Running Head: Homework 2 Homework 2 Homework 2 Care plan for MI NUR3125 Fall 2017 This patient is presenting to the emergency with symptoms that indicate a Myocardial Infarction. The patient, who is a 48-year-old man, is stating a 3-day history of sub sternal chest pain that is radiating to his back. The symptoms started up while he was mowing his lawn. He stated the pain has eased up over time. He also reported mild trouble with breathing and some nausea but no vomiting. He exercises daily, but does report that he eats a lot of fast food. His last total cholesterol was 232 mg/dL. He also has a 15-year history of tobacco use and family history of myocardial infarction (MI), specifically his father had an MI at age 54 and his grandfather at age 58. His current blood pressure is elevated at 158/98 and heartrate of 102 bpm, his respiratory rate is currently high at 26 breaths/min and noted mild use of accessory muscles upon examination. Lungs are noted to have slight inspiratory crackles at both lung bases. Jugular venous distention is noted at less than 2cm bilaterally. His lab work reveals an elevated Troponin at 2.9 ng/ml, elevated Creatinine phosphokinase at 141 units/L, and an elevated CK-MB/CK isoenzyme at 2%. Elevated troponin indicates damage to the heart muscle, and the elevated Creatinine phosphokinase and CK-MB/CK isoenzyme along with all these other symptoms and labs indicate a heart attack. ECG is done and shows ST elevation and T wave inversion, also noted with premature ventricular contractions. The lab values and ST elevation point to a Myocardial Infarction and Transmural ischemia that will require immediate attention. I have chosen three NANDA nursing diagnoses for this patient, with the first one being the priority. The three I choose are: · Decreased Cardiac Output related to altered heart rate and ischemia as evidenced by ECG showing an ST elevation, elevated Troponin, and patient stating he has had chest pain for three days. · Acute Pain related to tissue damage in the myocardium from inadequate blood supply as evidenced by elevated troponin labs and patient reporting chest pain that radiates to back for three days. · Ineffective Health Maintenance related to deficient knowledge about self-care and treatment as evidenced by patient stating he eats fast food often and has had elevated blood pressure and cholesterol at past appointments, and patient admitting to smoking ½ pack of cigarettes daily despite family history of MI. Care Plan Diagnosis #1 Myocardial Infarction NANDA Diagnosis 1: Decreased Cardiac Output related to altered heart rate and ischemia as evidenced by ECG showing an ST elevation, elevated Troponin, and patient stating he has had chest pain for three days. NOC (Nursing Outcome Classification) Label: Tissue Perfusion Expected Client Outcomes: 1. Patient will demonstrate adequate cardiac output evidenced by blood pressure, heart rate, and heart rhythm within normal pa.

1. Running Head: Homework 2
Homework 2
Homework 2
Care plan for MI
NUR3125
Fall 2017
This patient is presenting to the emergency with symptoms that

2. indicate a Myocardial Infarction. The patient, who is a 48-year-
old man, is stating a 3-day history of sub sternal chest pain that
is radiating to his back. The symptoms started up while he was
mowing his lawn. He stated the pain has eased up over time. He
also reported mild trouble with breathing and some nausea but
no vomiting. He exercises daily, but does report that he eats a
lot of fast food. His last total cholesterol was 232 mg/dL. He
also has a 15-year history of tobacco use and family history of
myocardial infarction (MI), specifically his father had an MI at
age 54 and his grandfather at age 58. His current blood pressure
is elevated at 158/98 and heartrate of 102 bpm, his respiratory
rate is currently high at 26 breaths/min and noted mild use of
accessory muscles upon examination. Lungs are noted to have
slight inspiratory crackles at both lung bases. Jugular venous
distention is noted at less than 2cm bilaterally. His lab work
reveals an elevated Troponin at 2.9 ng/ml, elevated Creatinine
phosphokinase at 141 units/L, and an elevated CK-MB/CK
isoenzyme at 2%. Elevated troponin indicates damage to the
heart muscle, and the elevated Creatinine phosphokinase and
CK-MB/CK isoenzyme along with all these other symptoms and
labs indicate a heart attack. ECG is done and shows ST
elevation and T wave inversion, also noted with premature
ventricular contractions. The lab values and ST elevation point
to a Myocardial Infarction and Transmural ischemia that will
require immediate attention.
I have chosen three NANDA nursing diagnoses for this patient,
with the first one being the priority. The three I choose are:
· Decreased Cardiac Output related to altered heart rate and
ischemia as evidenced by ECG showing an ST elevation,
elevated Troponin, and patient stating he has had chest pain for
three days.
· Acute Pain related to tissue damage in the myocardium from
inadequate blood supply as evidenced by elevated troponin labs
and patient reporting chest pain that radiates to back for three
days.

