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NURS 6630 Discussion Treatment for a Patient With a Common Condition

NURS 6630 Discussion Treatment for a Patient With a Common Condition

Insomnia, the second most prevalent mental condition, is also a significant risk factor for depression (Blanken et al., 2019). Insomnia is characterized by persistent problems with sleep quality and quantity, nightly awakenings and difficulty returning to sleep, and unscheduled early morning awakenings (Levenson et al., 2015). Insomnia is estimated to have a prevalence of between 5% and 15% and is related with an inability to sleep despite having the opportunity to do so (Levenson et al., 2015).

Three Reasonable Questions for this Patient

How many hours do you sleep at night?

This is critical to understand because proper sleep is necessary to sustain our mental, physical, and emotional health and well-being. Seven to eight hours of sleep each day is advised for persons 65 years of age and older. Sleep deprivation can have a detrimental effect on both mental and physical health (Hirshkowitz et al., 2015).

What is the pattern of sleeping issues in terms of frequency?

Sleep disturbances can occur as a result of hyperarousal caused by stress and other emotional stressors. This can have an effect on the start and quality of sleep and assist distinguish chronic from acute insomnia (Levenson et al., 2015).

Is there anyone in your family who has difficulty sleeping?

Justification: Genes are thought to be a risk factor for insomnia. It is critical to ascertain whether there is a hereditary tendency to insomnia (Blanken et al., 2019). Stressful circumstances can exacerbate the risk of chronic insomnia in persons who are already vulnerable (Blanken et al., 2019).

NURS 6630 Discussion Treatment for a Patient With a Common Condition

NURS 6630 Discussion Treatment for a Patient With a Common Condition

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Individuals for Further assessment

Individuals who are closely associated with the patient will be important. This includes her children if any, other relatives and close

friends.

Children: Have you noticed any problem sleeping at nights? Are there periods of wakefulness throughout the night? How early is she up in the mornings?

This will help to determine the duration and pattern of sleep throughout the night.

Relatives: Has there been regular communication since her husband’s death? Has her diet been ok?  Are there any concerns about her wellbeing? NURS 6630 Discussion Treatment for a Patient With a Common Condition

This will help to determine if there is increased depression and hopelessness as a result of the death of her husband.

Friends: Has there been communication? Has there been any changes in her behavior? Does she appear more tired? This will also help to determine the level of depression and the functional impairment from sleep deprivation.

Appropriate Physical Tests and Diagnostic Exams

A thorough physical and mental assessment is important to screen for increased depressing and the effects of insomnia. The Mini-Mental State Exam (MMSE) to assess for cognitive impairment. The Geriatric Depression Scale (GSD) or Cornell Scale for Depression in Dementia (CSDD) This will also help to determine the level of cognitive impairment (Patel et al., 2018). NURS 6630 Discussion Treatment for a Patient With a Common Condition

Baseline blood tests that include chemistry, complete blood count, Liver enzymes is also important to evaluate any imbalance.

Assessment for other medical problems such as thyroid disease, chronic pain respiratory problems. Sleep diary or modalities such as Polysomnography and Actigraphy for sleep study and sleep pattern evaluation (Patel et al., 2018).

NURS 6630 Discussion Treatment for a Patient With a Common Condition

Differential Diagnosis

a) Increased depression due to loneliness b) Restless legs c) Sleep pattern disturbance. The selected diagnosis is Increased Depression due to Loneliness. This is so because of the loss of her husband of 41 years. This could relate to drastic lifestyle changes that is affecting her and therefore resulting in her insomnia.

Two Appropriate Pharmacological agents: A selective serotonin reuptake inhibitor (SSRI) and Buspirone, a Tricyclic Antidepressant (TCA) are possible choices for the treatment of depression. The patient is already taking Sertraline 100mg daily which is a SSRI and one of its side effects is insomnia. ROSENBAUM) It is uncertain about the length of time since she has been taking Sertraline. Changing medication without tapering the dose is not recommended therefore the dose could be reduced and the patient then closely monitored for change in symptoms (Stern et al., 2016).

