sample argues it is not. In RABBIT 2, basal-bolus insulin reached a target below 140 mg/dL in 66 percent against 38 percent with sliding scale, without more hypoglycemia, and the ADA hospital standards discourage correction insulin used on its own.