Week 7 Discussion

Description

After completing your Aquifer case study, answer the following questions:What is your list of appropriate differential diagnoses and why?What is the final diagnosis, and what assessment findings serve to support this? Discuss normal versus abnormal findings.Describe the pathophysiology that may lead up to the final diagnoses.What pharmacology treatment would you recommend and why?

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Internal Medicine 21: 78-year-old male with fever, lethargy, and
anorexia
User: ARIADNA ZARZUELA
Email: [email protected]
Date: March 22, 2024 10:15 PM
Learning Objectives
The student should be able to:
Differentiate between the types of shock and their presentations.
Discuss the common causes for and symptoms of lower gastrointestinal blood loss.
Propose appropriate empiric therapy for sepsis due to urinary tract infection based on an understanding of urinary tract pathogens and resistance
patterns.
List the relevant elements of the physical exam in patients with suspected GI bleed.
Take an accurate blood pressure.
Interpret a urinalysis.
Propose laboratory and diagnostic tests to evaluate GI bleeding.
Define the clinician’s role when a patient is no longer capable of making medical decisions.
Differentiate palliative care from hospice.
Knowledge
Significance of Nonspecific Clinical Symptoms
Fever can be associated with infection, malignancies, and autoimmune conditions.
Lethargy is a form of drowsiness. Drowsiness is defined as not perceiving the environment fully, and responding to stimuli appropriately but slowly or
with delay. The patient may be roused by verbal stimuli but may ignore some of them. The patient is capable of verbal response unless aphasia,
aphonia, or anarthria is present. There are many causes of lethargy, including metabolic derangements, infections, medication effects, and
inflammatory, endocrine and neurologic conditions.
Anorexia is defined as loss of appetite. Anorexia can be seen in depression, malaise with febrile illnesses, gastroenteritis, dementia, as well as
alcohol and substance use disorder. Many medicines may also have the undesired side effect of suppressing appetite.
Defining Sepsis and Septic Shock
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
Septic shock is a subset of sepsis in which there are profound circulatory, cellular, and metabolic abnormalities. Septic shock is associated with a
greater risk of mortality than sepsis alone. Patients with septic shock can be clinically identified when presenting with sepsis and persistent
hypotension requiring vasopressors to maintain a MAP (mean arterial pressure) ≥ 65mmHg and have a serum lactate level > 2 mmol/L (18mg/dL)
despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%.
qSOFA Score
The qSOFA score (also known as quickSOFA) allows for prompt bedside identification of non-ICU patients with suspected infection who are at
greater risk for a poor outcome. It uses three criteria, assigning one point for low blood pressure (SBP ≤ 100 mmHg), high respiratory rate (≥ 22
breaths per min), or altered mentation (Glasgow coma scale < 15). Patients with a score of 2 or higher are at higher risk of in-hospital mortality and prolonged intensive care unit stay. Anion Gap The anion gap is calculated using the formula: Na - (chloride + bicarbonate) . The result should be 12 or less. An elevated anion gap is consistent with a metabolic acidosis caused by various ingestions, lactic acidosis from poor organ perfusion, diabetic ketoacidosis, or significant uremia (very elevated BUN). Organisms Responsible for UTI-Associated Sepsis © 2024 Aquifer, Inc. - ARIADNA ZARZUELA ([email protected]) - 2024-03-22 22:15 EDT 1/6 Although Gram-positive organisms account for most cases of sepsis, Gram-negative organisms are responsible for the majority of UTI-associated sepsis. Usually the community-acquired pathogens (E. coli, Klebsiella, and Proteus) would be the most likely (70 to 80%). A negative nitrite on UA, as in this case, makes them less likely, however. These organisms often produce the enzyme nitrate reductase, which is responsible for the conversion of urinary nitrate to nitrite. Although Citrobacter and Pseudomonas are gram negatives, they are typically associated with hospital or health care-related infections. Enterococci are a possible cause. Enterococci typically produce lower levels of nitrate reductase, hence should be suspected in cases where nitrites are negative on the UA. Staph saprophyticus is uncommon in males (< 10%) due to the length of the urethra. Group B Strep can sometimes be seen in patients with diabetes. Delirium: Definition and Associated Symptoms Definition: Relatively acute decline in cognition that fluctuates over hours or days. Hallmark: A deficit of attention, although all cognitive domains-including memory, executive function, visuospatial tasks, and language-are variably involved. Associated symptoms: Altered sleep-wake cycles, perceptual disturbances such as hallucinations or