| Course | NR 567 Advanced Pharmacology for the Adult Gerontology Acute Care Nurse Practitioner |
|---|---|
| Week | 8 |
| Paper type | De-escalation plan |
| Length | About 1,120 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Adult-Gerontology Acute Care NP (AGACNP) |
| Updated | October 2026 |
Free sample paper for NR 567 Week 8
De-Escalation Plan: Six Running Agents on Day 10 of a Septic Shock Admission, Each With the Endpoint It Must Hold, an Order for Coming Off and a Trigger to Restart
Student Name
College of Nursing, Chamberlain University
NR 567: Advanced Pharmacology for the Adult Gerontology Acute Care Nurse Practitioner
Instructor Name
Month Day, Year
De-Escalation Plan: Six Running Agents on Day 10 of a Septic Shock Admission, Each With the Endpoint It Must Hold, an Order for Coming Off and a Trigger to Restart
What Is Running, and Why
On day 10, the composite patient followed through this course is recovering. Vasopressors stopped on day 7. The pneumococcal bacteremia has cleared on repeat cultures, a tracheostomy was placed on day 9 without bleeding, and urine output has returned at about 600 mL in the last 24 hours. Six agents or therapies are still running, each against something it holds up.
Table 1
Agents Running on Day 10 and What Each Holds Up
| Agent | What it holds up | Current dose |
|---|---|---|
| Fentanyl infusion | Analgesia for tracheostomy, lines and turning | 75 mcg/h, running 9 days |
| Propofol infusion | Sedation, RASS minus 1 to 0 | 15 mcg/kg/min |
| Heparin infusion | Treatment of right femoral vein thrombosis | Anti-Xa 0.3 to 0.5 |
| Insulin infusion | Glucose 140 to 180 mg/dL | 2 to 4 units/h |
| Ceftriaxone | Pneumococcal pneumonia with bacteremia | 2 g daily, no stop date entered |
| Continuous hemodiafiltration | Kidney replacement | Effluent 25 mL/kg/h |
The Endpoint That Has to Hold
Each agent comes off only when its endpoint has held for a defined time, so that one reassuring number does not trigger several reductions at once.
Propofol: a successful daily awakening trial with RASS 0 to minus 1 and no distress, and a successful breathing trial on the tracheostomy collar for 2 hours.
Fentanyl: CPOT of 2 or below for 24 hours at the current rate, with the tracheostomy healed enough that suctioning is tolerated.
Insulin infusion: glucose in the 140 to 180 range for 24 hours on a stable rate, with tube feeding running at goal, since hydrocortisone stopped on day 8.
Ceftriaxone: seven days of therapy completed with clinical stability for at least 48 hours, as recommended for pneumonia with uncomplicated bacteremia that has cleared (Metlay et al., 2019).
Continuous hemodiafiltration: urine output above about 400 to 500 mL per day without diuretics, potassium and acid-base status stable, and no fluid overload.
Heparin infusion: remains on; the endpoint here is transition rather than stopping.
An Order, and Its Reason
Day 10: stop propofol. It has the shortest offset and the clearest endpoint. Stopping it first lets the team see the patient's true level of consciousness and pain while fentanyl is still running, which makes the next decisions safer. Agitation after stopping is assessed with CPOT and CAM-ICU before any sedative is restarted, in line with guidance favoring light sedation and treating pain first (Devlin et al., 2018).
Day 10: stop ceftriaxone. Effective therapy began on day 1, so seven days were complete on day 7. The course ran on because no stop date was entered when cefepime was narrowed to ceftriaxone. It stops today, and the missing stop date is reported so that future switches carry one.
Day 11: begin the fentanyl taper. Fentanyl has run for nine days, so it cannot stop flat (see below).
Day 11 to 12: transition insulin. Once the propofol is off and feeding is stable, the insulin infusion is converted to subcutaneous basal insulin at about 80% of the infusion's average daily requirement over the last 24 hours, given 2 hours before the infusion stops, with correction insulin every 6 hours while on continuous feeds.
