Case Study: An Elderly Iranian Man with Alzheimers Disease – NURS 6521
Neurologic and Musculoskeletal Disorders and Opioids Example 1
The patient in this case study is Mr. Akkad, a 76-year-old Iranian male brought to the clinic by his eldest son due to strange behavior. Mr. Akkad’s son reported that his father’s personality had changed, and he had been demonstrating unusual thoughts and behaviors for the past two years. Additionally, during the clinical interview, Mr. Akkad experienced memory loss, difficulty finding the right words, and exhibited confabulation.
He scored 18 out of 30 on the Mini-Mental State Exam, indicating moderate dementia. In Decision Point One, it was decided to begin treatment with Aricept (donepezil) at a dose of 5 mg orally at bedtime. However, when Mr. Akkad returned to the clinic after four weeks, there was no improvement in his condition. Confabulation persisted, and he scored the same on the MMSE.
In Decision Point Two, the dosage of Aricept was increased to 10 mg orally at bedtime. Four weeks later, Mr. Akkad’s son reported that his father was tolerating the medication well but showed no significant improvement. Although Mr. Akkad started attending religious services with the family, his disinhibited behaviors and easily amused nature persisted. In Decision Point Three, it was decided to continue Aricept at 10 mg orally at bedtime and gradually increase the dosage. The dosage was increased to 15 mg orally at bedtime for six weeks and then further increased to 20 mg orally at bedtime. There is no information available regarding the outcome of this decision.
Aricept (donepezil) is a commonly prescribed medication for Alzheimer’s disease, aiming to improve cognitive symptoms (Larkin, 2022). The initial decision to start Aricept at a dose of 5 mg orally at bedtime aligns with standard practice. Increasing the dosage to 10 mg orally at bedtime is also a reasonable step, as it is a common dosage adjustment for patients who do not show significant improvement with the lower dose. However, it is challenging to make a definitive judgment without more information on the patient’s specific clinical profile, response to treatment, and side effects.
Additionally, the case study does not provide information on the subsequent decision to continue Aricept at the current dosage or to switch to Namenda (memantine). To make a comprehensive evaluation of the decisions made, it is crucial to consider the patient’s individual characteristics, clinical guidelines, and the broader body of evidence-based literature (Larkin, 2022). Consulting professional medical resources, such as clinical practice guidelines and peer-reviewed literature, would be beneficial in assessing the appropriateness of the decisions made in this case.
The decisions recommended for the patient case study were aimed at managing the symptoms of a major neurocognitive disorder, presumptively due to Alzheimer’s disease. The primary goal was to potentially slow down the progression of cognitive decline, improve cognitive function, and enhance the patient’s overall quality of life. Aricept (donepezil) is one of the commonly prescribed medications for Alzheimer’s disease, targeting the cholinergic system and aiming to enhance cognitive function. Studies have shown its potential benefits in improving cognition, global function, and activities of daily living in patients with Alzheimer’s disease (Choi et al., 2021).
The decision to increase the dosage of Aricept from 5 mg to 10 mg orally at bedtime was based on the notion that higher doses may offer greater clinical benefits. Some studies have suggested that higher doses of donepezil may lead to additional cognitive benefits in patients with Alzheimer’s disease (Larkin, 2022). However, it is important to note that the response to donepezil can vary among individuals, and decisions regarding dosage adjustments should be made based on careful clinical evaluation and consideration of potential side effects.
The expected outcomes of Decision Points One and Two in the exercise were to see improvements in Mr. Akkad’s condition, including a reduction in disinhibited behaviors, increased interest in religious activities, and improvements in cognitive deficits.
However, the actual results did not align with these expectations. Despite the medication, Mr. Akkad’s symptoms persisted, including disinhibited behaviors, disinterest in religious activities, and confabulation. This suggests that the initial treatment approach with Aricept did not yield the desired results. Further adjustments or alternative treatment options may be necessary to address Mr. Akkad’s ongoing symptoms (Rosenthal & Burchum, 2021).