delusions, affect changes, and autonomic findings including heart rate and blood pressure instability. Differentiating Upper versus Lower Gastrointestinal Bleeds Upper GI Bleed Lower GI Bleed Melena: black, sticky, and tarry stools, typically associated with upper GI bleeding. Hematochezia: the passage of visible blood in the stool, typically associated with lower GI bleeding. Above the Ligament of Treitz Below the Ligament of Treitz Typically, upper bleeds are from erosive esophagitis, varices, gastritis, gastric, and duodenal ulcers. Bleeding below the Ligament of Treitz is almost always from the colon; jejunal or ileal sources of bleeding are rare. Conditions such as ulcerative colitis, diverticulosis, infectious colitis, and colon cancer are common causes. In the elderly, we must also consider angiodysplasia (degenerative or congenital structural abnormality of the normally distributed vasculature), mesenteric ischemia, and ischemic colitis. Transfusion Requirements Transfusion of red blood cells is usually reserved for patients with a hemoglobin less than 7 g/dL who are hemodynamically stable. Transfusions at higher hemoglobin levels is individualized based on factors such as hemodynamic stability, active hemorrhage, symptoms of blood loss and acute coronary syndrome. Ischemic Colitis versus Acute Mesenteric Ischemia Ischemic colitis must be differentiated from the more immediately life-threatening condition of acute mesenteric ischemia. These can often be distinguished clinically. Ischemic colitis Occlusive mesenteric ischemia Ischemic colitis is often found in older adult patients with underlying atherosclerotic cardiovascular disease (ASCVD). Prolonged hypotension and decreased perfusion affect blood supply to the colon. Occlusive mesenteric ischemia also occurs in older adult patients with ASCVD. Acute occlusive mesenteric ischemia is a catastrophic event resulting from complete occlusion of an artery or branch. It is usually due to thromboembolic disease. This often affects the "watershed areas" near the splenic flexure and sigmoid colon Risk factors include valvular heart disease, atrial fibrillation or where blood is supplied from terminal branches of several arteries. There often is recent vascular catheterization. Pain is often out of proportion little or no pain, and bleeding is usually self-limited once circulation is restored. to the examination findings. In other words, patients have Recovery is often complete. This is also known as nonocclusive mesenteric ischemia. severe pain while their exam can appear quite normal. Surrogate Decision-Makers Once a patient is determined to be incapable of making a medical decision, a surrogate decision-maker is identified to make medical decisions on his or her behalf. Thirty-one states have laws listing a legal hierarchy of surrogate decision-makers. © 2024 Aquifer, Inc. - ARIADNA ZARZUELA ([email protected]) - 2024-03-22 22:15 EDT 2/6 The order in Washington State, for example, is as follows: court-appointed guardian, DPOA for health care, spouse, adult children, parents, and adult siblings. If a patient is married, the spouse becomes the legal surrogate, unless he has completed a DPOA for health care or the court has appointed a legal guardian. Clinicians assess decision-making capacity as a part of routine clinical care. Any physician, not just a psychiatrist, has the authority to determine if a patient has decision-making capacity for a specific medical decision. In contrast, "competence" is a legal term. Only the courts can determine if a patient is competent to make one or more decisions. Clinicians do not determine if patients are competent but often testify at competency hearings. When courts determine competency, they rely on state laws that define incapacity, which differ slightly across states. Palliative Care versus Hospice Care Palliative care is often confused with hospice or end-of-life care. While hospice and palliative care have some overlapping approaches and goals, they are distinct entities (see the figure below). Hospice is a specialized form of palliative care for those who are in the terminal stage of illness with an expected prognosis of less than six months if the disease runs its natural course. Hospice is both a philosophy of care (focusing on comfort over cure) and an insurance benefit. Hospice referral is appropriate when the overall care plan is comfort-focused and patients meet prognostic and insurance criteria. Comparing palliative care and hospice care. Clinical Skills Recommendations for Blood Pressure Measurement The "ideal" cuff should have a bladder length that is 80% and a width that is at least 40% of arm circumference (a length-to-width ratio of 2:1). A study comparing intra-arterial and auscultatory blood pressure concluded that the error is minimized with a cuff width of 46% of the arm circumference. The recommended cuff sizes are: Arm circumference: Cuff size should be: 22 to 26 cm "small adult" size: 12 x 22 cm 27 to 34 cm "adult" size: 16 x 30 cm 35 