| Course | NSG 633 Safety and Quality |
|---|---|
| Unit | Unit 7 |
| Paper type | Escalation chain trace |
| Length | About 640 words, 5 pages |
| Format | APA 7 student paper |
| School | Herzing University |
| Program | BSN |
| Updated | October 2026 |
Free sample paper for NSG 633 Unit 7
Four Hours From Unease to Decision: Tracing the Escalation of Falling Urine Output After Bowel Surgery, Word by Word
Student Name
Department of Nursing, Herzing University
NSG 633: Safety and Quality
Instructor Name
February 25, 2026
Four Hours From Unease to Decision: Tracing the Escalation of Falling Urine Output After Bowel Surgery, Word by Word
The Concern and the Rules for This Trace
The patient is a composite man in his late sixties on the first evening after a planned open colectomy for a colon tumor, on the surgical side of the floor used throughout this course. He has a urinary catheter, maintenance intravenous fluids at 100 mL per hour, and a patient-controlled opioid pump. He weighs about 80 kg. Everyone in the trace is identified by role only. Words are recorded as they were said, as closely as the nurse could reconstruct them within an hour, because a summary would hide how each concern was phrased. What the nurse did while waiting is placed between the contacts, since the patient did not pause while the chain did.
The Trace
Times run down the left; each line shows who, what was said, and what came back.
| Time | Who and what | Words used, and reply |
|---|---|---|
| 1800 | Nurse notices | Hourly urine output 30 mL, then 25 mL at 1800. Heart rate 98, up from 84 at 1400. Blood pressure 112/68, down from 128/76. Nurse's note to self: "Watch it." No call made. |
| 1900 | Nurse checks | Output 20 mL. Catheter flushed and not blocked; bladder not distended on the bladder scanner. Nurse decides to wait one more hour "to be sure." |
| 2005 | Call 1: surgical resident covering the floor overnight, by page | Nurse: "Hi, sorry to bother you, it's about bed 14, the colectomy. His urine's been a bit low, maybe 20 an hour. Just wanted to let you know." Reply: "OK, thanks. Is he otherwise OK? ... Fine, let's keep an eye on it and let me know if it drops." |
| 2005 to 2100 | Nurse, while waiting | Repeated vital signs: heart rate 104, blood pressure 106/64, temperature 37.8 °C. Patient says he feels "a bit thirsty" and dizzy sitting up. Hourly output 15 mL at 2100. |
| 2110 | Nurse speaks to the charge nurse | Nurse: "I paged about bed 14's urine an hour ago. It's worse and his pressure's drifting. Should I page again?" Charge nurse: "Yes. Give it to them in SBAR, with numbers, and say what you want." |
| 2120 | Call 2: same resident, by phone | Nurse: "This is the nurse for bed 14, day zero after open colectomy. His urine output has been under 30 mL an hour for four hours, 15 in the last hour, total 90 mL since 1800. His heart rate has gone from 84 to 104 and his pressure from 128 over 76 to 106 over 64. He's dizzy sitting up. I'm concerned he's dry or bleeding. I'm asking you to assess him at the bedside, and I'd like to know if you want a fluid bolus and labs." Reply: "OK. Give 500 mL of lactated Ringer's now, send a hemoglobin and basic metabolic panel, and I'll be up after this admission, about 30 minutes." |
| 2125 to 2200 | Nurse, while waiting | Bolus started 2128. Labs drawn 2135. Patient kept lying flat with legs raised when dizzy. Output 20 mL at 2200. |
| 2205 | Resident at bedside | Assessed the patient; hemoglobin back at 2215, down from 12.8 g/dL before surgery to 10.9 g/dL; creatinine up from 0.9 to 1.3 mg/dL. Second bolus ordered; the attending surgeon informed by phone. Plan: repeat hemoglobin in four hours, strict hourly output, and a low threshold for a rapid response call. |
Where the Chain Stalled and Where It Moved
The chain stalled at 2005 and moved at 2120. The same resident received both calls, so the difference was not the person. It was the words. The first call opened with an apology, gave one soft number ("a bit low, maybe 20"), gave no vital signs, stated no concern, and asked for nothing: "just wanted to let you know." The reply, "keep an eye on it," was technically an answer and left the problem where it was. The second call gave numbers with their trend, gave the total over four hours, named a concern ("dry or bleeding"), and made two requests. SBAR was designed to create exactly this shared picture between a nurse and a physician who is not at the bedside (Haig et al., 2006), and the charge nurse's prompt to use it was the condition that moved the chain.
The larger delay, however, came before any call. From 1800 to 2005 the nurse held the concern for two hours. By the usual definition, urine output below 0.5 mL per kg per hour for six hours marks a stage of acute kidney injury (Kellum et al., 2013), and for this patient that threshold was about 40 mL an hour, which he had not reached since 1700. The nurse was waiting for the number to be "sure," when the number was already below the line. A trace that started at the 2005 page would have missed the longest interval in the whole account.
What the Reply Teaches About the Next Concern
Replies shape future speaking up. A literature review of speaking up among hospital staff found that whether people raise concerns depends heavily on the response they expect, including whether earlier concerns were taken seriously (Okuyama et al., 2014). This nurse received two different lessons in one evening. The 2005 reply, "keep an eye on it," could teach that low urine output is a nuisance to report. The 2120 reply, an immediate order and a visit, taught that a clearly stated concern with a request gets action.
