NU655 Unit 4 Escalation Handoff, Threatened Airway Example

Reviewed by Elspeth Marlowe, MSN, RN AGACNP Acute Care Diagnosis and Management Clinical III Purdue University Global Free custom sample in 24 to 48h

This NU655 Unit 4 sample is an escalation handoff note for a 46-year-old man with a floor-of-mouth infection from a lower molar, moving from the ward toward intensive care with drooling and a muffled voice. It was written for Purdue Global NU 655, AGACNP Acute Care Diagnosis and Management Clinical III, taken in the MSN acute care nurse practitioner program. The airway plan comes first: no intubation on the unit, awake fiberoptic intubation in the operating room, a cricothyrotomy kit at the bedside and no sedatives. The situation, interventions, awaited results and five finding-based triggers follow. An explanation of the awake technique and the receiver's read-back close the note.

CourseNU655 AGACNP Acute Care Diagnosis and Management Clinical III
UnitUnit 4
Paper typeEscalation handoff note
LengthAbout 620 words, 5 pages double-spaced
FormatAPA 7 student paper
SchoolPurdue University Global
ProgramMSN
UpdatedSeptember 2026

Free sample paper for NU655 Unit 4

1

Airway First, Everything Else After: An Escalation Handoff Note for a Floor-of-Mouth Infection Moving From the Ward to Intensive Care

[Student Name]

Purdue University Global

NU655: AGACNP Acute Care Diagnosis and Management Clinical III

Unit 4 Escalation Handoff Note

[Instructor Name]

[Date]

The patient is composite; times, values and doses are bracketed.

What this part is doingThe section most likely to be needed in a hurry sits at the top, because a receiving nurse at night needs it before any history.
2

Airway

1. No intubation attempted. Do not attempt a standard intubation on the unit.

2. Anesthesia and otolaryngology notified at [15:40]; both have seen him.

3. Plan: awake fiberoptic intubation in the operating room at [17:30], with otolaryngology scrubbed and ready for a surgical airway.

4. Cricothyrotomy kit and scalpel-bougie set at the bedside; the covering anesthesiologist is on pager [2214].

5. Head of bed upright at [60] degrees or more; let him sit forward if he prefers.

6. No sedatives or opioids beyond what anesthesia approves.

If this airway is lost, it will not be recovered by a face mask or a standard laryngoscope, so the plan names who is coming and what is already at the bedside.

Situation

Mr. [T.], [46], had a painful lower left molar for [one] week. Over [24] hours the swelling spread under his jaw and tongue. He has trismus, drooling, a muffled voice and a raised, firm floor of mouth, with swelling on both sides of the neck. CT with contrast at [14:30] showed cellulitis of the floor of the mouth and submandibular spaces on both sides without a drainable collection and with the airway narrowed but patent. Temperature [38.9] C, pulse [112], blood pressure [132/80], respiratory rate [22], saturation [96] percent on room air. He can swallow only small sips.

Interventions So Far

1. Ampicillin-sulbactam [3 g] intravenously at [15:05]; next dose [21:05].

2. Dexamethasone [10 mg] intravenously at [15:50], after discussion with otolaryngology.

3. Two intravenous lines; intravenous fluids at [100] mL per hour, since he cannot drink.

4. Dental and oral surgery aware; extraction and drainage to follow once the airway is secured.

Results Awaited

Blood cultures from [15:00]; lactate repeat at [18:00]; oral surgery's decision on operative drainage after intubation.

Triggers and Responses

1. Stridor, a new high-pitched sound on breathing in: call anesthesia and otolaryngology at once and bring him to the operating room now.

2. Saturation below [92] percent: sit him fully upright, give high-flow oxygen by face mask, and call the airway team.

3. He cannot manage his own secretions or begins to tripod, leaning forward on his hands to breathe: call the airway team.

4. Respiratory rate above [30] or rising agitation: call the airway team; do not sedate.

5. Complete obstruction, with no air movement and falling saturation: this is a cannot-intubate, cannot-oxygenate emergency, and the plan is front-of-neck access with the kit at the bedside, as difficult airway guidance describes (Frerk et al., 2015).

What this part is doingEvery trigger is a finding a receiving nurse can see or hear, with the call it requires, rather than a general instruction to watch closely.
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Why an Awake Intubation

When a difficult airway is anticipated, the ASA practice guideline supports awake intubation where it is feasible, because the patient keeps breathing on his own while the tube is placed (Apfelbaum et al., 2022). Mr. [T.]'s swollen tongue and floor of mouth make both face-mask ventilation and direct laryngoscopy likely to fail, so taking away his own breathing with an induction drug is the most dangerous step anyone could take. Doing it in the operating room puts otolaryngology in the room if a surgical airway is needed.