to 44 cm "large adult" size: 16 x 36 cm © 2024 Aquifer, Inc. - ARIADNA ZARZUELA ([email protected]) - 2024-03-22 22:15 EDT 3/6 45 to 52 cm "adult thigh" size: 16 x 42 cm The optimum ratios of width and length to arm circumference are shown for the small adult and standard adult cuffs. For the large adult and thigh cuffs, the ideal width ratio of 46% of arm circumference is not practical, because it would result in a width of 20 cm and 24 cm, respectively. These widths would give a cuff that would not be clinically usable for most patients, so for the larger cuffs, a less than ideal ratio of width to arm circumference must be accepted. The ideal ratio of length to arm circumference is maintained in all four cuffs. In practice, bladder width is easily appreciated by the clinician but bladder length often is not, because the bladder is enclosed in the cuff. To further complicate the issue for clinicians, there are no standards for manufacturers of different sizes of blood pressure cuff. This has led to significant differences in which arm circumferences are accurately measured by individual manufacturers' standard adult and large adult cuffs. Individual cuffs should be labeled with the ranges of arm circumferences, to which they can be correctly applied, preferably by having lines that show whether the cuff size is appropriate when it is wrapped around the arm. In patients with class III obesity, one will encounter very large arm circumferences with short upper arm length. This geometry often cannot be correctly cuffed, even with the thigh cuff. In this circumstance, the clinician may measure blood pressure from a cuff placed on the forearm and listening for sounds over the radial artery (although this may overestimate systolic blood pressure) or use a validated wrist blood pressure monitor held at the level of the heart. Management Fluid Challenge The best immediate treatment for sepsis is a fluid challenge or bolus, typically 10 to 30 cc/kg of normal saline (NS) or lactated ringer's (LR) over 30 minutes depending on the patient's status and associated conditions. For instance, if the patient suffers from congestive heart failure, give a smaller bolus, such as 10 cc/kg. If there are no other underlying problems, such as chronic kidney disease, then give him the larger bolus. Use NS or LR because they are isosmotic and will provide immediate restoration of intravascular volume while also providing tissue rehydration. Empiric Antibiotic Treatment of Community-Acquired UTI-Associated Sepsis Ampicillin may still be effective treatment; however, high resistance rates preclude its use as empiric first-line therapy. TMP/SFX is also an alternative, but resistance rates against this agent vary and make it, too, less desirable as first-line treatment. Both third and fourth generation cephalosporins are good choices because of their broad gram-negative and partial gram-positive coverage, but cephalosporins do not cover Enterococci, so these are not appropriate treatment if this is the suspected organism. An aminoglycoside is not a good choice of empiric drug, primarily due to its nephrotoxicity, but it should be considered if Pseudomonas is a possibility. Ideally, knowledge of your hospital's antibiogram for isolated pathogens can provide the best information in helping choose empiric therapy. After the organism and its sensitivities are known, antibiotic therapy can be better directed toward the offending pathogen. Choosing Empiric Antibiotics for Gram-Negative Source In general, if a Gram-negative source is suspected, choose a third- or fourth-generation cephalosporin, piperacillin/tazobactam, ticarcillin/clavulanate, imipenem, meropenem, or aztreonam. Consider adding an aminoglycoside if the patient is immunocompromised. Advance Care Planning Advance directives are a way to help a patient's family make decisions if the patient is too sick to make health care decisions on their own. Studies Recommended Evaluation of Suspected UTI-Associated Sepsis A CBC with differential is important to look for leukocytosis. Leukopenia can also indicate a poor prognosis. Low platelet count might CBC with indicate DIC. Peripheral smear can also be helpful if microangiopathic hemolytic anemia is suspected as it would show schistocytes and differential helmet cells associated with hemolysis. A chemistry panel evaluates for suspected metabolic derangement. When the physical exam is suspicious for dehydration, information Chemistry about electrolytes and renal function are needed to administer appropriate IV fluids. Elevation of the hepatic transaminases (AST/ALT) panel may indicate hepatic dysfunction due to sepsis. PT/PTT PT/PTT are important in assessing the presence of disseminated intravascular coagulation (DIC). Lactic Acid A serum lactic acid level is important in the initial evaluation of a patient with suspected sepsis. An elevated level (e.g. >2 mmol/L) in the
presence of hypotension may indicate organ hypoperfusion due to sepsis, and is associated with poor prognosis.
