NURS 6630 Week 8 Assignment 2 Assessing and Treating Patients with Sleep/Wake Disorders Essay

NURS 6630 Week 8 Assignment 2 Assessing and Treating Patients with Sleep/Wake Disorders Essay

NURS 6630 Week 8 Assignment 2 Assessing and Treating Patients with Sleep/Wake Disorders Essay

            In this discussion, the case of a 31-year-old patient presents to the clinic with worsening insomnia symptoms. He reports that this was precipitated by the death of his fiancé six months ago. Ever since he has been unable to concentrate appropriately at work because of a lack of enough sleep at night. He claims that he was using diphenhydramine to sleep before, but stopped taking the drug because of an unpleasant feeling the following morning. He further claims that he takes about 4 beers every night to help with his sleep. His previous physician reports that the patient broke his ankle in the past and was diagnosed with opiate analgesics. He later started abusing the drug but has not been prescribed for the past four years. Upon conducting a mental status examination, the patient reported no history of auditory or visual hallucination, suicidal/homicidal ideation, or any other psychiatric symptom. He was thus diagnosed with insomnia disorder.

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Considering patient-specific factors is crucial in promoting the prescription of effective medication of which the patient will be tolerant with reduced risks of side effects and positive patient outcomes. For the patient in the present case, such factors include his age and gender which are crucial in determining the dose and frequency. His worsening insomnia, loss of his fiancé, and previous use of diphenhydramine, in addition to the history of opiate abuse, will promote decisions concerning the specific drug to prescribe. His previous use of alcohol, and reported side effects will help promote the need for closely monitoring the treatment outcome. The purpose of this discussion is to promote appropriate decision-making skills when prescribing medication to a young adult patient diagnosed with insomnia.

 Decision #1

Selected Decision and Rationale

            The initial intervention was to administer trazodone at a starting dose of 50mg orally at bedtime. Trazodone is an antidepressant approved by the FDA but commonly prescribed off-label for the management of Insomnia (Rosenberg et al., 2021). The drug acts through three main mechanisms, antagonism of 5-HT2A and 5-HT2B, partial agonism at 5-HT1A, serotonin reuptake inhibition, and antagonism of alpha-1A, and alpha-2C receptors (Sateia et al., 2017). At doses of 50 to 100mg among adults, trazodone has proven to improve subjective sleep latency, wake time after the onset of sleep, the number of awakenings, and sleep duration (Winkelman, 2015; Stummer et al., 2018). Risks of toxicity of the drug are also low as trazodone elimination half-life is between 10 to 12 hours, with the active metabolite being m-chlorophenyl piperazine (mCPP) hence promoting a desirable safety profile (Campbell et al., 2021).

The benefit-to-risk ratio of zolpidem is low, with increased risks of life-threatening sleeping behavior, hence not recommended for this patient (Krystal et al., 2019; Roehrs et al., 2020). Consequently, since the patient mentioned that he was using diphenhydramine which is an antihistamine, and stopped due to the side effects, it was not appropriate to give hydroxyzine as they belong to the same class, with common side effects such as shortness of breath and chest pain (Stummer et al., 2018).

Expected Outcome

            Trazodone is expected to improve the patients sleeping latency and duration (Roehrs et al., 2020). As such, within the following 2 to 4 weeks, the patient is expected to report improved sleep duration and quality (Krystal et al., 2019). His productivity at work is also expected to improve significantly.

Ethical Considerations

            When deciding on which medication to prescribe, the PMHNP must observe three ethical principles which include beneficence, justice, and respect for the person (Rosenberg et al., 2021). The decisions made must be driven by the patient’s needs, values, and preferences (Earl & Van Tyle, 2020).

Decision #2

Selected Decision and Rationale

            Upon considering the outcome of the previous intervention, the second decision was to lower the dose from 50 mg to 25 mg once daily at bedtime. The patient reported improved sleep, which proves the potential effectiveness of the drug (Stummer et al., 2018). However, he also reported an erection lasting for about 15 minutes every morning, which is a common side effect of trazodone (Roehrs et al., 2020). Studies demonstrate that trazodone only exhibits side effects at toxic levels (Sateia et al., 2017). As such, reducing the dose is normally recommended in such cases, while observing the patient closely for any changes (Winkelman, 2015). Consequently, looking at the benefit-to-risk ratio, the reported side effect is self-limiting, hence will disappear with time, proving a desirable safety profile for the drug (Campbell et al., 2021). Finally, the patient seemed to be quite satisfied with the impact of the drug on his insomnia and was only concerned with the side effect which can be managed by reducing the dose (Earl & Van Tyle, 2020).

Educating the patient that erection which lasts for only 15 minutes is not priapism without taking an actual course of action will undermine their trust in the care plan, hence promoting non-compliance (Krystal et al., 2019). Suvorexant is also not a good alternative for trazodone as the hypnotic effect of the drug has been reported to promote daytime drowsiness among patients with a history of opiate addiction (Campbell et al., 2021).