References
Choi, G. W., Lee, S., Kang, D. W., Kim, J. H., & Cho, H. Y. (2021). Long-acting injectable donepezil microspheres: Formulation development and evaluation. Journal of Controlled Release, 340, 72-86. https://doi.org/10.1016/j.jconrel.2021.10.022
Larkin, H. D. (2022). First donepezil transdermal patch approved for Alzheimer disease. JAMA, 327(17), 1642-1642. https://doi.org/10.1001/jama.2022.6662
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Examine Case Study An Elderly Iranian Man With Alzheimers
You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point, there will be three decisions. I will choose one out of the three and give the outcome. At each decision point, these are the thoughts to ponder:
Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources Examine Case Study: An Elderly Iranian Man With Alzheimer’s
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
***Also include how ethical considerations might impact your treatment plan and communication with clients.***
Finally: 1. Complete the decision tree (keep track of what you selected. Come up with a rational reason why you chose it. Come up with a patient-specific rational reason behind not choosing the other two options not chosen).
2. Write a paper addressing all sections listed based on the decision tree.
Case Study: Alzheimer’s Disease
(76-Year-old Iranian Male)
BACKGROUND
Mr. Akkad is a 76-year-old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including a CT scan of the head) were normal.
According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”
Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficulty “finding the right words” in a conversation and then will shift to an entirely different line of conversation.
SUBJECTIVE
During the clinical interview, Mr. Akkad is pleasant, and cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so the PMHNP performs a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia.
MENTAL STATUS EXAM
Mr. Akkad is a 76-year-old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear and coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic.
The self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes were noted.
He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh].
Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When the PMHNP asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.
Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)
RESOURCES
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources.
Decisions Made and Outcomes (Needed to formulate the paper) (Must use and formulate paper based off of the chosen decision. Then tell why the other two decisions were not a good choice with in-text citations noted for each.)
Choices for Decision 1: Select what the PMHNP should do:
- Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks
- Begin Aricept (donepezil) 5 mg orally at BEDTIME
- Begin Razadyne (galantamine) 4 mg orally BID
Decision Choice Chosen: Begin Exelon (rivastigmine) 1.5 mg orally BID with an examine Case Study:
- An Elderly Iranian Man With Alzheimer’s
- Increase to 3 mg orally BID in 2 weeks
***Explain why the other two choices were rejected (not adequate choices)***
RESULTS OF DECISION POINT ONE
The client returns to the clinic in four weeks
The client is accompanied by his son who reports that his father is “no better” from this medication. He reports that his father is still disinterested in attending religious services/activities, and continues to exhibit disinhibited behaviors
You continue to note confabulation and decide to administer the MMSE again. Mr. Akkad again scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall
Choices for Decision 2: Select what the PMHNP should do:
- Increase Exelon to 4.5 mg orally BID
- Increase Exelon to 6 mg orally BID
- Discontinue Exelon and begin Namenda (memantine) 10 mg orally BID
Decision Choice Chosen: Increase Exelon to 4.5 mg orally BID
***Explain why the other two choices were rejected (not adequate choices)***
RESULTS OF DECISION POINT TWO
The client returns to the clinic in four weeks
The client’s son reports that the client is tolerating the medication well, but is still concerned that his father is no better
He states that his father is attending religious services with the family, which the son and the rest of the family are happy about. He reports that his father is still easily amused by things he once found serious
Choices for Decision 3: Select what the PMHNP should do:
- Increase Exelon to 6 mg orally BID
- Maintain current dose of Exelon
- Add Namenda (memantine) 5 mg orally per day
Decision Choice Chosen: Increase Exelon to 6 mg orally BID
***Explain why the other two choices were rejected (not adequate choices)***
Outcome: Guidance to Student at this point, the client is reporting no side effects and is participating in an important part of family life (religious services). This could speak to the fact that the medication may have improved some symptoms.
The PMHNP needs to counsel the client’s son on the trajectory of presumptive Alzheimer’s disease in that it is irreversible, and while cholinesterase inhibitors can stabilize symptoms, this process can take months. Also, these medications are incapable of reversing the degenerative process. Some improvements in problematic behaviors (such as disinhibition) may be seen, but not in all clients.
At this point, the PMHNP could maintain the current dose until the next visit in 4 weeks, or the PMHNP could increase it to 6 mg orally BID and see how the client is doing in 4 more weeks.