Contraindications: Buspirone: patient with kidney or liver disease because of slow excretion. Sertraline: patient taking monoamine oxidase inhibitors, thioridazines and serotonergic preparation (Rosenbaum).

The patient will be evaluated on a 4-week basis and evaluated for change in symptoms and for medication adjustment as required.

References

Blanken, T. F., Benjamins, J. S., Borsboom, D., Vermunt, J. K., Paquola, C., Ramautar, J., Dekker, K., Stoffers, D., Wassing, R., Wei, Y., & Van Someren, E. W. (2019). Insomnia disorder subtypes derived from life history and traits of affect and personality. The Lancet Psychiatry6(2), 151–163. https://doi.org/10.1016/s2215-0366(18)30464-4

Hirshkowitz, M., Whiton, K., Albert, S. M., Alessi, C., Bruni, O., DonCarlos, L., Hazen, N., Herman, J., Adams Hillard, P. J., Katz, E. S., Kheirandish-Gozal, L., Neubauer, D. N., O’Donnell, A. E., Ohayon, M., Peever, J., Rawding, R., Sachdeva, R. C., Setters, B., Vitiello, M. V., & Ware, J. (2015). National sleep foundation’s updated sleep duration recommendations: Final report. Sleep Health1(4), 233–243. https://doi.org/10.1016/j.sleh.2015.10.004

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: A review. Journal of Clinical Sleep Medicine14(06), 1017–1024. https://doi.org/10.5664/jcsm.7172

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Psychopharmacology and neurotherapeutics (1st ed.). Elsevier Inc. NURS 6630 Discussion Treatment for a Patient With a Common Condition

RE: Discussion – Week 7, response 1

       I agree with you that depression and insomnia are somehow correlated. Chronic insomnia is the prodrome for a major depressive disorder as well as depression is a risk factor for Insomnia. It has been well documented that depression can lead to insomnia (Depression and insomnia: Questions of cause and effect. (2018, Oct 12). However, evidence from previous research and clinical experience indicates that the reverse can also be the case: long-standing insomnia can often lead to depression (Major Depression and Insomnia in Chronic pain n.d). Chronic and more severe depression responds better to a combination of antidepressant and, insomnia therapy.

PMHNP should also suggest a sleep study (including sleep history, polysomnography) to confirm if the patient has narcolepsy. PMHNP can also do screening tests for anxiety, for example, Hamilton Anxiety Rating Scale (HAM-A). The scale measures the severity of anxiety symptoms, and it consists of 14 items. Each is defined by a series of symptoms and measures both psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety). Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where less than 17 indicates mild severity, 18 to 24 mild to moderate severity, and 25 to 30 moderates to severe (UF College of Medicine, 2018).

Another question I think should be asked of the client is whether her job was a day or night job. This is because most people who have worked night shift job for an extended period do get their circadian rhythm messed up and thus suffers from circadian rhythm disorder which makes these people suffer from having a restful sleep at night and also from impairments in their cognitive performance. As indicated in your post that the client might be having difficulty sleeping due to her medications such as the HTZ, there could be other medications that the client is currently taking that alter the neurotransmitters in her brain and causes wake abnormalities that are accompanied by neurodegenerative or neurotransmitter changes. (Videnovic, & Abbott, (2016)

References

Major Depression and Insomnia in Chronic Pain: The Clinical Journal of Pain. (n.d.). Retrieved October 12, 2018, from https://journals.lww.com/clinicalpain/Abstrct/2002/03000/Major_Depression_and_Insomnia_in_Chronic_Pain.2.aspx

UF College of Medicine. (2018). Hamilton Anxiety Rating Scale (HAM-A). Retrieved from https://dcf.psychiatry.ufl.edu/files/2011/05/HAMILTON-ANXIETY.pdf

Videnovic, A., & Abbott, S. (2016). Chronic sleep disturbance and neural injury: links to neurodegenerative disease. Nature and Science of Sleep, 55.

