| Course | NRNP 6537 Adult Acute Care: Comprehensive Patient Management I |
|---|---|
| Week | Week 3 |
| Paper type | Focused note |
| Length | About 760 words, 5 pages |
| Format | APA 7 student paper |
| School | Walden University |
| Program | MSN Adult-Gerontology Acute Care Nurse Practitioner (AGACNP) |
| Updated | October 2026 |
Free sample paper for NRNP 6537 Week 3
Focused Note: Increasing Drowsiness and Acute-on-Chronic Hypercapnic Respiratory Failure in a 68-Year-Old Woman With COPD
Student Name
College of Nursing, Walden University
NRNP 6537: Advanced Nurse Practice in Adult/Gerontology Acute Care I
Instructor Name
Month Day, Year
Focused Note: Increasing Drowsiness and Acute-on-Chronic Hypercapnic Respiratory Failure in a 68-Year-Old Woman With COPD
Reason for Encounter
Rapid response call to the medical floor for increasing drowsiness in a patient admitted yesterday with a COPD exacerbation.
Subjective
History is limited by drowsiness; the patient, E.F., a composite 68-year-old woman, rouses to voice and answers briefly. She says she is "so tired" and denies chest pain. Her nurse reports that she was alert and talking this morning, received supplemental oxygen at 4 L/min by nasal cannula after her saturation was noted at 86 percent, and has become progressively sleepier over three hours. She has known severe COPD with a prior hospitalization for hypercapnic respiratory failure, uses home oxygen at night only, and was admitted with two days of increased dyspnea and purulent sputum. She received a dose of an oral opioid for rib pain from coughing two hours ago.
Objective
Vital signs: respiratory rate 26 and shallow, oxygen saturation 97 percent on 4 L/min, heart rate 104, blood pressure 148/86, temperature 99.8 F. Somnolent but rousable to voice, following commands, with asterixis in both hands. Using accessory muscles; diminished breath sounds throughout with prolonged expiration and scattered expiratory wheeze; no stridor.
Arterial blood gas on 4 L/min: pH 7.26, PaCO2 78 mm Hg, PaO2 94 mm Hg, bicarbonate 34 mmol/L. Interpretation: the low pH with a high PaCO2 identifies a respiratory acidosis. The bicarbonate of 34 is well above what acute retention alone would produce, which indicates chronic metabolic compensation for long-standing carbon dioxide retention; but the pH of 7.26 is lower than a fully compensated chronic acidosis at this PaCO2 would produce, indicating an acute rise in carbon dioxide on top of her chronic baseline (Berend et al., 2014). The reading is therefore acute-on-chronic hypercapnic respiratory failure, and the high PaO2 on 4 L/min is part of the story, not a reassurance.
Chest radiograph, portable, compared with admission: hyperinflation and flattened diaphragms as before. No pneumothorax, a finding specifically sought because it would change management immediately in a patient with emphysema. No pleural effusion. No vascular congestion or interstitial edema. No new consolidation compared with yesterday.
Early warning score: using NEWS2, her score is calculated on Scale 2 for oxygen saturation, the scale intended for patients with confirmed hypercapnic respiratory failure and a prescribed saturation target of 88 to 92 percent (Royal College of Physicians, 2017). On Scale 2, a saturation of 97 percent on supplemental oxygen scores points rather than none, because it exceeds her target, and together with her respiratory rate, heart rate, oxygen use, and new confusion her aggregate score is in the high range, which calls for emergency assessment by a team with critical care competencies.
Assessment
Acute-on-chronic hypercapnic respiratory failure due to a COPD exacerbation, worsened by excess supplemental oxygen and a recent opioid dose. High-flow oxygen in patients with chronic hypercapnia can raise PaCO2 through worsening ventilation-perfusion matching and loss of hypoxic vasoconstriction, and sedating medications reduce respiratory drive. Pneumothorax, effusion, pulmonary edema, and new pneumonia were excluded on the radiograph.