Which lesson lasts depends on what happens next. If the resident or the charge nurse says afterward that the second call was the right call and would have been right at 1900, the nurse is more likely to escalate the next concern an hour earlier. If nobody comments, the nurse may remember only that the first call was brushed off and that waiting two hours did not visibly harm the patient. The floor can shape this cheaply: a brief after-shift conversation about calls that moved care, and a charge nurse who asks "have you called yet?" when a nurse mentions a worrying trend. The aim is to shorten the interval between noticing and calling, which in this trace was longer than the interval between the effective call and the decision.
References
Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety, 32(3), 167-175. https://doi.org/10.1016/S1553-7250(06)32022-3
Kellum, J. A., Lameire, N., & KDIGO AKI Guideline Work Group. (2013). Diagnosis, evaluation, and management of acute kidney injury: A KDIGO summary (Part 1). Critical Care, 17(1), Article 204. https://doi.org/10.1186/cc11454
Okuyama, A., Wagner, C., & Bijnen, B. (2014). Speaking up for patient safety by hospital-based health care professionals: A literature review. BMC Health Services Research, 14, Article 61. https://doi.org/10.1186/1472-6963-14-61
NSG 633 Unit 7 instructions, in plain terms
Unit 7 asks you to trace how a clinical concern was escalated. Expect to set rules for the trace, record each contact with times, words and replies, identify where the chain stalled and moved and reflect on how replies shape future speaking up. Students often ask how much to quote and how to stay fair to physicians. Quote key sentences exactly. Show what changed between a stalled contact and one that worked, such as structure or a specific request. Fairness means looking at the communication, not judging the resident. Research on speaking up shows that replies affect whether nurses raise the next concern. Keep the patient composite and staff unnamed.
How this NSG 633 Unit 7 example is built
The trace opens with the patient and the trace rules. A timed table lists each contact with who spoke, what was said and the reply. The stall section compares the 2005 and 2120 calls, showing the second used SBAR, gave a trend and asked for a specific action. The movement section explains why the same data produced a different reply. The reply section explains how being told to keep watching makes the next call harder, citing research. The trace is fair to all parties and focuses on what words moved the chain, which gives a nurse something concrete to change on the next shift.
NSG 633 Unit 7 rubric: what full points look like
Herzing's rubric for an escalation trace typically covers the rules, timed contacts with exact words, analysis of stalls and movement, fairness and reflection on speaking up. The comparison between the stalled call and the one that worked carries the most weight, because that difference is what a nurse can change next time. Rule points reward clear limits on what the account includes. Contact criteria look for times, roles, patient data at each call and quoted words. Fairness earns credit when the communication is examined rather than the resident judged. Reflection points go to research on how replies affect future speaking up. Next steps up the chain, such as the charge nurse or attending, are often credited. Okuyama's review and TeamSTEPPS CUS language support the analysis.
NSG 633 Unit 7 help before you submit
Escalation traces in Unit 7 often slip by summarizing calls instead of quoting what was said. Another frequent problem is blaming the resident rather than examining the communication. Students often skip what changed between calls, which is the whole lesson. Times are missing. The patient's urine output and vital signs at each call are not given. Research on speaking up is ignored. The chain of command beyond the resident is not described. The charge nurse's role is left out. The nurse's own hesitation before the first call is not examined. Finally, show which words moved the chain, because graders reward a trace that teaches how to make the next call work the first time.
Get a NSG 633 Unit 7 example written to your instructions
Send the Unit 7 instructions and the rubric from your NSG 633 classroom, and say what kind of concern the trace should follow. We write a custom example that opens before the first call, keeps times and roles down the record, quotes the words used and reads the reply. First custom sample free, back in 24 to 48 hours.
More NSG 633 papers and BSN samples
- NSG 633 Unit 1: Barrier to reporting analysis
- NSG 633 Unit 2: Near miss narrative analysis
- NSG 633 Unit 3: Unit level hazard walk
- NSG 633 Unit 4: Control strength comparison
- NSG 633 Unit 5: Patient identification audit
- NSG 633 Unit 6: Interruption and workload study
- NSG 633 Unit 8: Frontline improvement pitch
- NSG 221 Unit 7: Condition presentation summary
- NSG 222 Unit 7: Family assessment write-up
- NSG 223 Unit 7: Multi problem patient record
- NSG 233 Unit 7: Urgent report script
NSG 633 Unit 7 questions, answered
Can I trace something that happened to me?
Build a composite from the pattern rather than from the event. A timed sequence of contacts on a named floor identifies the people in it even without names, and any message or note from a workplace system belongs to the employer. Composite material also lets the chain stall exactly where your analysis needs it to stall.
What if the escalation worked?
Then the trace explains why, which is harder and often scores better. A chain that moved quickly usually did so for a specific reason: a role that answers a certain phrase, a colleague who had seen it before, a policy naming a time limit. Naming that condition gives a reader something that transfers to another floor.
Should the chain of command policy be quoted?
Describe the type of pathway instead of reproducing an employer document. Many sections accept a general chain, first the charge nurse, then the responsible clinician, then whoever the setting names above them, with a note that the real route is set locally. What the trace needs is the route as it behaves, not as it is written.
Where can I find a free NSG 633 Unit 7 sample paper?
The full NSG 633 Unit 7 escalation trace is free on this page, four hours of contacts with the words that stalled and moved the chain. A trace of your own escalation can be built on request.
Why does the way a nurse reports a concern matter?
A structured report with a trend and a specific request is more likely to get action. This sample shows the same resident saying keep watching at 2005 and ordering fluids at 2120 after a clearer call.