Discussion Insomnia

Discussion Week 7 Main Post

The discussion topic is on the following case study which will address questions asked to gain a better understanding of therapy approaches to effectively manage the client’s health care needs. The case study in question is about a 75-year-old female widow who recently lost her spouse of 41 years of marriage. Her chief complaint is insomnia with worsening of depression. Her PMH is DM, HTN and MDD. Her current medications are Metformin 500mg BID, Januvia 100mg daily, Losartan 100mg daily, HCTZ 25mg daily and Sertraline 100 mg daily. Her BMI is 33.3 in which obesity can be added to her list of diagnoses. V.S. stable. As the psychiatric mental health nurse practitioner, I will address her complaint of insomnia.  

Questions Concerning Insomnia with Rationale

I would interview the client with specific questions concerning her insomnia to gain a better understanding of her insomnia. The psychiatric interview, Carlat (2017) addresses the following questions: Have you been sleeping normally? This helps open up the conversation to ask more questions. Have you been sleeping normally? What has your sleep pattern been lately? What time do you lie down to fall asleep? What time do you actually fall asleep? These questions help diagnose difficulty falling asleep. The next question helps to diagnose frequent awakenings: Do you sleep through the night, or do you wake up often during the night? Then to diagnose early morning awakening and diurnal variation in mood; ask the following questions: What time do you usually wake up in the morning? Do you generally feel rested when you wake up? Do you feel depressed when you wake up? How does your mood change as the day goes on? The more detailed interview gives the practitioner the ability to provide interventions accordingly (medication or alternative) and to measure the outcomes.

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

I would the client if there is anyone she trusts and confides in that can be present if she wished for support. What social support does she have? Is there a friend, family or neighbor that is a support person in her life?  I would ask permission to speak to that support person. I would ask the support person if the client’s depression affected her activities of daily living? Does the client’s mood change over the course of the day as in “Sundowners” syndrome? The purpose of these questions would be for the client’s safety at home.

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.

The client has comorbidities that evaluated by her PCP at least twice a year. I would order the following diagnostic tests unless recently completed within 3 months. I would order lab work to include CBC, CMP & EKG to evaluate the diabetes. I would order a sleep apnea test to rule out the possibility of sleep apnea causing her insomnia.

Differential Diagnosis for the Patient

The differential diagnosis I chose was “Adjustment disorder with depressed mood” because her grief is not over 12 months to diagnose complicated grieving.  I would next try to determine is the insomnia episodic, persistent, or recurrent.

Two Pharmacologic Agents Appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.

Interestingly, Markota et al., (2016) advises against using benzodiazepines or non-benzodiazepine hypnotics per the American Geriatrics Society. Markota suggests doxepin (Silenor) for geriatric insomnia. IBM (2020) suggests for the age of 65 years or older, the initial dose of 3 mg once daily 30 minutes before bedtime: a max of 6 mg daily. Doxepin is metabolized by CYP2C19 and CYP2D6, the active metabolite is N-desmethyldoxepin. The side effects are anticholinergic and sedative and may cause orthostatic hypotension. The patient needs to be instructed to move slowly. Markota et al., (2016) also suggests, Ramelteon is an FDA, a (melatonin receptor agonist) is an approved hypnotic for insomnia that is not mentioned in the AGS criteria. It is effective in treating initial insomnia in both the short and long term, is not sedating, has no abuse potential, and has a more benign adverse effect profile. I would prefer the Ramelteon over the doxepin for this patient because the anticholinergic side effects.

For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?