Augmentation with Namenda is another possibility, but the PMHNP should maximize the dose of the cholinesterase inhibitor before adding augmenting agents. However, some experts argue that combination therapy should be used from the onset of treatment.
Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.
***Write on each decision. Make sure that in each decision choice, you explain why the other two decisions were not good choices. Use cited sources to validate points. Make sure that this paper has at least 7 References. Please use in-text citations for each section of each decision. Don’t forget the ethical considerations for this assignment. Make it a section by itself.***
***Also please make sure when looking at the ethical consideration for this assignment that you look at how the Caucasian (male) ethnicity and pain medications interact.***
Please use the following format when formulating the paragraphs for each section. Don’t forget the in-text citations. Remember to use at least 7 references.
Introduction to Examine Case Study An Elderly Iranian Man With Alzheimers
Decision #1
Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)
Anticipated Results (of Chosen Decision)
The difference in Results (Anticipated VS Actual)
Decision #2
Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)
Anticipated Results (of Chosen Decision)
The difference in Results (Anticipated VS Actual)
Decision #3
Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)
Anticipated Results (of Chosen Decision)
The difference in Results (Anticipated VS Actual)
Ethical Considerations
Conclusion
References
CHECK OUT THE ATTACHMENT FOR MORE INFORMATION
An Elderly Iranian Man with Alzheimers’s Disease Paper Sample
Alzheimer’s disease is a lifelong neurodegenerative disorder that builds up slowly, but eventually, becomes worse. People with this disorder find it difficult to remember current events. In the course of the disorder progression, other symptoms manifest in the patient where some of them are mood swings, language, behavioral concerns, disorientation, along with motivation loss. It would also be possible to tell that a person is vulnerable to the disorder if he or she is unable to manage self-care (Kales et al., 2019).
Looking at the case study involving an 86-year- old Iranian man, his symptoms suggest that he suffers from the disorder. Even his family reported that he was fond of forgetting things and this can be confirmed by looking at the background information. Again, the subjective information, principally, the mini-mental state exam (MMSE) revealed that he had moderate dementia and this relates his mental status exam that showed that his judgment and insights were impaired. This paper presents various decisions that are aimed at promoting his cognitive functioning.
Background Information
The client in the case is a 76-year-old Iranian male identified as Mr. Akkad aged who came to the clinic being accompanied by his son following his strange behavior. The family physician ruled out potential organic basis, and the imaging along with the laboratory tests were normal. His son reported that his father acted strangely that has become intense over the two years.
He added that his father started being disengaged from the religious activities with the family and becomes critical of every member of the family. Unfortunately, what he perceives as being serious becomes his source of ridicule and amusement. His son added that it has been difficult for the client to remember current things to an extent, he finds it difficult to identify the right words in a conversation and would sometimes even change the conversation, promptly.
Decision #1
After analyzing the background, subjective, in conjunction with the objective data of the patient, the PMHNP decided to present the patient with Aricept 5mg orally BID that was to be taken prior to getting to bed. The physician opted for this medication because it is normally used as a startup medication for patients with Alzheimer’s disease and so it is considered as a startup medication alongside being used as a progressive medication.
After subjecting the patient to this decision, the PMHNP hoped to see a slight improvement in the health of the patient in the sense the medication has been designed to reduce the disorder symptoms (Kales et al., 2019). In contrary to the anticipated results, four weeks after adhering the decision, the patient was accompanied by his son back to the clinic who reported that he had not noticed any improvement in his father. His son stated that his father was still disengaged from religious activities.
Furthermore, the confabulation of the patient read 18 out of 30 in the MMSE the same results he scored before being engaged in the decision. Certainly, the patient did not respond to the medication which suggests nonalignment between the anticipated results with the real outcome.
Decision #2
Following the results of the previous decision, it would be necessary for the physician to introduce the patient to a new decision which, specifically, entailed increasing the Aricept dosage to Aricept 10mg orally BID. So, in this decision, the physician augmented the drug dosage for the patient to Aricept 10mg orally BID that was to be taken prior going to bed. By increasing the drug dosage, I hoped the health condition of the patient would improve gradually as the patient may even stay for some months for him to recover from the illness (Nowrangi, Lyketsos, & Rosenberg, 2015).