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A UA can be done quickly once urine is obtained. Examination of sediment can determine the presence of WBCs, indicating infection;
WBC casts, indicating pyelonephritis; and RBCs and RBC casts indicating possible glomerulonephritis. Gram stain of an unspun
specimen can confirm the presence of bacterial infection as well as morphology of the offending bacteria and help direct appropriate
therapy. Specific gravity can aid in confirming dehydration.
UA
Blood and Blood and urine cultures are necessary in isolating the causative organism(s) and determining sensitivities to direct appropriate antibiotic
urine
therapy.
cultures
Elevated PT/INR and PTT
Elevated PT/INR and PTT indicates there are multiple issues with the coagulation cascade. This can be seen in disseminated intravascular
coagulation (DIC) due to sepsis.
Recommended Initial Workup of Hematochezia
CBC
It is important to determine how severe the hematochezia is. A CBC will help you determine how much blood has been lost. One must
be cautious, as very acute blood losses may not be evident on a CBC until after IV fluid has been given. An elevated white count can
be present with ischemia or infectious colitis.
C. difficile
toxin
Clostridium difficile infection should be excluded in hospitalized patients exposed to antibiotics. This infection produces marked
thickening of the colon on CT scan as well as very high total white blood counts. However, bloody stools are quite rare in C. difficile
infection and also it typically does not develop for at least 48 hours after initiation of antibiotic therapy.
Type and
screen
Type and screen should be performed on any patient you suspect you may need to transfuse with blood products, such as packed red
blood cells. A type and cross minimizes the risk of transfusion reactions by matching the patient’s blood type and potential antibodies to
donor blood. Some hospitals prefer to obtain a type and screen first, since if a type and cross is done, the blood will be wasted if not
administered to the patient.
Plain
abdominal
x-ray
A plain abdominal x-ray is a good initial imaging choice for severe abdominal pain, but is frequently non-specific. Plain films of the
abdomen can be helpful in ruling out perforation (seen as free air under the diaphragm) or obstruction (seen as air-fluid levels).
Distention or pneumatosis (gas in the bowel wall) can be seen in advanced ischemic colitis.
Electrolytes Electrolytes will likely be abnormal with bowel ischemia. Lactic acidosis may be present, manifesting as an elevated anion gap.
Coagulation
Elevated PT and aPTT are likely suggestive of disseminated intravascular coagulation.
studies
Although not always part of the initial workup, a CT scan may be helpful if plain abdominal films are unrevealing in a patient with abdominal pain and
abnormal bowel sounds. Although not very useful for acute GI bleeding, if ischemic colitis or obstruction is suspected, CT scan may confirm the
presence of obstruction or show pneumatosis, bowel-wall thickening in a segmental pattern, and gas in the mesenteric veins consistent with
ischemic colitis or mesenteric ischemia.
A colonoscopy can be considered if the diagnosis remains unclear after a CT scan and only if there is no clinical or radiologic evidence of peritonitis
or perforation. A colonoscopy offers the opportunity to biopsy the colon to determine the underlying pathophysiology further. With suspected or
known lower GI bleeding, a colonoscopy should be performed within 48 hours of onset. If a source of the bleeding is identified, colonoscopic
procedures such as electrocautery or injection with epinephrine (depending on the identified cause) can be performed at the time of the initial
procedure. Ischemic colitis may show pale mucosa with petechial bleeding; cyanotic mucosa can be seen in more severe disease. If ischemic colitis
is identified, supportive measures can be instituted to restore intravascular volume and perfusion. If the bleeding is refractory despite colonoscopic
intervention, a surgical consult should be obtained for possible resection of the ischemic segment. Pseudomembranous colitis is a hallmark of C.
difficile infection and is seen as yellowish round plaques and membranes. Inflammatory bowel disease may also be diagnosed by pathology.
Clinical Reasoning
Differential of Shock
Septic shock, the most common type of distributive shock, often presents with delirium, a history of fever, and a suspected source of infection.