In a study by Shadyab et al., (2015) suggested there were ethnic differences in nighttime sleep and daytime napping durations with type 2 diabetes. Ethnic- specific associations of sleep and napping durations with diabetes were reported. Type 2 diabetes prevalence was the highest in Filipina women. Sleep duration was in the Filipina women and napping over 30 minutes daily was associated with type 2 diabetes in white women only. I did not find ethnic dose adjustments as I did with adjusting the dose for the elderly client adjustment.

The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, healthcare administrators, and regulators.

Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.

Brasure et al., (2016) advises against benzodiazepines and nonbenzodiazepine hypnotics in older patients. Therefore, I would monitor and follow the patient at the 4 week- follow up and adjust according or switch medication to doxepin and monitor for side effects every 4 weeks until the 3- month threshold then at six months.

References

Carlat, D. (2017). The Psychiatric Interview. 4th edition. Wolters Kluwer

Brasure, M., Fuchs, E., MacDonald, R., Nelson, V. A., Koffel, E., Olson, C. M., Khawaja, I. S., Diem, S., Carlyle, M., Wilt, T. J., Ouellette, J., Butler, M., & Kane, R. L. (2016). Psychological and Behavioral Interventions for Managing Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Annals of Internal Medicine165(2), 113–125. https://doi-org.ezp.waldenulibrary.org/10.7326/M15-1782

Markota, M., Rummans, T. A., Bostwick, J. M., & Lapid, M. I. (2016). Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies. Mayo Clinic Proceedings91(11), 1632–1639. https://doi-org.ezp.waldenulibrary.org/10.1016/j.mayocp.2016.07.024

Fick, Donna M., Todd P. Semla, Michael Steinman, Judith Beizer, Nicole Brandt, Robert Dombrowski, Catherine E. DuBeau, et al. “American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults.” Journal of the American Geriatrics Society 67, no. 4 (April 2019): 674–94. doi:10.1111/jgs.15767.

Shadyab, A. H., Kritz-Silverstein, D., Laughlin, G. A., Wooten, W. J., Barrett-Connor, E., & Araneta, M. R. G. (2015). Ethnic-specific associations of sleep duration and daytime napping with prevalent type 2 diabetes in postmenopausal women. Sleep Medicine16(2), 243–249. https://doi-org.ezp.waldenulibrary.org/10.1016/j.sleep.2014.11.010

RE: Discussion Insomnia

Hello Jo, I did really enjoy reading your post; you did make some essential points. Aging is associated with changes in sleep. When aging, people spend more time in bed but less time asleep. Sleep becomes less efficient and more disrupted. This goes along with decreases in slow-wave sleep and increased early-morning awakenings. The prevalence of sleep problems increases from the age of 65 years. Approximately 50% of older adults suffer from difficulties in sleeping, of which up to 30% suffer from insomnia, and 20% suffer from sleep apnea. Sleep problems in older adults can cause fatigue, daytime sleepiness, and napping. Sleep problems also affect general functioning, activities of daily living (ADL) Moreover, they are associated with lower quality of life and cognitive and mental health issues (Effects of physical activity programs on sleep outcomes in older adults: A systematic review, 2020).

I would also like to add that the patient should be questioned if she uses alcohol. Research has shown that adults in mid to later life consume alcohol for several reasons, categorized as either positive or negative reinforcement. While stressful life events, such as bereavement or retirement, may trigger late-onset drinking in some, this is not the case for all. Alcohol use has been associated with self-medication for physical and mental health problems and insomnia and has also been linked to boredom, loneliness, isolation, and homelessness. However, the direction of causality in the relationship between alcohol use and many of these factors is often in doubt. Older people also report consuming alcohol for positive reasons such as enjoyment and socialization (Haighton, Amy O’Donnell, Wilson, McCabe & Ling, 2018

References

Effects of physical activity programs on sleep outcomes in older adults: A systematic review. (2020). International Journal of Behavioral Nutrition and Physical Activity, 17, 1. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1186/s12966-020-0913-3

