NSGCB 302 Interdisciplinary Care Provider Plan Using Evidence-Based Best Practices Assignment

NSGCB 302 Competency 2 

Interdisciplinary care entails team members from various disciplines working collaboratively, with a common objective, to set patient care goals, make clinical decisions, and share resources and responsibilities. In the interdisciplinary care approach, a team of healthcare providers from different disciplines, alongside the patient, conduct assessment, diagnosis, goal-setting, intervention, and create a care plan. The purpose of this paper is to create an interdisciplinary care provider plan for the patient in the case study.

The Interdisciplinary Care Providers to Include to Ensure the Patient Receives the Best Treatment

nsgcb 302 interdisciplinary care provider plan using evidence-based best practices assignment

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The interdisciplinary care team that will be involved in the patient’s care will include an ICU physician, ICU nurse, respiratory physiotherapist, infection preventionist, pharmacist, and dietician. The ICU physician will conduct daily patient assessments, develop the treatment plan, and evaluate and modify the plan when necessary. Besides, the ICU nurse will monitor the patient’s progress, administer treatment, ensure the patient’s comfort, and inform the team of any changes in health status (Ladbrook et al., 2019). The infection preventionist will oversee the team’s practices in patient care, educate the team on infection-prevention measures, and review the patient’s tracheal aspirate cultures.  

The respiratory therapist will check mechanical ventilators every 4 hours, document ventilator parameters, administer nebulizers, wean oxygen down, and suction airways and subglottic secretions (Seaver et al., 2020). In addition, the pharmacist will review the medication plan and collaborate with the physician to determine the patient’s medications and dosages. The dietitian will monitor the patient’s nutritional status and develop a nutritional treatment plan to ensure adequate caloric intake.

The transition to an interdisciplinary care approach will be facilitated by the team leader (ICU nurse), who will communicate with the patient of the team. The leader will guide the team members in introducing themselves to the patient and their role in his care (Ladbrook et al., 2019). Besides, interdisciplinary communication and accountability will be emphasized since they are key factors in promoting transitions in care.

Strategies to Use to Search For Evidence Related To Best Practice

The evidence on best practices for suctioning will be obtained through a literature search for peer-reviewed articles focusing on the use of saline in loosening secretions. In addition, I will search for evidence-based practices (EBP) that have been found effective in loosening endotracheal secretions. The articles will be retrieved from databases like PubMed, MEDLINE, CINAHL Plus, and the Cochrane Central Register of Controlled Trials.

Evidence Related To Best Practices

Normal saline has been widely used during endotracheal suctioning in ventilated patients. The practice is driven by a belief that saline breaks up pulmonary secretions and helps to remove thick secretions during suctioning. However, some studies have refuted this practice. Kacmarek & Li Bassi (2019) assert that routine saline instillation during endotracheal suctioning is associated with increased airway pressure, desaturation, asynchrony, and cardiovascular compromise. The amount of fluid instilled is not recovered during the consequent suctioning, which increases retained secretions. Mwakanyanga et al. (2018) explain that suctioning secretions after ventilation with non-humidified air without normal saline instillation may damage the dried mucous membrane, causing bleeding and reactions with the eventual impact on VAP. According to the article, studies that refute the instillation of sail have failed to provide alternative solutions of effective interventions of endotracheal suctioning, especially for patients ventilated with non-humidified air in low-resource settings. According to Halm (2019), the best practices to manage thick tenacious secretions and mucus plugs are humidification through adequate systemic hydration and passive or active humidification for ventilated patients and administering mucolytic agents. Al Dorzi et al. (2022) found that the rate of endotracheal tube occlusion reduced after changing humidification practices from universal heat moisture exchangers (HMEs) to active and passive humidification.

PICO Question

Among ventilated patients (P), does active and passive humidification during endotracheal suctioning (I), compared to normal saline instillation (C), reduce incidences of endotracheal tube occlusion (O) by 50% within three months (T)?

Application of PICO

PICO can be applied to address challenges and influence desirable practices in clinical practice. Health providers can be encouraged to develop PICO questions to address clinical inquiries, especially for practices that do not improve patient outcomes. This can guide them in researching various EBP practices that promote better patient outcomes and influence them to change their practices.

