| Course | NU654 AGACNP Acute Care Diagnosis and Management III |
|---|---|
| Unit | Unit 9 |
| Paper type | Overnight contingency plan |
| Length | About 850 words, 6 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NU654 Unit 9
Four Ways the Night Could Go Wrong Before Coiling: An Overnight Contingency Plan for Aneurysmal Subarachnoid Hemorrhage in a 54-Year-Old Woman
[Student Name]
Purdue University Global
NU654: AGACNP Acute Care Diagnosis and Management III
Unit 9 Overnight Contingency Plan
[Instructor Name]
[Date]
The patient is composite; values, doses and times are bracketed.
Situation
Mrs. [P.], [54], developed a sudden severe headache while gardening at [15:30] and vomited once. CT showed subarachnoid blood in the basal cisterns, modified Fisher grade [3], without hydrocephalus. CT angiography showed a [7] mm anterior communicating artery aneurysm. On arrival in the neuro ICU at [19:00] she was alert, oriented and had no focal deficit: Hunt and Hess grade [2]. Coiling is booked for [08:00]. Current orders: nimodipine [60 mg] by mouth every [four] hours; nicardipine infusion titrated to a systolic pressure below [160] mmHg; neurological checks every hour; isotonic fluids to maintain normal volume; acetaminophen and low-dose opioid for headache; no anticoagulant; stool softener. Baseline: Glasgow Coma Scale [15]; pupils [3] mm and equal; sodium [138] mEq/L; ECG sinus rhythm; troponin [0.02] ng/mL.
Pathway 1: Rebleeding
Trigger: a sudden new or worse headache, a fall of [2] or more points in the Glasgow Coma Scale, a new pupil difference, vomiting or a seizure. First actions: call neurosurgery and the intensivist at once; secure the airway if Glasgow Coma Scale is [8] or below; urgent CT head; keep systolic pressure below [160]; prepare for emergency external ventricular drain or immediate aneurysm treatment. Why it comes first: rebleeding before the aneurysm is secured carries a high mortality and is most likely in the first day, which is why the guidelines recommend securing the aneurysm as early as feasible and controlling blood pressure until then. A decrease in systolic pressure to below 160 mmHg before securing the aneurysm has been described as reasonable to reduce the risk of rebleeding (Connolly et al., 2012). Every other pathway on this page can wait a few minutes for a CT; a rebleed cannot wait for anything.
Pathway 2: Acute Hydrocephalus
Trigger: drowsiness, confusion, a fall of [2] or more points in the Glasgow Coma Scale without the other features of rebleeding, or new downward gaze. First actions: urgent CT head; call neurosurgery for an external ventricular drain. The 2023 guideline recommends cerebrospinal fluid diversion for symptomatic acute hydrocephalus after subarachnoid hemorrhage (Hoh et al., 2023).
Pathway 3: Seizure
Trigger: any clinical seizure, or a sudden unexplained fall in consciousness. First actions: lorazepam [2 mg] intravenously, repeat once if needed; levetiracetam loading dose; CT head to look for rebleeding, since a seizure can be its first sign.
Pathway 4: Blood Pressure Out of Range
Trigger: systolic pressure above [160] despite nicardipine at [15 mg] per hour, or below [110]. First actions: above [160], add labetalol [10 mg] intravenously and call the intensivist; below [110], reduce nicardipine, give a [250] mL isotonic bolus, and if the nimodipine dose was given in the past hour, ask pharmacy about splitting it into [30 mg] every [two] hours. Nimodipine is not stopped for low pressure without discussion, because it reduced cerebral infarction and poor outcomes in the trial that established it (Pickard et al., 1989).
Pathway 5: Sodium Below [133]
Trigger: sodium below [133] mEq/L on the [04:00] draw. First actions: do not restrict fluids, because hypovolemia raises the risk of delayed cerebral ischemia; call the intensivist to consider hypertonic saline or fludrocortisone; repeat sodium in [four] hours.
Pathway 6: Heart
Trigger: new arrhythmia, chest pain, hypotension or a troponin rise. First actions: 12-lead ECG, troponin, bedside echocardiogram; stress-related cardiac injury is common after subarachnoid hemorrhage and can lower blood pressure at a dangerous time.
Talking With Her Tonight
Mrs. [P.] is alert and frightened. She was told what the bleeding is, that the procedure in the morning closes the weak spot in the artery from the inside, and that the nurses will wake her every hour tonight to check her speech, strength and eyes, because a change in any of them is the earliest sign that the team needs to act. She was asked to tell her nurse at once if her headache suddenly gets worse, since she is the first person who will know. Her husband is staying overnight and has the number of the unit. The purpose of this conversation is practical as well as kind: a patient who understands why she is being woken is more likely to report a change than to sleep through it.
What Not to Do Overnight
1. Do not give anticoagulants or antiplatelet drugs, including for a new DVT concern, without discussion with neurosurgery.
2. Do not sedate heavily for headache, since sedation hides the neurological signs the plan depends on.
3. Do not restrict fluids for low sodium.
4. Do not delay a CT to wait for the next scheduled neurological check once a trigger is met.
Handoff Line
"Mrs. [P.], unsecured anterior communicating aneurysm, Hunt and Hess [2], coiling at [08:00]. Watch for rebleeding and hydrocephalus. Systolic under 160. Neuro checks hourly. Any drop in consciousness: CT and call neurosurgery."