Haighton, C., J. K., Amy O’Donnell, Wilson, G., McCabe, K., & Ling, J. (2018). ‘I take my tablets with the whiskey’: A qualitative study of alcohol and medication use in mid to later life. PLoS One, 13(10) doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1371/journal.pone.0205956

Thank you for your post. Very informative information on medications I was not as familiar with. You mentioned Doxepin, Doxepin is said by Yeung et al. (2015), as being a sedating tricyclic drug, at 3 mg and 6 mg doses was recently approved by the U.S. food and drug administration (FDA) for the treatment of insomnia. Although TCAs’ overall efficacy in treating depression is parallel to SSRIs, Stern et al. (2016), states they have a considerable amount of side effects. It is recommended to use lower dosing in older adults: doses of 1, 3, and 6 mg were suggested (Sys et al., 2020). Studies show symptoms of insomnia improved during weeks 2 (3 and 6 mg), week 4 (3 mg), and week 12 (1 mg and 3 mg); the insomnia severity index improved with Doxepin 3 mg and 6 mg at all time points compared to placebo. Doxepin does show promising results, but Sys et al. (2020), recommends further trials are needed to evaluate long-term efficacy, safety, and its impact on daily functioning.

I’d encourage discussing side effects with the patient. Doxepin is said to cause drowsiness, dizziness, dry mouth, blurred vision, and constipation. Because dizziness and lightheadedness may occur, I agree that telling patients they should get up slowly when rising from a sitting or lying position is important. Yeung et al. (2015), states patients may experience rebound insomnia during the discontinuation period – and this was noted on low doses as well. As you stated Ramelteon, which is a FDA-approved pharmacologic agent, is recommended for people over 55 year who have difficulty sleeping. Studies performed by Yeung et al. (2015), state that Ramelteon plus doxepin was significantly more effective than Ramelteon alone.

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and Neurotherapeutics E-book. Elsevier Health Sciences.

Sys, J., Van Cleynenbreugel, S., Deschodt, M., Van der Linden, L., & Tournoy, J. (2020). Efficacy and safety of non-benzodiazepine and non-Z-drug hypnotic medication for insomnia in older people: a systematic literature review. European Journal of Clinical Pharmacology76(3), 363–381. https://doi-org.ezp.waldenulibrary.org/10.1007/s00228-019-02812-z

Yeung, W.-F., Chung, K.-F., Yung, K.-P., & Ng, T. H.-Y. (2015). Doxepin for insomnia: a systematic review of randomized placebo-controlled trials. Sleep Medicine Reviews19, 75–83. https://doi-org.ezp.waldenulibrary.org/10.1016/j.smrv.2014.06.001

Thanks again for your post and introduction to new medication,

Excellent

Point range: 90–100

Good

Point range: 80–89

Fair

Point range: 70–79

Poor

Point range: 0–69

Main Posting:

Response to the Discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.

40 (40%) – 44 (44%)

Thoroughly responds to the Discussion question(s).

Is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.

No less than 75% of post has exceptional depth and breadth.

Supported by at least three current credible sources.

35 (35%) – 39 (39%)

Responds to most of the Discussion question(s).

Is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module.

50% of the post has exceptional depth and breadth.

Supported by at least three credible references.

31 (31%) – 34 (34%)

Responds to some of the Discussion question(s).

One to two criteria are not addressed or are superficially addressed.

Is somewhat lacking reflection and critical analysis and synthesis.

Somewhat represents knowledge gained from the course readings for the module.

Post is cited with fewer than two credible references.

(0%) – 30 (30%)

Does not respond to the Discussion question(s).

Lacks depth or superficially addresses criteria.

Lacks reflection and critical analysis and synthesis.

Does not represent knowledge gained from the course readings for the module.

Contains only one or no credible references.

Main Posting:

Writing

(6%) – 6 (6%)

Written clearly and concisely.

Contains no grammatical or spelling errors.

Adheres to current APA manual writing rules and style.