Conclusion

The interdisciplinary team in the care of the patient on ventilation will comprise an ICU physician, ICU nurse, respiratory physiotherapist, infection preventionist, pharmacist, and dietician. Each will be assigned roles according to their profession. Installation of saline in endotracheal tube suctioning has been challenged since it reduces oxygenation levels and increases the risk of infection. Humidification and the use of mucolytics have been recommended as alternative practices.

References

Al Dorzi, H. M., Ghanem, A. G., Hegazy, M. M., AlMatrood, A., Alchin, J., Mutairi, M., Aqeil, A., & Arabi, Y. M. (2022). Humidification during mechanical ventilation to prevent endotracheal tube occlusion in critically ill patients: A case-control study. Annals of thoracic medicine17(1), 37–43. https://doi.org/10.4103/atm.atm_135_21

Halm, M. (2019). Normal Saline Instillation during Suctioning. Nursing Research Council of United Hospital.

Kacmarek, R. M., & Li Bassi, G. (2019). Endotracheal tube management during mechanical ventilation: less is more!. Intensive Care Medicine45(11), 1632-1634. https://doi.org/10.1007/s00134-019-05777-w

Ladbrook, E., Bouchoucha, S. L., & Hutchinson, A. (2019). Lessons learned from a rapid implementation of a ventilator-associated pneumonia prevention bundle. Journal of infection prevention20(6), 274–280. https://doi.org/10.1177/1757177419846588

Mwakanyanga, E. T., Masika, G. M., & Tarimo, E. A. (2018). Intensive care nurses’ knowledge and practice on endotracheal suctioning of the intubated patient: A quantitative cross-sectional observational study. PloS one13(8), e0201743. https://doi.org/10.1371/journal.pone.0201743

Seaver, J., Grant, K., Lunn, J., Sandor, P., Moran, P., & Shapiro, D. S. (2020). A multidisciplinary approach to reducing ventilator-associated events in a busy urban hospital. American Journal of Infection Control48(7), 828–830. https://doi.org/10.1016/j.ajic.2020.02.015

Competency 2 instruction NSGCB/302

Competency 2 Assessment and Rubric Course Title: Professional Contemporary Nursing Role and Practice Competency Assessment Title:

Interdisciplinary Care Provider Plan Using Evidence-Based Best Practices Assignment Directions

 You are a staff nurse working in an intensive care unit and assigned to care for a 75-year-old Asian man who had coronary artery bypass graft surgery four days ago. The patient has a history of chronic obstructive pulmonary disease exacerbated by heavy smoking. His postoperative course has been difficult, and he has suffered a number of setbacks.

Critical Thinking Case Study Staff members, despite their diligent efforts, have not been able to wean him off the ventilator since the surgery. He has required frequent suctioning throughout the shift, and he is being evaluated for the development of ventilator-associated pneumonia. Today, when returning from lunch, you observed that an experienced nurse was suctioning your patient. His secretions were thick and you observed that the nurse was instilling saline into the patient’s endotracheal tube as she was suctioning him. The patient turned red and began coughing, and it was obvious he was in distress. You asked the nurse why she was instilling saline into his endotracheal tube. She replied that this was being done to loosen the secretions. You told her this was no longer an acceptable practice. She stated that she has many years of critical care experience and she did not care what anyone said. She insists that the only way you could loosen the patient’s secretions would be to instill saline. She also said that would be the last time she would do something for one of your patients while you were at lunch.

Use the Critical Thinking Case Study to develop your interdisciplinary care provider plan, including evidence-based best practices in which you:

 • Identify the interdisciplinary care providers you need to include to ensure your patient receives the best treatment.

 • Outline and describe how the interdisciplinary providers will be engaged in the patient’s care. • Explain how the patient will be transitioned to the care of the interdisciplinary providers.

 • Outline the strategies you will use to search for evidence related to best practices for suctioning and whether the instillation of saline while suctioning is an acceptable technique.

 • Summarize the evidence related to best practices based on your search.

 • Develop a PICO question for the instillation of saline during endotracheal suctioning.

 • Explain how you could apply PICO to problems in the workplace to influence things in clinical practice.

Include at least 2 scholarly articles as a basis for your interdisciplinary recommendations.

 Cite at least 2 scholarly articles in APA format as a basis for your interdisciplinary recommendations and evidence-based best practices presentation.