Plan
Oxygen: reduce to a controlled delivery targeting saturation of 88 to 92 percent, as recommended for patients at risk of hypercapnia (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2024).
Ventilatory support: the case for noninvasive ventilation is strong. She has an acute respiratory acidosis with a pH below 7.35 due to a COPD exacerbation, the situation in which noninvasive ventilation is recommended to reduce the need for intubation and mortality (Rochwerg et al., 2017). She is rousable, following commands, and protecting her airway, which makes her a candidate rather than a patient needing immediate intubation. The case against, which would favor intubation, would be inability to protect her airway, vomiting, hemodynamic instability, or failure to improve.
Medications: hold further opioids and sedatives; continue bronchodilators, systemic corticosteroid, and antibiotics started on admission.
Escalation: transfer to the intermediate or intensive care unit for noninvasive ventilation with close monitoring. Findings that would prompt intubation: worsening consciousness or inability to follow commands, a repeat gas at one to two hours showing no improvement in pH, rising respiratory rate or exhaustion, or inability to tolerate the mask. A repeat arterial gas is ordered one hour after starting support.
Communication: her daughter was called and told that her mother needs breathing support and a move to a unit with closer monitoring, and her previously documented wishes were confirmed: she accepts noninvasive ventilation and intubation if needed. The bedside nurse will document the prescribed saturation target in the chart so the next shift does not raise the oxygen again.
References
Berend, K., de Vries, A. P. J., & Gans, R. O. B. (2014). Physiological approach to assessment of acid-base disturbances. New England Journal of Medicine, 371(15), 1434-1445. https://doi.org/10.1056/NEJMra1003327
Global Initiative for Chronic Obstructive Lung Disease. (2024). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2024 report. https://goldcopd.org/2024-gold-report/
Rochwerg, B., Brochard, L., Elliott, M. W., Hess, D., Hill, N. S., Nava, S., Navalesi, P., Antonelli, M., Brozek, J., Conti, G., Ferrer, M., Guntupalli, K., Jaber, S., Keenan, S., Mancebo, J., Mehta, S., & Raoof, S. (2017). Official ERS/ATS clinical practice guidelines: Noninvasive ventilation for acute respiratory failure. European Respiratory Journal, 50(2), 1602426. https://doi.org/10.1183/13993003.02426-2016
Royal College of Physicians. (2017). National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Royal College of Physicians.
What the NRNP 6537 Week 3 instructions ask for
In Week 3, NRNP 6537 often asks for a focused note on an acute respiratory event in a hospitalized adult. You document the reason for the encounter, a targeted history, vital signs, an early warning score where used, blood gas and examination findings, an interpretation and a plan with escalation criteria. Faculty weight interpretation heavily: what the gas means, not just its values. Keep it to two or three pages with APA 7 sources. Oxygen targets and noninvasive ventilation decisions should follow current guidelines. Some sections ask for a short handoff summary too. Keep the note focused on the event rather than the whole admission. NRNP 6537 faculty want the blood gas shown with its values and the expected compensation worked out. Name the early warning score and its value. State the oxygen saturation target and why it suits a patient with COPD.
Inside the NRNP 6537 Week 3 example
Two pages in focused-note form, headed by a one-line reason for the encounter. Subjective content is brief, since drowsiness limits the history. The objective section reports the arterial gas in words and interprets it as an acute respiratory acidosis layered on a compensated chronic one, explaining which feature of the result supports each half of that reading. The chest film is read against the alternatives that matter here: pneumothorax, effusion, edema and new consolidation, each confirmed or excluded. Early warning is addressed through NEWS2, including its separate oxygen saturation scale for patients with confirmed hypercapnic failure. The plan argues for or against ventilatory support in reasoning only, with no settings, and closes on observed findings that would send her to intensive care. No real admission sits behind the case.