(5%) – 5 (5%)

Written concisely.

May contain one to two grammatical or spelling errors.

Adheres to current APA manual writing rules and style.

(4%) – 4 (4%)

Written somewhat concisely.

May contain more than two spelling or grammatical errors.

Contains some APA formatting errors.

(0%) – 3 (3%)

Not written clearly or concisely.

Contains more than two spelling or grammatical errors.

Does not adhere to current APA manual writing rules and style.

Main Posting:

Timely and full participation

(9%) – 10 (10%)

Meets requirements for timely, full, and active participation.

Posts main Discussion by due date.

(8%) – 8 (8%)

Posts main Discussion by due date.

Meets requirements for full participation.

(7%) – 7 (7%)
Posts main Discussion by due date.
(0%) – 6 (6%)

Does not meet requirements for full participation.

Does not post main Discussion by due date.

First Response:

Post to colleague’s main post that is reflective and justified with credible sources.

(9%) – 9 (9%)

Response exhibits critical thinking and application to practice settings.

Responds to questions posed by faculty.

The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

(8%) – 8 (8%)
Response has some depth and may exhibit critical thinking or application to practice setting.
(7%) – 7 (7%)
Response is on topic, may have some depth.
(0%) – 6 (6%)
Response may not be on topic, lacks depth.
First Response:
Writing
(6%) – 6 (6%)

Communication is professional and respectful to colleagues.

Response to faculty questions are fully answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in Standard, Edited English.

(5%) – 5 (5%)

Communication is mostly professional and respectful to colleagues.

Response to faculty questions are mostly answered, if posed.

Provides opinions and ideas that are supported by few credible sources.

Response is written in Standard, Edited English.

(4%) – 4 (4%)

Response posed in the Discussion may lack effective professional communication.

Response to faculty questions are somewhat answered, if posed.

Few or no credible sources are cited.

(0%) – 3 (3%)

Responses posted in the Discussion lack effective communication.

Response to faculty questions are missing.

No credible sources are cited.

First Response:
Timely and full participation
(5%) – 5 (5%)

Meets requirements for timely, full, and active participation.

Posts by due date.

(4%) – 4 (4%)

Meets requirements for full participation.

Posts by due date.

(3%) – 3 (3%)
Posts by due date.
(0%) – 2 (2%)

Does not meet requirements for full participation.

Does not post by due date.

Second Response:
Post to colleague’s main post that is reflective and justified with credible sources.
(9%) – 9 (9%)

Response exhibits critical thinking and application to practice settings.

Responds to questions posed by faculty.

The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

(8%) – 8 (8%)
Response has some depth and may exhibit critical thinking or application to practice setting.
(7%) – 7 (7%)
Response is on topic, may have some depth.
(0%) – 6 (6%)
Response may not be on topic, lacks depth.
Second Response:
Writing
(6%) – 6 (6%)

Communication is professional and respectful to colleagues.

Response to faculty questions are fully answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in Standard, Edited English.

(5%) – 5 (5%)

Communication is mostly professional and respectful to colleagues.

Response to faculty questions are mostly answered, if posed.

Provides opinions and ideas that are supported by few credible sources.

Response is written in Standard, Edited English.

(4%) – 4 (4%)

Response posed in the Discussion may lack effective professional communication.

Response to faculty questions are somewhat answered, if posed.

Few or no credible sources are cited.

(0%) – 3 (3%)

Responses posted in the Discussion lack effective communication.

Response to faculty questions are missing.

No credible sources are cited.

Second Response:
Timely and full participation
(5%) – 5 (5%)

Meets requirements for timely, full, and active participation.

Posts by due date.

(4%) – 4 (4%)

Meets requirements for full participation.

Posts by due date.

(3%) – 3 (3%)
Posts by due date.
(0%) – 2 (2%)

Does not meet requirements for full participation.

Does not post by due date.

Total Points: 100
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