NU657 Unit 4 Progress Note, Myasthenic Crisis Example

Course	NU657 AGACNP Critical Care Management Clinical
Unit	Unit 4
Paper type	Daily progress note
Length	About 820 words, 5 pages double-spaced
Format	APA 7 student paper
School	Purdue University Global
Program	MSN
Updated	September 2026

Free sample paper for NU657 Unit 4

Each Change Tied to Its Number: A Daily Progress Note on Day Four of Myasthenic Crisis Treated With Plasma Exchange in a 67-Year-Old Man

[Student Name]

Purdue University Global

NU657: AGACNP Critical Care Management Clinical

Unit 4 Daily Progress Note

[Instructor Name]

[Date]

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

What this part is doingThe interval section is short and ends on the two numbers that drive today's changes.

Interval Events, Last 24 Hours

Mr. [W.] had plasma exchange number [two] yesterday at [14:00], [3.2] liters replaced with [5] percent albumin, without hypotension. He reported tingling around his mouth near the end of the exchange, which settled after calcium gluconate. His voice is less nasal this morning and he can count to [22] in one breath, up from [14] on admission. He coughed up secretions without suctioning overnight. No aspiration events. He remains on the unit, not intubated, with oxygen at [two] liters by nasal cannula.

Data, Today Beside Yesterday

1. Forced vital capacity: [1.6] L today, [1.3] L yesterday; weight [80] kg, so [20] mL/kg today, [16] mL/kg yesterday.

2. Negative inspiratory force: minus [30] cm H2O today, minus [24] yesterday.

3. Arterial gas at [06:00]: pH [7.41], PaCO2 [41] mmHg, PaO2 [82] mmHg on [two] liters.

4. Fibrinogen [118] mg/dL today, [196] yesterday, [310] before plasma exchange.

5. Ionized calcium [1.02] mmol/L after yesterday's exchange; [1.16] this morning.

6. Urine culture from admission: Escherichia coli, sensitive to nitrofurantoin and cefalexin.

7. Bedside swallow screen: failed on thin liquids yesterday; nasogastric feeding at goal.

What this part is doingToday's values sit beside yesterday's, so the direction of each is visible before any plan is read.

Assessment and Plan

Mr. [W.] is a [67]-year-old man with acetylcholine receptor antibody positive generalized myasthenia gravis, diagnosed [two] years ago and maintained on pyridostigmine and prednisone [10] mg daily, admitted with an impending crisis. Bulbar and respiratory weakness began [three] days after ciprofloxacin was started for a urinary infection; fluoroquinolones can worsen myasthenic weakness and were stopped on admission. He is improving after two exchanges.

1. Impending myasthenic crisis, improving.

Number: vital capacity [16] to [20] mL/kg; inspiratory force minus [24] to minus [30]; count to [22]. Change: bedside measurements reduced from every [four] hours to every [six] hours. Intubation criteria stay in place and are written on the whiteboard: vital capacity below [15] mL/kg ([1.2] L), inspiratory force weaker than minus [20] cm H2O, a rising PaCO2, or inability to clear secretions. A vital capacity of 20 mL/kg after two exchanges is a trend worth trusting, but not yet a reason to relax the criteria that would send him to the ventilator.

2. Plasma exchange course, planned for [five] exchanges on alternate days.

Number: fibrinogen [118] mg/dL, down from [310]. Change: exchange number [three] goes ahead today, but the last [one] liter of replacement fluid will be plasma instead of albumin, to replace clotting factors, and fibrinogen will be rechecked before exchange number [four]. If it falls below [100], that exchange will be delayed by [24] hours. Plasma exchange and intravenous immunoglobulin performed similarly in a randomized comparison in worsening myasthenia gravis (Barth et al., 2011); exchange was chosen here for its faster onset in a patient close to respiratory failure, and the consensus guidance supports either in impending crisis (Sanders et al., 2016).

3. Citrate-related hypocalcemia during exchange.

Number: ionized calcium [1.02] after the last exchange, with perioral tingling. Change: calcium gluconate [2] g as an infusion during today's exchange, rather than as needed; ionized calcium at the midpoint and end.

4. Precipitating urinary infection.

Number: culture sensitive to cefalexin. Change: cefalexin, started on admission as a fluoroquinolone substitute, is continued for [three] more days to complete [seven]. Ciprofloxacin is added to his allergy and intolerance list with the reaction described, so it is not prescribed again. Aminoglycosides and magnesium infusions are also flagged, since both can worsen neuromuscular transmission.

5. Swallowing and nutrition.

Number: failed swallow screen on thin liquids. Change: nasogastric feeding continues; speech and language therapy will reassess tomorrow, once the count-to-breath and voice have improved for a second day.

6. Maintenance immunotherapy.

Number: none today; this is a plan for the week. Change: pyridostigmine continues at [30] mg every [six] hours, half his home dose, to limit secretions while his cough is weak. Prednisone is held at [10] mg for now. High-dose corticosteroids can cause an early, temporary worsening of weakness, a risk the consensus guidance describes (Sanders et al., 2016), so the increase will begin toward the end of the exchange course, while he is still monitored in hospital. Neurology will review a steroid-sparing agent before discharge, drawing on the options in the 2020 update (Narayanaswami et al., 2021).

7. Prophylaxis and lines.

Enoxaparin held on exchange days until fibrinogen recovers, with mechanical compression. The apheresis catheter in the right internal jugular vein, placed on [day 1], is reviewed daily.