Expected Outcome

            After 2 to 4 weeks, the patient will report back to the hospital with improved sleep duration and latency (Sateia et al., 2017). The side effects that were initially reported will also resolve completely within this time. He should be able to concentrate well at work, with improved productivity (Campbell et al., 2021).

Ethical Considerations

            Respecting the patient’s wish is crucial in promoting patient-centered care (Rosenberg et al., 2021). As such, since the patient was bothered by the side effects of the drug, the PMHNP needed to decide on an intervention that the patient has consented to, and does not lead to harm (Earl & Van Tyle, 2020). Ethical principles such as respect for human and beneficence also applies in this step.

Decision #3

Selected Decision and Rationale

            At this point, it was necessary to recommend continuous use of the same medication and introduce appropriate sleep hygiene as the third decision. The patient reported resolved side effects, which suggest the safety of the drug (Campbell et al., 2021). Consequently, the drug displayed potential effectiveness as the patient reported his sleep has significantly improved but was only concerned that the dose was quite low to help him sleep through the night (Winkelman, 2015). Studies also show that, unlike other prescription sleeping pills, trazodone can be safely used for more than two weeks among patients with severe insomnia, as the drug is not addictive (Stummer et al., 2018). Studies also show that when used with other nonpharmacological approaches such as restrictive use of caffeine and sleep hygiene, the effectiveness of the drug in promoting sleep is amplified (Krystal et al., 2019).

Using ramelteon in place of trazodone is not appropriate as the risks of the drug outweigh its benefits with most patients reporting drowsiness the following morning (Sateia et al., 2017; Roehrs et al., 2020). As mentioned earlier, hydroxyzine can also not be used in place of trazodone, as the drug is an antihistamine with increased risks of cardiovascular complications among adult patients (Earl & Van Tyle, 2020).

Expected Outcome

            The patient has displayed great tolerance and adherence to the medication (Stummer et al., 2018). With the introduction of appropriate sleep hygiene, the patient will report further improved sleep, for an adequate amount of time (Winkelman, 2015; Earl & Van Tyle, 2020). He should not experience any side effects, with improved concentration and productivity in the workplace (Campbell et al., 2021).

Ethical Considerations

            In making this decision, the PMHNP exhibited a high level of integrity while observing the ethical principle of nonmaleficence, fidelity, beneficence, and justice (Krystal et al., 2019). Respecting a patient’s autonomy is also crucial to promoting positive treatment outcomes (Rosenberg et al., 2021).

Conclusion

The discussion demonstrates the decisions made when deciding on prescription drugs for a middle-aged patient with a chief complaint of worsening insomnia. Since the patient was initially taking diphenhydramine to promote his sleep but stopped due to the side effects, the initial intervention was to start the patient on trazodone 25mg once daily (Sateia et al., 2017). The drug has been recommended by most clinical guidelines to be used off-label for the management of insomnia, despite its approval by the FDA in treating depression (Roehrs et al., 2020). The other two options, zolpidem and hydroxyzine were also not appropriate drugs for this patient. After two weeks, the patient came back complaining of an erection lasting for about 15 minutes the following morning, but with well-improved sleep (Winkelman, 2015). As such, it was necessary to reduce the dose to 25mg once daily in the second intervention, to promote resolving the side effects while still benefiting from the drug in improving sleep (Earl & Van Tyle, 2020). At this point, explaining to the patient about the side effect with no action or replacing trazodone with suvorexant was also inappropriate (Stummer et al., 2018).

Based on the outcome of the second decision, it was necessary to advise the patient to continue taking 25mg of trazodone at bedtime as before, but consider the adoption of appropriate sleep hygiene to promote a positive outcome (Krystal et al., 2019). The drug had already displayed high effectiveness and tolerance levels in the patient. Several legal and ethical principles were considered in each decision process by the PMHNP (Rosenberg et al., 2021). Such principles include respect for the person, nonmaleficence, fidelity, beneficence, justice, and integrity (Campbell et al., 2021). The patient’s autonomy and right to privacy and confidentiality were also observed.

References

Campbell, R., Chabot, I., Rousseau, B., Bridge, D., Nicol, G., & Meier, G. (2021). Understanding the unmet needs in insomnia treatment: a systematic literature review of real-world evidence. International Journal of Neuroscience, 1–22. https://doi.org/10.1080/00207454.2021.1995383

Earl, D. C., & Van Tyle, K. M. (2020). New pharmacologic agents for insomnia and hypersomnia. Current Opinion in Pulmonary Medicine, Publish Ahead of Print. https://doi.org/10.1097/mcp.0000000000000722

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World Psychiatry, 18(3), 337–352. https://doi.org/10.1002/wps.20674

Roehrs, T. A., Auciello, J., Tseng, J., & Whiteside, G. (2020). Current and potential pharmacological treatment options for insomnia in patients with alcohol use disorder in recovery. Neuropsychopharmacology Reports. https://doi.org/10.1002/npr2.12117