Physical exam findings commonly seen with septic shock include fever or hypothermia (< 96.8F), tachycardia (> 90 beat/min), and tachypnea
(RR > 20 breaths/min). In many cases, there are additional signs or symptoms that suggest a specific source of infection.
Cardiogenic shock is often associated with acute coronary syndromes and characterized by acute pulmonary edema and elevated jugular
venous pressure (JVP).
In hypovolemic shock there is typically a history of hemorrhage or significant volume loss (diarrhea, vomiting, or polyuria).
Neurogenic shock is associated with severe spinal cord or central nervous system injury and bradycardia rather than tachycardia.
Anaphylactic shock is typically associated with antigenic exposure and usually presents with urticaria, angioedema, and wheezing.
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Adrenal crisis often presents with abdominal pain, nausea, vomiting, weakness, lethargy, hypotension, and skin pigmentation.
References
American Medical Association. Council on Ethical and Judicial Affairs, American Medical Association. E-2.00 Opinions on Social Policy Issues. Code of
Medical Ethics. Chicago: AMA Press; 2006.
Beauchamp TL, Childress JR. Principles of Biomedical Ethics. 4th ed. New York, NY: Oxford University Press; 1994.
Guirguis-Blake JM, Beil TL, Senger CA, Coppola EL. Primary Care Screening for Abdominal Aortic Aneurysm: A Systematic Evidence Review for the
U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); December 2019 .
Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower
extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular
Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and
the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial
Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for
Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006;113(11):e463-e654.
Lo B, Steinbrook R. Resuscitating advance directives. Arch Intern Med. 2004;164(14):1501-6. DOI: 10.1001/archinte.164.14.1501.
Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. Harrison’s Principles of Internal Medicine, 18e . New York, NY: McGraw-Hill
Companies, Inc.; 2012.
Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Crit Care Med.
2009;37(12):3124-57. DOI: 10.1097/CCM.0b013e3181b39f1b.
National Hospice and Palliative Care Organization. http://www.nhpco.org/. Accessed January 17, 2023.
Opole, IO. Sepsis Syndrome. In: Alguire PC, ed. Internal medicine essentials for students: a companion to MKSAP for students 5. Philadelphia: American
College of Physicians Press; 2011: 190-3
Pickering TG, Hall JE, Appel LJ, et al. American Heart Association Scientific Statement: Recommendations for blood pressure measurement in humans
and experimental animals. Part 1: Blood pressure measurement in humans: A statement for professionals from the Subcommittee of Professional and
Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2005;45(1):142-61. DOI:
10.1161/01.HYP.0000150859.47929.8e.
Quick Sepsis Related Organ Failure Assessment website. https://www.qsofa.org/. Accessed January 17, 2023.
Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA.
2016;315(8):801-10. doi:10.1001/jama.2016.0287.
Smerud MJ, Johnson CD, Stephens DH. Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases. AJR Am J Roentgenol.
1990;154(1):99-103. DOI: 10.2214/ajr.154.1.2104734.
Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth
edition. Ann Intern Med. 2012;156(1 Pt 2):73-104 .
Swetz,KM, Kamal, AH. Palliative care. Ann Intern Med. 2018;168(5):ITC33-ITC48. DOI: 10.7326/AITC201803060.
Tools and Training for Clinicians | Palliative Care Programs. Center to Advance Palliative Care. http://www.capc.org. Accessed January 17, 2023.
Wayne JT. Approach to fever. In Internal Medicine Essentials for Clerkship Students 2007-2008. Alguire PC, ed. Philadelphia: ACP Publishing: 2008.
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Rubric Assessment – NSG6023-Nurse Practitioner Enhancement CP01 – South University
3/22/24, 10:17 PM
SUO Discussion Rubric (80 Points) – Version 1.2
Course: NSG6023-Nurse Practitioner Enhancement CP01
Response
Quality of Initial
Posting
Participation
Participation in
Discussion
No Submission
0 points
Emerging (F-D: 1-27)
27 points
Satisfactory (C: 2831)
31 points
Proficient (B: 32-35)
35 points
Exemplary (A: 36-40)
40 points
Criterion Score
No initial posting
The information
The information
The information
The information
/ 40
exists to evaluate.