 Submit your assignment

NSGCB 302 Interdisciplinary Care Provider Plan Using Evidence-Based Best Practices Assignment

NSGCB 302 Competency 2 

Interdisciplinary care entails team members from various disciplines working collaboratively, with a common objective, to set patient care goals, make clinical decisions, and share resources and responsibilities. In the interdisciplinary care approach, a team of healthcare providers from different disciplines, alongside the patient, conduct assessment, diagnosis, goal-setting, intervention, and create a care plan. The purpose of this paper is to create an interdisciplinary care provider plan for the patient in the case study.

The Interdisciplinary Care Providers to Include to Ensure the Patient Receives the Best Treatment

nsgcb 302 interdisciplinary care provider plan using evidence-based best practices assignment

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The interdisciplinary care team that will be involved in the patient’s care will include an ICU physician, ICU nurse, respiratory physiotherapist, infection preventionist, pharmacist, and dietician. The ICU physician will conduct daily patient assessments, develop the treatment plan, and evaluate and modify the plan when necessary. Besides, the ICU nurse will monitor the patient’s progress, administer treatment, ensure the patient’s comfort, and inform the team of any changes in health status (Ladbrook et al., 2019). The infection preventionist will oversee the team’s practices in patient care, educate the team on infection-prevention measures, and review the patient’s tracheal aspirate cultures.  

The respiratory therapist will check mechanical ventilators every 4 hours, document ventilator parameters, administer nebulizers, wean oxygen down, and suction airways and subglottic secretions (Seaver et al., 2020). In addition, the pharmacist will review the medication plan and collaborate with the physician to determine the patient’s medications and dosages. The dietitian will monitor the patient’s nutritional status and develop a nutritional treatment plan to ensure adequate caloric intake.

The transition to an interdisciplinary care approach will be facilitated by the team leader (ICU nurse), who will communicate with the patient of the team. The leader will guide the team members in introducing themselves to the patient and their role in his care (Ladbrook et al., 2019). Besides, interdisciplinary communication and accountability will be emphasized since they are key factors in promoting transitions in care.

Strategies to Use to Search For Evidence Related To Best Practice

The evidence on best practices for suctioning will be obtained through a literature search for peer-reviewed articles focusing on the use of saline in loosening secretions. In addition, I will search for evidence-based practices (EBP) that have been found effective in loosening endotracheal secretions. The articles will be retrieved from databases like PubMed, MEDLINE, CINAHL Plus, and the Cochrane Central Register of Controlled Trials.

Evidence Related To Best Practices

Normal saline has been widely used during endotracheal suctioning in ventilated patients. The practice is driven by a belief that saline breaks up pulmonary secretions and helps to remove thick secretions during suctioning. However, some studies have refuted this practice. Kacmarek & Li Bassi (2019) assert that routine saline instillation during endotracheal suctioning is associated with increased airway pressure, desaturation, asynchrony, and cardiovascular compromise. The amount of fluid instilled is not recovered during the consequent suctioning, which increases retained secretions. Mwakanyanga et al. (2018) explain that suctioning secretions after ventilation with non-humidified air without normal saline instillation may damage the dried mucous membrane, causing bleeding and reactions with the eventual impact on VAP. According to the article, studies that refute the instillation of sail have failed to provide alternative solutions of effective interventions of endotracheal suctioning, especially for patients ventilated with non-humidified air in low-resource settings. According to Halm (2019), the best practices to manage thick tenacious secretions and mucus plugs are humidification through adequate systemic hydration and passive or active humidification for ventilated patients and administering mucolytic agents. Al Dorzi et al. (2022) found that the rate of endotracheal tube occlusion reduced after changing humidification practices from universal heat moisture exchangers (HMEs) to active and passive humidification.

PICO Question

Among ventilated patients (P), does active and passive humidification during endotracheal suctioning (I), compared to normal saline instillation (C), reduce incidences of endotracheal tube occlusion (O) by 50% within three months (T)?

Application of PICO

PICO can be applied to address challenges and influence desirable practices in clinical practice. Health providers can be encouraged to develop PICO questions to address clinical inquiries, especially for practices that do not improve patient outcomes. This can guide them in researching various EBP practices that promote better patient outcomes and influence them to change their practices.