This nearly matched the real results because the outcome showed that the patient is tolerating the medication only that his son is still not comfortable with the condition of his father. Nevertheless, his son reports that the patient has started attending religious services, an act that makes his family happy. This suggests that the patient has started responding to the medication.
Decision #3
After learning about the potentiality of the previous decision, I felt that it is necessary to maintain the same approach and this will entail maintaining Aricept 10mg orally BID for the patient. When using Aricept pharmacological agent to treat a patient, the physicians are recommended to present a maximum of Aricept 10mg orally BID as no piece of evidence has confirmed about the potentiality of Aricept on a patient when its dosage exceeds Aricept 10mg orally BID.
Increasing the dosage beyond the recommended drug dosage may see the patient suffer some side effects associated with the drug (Berry & Amp, 2017). After adhering this decision, I hoped to see further improvement in the health condition of the patient. This would be by hearing from his son about his increased engagement in religious activities. Certainly, this nearly matched the real results where the response of the patient to the medication was positive, though, it gradual.
Ethical Considerations
The physicians, especially, those who deal with their patients vulnerable to various cognitive health complications usually face a hard time in the course of dealing with their patients. As a way of managing such constraints, ethical considerations have been developed and then, the physicians are challenged to engage these considerations when dealing with their patients. Proper administration is the first ethical consideration where the physicians are advised to adhere to the directives that have been set for them when prescribing medications to their patients.
Proper prescription is another ethical consideration where the physician is advised to prescribe the right drug dosage to the patient (Heneka et al., 2015). Based on this consideration, a physician is encouraged to modify the drug dosage based on how the patient responds to the medication. To be specific, it may be necessary for the physician to augment the drug dosage if the patient is responding positively and reduce the drug dosage or even change the medication if the patient suffers side effects associated with the medication.
Conclusion
Alzheimer’s is a neurodegenerative disorder that advances slowly but, becomes potential over time. People with the disorder find it difficult to recall current events. Some symptoms evident in such people are mood swings, motivation loss, and being disoriented among other disorder symptoms. While various medications have been designed to treat the disorder, the physicians are encouraged to stick to Aricept following its potentiality in relieving the disorder symptoms (Heneka et al., 2015).
However, they should not introduce a higher drug dosage to the patient as it may predispose the patient to serious side effects that may affect the health of the patient, potentially. That said, the physician should subject their patients to a low drug dosage when introducing them to such drugs to find out how their bodies respond to the medication.
References
Heneka, M. T., Carson, M. J., El Khoury, J., Landreth, G. E., Brosseron, F., Feinstein, D. L., … & Herrup, K. (2015). Neuroinflammation in Alzheimer's disease. The Lancet
Neurology, 14(4), 388-405. behavioral control in Alzheimer's. Social Science & Medicine, 188, 51-59. https://doi.org/10.1016/S1474-4422(15)70016-5
Berry, B., & Apesoa-Varano, E. C. (2017). Berry, B., & Apesoa-Varano, E. C. (2017).
Medication takeovers: Covert druggings and behavioral control in Alzheimer’s. Social Science & Medicine, 188, 51-59. https://doi.org/10.1016/j.socscimed.2017.07.003
Kales, H. C., Lyketsos, C. G., Miller, E. M., & Ballard, C. (2019). Management of behavioral and psychological symptoms in people with Alzheimer’s disease: an international Delphi consensus. International Psychogeriatrics, 31(1), 83-90. https://doi.org/10.1017/S1041610218000534
Nowrangi, M. A., Lyketsos, C. G., & Rosenberg, P. B. (2015). Principles and management of neuropsychiatric symptoms in Alzheimer’s dementia. Alzheimer’s research & therapy, 7(1), 12. https://doi.org/10.1186/s13195-015-0096-3
Nurs 6521 Week 8: Pharmacology for Psychological Disorders
INTRODUCTION
Woohoo! You just completed your mid-term exam! Please take a brief moment to listen to the valuable advice and inspiration from faculty and a proud graduate of the MSN program who is using her Education for Good.
How does an advanced practice nurse determine the best treatment option or pharmacotherapeutic to recommend for patients with psychological disorders?