Reading the NRNP 6537 Week 3 rubric
Most of the available credit follows interpretation. A note that reports the gas accurately and never says whether the acidosis is acute, chronic or both has transcribed a lab slip, and faculty reading focused notes are looking for exactly that judgment sentence. Imaging draws the next share: a film described as abnormal, without the specific alternatives ruled in or out, tells a grader nothing about reasoning. Third, the escalation line is frequently vague, written as monitoring closely, when the course expects named findings that would change the level of care. Plans that recite a standard exacerbation bundle without tying each element to this patient's data lose the applied points. Notes that swell past the focused format, with a full review of systems attached, can lose for structure alone, since brevity is part of the genre.
NRNP 6537 Week 3 help: mistakes that cost marks
Respiratory notes lose most of their credit when the gas is reported accurately and never interpreted. Say whether the acidosis is acute, chronic or both, and why. Another common error is overlooking oxygen as a cause of rising carbon dioxide in COPD; check the target. Writers also start noninvasive ventilation without stating criteria for failure and intubation. Name them. Avoid long histories in a focused note. Keep the gas values consistent between the objective section and the assessment. Include when the gas will be repeated. Close with who was notified and when. Students also forget to check for other causes of drowsiness, such as sedatives or hypoglycemia. Rule them out in a sentence each. Another frequent gap is no comment on the patient's wishes about intubation. Record them if known. Name the time for the repeat gas.
Get a NRNP 6537 Week 3 example written to your instructions
If your faculty supplied gas and imaging values, include them with the Week 3 prompt and rubric so the focused note example interprets those exact findings in place. The first costs nothing and comes back in 24-48h, with the escalation findings named outright rather than left for the reader to infer.
More NRNP 6537 papers and AGACNP samples
- NRNP 6537 Week 1: AGACNP Scope Discussion
- NRNP 6537 Week 2: Unstable Tachycardia Case
- NRNP 6537 Week 4: Septic shock case write-up
- NRNP 6537 Week 5: Pulmonary embolism SOAP note
- NRNP 6537 Week 6: DKA management note
- NRNP 6537 Week 7: Acute liver failure escalation thread
- NRNP 6537 Week 8: Acute stroke pathway write-up
- NRNP 6537 Week 9: Multisystem ICU progress note
- NRNP 6537 Week 10: Acute hyperthermia capstone case
- NRNP 6537 Week 11: Acute care judgment reflection
- NRNP 6539 Week 3: Hyperthyroidism evaluation note
- NRNP 6531 Week 3: Chronic Cough Differential
- NRNP 6540 Week 3: Post-fall evaluation note
- NRNP 6831 Week 3: Care coordination plan
NRNP 6537 Week 3 questions, answered
Does the note include ventilator or oxygen settings?
It does not. The plan argues whether noninvasive support is reasonable for this patient and what would make it fail, then stops. Settings belong to the ordering clinician and current protocols, and a sample that supplied them would be offering clinical direction rather than modeling reasoning. Most sections' rubrics score the argument, which the note keeps intact without a single number.
Why use NEWS2 instead of the unit's own score?
NEWS2 is widely published and has a feature that fits this case exactly: a separate saturation scale for patients with confirmed hypercapnic failure, which stops a chronically low reading from inflating the score. If your unit or section uses a different early warning system, the paragraph is rewritten around that score and keeps the same purpose in the note.
How short is a focused note supposed to be?
Short enough that every sentence bears on the problem named in the first line. The sample runs about two pages, which suits most sections, and it omits a full review of systems deliberately. Where your prompt asks for a complete admission-style note instead, the structure expands while the habit of interpreting each result in place stays exactly as it is.
Where can I find a free NRNP 6537 Week 3 sample paper?
The rapid response note on hypercapnic respiratory failure is laid out here with the gas interpretation, the NEWS2 score and the escalation plan.
How do you tell acute from chronic hypercapnia in NRNP 6537 Week 3?
Compare the pH with the bicarbonate. A raised bicarbonate shows chronic compensation, while a pH lower than that compensation predicts points to an acute rise on top.