Conclusion

The interdisciplinary team in the care of the patient on ventilation will comprise an ICU physician, ICU nurse, respiratory physiotherapist, infection preventionist, pharmacist, and dietician. Each will be assigned roles according to their profession. Installation of saline in endotracheal tube suctioning has been challenged since it reduces oxygenation levels and increases the risk of infection. Humidification and the use of mucolytics have been recommended as alternative practices.

References

Al Dorzi, H. M., Ghanem, A. G., Hegazy, M. M., AlMatrood, A., Alchin, J., Mutairi, M., Aqeil, A., & Arabi, Y. M. (2022). Humidification during mechanical ventilation to prevent endotracheal tube occlusion in critically ill patients: A case-control study. Annals of thoracic medicine17(1), 37–43. https://doi.org/10.4103/atm.atm_135_21

Halm, M. (2019). Normal Saline Instillation during Suctioning. Nursing Research Council of United Hospital.

Kacmarek, R. M., & Li Bassi, G. (2019). Endotracheal tube management during mechanical ventilation: less is more!. Intensive Care Medicine45(11), 1632-1634. https://doi.org/10.1007/s00134-019-05777-w

Ladbrook, E., Bouchoucha, S. L., & Hutchinson, A. (2019). Lessons learned from a rapid implementation of a ventilator-associated pneumonia prevention bundle. Journal of infection prevention20(6), 274–280. https://doi.org/10.1177/1757177419846588

Mwakanyanga, E. T., Masika, G. M., & Tarimo, E. A. (2018). Intensive care nurses’ knowledge and practice on endotracheal suctioning of the intubated patient: A quantitative cross-sectional observational study. PloS one13(8), e0201743. https://doi.org/10.1371/journal.pone.0201743

Seaver, J., Grant, K., Lunn, J., Sandor, P., Moran, P., & Shapiro, D. S. (2020). A multidisciplinary approach to reducing ventilator-associated events in a busy urban hospital. American Journal of Infection Control48(7), 828–830. https://doi.org/10.1016/j.ajic.2020.02.015

Competency 2 instruction NSGCB/302

Competency 2 Assessment and Rubric Course Title: Professional Contemporary Nursing Role and Practice Competency Assessment Title:

Interdisciplinary Care Provider Plan Using Evidence-Based Best Practices Assignment Directions

 You are a staff nurse working in an intensive care unit and assigned to care for a 75-year-old Asian man who had coronary artery bypass graft surgery four days ago. The patient has a history of chronic obstructive pulmonary disease exacerbated by heavy smoking. His postoperative course has been difficult, and he has suffered a number of setbacks.

Critical Thinking Case Study Staff members, despite their diligent efforts, have not been able to wean him off the ventilator since the surgery. He has required frequent suctioning throughout the shift, and he is being evaluated for the development of ventilator-associated pneumonia. Today, when returning from lunch, you observed that an experienced nurse was suctioning your patient. His secretions were thick and you observed that the nurse was instilling saline into the patient’s endotracheal tube as she was suctioning him. The patient turned red and began coughing, and it was obvious he was in distress. You asked the nurse why she was instilling saline into his endotracheal tube. She replied that this was being done to loosen the secretions. You told her this was no longer an acceptable practice. She stated that she has many years of critical care experience and she did not care what anyone said. She insists that the only way you could loosen the patient’s secretions would be to instill saline. She also said that would be the last time she would do something for one of your patients while you were at lunch.

Use the Critical Thinking Case Study to develop your interdisciplinary care provider plan, including evidence-based best practices in which you:

 • Identify the interdisciplinary care providers you need to include to ensure your patient receives the best treatment.

 • Outline and describe how the interdisciplinary providers will be engaged in the patient’s care. • Explain how the patient will be transitioned to the care of the interdisciplinary providers.

 • Outline the strategies you will use to search for evidence related to best practices for suctioning and whether the instillation of saline while suctioning is an acceptable technique.

 • Summarize the evidence related to best practices based on your search.

 • Develop a PICO question for the instillation of saline during endotracheal suctioning.

 • Explain how you could apply PICO to problems in the workplace to influence things in clinical practice.

Include at least 2 scholarly articles as a basis for your interdisciplinary recommendations.

 Cite at least 2 scholarly articles in APA format as a basis for your interdisciplinary recommendations and evidence-based best practices presentation.