What this part is doingThe awake technique is justified by the specific anatomy that makes the usual rescue methods likely to fail.
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Receiver's Read-Back

The intensive care nurse repeated: "No intubation on the unit. Awake fiberoptic in the operating room at 17:30. Kit at the bedside. Stridor or saturation under 92, call airway team. No sedation." Structured handoffs that include a read-back by the receiver were associated with fewer medical errors in a multicenter study (Starmer et al., 2014).

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References

Apfelbaum, J. L., Hagberg, C. A., Connis, R. T., Abdelmalak, B. B., Agarkar, M., Dutton, R. P., Fiadjoe, J. E., Greif, R., Klock, P. A., Mercier, D., Myatra, S. N., O'Sullivan, E. P., Rosenblatt, W. H., Sorbello, M., & Tung, A. (2022). 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology, 136(1), 31-81. https://doi.org/10.1097/ALN.0000000000004002

Frerk, C., Mitchell, V. S., McNarry, A. F., Mendonca, C., Bhagrath, R., Patel, A., O'Sullivan, E. P., Woodall, N. M., & Ahmad, I. (2015). Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia, 115(6), 827-848. https://doi.org/10.1093/bja/aev371

Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., . . . Landrigan, C. P. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803-1812. https://doi.org/10.1056/NEJMsa1405556

The Purdue Global NU655 Unit 4 instructions

The Unit 4 assignment asks you to write the handoff for a patient who is deteriorating and moving to a higher level of care. You place the most urgent information first, summarize only the situation that explains the danger, list what has been done and what is pending, and write triggers as findings the receiving team can observe, each with its response. A page and a half is a common length. The note should be usable at night by someone who has never met the patient. A read-back by the receiver, recorded in the note, shows that the handoff was understood. Record the read-back in the receiver's own words.

Inside the NU655 Unit 4 example

The example opens with a six-line airway section that names who is coming, where the intubation will happen and what is already at the bedside, with a highlighted sentence explaining why. The situation paragraph is compressed to the infection, the CT result and the vital signs. Interventions are numbered with times and next doses. Triggers are written as things the nurse can see or hear, from stridor to complete obstruction, each with a call to make. A section explains why an awake intubation is safer here, citing the ASA and DAS guidance, and the receiver's words are quoted at the end. No history appears until the airway is settled on the page.

Where the points sit in the NU655 Unit 4 rubric

The Unit 4 rubric weighs the prioritization of content, the clarity of triggers, the completeness of interventions and pending items, safety and the confirmation of understanding. Prioritization earns full credit when the airway plan sits at the top. Triggers are judged on whether each is observable and paired with an action. Completeness counts when doses, times and pending results are all present. Safety includes what not to do, such as sedating the patient. A recorded read-back meets the confirmation criterion. Evidence supporting the airway approach strengthens the note but should stay brief. Notes that name the people coming, and when, give the receiving team the most useful information first.

NU655 Unit 4 help: mistakes that cost points

The most common mistake is starting with the history, which puts the airway plan where a hurried reader may miss it. Another is writing triggers such as monitor closely, which no one can act on. Students often omit the rescue plan if intubation fails. Sedatives are sometimes left unaddressed, although they can close a threatened airway. Some notes forget the next antibiotic dose. And handoffs that end without the receiver's read-back give no evidence that the most important instruction was heard. Also say where the rescue equipment is, not only that it exists. And read the triggers to yourself as a night nurse would, checking that each one names what to do.

Get an NU655 Unit 4 example written to your instructions

Every trigger tied to a finding, the most urgent section on top: that is what a first note delivers, free and inside 24-48h. It needs the deterioration described, the receiving unit named, identifiers stripped and the rubric or template attached, since the transfer itself was the student's and the sample's patient is a composite. 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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NU655 Unit 4 questions, answered

What makes an escalation handoff different from a routine one?

A routine handoff keeps a stable plan going; an escalation handoff transfers a patient who is getting worse, so its triggers and awaited results matter most. The sample puts the airway plan first because that is the likeliest emergency. Structured tools such as SBAR can still frame the note if your program requires one.

Why is the airway plan written before the history?

Because in Ludwig angina the airway can close with little warning, and the receiving nurse needs to know what to do in that moment before learning how the infection began. The history still appears, shortened to the facts that explain the danger, below the plan and the list of things to avoid.

Can the handoff be modeled on a transfer I took part in?

Your own note should reflect the transfer you took part in, de-identified as your program requires. The sample cannot use a real patient, so it models the structure with a composite. Anything tied to your actual clinical days, including hours, logs and preceptor sign-offs, stays with you.

Where can I find a free NU655 Unit 4 sample paper?

The full NU655 Unit 4 escalation handoff note is on this page, with the airway plan first, finding-based triggers and the ICU nurse's read-back quoted at the end. Any escalation you handled on your own rotation can be turned into a free handoff note.

Why an awake intubation in NU655 Unit 4?

Because swelling of the tongue and floor of the mouth makes both mask ventilation and standard laryngoscopy likely to fail. An awake technique lets the patient keep breathing while the tube is placed, and doing it in the operating room puts a surgeon beside him.