Day 12 onward: trial off dialysis. When urine output stays above the threshold for 24 hours, continuous hemodiafiltration is stopped, and the nephrology team watches potassium, creatinine trend and volume daily.
Heparin: transition after dialysis decisions. The heparin infusion continues until kidney function is clearer, then converts to an oral anticoagulant chosen for the recovered kidney function, to complete three months of treatment.
What Cannot Stop Flat
Fentanyl given for more than about five to seven days produces physical dependence, and an abrupt stop causes withdrawal: agitation, sweating, tachycardia, diarrhea and yawning, which can be mistaken for delirium or new sepsis. The taper reduces the infusion by about 10 to 20% of the original rate each day, from 75 mcg/h to 60, 50, 40, 25 and then off, while the patient is assessed with a withdrawal scale every 8 hours. If withdrawal signs appear, the previous rate is resumed for 24 hours. An enteral long-acting opioid can replace the infusion if the taper stalls.
Mobility and Nutrition as Part of the Plan
De-escalation is not only about stopping drugs. As propofol comes off, the physical therapist progresses from in-bed exercises to dangling the legs over the side, then to standing with two helpers, and the speech-language pathologist begins assessment for a speaking valve once the patient tolerates cuff deflation. Tube feeds continue at goal and are reviewed by the dietitian, especially as the insulin plan changes. Early mobility and a careful wean of sedation reduce delirium and weakness after critical illness, which are the main obstacles to leaving the unit (Devlin et al., 2018).
What Each Team Needs to Know Today
The bedside nurse needs today's stops and the restart triggers. The pharmacist needs the fentanyl taper schedule and the insulin conversion. The nephrology team needs the urine output target for stopping dialysis. The physical therapist needs to know sedation is off. Writing these into one plan prevents each team from discovering the changes on their own.
Restart Triggers
Propofol restarts only for distress not relieved by analgesia, at half the previous rate, with a reason documented.
Insulin infusion restarts if two glucose readings exceed 250 mg/dL within 12 hours.
Vasopressors come back if the mean pressure stays under 65 for a quarter of an hour after fluid has been assessed, which would also prompt a search for a new infection or bleeding (Evans et al., 2021).
Antibiotics restart only with a new source, new fever with cultures sent, or a rising lactate, not for a single temperature reading.
Continuous hemodiafiltration restarts for potassium above 6.0, refractory acidosis, fluid overload with worsening oxygenation or uremic symptoms.
Handover
The plan is handed to the step-down team with a single list: what has stopped and when, what is tapering and the daily rate, what restarts on which trigger, and the date of the next review. The family is told which lines and infusions will come out first, so that the changes read as progress rather than as worrying events.
The step-down team signs the list to show it was received.
References
Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., . . . Alhazzani, W. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine, 46(9), e825-e873. https://doi.org/10.1097/CCM.0000000000003299
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., . . . Levy, M. (2021). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Critical Care Medicine, 49(11), e1063-e1143. https://doi.org/10.1097/CCM.0000000000005337
Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., Cooley, L. A., Dean, N. C., Fine, M. J., Flanders, S. A., Griffin, M. R., Metersky, M. L., Musher, D. M., Restrepo, M. I., & Whitney, C. G. (2019). Diagnosis and treatment of adults with community-acquired pneumonia: An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine, 200(7), e45-e67. https://doi.org/10.1164/rccm.201908-1581ST
The Chamberlain NR 567 Week 8 instructions
The de-escalation plan usually asks you to take a recovering critically ill patient and plan the withdrawal of each therapy. Expect the prompt to ask for the order of discontinuation, the criteria for each step, tapers and monitoring. List every running agent against what it currently holds up. Give each an endpoint and a length of time that endpoint must hold before the agent comes off. Put the reductions in an order and explain the reason for that order. Identify anything that cannot stop abruptly and write the taper. Set restart triggers as values. Include the nondrug parts of recovery, and finish with a handover that tells each team what changes and when.
