| Course | NU655 AGACNP Acute Care Diagnosis and Management Clinical III |
|---|---|
| Unit | Unit 3 |
| Paper type | Priority defense memo |
| Length | About 780 words, 5 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NU655 Unit 3
Breathing Before the Anticoagulant: A Priority Defense Memo for Four Rib Fractures in an 83-Year-Old Woman Taking Apixaban
[Student Name]
Purdue University Global
NU655: AGACNP Acute Care Diagnosis and Management Clinical III
Unit 3 Priority Defense Memo
[Instructor Name]
[Date]
The patient is composite; values, doses and times are bracketed.
Summary
To: trauma attending. From: AGACNP student, trauma service. Re: Mrs. [V.], bed [7]. Fractures of right ribs [five] through [eight], a small right hemothorax, and a normal head CT after a fall at [10:30]. Apixaban [5 mg] last taken at [08:00] for atrial fibrillation. Incentive spirometer volume [600] mL against a predicted [1,700]. Pain [8] of 10 on deep breathing. Saturation [91] percent on [2] liters; respiratory rate [24].
Priorities, in Order
1. Pain control that allows deep breathing and coughing: a serratus anterior plane block by the anesthesia team today, with scheduled acetaminophen and low-dose opioid only for breakthrough pain.
2. Pulmonary care and monitoring: step-down admission, incentive spirometry every hour while awake with volumes recorded, respiratory therapy twice daily, early mobilization.
3. Anticoagulation: hold apixaban; no reversal agent while the hemothorax is small and stable; repeat chest radiograph at [six] hours; plan the restart with the team.
4. Delirium prevention and fall assessment: glasses and hearing aids, family presence, a review of why she fell.
Why Pain Control Ranks First
In older adults with several broken ribs, the usual path to death does not run through the fracture; it runs through shallow breathing, retained secretions and pneumonia. In a study comparing older and younger patients with similar rib injuries, the older patients had twice the mortality and more pneumonia, and for each additional rib fracture, the risk of death rose by 19 percent and the risk of pneumonia by 27 percent (Bulger et al., 2000). Her spirometer volume at about a third of predicted shows that the path has already started.
The regional block is chosen over rising doses of opioids, which would sedate the breathing the plan is trying to protect. The EAST guideline conditionally recommends epidural analgesia and multimodal analgesia for blunt chest trauma, while noting the evidence is of low quality (Galvagno et al., 2016). An epidural is not an option today, because regional anesthesia guidance advises holding apixaban for about 72 hours before a neuraxial block (Horlocker et al., 2018). A serratus anterior plane block is a superficial fascial plane block, which that guidance treats as lower risk in patients on anticoagulants, and it covers the lateral chest wall where her fractures are.
Why the Anticoagulant Ranks Third, Not First
The anticoagulant question feels urgent because apixaban was taken this morning and there is blood in her chest. But the hemothorax is small, her hemoglobin is stable at [11.8] and [11.6] g/dL four hours apart, her pressure is [138/76] and her head CT is normal. Reversal would expose her to the thrombotic risk of reversal agents and to stroke from her atrial fibrillation without treating an active problem. Holding the next doses, repeating the imaging and hemoglobin and planning the restart meet the need. The ACC decision pathway describes reversal for major or life-threatening bleeding and holding for bleeding that is not (Tomaselli et al., 2020).
What Would Reverse This Order
1. An enlarging hemothorax on the repeat film, a hemoglobin fall of [2] g/dL, or hypotension: anticoagulation reversal and a chest tube move to first.
2. A change in consciousness or a new neurological sign: repeat head CT and reversal move to first.
3. A saturation below [88] percent or rising carbon dioxide despite the block: ventilatory support moves to first.
Each of these is a measurement or an observation the nurse can report, and the memo asks to be called for any of them.
What the Ranking Asks of the Team
The ranking changes what the team does in the next few hours. The anesthesia consult is placed now, with the fracture levels and the time of her last apixaban dose, so the block can be done this afternoon rather than tomorrow. Her nurse records spirometer volumes every hour, and a fall below [500] mL or a rise in respiratory rate above [28] prompts a call. Opioid doses are kept small and paired with a sedation score. Her daughter is asked to bring her glasses and hearing aids and to stay this evening, since confusion would make coughing and spirometry impossible. Each of these orders serves the first priority.
Restart of Apixaban
The plan is to restart apixaban at [48 to 72] hours if the hemothorax is stable and no chest tube or procedure is planned, and after the block catheter, if one is used, is removed.