 Submit your assignment

NSGCB 302 Interdisciplinary Care Provider Plan Using Evidence-Based Best Practices Assignment

NSGCB 302 Competency 2 

Interdisciplinary care entails team members from various disciplines working collaboratively, with a common objective, to set patient care goals, make clinical decisions, and share resources and responsibilities. In the interdisciplinary care approach, a team of healthcare providers from different disciplines, alongside the patient, conduct assessment, diagnosis, goal-setting, intervention, and create a care plan. The purpose of this paper is to create an interdisciplinary care provider plan for the patient in the case study.

The Interdisciplinary Care Providers to Include to Ensure the Patient Receives the Best Treatment

nsgcb 302 interdisciplinary care provider plan using evidence-based best practices assignment

Struggling to meet your deadline?

Get your work done on time by medical experts. Don’t wait – ORDER NOW!

The interdisciplinary care team that will be involved in the patient’s care will include an ICU physician, ICU nurse, respiratory physiotherapist, infection preventionist, pharmacist, and dietician. The ICU physician will conduct daily patient assessments, develop the treatment plan, and evaluate and modify the plan when necessary. Besides, the ICU nurse will monitor the patient’s progress, administer treatment, ensure the patient’s comfort, and inform the team of any changes in health status (Ladbrook et al., 2019). The infection preventionist will oversee the team’s practices in patient care, educate the team on infection-prevention measures, and review the patient’s tracheal aspirate cultures.  

The respiratory therapist will check mechanical ventilators every 4 hours, document ventilator parameters, administer nebulizers, wean oxygen down, and suction airways and subglottic secretions (Seaver et al., 2020). In addition, the pharmacist will review the medication plan and collaborate with the physician to determine the patient’s medications and dosages. The dietitian will monitor the patient’s nutritional status and develop a nutritional treatment plan to ensure adequate caloric intake.

The transition to an interdisciplinary care approach will be facilitated by the team leader (ICU nurse), who will communicate with the patient of the team. The leader will guide the team members in introducing themselves to the patient and their role in his care (Ladbrook et al., 2019). Besides, interdisciplinary communication and accountability will be emphasized since they are key factors in promoting transitions in care.

Strategies to Use to Search For Evidence Related To Best Practice

The evidence on best practices for suctioning will be obtained through a literature search for peer-reviewed articles focusing on the use of saline in loosening secretions. In addition, I will search for evidence-based practices (EBP) that have been found effective in loosening endotracheal secretions. The articles will be retrieved from databases like PubMed, MEDLINE, CINAHL Plus, and the Cochrane Central Register of Controlled Trials.

Evidence Related To Best Practices

Normal saline has been widely used during endotracheal suctioning in ventilated patients. The practice is driven by a belief that saline breaks up pulmonary secretions and helps to remove thick secretions during suctioning. However, some studies have refuted this practice. Kacmarek & Li Bassi (2019) assert that routine saline instillation during endotracheal suctioning is associated with increased airway pressure, desaturation, asynchrony, and cardiovascular compromise. The amount of fluid instilled is not recovered during the consequent suctioning, which increases retained secretions. Mwakanyanga et al. (2018) explain that suctioning secretions after ventilation with non-humidified air without normal saline instillation may damage the dried mucous membrane, causing bleeding and reactions with the eventual impact on VAP. According to the article, studies that refute the instillation of sail have failed to provide alternative solutions of effective interventions of endotracheal suctioning, especially for patients ventilated with non-humidified air in low-resource settings. According to Halm (2019), the best practices to manage thick tenacious secretions and mucus plugs are humidification through adequate systemic hydration and passive or active humidification for ventilated patients and administering mucolytic agents. Al Dorzi et al. (2022) found that the rate of endotracheal tube occlusion reduced after changing humidification practices from universal heat moisture exchangers (HMEs) to active and passive humidification.

PICO Question

Among ventilated patients (P), does active and passive humidification during endotracheal suctioning (I), compared to normal saline instillation (C), reduce incidences of endotracheal tube occlusion (O) by 50% within three months (T)?

Application of PICO

PICO can be applied to address challenges and influence desirable practices in clinical practice. Health providers can be encouraged to develop PICO questions to address clinical inquiries, especially for practices that do not improve patient outcomes. This can guide them in researching various EBP practices that promote better patient outcomes and influence them to change their practices.