How this NR 567 Week 8 example is built
The sample opens with a table of six agents and therapies, what each holds up and the current dose. An endpoint section gives each a measurable condition and hold time. The order follows: propofol stops first because its short offset reveals the patient's true state, ceftriaxone stops because seven days were completed and no stop date had been entered, the fentanyl taper begins next, insulin converts to basal insulin with a two-hour overlap, and dialysis comes off when urine output holds. A section explains why fentanyl cannot stop flat after nine days and gives the daily reductions. Mobility, nutrition, team-by-team notes, restart triggers for each agent and a signed handover complete the plan.
Where the points sit in the NR 567 Week 8 rubric
De-escalation plans are typically assessed on a clear order with reasons, endpoints with hold times, tapers for agents that cannot stop flat, restart triggers and a handover. A plan in which every infusion ends on the same page loses the most, so this sample sequences each change and explains why propofol goes first. Hold times prevent one good reading from triggering several reductions. The fentanyl taper, with a withdrawal scale and a fallback, shows awareness of dependence after a week of infusion. Catching an antibiotic course that ran past its endpoint because no stop date was entered shows practical stewardship. Numeric restart triggers and a handover to the step-down team ensure the plan survives transfer. Guideline citations support the endpoints.
NR 567 Week 8 help from the desk
The heaviest loss in this assignment is a plan with no order, where four infusions stop together and any problem that follows cannot be traced. Another is a missing hold time, so one reassuring number leads to several cuts at once. Many plans stop an opioid or sedative that has run for days without a taper, causing withdrawal that looks like delirium or sepsis. Some forget restart triggers, or write them as feelings rather than values. Others never hand the plan to the next team. List what is running and why, set endpoints with hold times, sequence the changes, taper what needs it and hand over in writing. A plan for your own patient's recovery can be drafted from the list of running therapies.
Get a NR 567 Week 8 example written to your instructions
Send the Week 8 instructions and the list of agents you want unwound, and a custom example is written to it, with the order, the hold times, the conversions and the handover included. It comes back within 24-48h and the first one costs nothing. A supplied table or template is filled in as issued.
More NR 567 papers and AGACNP samples
- NR 567 Week 1: Status Epilepticus Route Discussion
- NR 567 Week 2: CRRT Vancomycin Dosing Brief
- NR 567 Week 3: Nicardipine Titration Plan
- NR 567 Week 4: Septic Shock Vasopressor Write-Up
- NR 567 Week 5: ICU Sedation and Analgesia Plan
- NR 567 Week 6: Empiric Antibiotic Rationale
- NR 567 Week 7: ICU Anticoagulation Case Analysis
NR 567 Week 8 questions, answered
Is this the same skill as deprescribing?
The vocabulary overlaps and the tempo does not. Unwinding a list somebody has taken for years is measured in weeks and negotiated across visits. Here an endpoint holds for a few hours and something comes off in the same shift. What the two share is only the discipline of writing a reason for stopping rather than letting an order survive by default.
Which agents cannot simply be stopped?
The ones a patient has adapted to. Opioid and sedative infusions running for days produce agitation, tachycardia, sweating and loose stools when they end abruptly, and that picture gets investigated as a fresh illness by a team who never wrote the original order. The plan converts them to a scheduled equivalent and reduces in stages instead.
How detailed does the handover have to be?
Detailed enough to survive a change of team. Each stop carries a restart trigger, a number saying the step failed, and the name of the next thing to try. A de-escalation plan reading as a description of the day gives an incoming team no authority to act and quietly pushes every decision back onto them.
Where can I find a free NR 567 Week 8 sample paper?
The day 10 plan above, which sequences six agents with endpoints, tapers and restart triggers, is the complete NR 567 Week 8 sample. Your own patient's de-escalation can be planned from the therapies still running.
Why does propofol come off first in the NR 567 Week 8 plan?
Its effect fades within minutes, so stopping it first reveals the patient's real level of consciousness and pain while the other agents are still in place.