Much like assessing or recommending pharmacotherapeutics for other conditions or disorders, as an advanced practice nurse, you may encounter a patient who presents with a psychological disorder. Understanding the guiding principles related to treating patients with psychological disorders as well as the effects of pharmacotherapeutics on a patient’s overall health and well-being is critical for the safe and effective delivery of care.
This week, you examine types of drugs prescribed to patients with psychological disorders. You also examine potential impacts of pharmacotherapeutics used to treat psychological disorders on a patient’s pathophysiology.
LEARNING OBJECTIVES
Students will:
- Evaluate patients for treatment of psychological disorders
- Analyze decisions made throughout the diagnosis and treatment of patients with psychological disorders
- Analyze impacts of pharmacotherapeutics for psychological disorders on patient pathophysiology
- Evaluate patients for treatment of generalized anxiety disorder
- Analyze decisions made throughout the diagnosis and treatment of patients with generalized anxiety disorder
LEARNING RESOURCES
- Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants(2nd ed.) St. Louis, MO: Elsevier.
- Chapter 26, “Antipsychotic Agents and Their Use in Schizophrenia” (pp. 203–213)
- Chapter 27, “Antidepressants” (pp. 214–226)
- Chapter 28, “Drugs for Bipolar Disorder” (pp. 228–233)
- Chapter 29, “Sedative-Hypnotic Drugs” (pp. 234–242)
- Chapter 30, “Management of Anxiety Disorders” (pp. 243–247)
- Chapter 31, “Central Nervous System Stimulants and Attention-Deficit/Hyperactivity Disorder” (pp. 248–254)
- Walden University, LLC. (Producer). (2019a). Adult geriatric depressionLinks to an external site.[Interactive media file]. Baltimore, MD: Author.
In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat adult geriatric depression.
- Walden University, LLC. (Producer). (2019c). Attention deficit hyperactivity disorderLinks to an external site.[Interactive media file]. Baltimore, MD: Author.
In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat attention deficit hyperactivity disorder.
- Walden University, LLC. (Producer). (2019d). Bipolar therapyLinks to an external site.[Interactive media file]. Baltimore, MD: Author.
In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics for bipolar therapy.
- Walden University, LLC. (Producer). (2019g). Generalized anxiety disorderLinks to an external site.[Interactive media file]. Baltimore, MD: Author.
In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat generalized anxiety disorder.
- Speed Pharmacology. (2018). Pharmacology – Benzodiazepines, Barbiturates, Hypnotics (Made Easy)Links to an external site.[Video]. https://www.youtube.com/watch?v=4ZHudeMho8g&t=24s
Note: This media program is approximately 8 minutes
Week 8: Discussion COMPARING AND CONTRASTING PHARMACOLOGIC OPTIONS FOR THE TREATMENT OF GENERALIZED ANXIETY DISORDER
Psychological disorders, such as depression, bipolar, and anxiety disorders can present several complications for patients of all ages. These disorders affect patients physically and emotionally, potentially impacting judgment, school and/or job performance, and relationships with family and friends. Since these disorders have many drastic effects on patients’ lives, it is important for advanced practice nurses to effectively manage patient care. With patient factors and medical history in mind, it is the advanced practice nurse’s responsibility to ensure the safe and effective diagnosis, treatment, and education of patients with psychological disorders.
Generalized Anxiety Disorder is a psychological condition that affects 6.1 million Americans, or 3.1% of the US Population. Despite several treatment options, only 43.2% of those suffering from GAD receive treatment. This week you will review several different classes of medication used in the treatment of Generalized Anxiety Disorder. You will examine potential impacts of pharmacotherapeutics used in the treatment of GAD. Please focus your assignment on FDA approved indications when referring to different medication classes used in the treatment of GAD.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
To Prepare:
- Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
- Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
- Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
- Think about a personalized plan of care based on these influencing factors and patient history with GAD.
BY DAY 3 OF WEEK 8
Post a discussion of pharmacokinetics and pharmacodynamics related to anxiolytic medications used to treat GAD. In your discussion, utilizing the discussion highlights, compare and contrast different treatment options that can be used.
BY DAY 6 OF WEEK 8
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by suggesting additional factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients diagnosed with GAD. In addition, suggest different treatment options you would suggest to treat a patient with the topic of discussion.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!