Disposition and Communication

Remains in intensive care until the vital capacity has held above [20] mL/kg for [24] hours after the final exchange. His daughter was updated by phone at [10:15] and understands the plan for today's exchange.

What this part is doingEvery plan line begins with the value that changed it, so a reader can see the logic without reconstructing it.

References

Barth, D., Nabavi Nouri, M., Ng, E., Nwe, P., & Bril, V. (2011). Comparison of IVIg and PLEX in patients with myasthenia gravis. Neurology, 76(23), 2017-2023. https://doi.org/10.1212/WNL.0b013e31821e5505

Narayanaswami, P., Sanders, D. B., Wolfe, G., Benatar, M., Cea, G., Evoli, A., Gilhus, N. E., Illa, I., Kuntz, N. L., Massey, J., Melms, A., Murai, H., Nicolle, M., Palace, J., Richman, D., & Verschuuren, J. (2021). International consensus guidance for management of myasthenia gravis: 2020 update. Neurology, 96(3), 114-122. https://doi.org/10.1212/WNL.0000000000011124

Sanders, D. B., Wolfe, G. I., Benatar, M., Evoli, A., Gilhus, N. E., Illa, I., Kuntz, N., Massey, J. M., Melms, A., Murai, H., Nicolle, M., Palace, J., Richman, D. P., Verschuuren, J., & Narayanaswami, P. (2016). International consensus guidance for management of myasthenia gravis: Executive summary. Neurology, 87(4), 419-425. https://doi.org/10.1212/WNL.0000000000002790

NU657 Unit 4 instructions, in plain terms

Unit 4 calls for one day's progress note on an ICU patient, written in problem-oriented form. The note usually includes interval events over the last 24 hours, current data with trends, an assessment of each active problem and a plan that shows what changed and why. Around 500 to 800 words is common. Graders want to see that the plan responds to the data, so a note that repeats yesterday's plan beside new values loses points even when the plan is reasonable. Sources are expected for any contested decision. Many prompts also ask for disposition and communication with the family, which are easy to forget in a note focused on numbers. Keep the interval section short and specific.

Inside the NU657 Unit 4 example

The interval section covers the second exchange, the perioral tingling and the improved voice and breath count in five sentences. Seven data items follow, each with today's value next to yesterday's. The assessment summarizes the diagnosis and the fluoroquinolone trigger in two sentences. Seven problems then follow the same pattern, a number line and a change line. The intubation criteria stay written out even as the patient improves, and the highlighted sentence explains why. The exchange plan swaps the last liter of albumin for plasma, citing Barth for the choice of exchange over immunoglobulin. Steroid timing cites the consensus guidance. Disposition names the capacity threshold for leaving the unit, and the daughter's phone update is logged with its time.

Reading the NU657 Unit 4 grading rubric

Progress notes in this course are usually graded on data presentation, assessment, the link between data and plan, safety and communication. Data presentation earns full points when trends are visible, which is why values appear beside the previous day's. The assessment row rewards a clear statement of the problem and its current direction. The link between data and plan is typically weighted most, and it is scored by whether each change can be traced to a value. Safety covers escalation criteria and medication precautions, such as flagging drugs that worsen myasthenia. Communication points come from the disposition line and a family update logged with its time and content.

NU657 Unit 4 help: mistakes that cost points

Students often copy the previous day's plan, which suggests the new data were never read. Another frequent mistake is relaxing intubation criteria as soon as the numbers improve, when a single good day in myasthenic crisis can reverse. Some notes forget citrate toxicity and fibrinogen depletion during plasma exchange. Others start high-dose steroids early in crisis without noting the risk of a temporary decline. Students also leave the precipitating drug on the medication list without recording the reaction, so it may be given again. And a disposition line that says only "continue ICU care" gives no threshold for transfer, so write the number that would let him leave.

Get an NU657 Unit 4 example written to your instructions

Yesterday's note, today's data and your NU657 Unit 4 rubric: those three inputs carry the model. Arriving in 24-48h, with the first one on us, it pairs every plan change with the number that caused it and keeps the interval to what actually happened since the last note. 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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NU657 Unit 4 questions, answered

What if nothing changed overnight?

Then the note says so, with the values that confirm it. Stable is a finding worth recording, and a problem can carry the line no change, continue, beside the numbers that support it. What reviewers object to is a copied plan beside new data that should have altered it, which suggests the plan was never revisited.

Does the sample use real progress notes?

No. The patient is invented and values are bracketed. Notes entered in a chart during your clinical hours are cosigned at the site and stay there, and nothing in the sample substitutes for them. Coursework notes about rotation patients should be de-identified, and the sample demonstrates that standard throughout.

Where can I find a free NU657 Unit 4 sample paper?

The complete NU657 Unit 4 daily progress note is on this page, with interval events, today's and yesterday's values, seven problems each tied to a number, disposition and three references. A note for the patient in your own prompt can be requested.

What intubation criteria does the NU657 Unit 4 note use?

A vital capacity below 15 mL/kg, which is 1.2 liters for this 80 kg man, an inspiratory force weaker than minus 20 cm H2O, a rising PaCO2, or inability to clear secretions. The note keeps these criteria in place even though he is improving.

Why does the NU657 Unit 4 note change the replacement fluid?

His fibrinogen fell from 310 to 118 after two exchanges with albumin. The last liter of the next exchange uses plasma to replace clotting factors, and a fibrinogen below 100 before exchange four would delay it by a day.