provided is
provided is accurate,
provided is accurate,
provided is accurate,
inaccurate, not
giving a basic
displaying a good
providing an in-depth,
focused on the
understanding of the
understanding of the
well thought-out
assignment’s topic,
topic(s) covered. A
topic(s) covered. A
understanding of the
and/or does not
basic understanding is
good understanding is
topic(s) covered. An
answer the
when you are able to
when you are able to
in-depth
question(s) fully.
describe the terms
explain the terms and
understanding
Response
and concepts covered.
topics covered. Initial
provides an analysis
demonstrates
Despite this basic
posting demonstrates
of the information,
incomplete
understanding, initial
sincere reflection and
synthesizing what is
understanding of the
posting may not
addresses most
learned from the
topic and/or
include complete
aspects of the
course/assigned
inadequate
development of all
assignment, although
readings.
preparation.
aspects of the
all concepts may not
assignment.
be fully developed.
No Submission
0 points
Emerging (F-D: 1-13)
13 points
Satisfactory (C: 1416)
16 points
Proficient (B: 17-18)
18 points
Exemplary (A: 19-20)
20 points
Criterion Score
No responses to other
May include one or
Comments to two or
Comments to two or
Comments to two or
/ 20
classmates were
more of the following:
more classmates’
more classmates’
more classmates’
posted in this
*Comments to only
initial posts but only
initial posts on more
initial posts and to the
discussion forum.
one other student’s
on one day of the
than one day.
instructor’s comment
post.
week. Comments are
Comments are
(if applicable) on two
*Comments are not
substantive, meaning
substantive, meaning
or more days.
substantive, such as
they reflect and
they reflect and
Responses
just one line or saying,
expand on what the
expand on what the
demonstrate an
“Good job” or “I agree.
other student wrote.
other student wrote.
analysis of peers’
*Comments are off
comments, building
topic.
on previous posts.
Comments extend
and deepen
meaningful
conversation and may
include a follow-up
question.
Writing
No Submission
0 points
Emerging (F-D: 1-13)
13 points
Satisfactory (C: 1416)
16 points
Proficient (B: 17-18)
18 points
Exemplary (A: 19-20)
20 points
Criterion Score
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Rubric Assessment – NSG6023-Nurse Practitioner Enhancement CP01 – South University
Writing
Mechanics
(Spelling,
Grammar,
Citation Style)
and Information
Literacy
3/22/24, 10:17 PM
/ 20
No postings for which
Numerous issues in
Some spelling,
Minor errors in
Minor to no errors
to evaluate language
any of the following:
grammatical, and/or
grammar, mechanics,
exist in grammar,
and grammar exist.
grammar, mechanics,
structural errors are
or spelling in the
mechanics, or spelling
spelling, use of slang,
present. Some errors
initial posting are
in both the initial post
and incomplete or
in formatting citations
present. Minor errors
and comments to
missing citations and
and references are
in formatting citations
others. Formatting of
references. If required
present. If required
and references may
citations and
for the assignment,
for the assignment,
exist. If required for
references is correct.
did not use course,
utilizes sources to
the assignment,
If required for the
text, and/or outside
support work for
utilizes sources to
assignment, utilizes
readings (where
initial post but not
support work for both
sources to support
relevant) to support
comments to other
the initial post and
work for both the
work.
students. Sources
some of the
initial post and the
include course/text
comments to other
comments to other
readings but outside
students. Sources
students. Sources
sources (when
include course and
include course and
relevant) include non-
text readings as well
text readings as well
academic/authoritativ
as outside sources
as outside sources
e, such as Wikis and
(when relevant) that
(when relevant) that
.com resources.
are academic and
are academic and
authoritative (e.g.,
authoritative (e.g.,
journal articles, other
journal articles, other
text books, .gov Web
text books, .gov Web
sites, professional
sites, professional
organization Web
organization Web
sites, cases, statutes,
sites, cases, statutes,
or administrative
or administrative
rules).
rules).
Total
/ 80
Overall Score
No Submission
Emerging (F to D Range)
Satisfactory (C Range)
Proficient (B Range)
Exemplary (A Range)
0 points minimum
There was no
submission for this
assignment.
1 point minimum
Satisfactory progress has not been
met on the competencies for this
assignment.
56 points minimum
Satisfactory progress has been
achieved on the competencies for
this assignment.
64 points minimum
Proficiency has been achieved
on the competencies for this
assignment.
72 points minimum
The competencies for
this assignment have
been mastered.
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