Rosenberg, R., Citrome, L., & Drake, C. L. (2021). Advances in the Treatment of Chronic Insomnia: A Narrative Review of New Nonpharmacologic and Pharmacologic Therapies. Neuropsychiatric Disease and Treatment, Volume 17, 2549–2566. https://doi.org/10.2147/ndt.s297504

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine, 13(02), 307–349. https://doi.org/10.5664/jcsm.6470

Stummer, L., Markovic, M., & Maroney, M. (2018). Pharmacologic Treatment Options for Insomnia in Patients with Schizophrenia. Medicines, 5(3), 88. https://doi.org/10.3390/medicines5030088

Winkelman, J. W. (2015). Insomnia Disorder. New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/nejmcp1412740

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Assignment 2 Assessing and Treating Patients With Sleep Wake Disorders
Sleep disorders are conditions that result in changes in an individual’s pattern of sleep (Mayo Clinic, 2020). Not surprisingly, a sleep disorder can affect an individual’s overall health, safety, and quality of life. Psychiatric nurse practitioners can treat sleep disorders with psychopharmacologic treatments, however, many of these drugs can have negative effects on other aspects of a patient’s health and well-being. Additionally, while psychopharmacologic treatments may be able to address issues with sleep, they can also exert potential challenges with waking patterns. Thus, it is important for the psychiatric nurse practitioner to carefully evaluate the best psychopharmacologic treatments for patients that present with sleep/wake disorders.
Reference: Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/syc-20354018
To prepare for this Assignment:
• Review this week’s Learning Resources, including the Medication Resources indicated for this week.
• Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with sleep/wake disorders.
The Assignment: 5 pages
Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
• Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.
Insomnia
31-year-old Male

BACKGROUND
This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.

SUBJECTIVE
Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.

MENTAL STATUS EXAM
The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.

Decision Point One
Select what you should do:

Zolpidem: 10 mg daily at bedtime

Trazodone 50 mg po at bedtime

Hydroxyzine: 50 mg daily at bedtime

Decision Point One
Trazodone 50 mg po at bedtime

RESULTS OF DECISION POINT ONE
• Patient returns to clinic in 2 weeks
• Patient states medication works well but gives him an unpleasant side effect of an erection lasting approximately 15 minutes after waking
• Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning
• Patient denies auditory/visual hallucinations and is future oriented

Decision Point Two
Select what you should do next:

Explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, continue with current dose

Discontinue trazodone. Initiate therapy with suvorexant 10 mg daily at bedtime

Decrease trazodone to 25 mg daily at bedtime

Decision Point Two

Decrease trazodone to 25 mg daily at bedtime

RESULTS OF DECISION POINT TWO
• Patient returns to clinic in 2 weeks
• Patient states trazodone is very effective for sleep
• Patient states sometimes the 25 mg dosage isn’t quite enough to help him sleep through the night
• Patient denies auditory/visual hallucinations and is future oriented

Decision Point Three
Select what you should do next:

Discontinue trazodone. Initiate therapy with ramelteon 8 mg nightly at bedtime. Follow up in 4 weeks

Continue dose. Encourage sleep hygiene. Follow up in 4 weeks

Discontinue trazodone. Initiate therapy with hydroxyzine 50 mg nightly at bedtime. Follow up in 4 weeks

Decision Point Three

Continue dose. Encourage sleep hygiene. Follow up in 4 weeks

Guidance to Student

Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy. A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well as at reassessments. If you find the patient isn’t practicing proper sleep hygiene, you may continue the dose and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing trazodone and initiating hydroxyzine. Although there are some negative side effects associated with hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.

Learning Resources
Required Readings (click to expand/reduce)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health. Current Psychiatry Reports, 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

Morgenthaler, T. I., Kapur, V. K., Brown, T. M., Swick, T. J., Alessi, C., Aurora, R. N., Boehlecke, B., Chesson, A. L., Friedman, L., Maganti, R., Owens, J., Pancer, J., & Zak, R. (2007). Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. SLEEP, 30(12), 1705–1711. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_Narcolepsy.pdf

Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B, Brown, T. M., Coleman, J., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. SLEEP, 29(1), 1277–1281. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_NightWakingsChildren.pdf

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470

Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740

Rubric Detail
Name: NURS_6630_Week8_Assignment2_Rubric

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.–
Excellent

Point range: 90–100 9 (9%) – 10 (10%)
The response accurately, clearly, and fully summarizes in detail the case for the Assignment.

The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient.

Decision #1 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.–
Excellent

Point range: 90–100 18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

Decision #2 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.–
Excellent

Point range: 90–100 18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

Decision #3 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.–
Excellent

Point range: 90–100 18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

Conclusion (1 page)

• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.–
Excellent

Point range: 90–100 14 (14%) – 15 (15%)
The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient.

The response accurately and clearly explains a justification for the recommendations provided, including clinically relevant resources that fully support the recommendations provided.

Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.–
Excellent

Point range: 90–100 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation–
Excellent

Point range: 90–100 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.–
Excellent

Point range: 90–100 5 (5%) – 5 (5%)
Uses correct APA format with no errors.
Total Points: 100
Name: NURS_6630_Week8_Assignment2_Rubric