References
Connolly, E. S., Jr., Rabinstein, A. A., Carhuapoma, J. R., Derdeyn, C. P., Dion, J., Higashida, R. T., Hoh, B. L., Kirkness, C. J., Naidech, A. M., Ogilvy, C. S., Patel, A. B., Thompson, B. G., & Vespa, P. (2012). Guidelines for the management of aneurysmal subarachnoid hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 43(6), 1711-1737. https://doi.org/10.1161/STR.0b013e3182587839
Hoh, B. L., Ko, N. U., Amin-Hanjani, S., Chou, S. H.-Y., Cruz-Flores, S., Dangayach, N. S., Derdeyn, C. P., Du, R., Hänggi, D., Hetts, S. W., Ifejika, N. L., Johnson, R., Keigher, K. M., Leslie-Mazwi, T. M., Lucke-Wold, B., Rabinstein, A. A., Robicsek, S. A., Stapleton, C. J., Suarez, J. I., . . . Welch, B. G. (2023). 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage: A guideline from the American Heart Association/American Stroke Association. Stroke, 54(7), e314-e370. https://doi.org/10.1161/STR.0000000000000436
Pickard, J. D., Murray, G. D., Illingworth, R., Shaw, M. D., Teasdale, G. M., Foy, P. M., Humphrey, P. R., Lang, D. A., Nelson, R., & Richards, P. (1989). Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ, 298(6674), 636-642. https://doi.org/10.1136/bmj.298.6674.636
NU654 Unit 9 instructions, in plain terms
The Unit 9 assignment asks you to write a plan for the clinician covering an unstable patient overnight. You summarize the situation, identify the ways the patient could deteriorate before morning, set a trigger for each, list the first actions in order and say whom to call. Most prompts set about three pages. Pathways should be ranked by urgency, and each trigger should be a measurement or an observation the night team can check quickly. The plan should also say what not to do, since some reflex actions are harmful in particular conditions, and end with a line that can be read aloud at handoff. Keep the plan to what matters before morning, not the whole admission. List the baselines, so a change can be recognized.
How the NU 654 Unit 9 example is put together
The example's situation block gives the diagnosis, grades, orders and baselines in one place. Six pathways follow in the same format: trigger, first actions and, for the first, a paragraph on why it leads, with a highlighted sentence. Guidelines support blood pressure control, cerebrospinal fluid diversion for hydrocephalus and continued nimodipine. The sodium pathway warns against fluid restriction. A section records what the patient was told and asked to report. A list of four things not to do and a spoken handoff line complete the plan, so the covering clinician has both the detail and the summary.
NU654 Unit 9 rubric: what earns full points
The Unit 9 rubric generally scores the situation summary, the identification and ranking of pathways, the specificity of triggers and actions, safety and the handoff. The summary earns full points when it holds everything needed to act without another screen. Pathways are judged on whether they cover the likely and the dangerous ways the night could go wrong, ranked by urgency. Triggers must be measurable. Actions should be ordered and name whom to call. Safety includes things to avoid. A handoff line that can be read aloud in under a minute is part of a complete plan. Plans that explain why the first pathway leads show the ranking was reasoned.
NU654 Unit 9 help: mistakes that cost points
The most common mistake is writing pathways with vague triggers, such as neurological decline, instead of a change in score or a new pupil difference. Another is restricting fluids for low sodium after subarachnoid hemorrhage, which can increase the risk of delayed ischemia. Students often forget nimodipine's effect on blood pressure or stop it without discussion. Heavy sedation for headache is sometimes allowed, which hides the signs the plan depends on. Seizure pathways may omit a CT for rebleeding. And plans that leave out the patient herself miss the person most likely to notice a change first. Read the handoff line aloud to check it takes less than a minute.
Get an NU654 Unit 9 example written to your instructions
Who is the patient, what has already been done, and what does your rubric ask for? Those three answers are enough. A post-operative bleed, sepsis near shock or a diabetic crisis all suit the same method, and the first plan, free and back in 24-48h, opens every pathway on a number and closes it on a named call. 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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NU654 Unit 9 questions, answered
Is the plan the same as an order set?
No. An order set lists what to give; the contingency plan says when to give it, in what order, and whom to call if it does not work. The sample includes bracketed doses, but its value lies in the triggers and the reasoning behind them, which is typically what the rubric assesses.
Where can I find a free NU654 Unit 9 sample paper?
This page holds the complete NU654 Unit 9 overnight contingency plan, with the situation block, six ranked pathways, things to avoid and a handoff line. For a different unstable patient, a free contingency plan can be written from your case.
What is the blood pressure target before coiling in NU654 Unit 9?
The plan keeps systolic pressure below 160 until the aneurysm is secured, the level earlier AHA/ASA guidance described as reasonable to reduce rebleeding. Nicardipine is titrated to it, with labetalol added if needed.
Why not restrict fluids for low sodium in NU654 Unit 9?
Because after subarachnoid hemorrhage low sodium often comes with salt and water loss, and restricting fluid can cause low blood volume, which raises the risk of delayed cerebral ischemia. The plan calls for hypertonic saline or fludrocortisone instead.
Why is rebleeding the first pathway in NU654 Unit 9?
Because rebleeding before the aneurysm is secured carries a high mortality and is most likely in the first day. Every other pathway can wait a few minutes for a CT; a rebleed needs neurosurgery at once.