Conclusion

The interdisciplinary team in the care of the patient on ventilation will comprise an ICU physician, ICU nurse, respiratory physiotherapist, infection preventionist, pharmacist, and dietician. Each will be assigned roles according to their profession. Installation of saline in endotracheal tube suctioning has been challenged since it reduces oxygenation levels and increases the risk of infection. Humidification and the use of mucolytics have been recommended as alternative practices.

References

Al Dorzi, H. M., Ghanem, A. G., Hegazy, M. M., AlMatrood, A., Alchin, J., Mutairi, M., Aqeil, A., & Arabi, Y. M. (2022). Humidification during mechanical ventilation to prevent endotracheal tube occlusion in critically ill patients: A case-control study. Annals of thoracic medicine17(1), 37–43. https://doi.org/10.4103/atm.atm_135_21

Halm, M. (2019). Normal Saline Instillation during Suctioning. Nursing Research Council of United Hospital.

Kacmarek, R. M., & Li Bassi, G. (2019). Endotracheal tube management during mechanical ventilation: less is more!. Intensive Care Medicine45(11), 1632-1634. https://doi.org/10.1007/s00134-019-05777-w

Ladbrook, E., Bouchoucha, S. L., & Hutchinson, A. (2019). Lessons learned from a rapid implementation of a ventilator-associated pneumonia prevention bundle. Journal of infection prevention20(6), 274–280. https://doi.org/10.1177/1757177419846588

Mwakanyanga, E. T., Masika, G. M., & Tarimo, E. A. (2018). Intensive care nurses’ knowledge and practice on endotracheal suctioning of the intubated patient: A quantitative cross-sectional observational study. PloS one13(8), e0201743. https://doi.org/10.1371/journal.pone.0201743

Seaver, J., Grant, K., Lunn, J., Sandor, P., Moran, P., & Shapiro, D. S. (2020). A multidisciplinary approach to reducing ventilator-associated events in a busy urban hospital. American Journal of Infection Control48(7), 828–830. https://doi.org/10.1016/j.ajic.2020.02.015

Competency 2 instruction NSGCB/302

Competency 2 Assessment and Rubric Course Title: Professional Contemporary Nursing Role and Practice Competency Assessment Title:

Interdisciplinary Care Provider Plan Using Evidence-Based Best Practices Assignment Directions

 You are a staff nurse working in an intensive care unit and assigned to care for a 75-year-old Asian man who had coronary artery bypass graft surgery four days ago. The patient has a history of chronic obstructive pulmonary disease exacerbated by heavy smoking. His postoperative course has been difficult, and he has suffered a number of setbacks.

Critical Thinking Case Study Staff members, despite their diligent efforts, have not been able to wean him off the ventilator since the surgery. He has required frequent suctioning throughout the shift, and he is being evaluated for the development of ventilator-associated pneumonia. Today, when returning from lunch, you observed that an experienced nurse was suctioning your patient. His secretions were thick and you observed that the nurse was instilling saline into the patient’s endotracheal tube as she was suctioning him. The patient turned red and began coughing, and it was obvious he was in distress. You asked the nurse why she was instilling saline into his endotracheal tube. She replied that this was being done to loosen the secretions. You told her this was no longer an acceptable practice. She stated that she has many years of critical care experience and she did not care what anyone said. She insists that the only way you could loosen the patient’s secretions would be to instill saline. She also said that would be the last time she would do something for one of your patients while you were at lunch.

Use the Critical Thinking Case Study to develop your interdisciplinary care provider plan, including evidence-based best practices in which you:

 • Identify the interdisciplinary care providers you need to include to ensure your patient receives the best treatment.

 • Outline and describe how the interdisciplinary providers will be engaged in the patient’s care. • Explain how the patient will be transitioned to the care of the interdisciplinary providers.

 • Outline the strategies you will use to search for evidence related to best practices for suctioning and whether the instillation of saline while suctioning is an acceptable technique.

 • Summarize the evidence related to best practices based on your search.

 • Develop a PICO question for the instillation of saline during endotracheal suctioning.

 • Explain how you could apply PICO to problems in the workplace to influence things in clinical practice.

Include at least 2 scholarly articles as a basis for your interdisciplinary recommendations.

 Cite at least 2 scholarly articles in APA format as a basis for your interdisciplinary recommendations and evidence-based best practices presentation.

 Submit your assignment