References
Bulger, E. M., Arneson, M. A., Mock, C. N., & Jurkovich, G. J. (2000). Rib fractures in the elderly. The Journal of Trauma: Injury, Infection, and Critical Care, 48(6), 1040-1047. https://doi.org/10.1097/00005373-200006000-00007
Galvagno, S. M., Jr., Smith, C. E., Varon, A. J., Hasenboehler, E. A., Sultan, S., Shaefer, G., To, K. B., Fox, A. D., Alley, D. E. R., Ditillo, M., Joseph, B. A., Robinson, B. R. H., & Haut, E. R. (2016). Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. Journal of Trauma and Acute Care Surgery, 81(5), 936-951. https://doi.org/10.1097/TA.0000000000001209
Horlocker, T. T., Vandermeuelen, E., Kopp, S. L., Gogarten, W., Leffert, L. R., & Benzon, H. T. (2018). Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (fourth edition). Regional Anesthesia and Pain Medicine, 43(3), 263-309. https://doi.org/10.1097/AAP.0000000000000763
Tomaselli, G. F., Mahaffey, K. W., Cuker, A., Dobesh, P. P., Doherty, J. U., Eikelboom, J. W., Florido, R., Gluckman, T. J., Hucker, W. J., Mehran, R., Messé, S. R., Perino, A. C., Rodriguez, F., Sarode, R., Siegal, D. M., & Wiggins, B. S. (2020). 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants. Journal of the American College of Cardiology, 76(5), 594-622. https://doi.org/10.1016/j.jacc.2020.04.053
The Purdue Global NU655 Unit 3 instructions
The Unit 3 assignment asks you to write a memo to an attending defending the order of priorities for a patient with several competing problems. You summarize the case in a few lines, list your priorities in order, defend each rank with evidence about the harm it prevents, explain why the problem that feels most urgent may not rank first, and state the findings that would change the order. Most prompts set two pages. The memo should be addressed to a specific reader and written to be acted on, with measurable triggers for reordering and a plan for the lower priorities as well. Name the reader at the top.
Inside the NU655 Unit 3 example
The example opens with a four-line summary that gives the numbers the ranking depends on. The priorities follow as a numbered list. Pain control is defended with data on mortality and pneumonia per additional rib fracture in older adults, with a highlighted sentence, and the choice of block is argued from both the EAST guideline and the regional anesthesia guidance on anticoagulants. The anticoagulant section explains why reversal is not needed while the hemothorax is small and stable. Three reversal triggers follow. A section describes what the ranking asks of the team, and the restart plan for apixaban closes the memo. The memo is signed by role and addressed to one attending.
Reading the NU655 Unit 3 grading rubric
The Unit 3 rubric usually weighs the clarity of the ranking, the justification of each priority, the handling of the apparent top priority, the reversal criteria and professional communication. Justification earns full credit when each rank is tied to a specific harm prevented. The rubric often rewards explaining why the most anxiety-provoking problem ranks lower. Reversal criteria must be measurable. Communication counts when the memo is concise and written for its reader. Evidence should fit the patient, as rib fracture outcome data in older adults do here, and constraints such as anticoagulation should shape the plan. Memos that say what the ranking asks the team to do today tend to earn full communication points.
NU655 Unit 3 help: mistakes that cost points
The most common mistake is ranking the anticoagulant first because it feels urgent, without evidence of active bleeding. Another is choosing an epidural for rib fracture pain in a patient who took apixaban hours ago. Students often treat pain control as comfort rather than as prevention of pneumonia. Reversal criteria are frequently vague. Some memos list priorities without defending them. And plans that do not say when to restart the anticoagulant leave a patient with atrial fibrillation unprotected longer than needed. Address the memo to its actual reader and keep it to two pages. Finally, make sure the reversal triggers are things a nurse could report without interpretation.
Get an NU655 Unit 3 example written to your instructions
Diabetic crisis, sepsis with an arrhythmia, an overdose with a failing liver: the unstable patient differs, the method of ranking does not. Outline yours and the order your preceptor questioned, stripped of identifiers, along with the rubric. A first memo arrives free of charge inside 24-48h, each rank justified against the one beneath 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.
More NU655 papers and MSN samples
- NU655 Unit 1: Salicylate Toxicity Discussion Post
- NU655 Unit 2: Integrated Presentation, Myxedema Coma
- NU655 Unit 4: Escalation Handoff Note
- NU655 Unit 5: Seminar Reflection
- NU655 Unit 6: Family Meeting Summary
- NU655 Unit 7: Code Debrief
- NU655 Unit 8: Transfer Summary
- NU655 Unit 9: End-of-life Reflection
- NU655 Unit 10: Acute Care Synthesis Paper
- NU654 Unit 3: Competing Priorities, Aortic Stenosis
- NU653 Unit 3: Revised Case Presentation, DRESS
- NU652 Unit 3: Revised Differential, Red Leg
- NU651 Unit 3: Sickle Cell Crisis Progress Note
NU655 Unit 3 questions, answered
What makes a priority defense different from a care plan?
A care plan lists what will be done; a priority defense argues why one thing comes before another and what would change that order. Most of the sample's length goes to comparisons between ranks and to the reorder conditions. Rubrics for this unit often weigh those comparative reasons above the completeness of the list.
Why not reverse the anticoagulant straight away?
Because she is not bleeding dangerously, and reversal agents carry their own risk of clotting in a patient taking apixaban for atrial fibrillation. Holding the drug lets its effect fade over a day or two. The memo names the findings that would change that answer: an enlarging hemothorax, a falling hemoglobin or any bleeding inside the skull.
Is this the priority order my preceptor will expect?
Your preceptor's expectations depend on the patient you present and the site's practice, and the memo you submit should reflect your own patient and reasoning. The sample shows the method: rank by near-term harm, justify each rank against its neighbor and name the conditions that would change the list. A composite cannot stand in for your clinical judgment.
Where can I find a free NU655 Unit 3 sample paper?
This page contains the complete NU655 Unit 3 priority defense memo, with the ranking, the defense of each priority, reversal triggers and the restart plan. Your own trauma or medicine patient with clashing priorities can be the basis for a free memo.
Why is pain control ranked first in NU655 Unit 3?
Because in older adults with several rib fractures, shallow breathing leads to retained secretions and pneumonia. For each additional fracture, the risk of death rose about 19 percent and of pneumonia about 27 percent in the study the sample cites.