3. · Ineffective Health Maintenance related to deficient knowledge
about self-care and treatment as evidenced by patient stating he
eats fast food often and has had elevated blood pressure and
cholesterol at past appointments, and patient admitting to
smoking ½ pack of cigarettes daily despite family history of MI.
Care Plan Diagnosis #1 Myocardial Infarction
NANDA Diagnosis 1: Decreased Cardiac Output related to
altered heart rate and ischemia as evidenced by ECG showing an
ST elevation, elevated Troponin, and patient stating he has had
chest pain for three days.
NOC (Nursing Outcome Classification) Label: Tissue Perfusion
Expected Client Outcomes:
1. Patient will demonstrate adequate cardiac output evidenced
by blood pressure, heart rate, and heart rhythm within normal
parameters by shift end tonight (7pm).
2. Patient will report resolution of chest pain by shift end
tonight (7pm).
3. Patient’s respiratory rate will be within normal limits by shift
end tonight (7pm).
NIC (Nursing Intervention Classification) Label: Cardiac Care
Nursing Interventions/Strategies
1. Administer oxygen to the patient as needed and as ordered by
the physician.
2. Administer aspirin to the patient as ordered by the physician.
3.Prepare the patient with intravenous access and education for
cardiac catheterization and possible PCI in under 90 minutes
door to balloon time for a STEMI.
4.Maintain the patient on bedrest as ordered by the physician.
Scientific Rationales with Citations
1.Supplementing oxygen increases the oxygen availability to the
myocardium (Ackley and Ladwig 2014).
2. Aspirin prevents platelet clumping and aggregation, thus
preventing thrombus formation (Anderson et al,2011; Antman et

4. al,2008).
3. A time of under 90 mins door to balloon has been associated
with improved client outcomes (Anderson et al, 2011; Antman
et al, 2008).
4. Anti-ischemic therapy would include reducing and
minimizing oxygen demand by the myocardium in the early
hospital phase (Anderson et al, 2011).
A common alteration of cardiovascular function is
Hypertension. Hypertension is defined as a consistent elevation
of systemic arterial blood pressure. It is the most common
primary diagnosis in the United States, and, one in three
American people has hypertension. Stage one Hypertension is
diagnosed when blood pressures are in the 140-159/90-99 range,
and Stage two is diagnosed when blood pressures are Systolic
greater than or equal to 160 and Diastolic greater than or equal
to 100.
The pathophysiology of Hypertension is a prolonged and
sustained increase in peripheral resistance, an increase in
volume of circulating blood, or both. Primary hypertension
accounts for 92 to 95% of individuals with Hypertension, while
Secondary, which is caused by an underlying disorder such as
kidney disease, accounts for 5-8% of cases.
The Wisconsin Medical Journal published an article in 2012
regarding tracking patient blood pressures in an outpatient
medical office setting. All staff were retrained on how to take a
proper blood pressure, and patient’s results were tracked and
followed so they could stay on top of diagnosing early signs of
hypertension if needed. The staff was also followed, and
randomly observed to ensure the blood pressures were being
taken properly and accurate. As a result, Blood pressure control
(<140/90) in patients age 18-85 without diabetes improved from
68.4% to 75.8% in 3 months.
This would be a huge help in the hospital setting. We as nurses,

5. often have so many things to pay attention to, that tracking a
patient’s boarder line blood pressure is sometimes missed. If we
could train Nursing assistants and Nurses again to properly
check and get accurate blood pressure readings, this would also
be a huge benefit for patient’s. I have observed many times that
a patient’s blood pressure is reported as high, when in fact the
patient had just been ambulating and was out of breath when the
blood pressure was measured. This is not an accurate reading. I
also feel, because we have so many readmissions, having a
system that tacks and trends blood pressure readings and can
spot early hypertension in patient’s, would be a great benefit for
the nursing practice. The journal article is attached to this
assignment.
References:
Ackley, B.J, & Ladwig, G.B. (2014. Nursing diagnosis
handbook: an evidence-based guide to planning care. Tenth

6. edition. Maryland Heights, Missouri: Mosby Elsevier
Huether, S. E., & McCance, K. L. (2017). Understanding
pathophysiology. United States: Elsevier.
Wisconsin Medical Journal. Office based Nursing Staff
Management of Hypertension in Primary Care. 2012. Retrieved
from
http://eds.b.ebscohost.com.db24.linccweb.org/ehost/pdfviewer/p
dfviewer?vid=2&sid=b53dee4f-f5b0-45e3-9f4d-
a1814e8856d1%40sessionmgr104
Betsey Barnett, PhD MCS 105
Shoreline Community College Shoreline, WA 98133 USA
Racial/Ethnic Identity Development
(From Ponterotto, J.G.; Pedersen, P.B. (1993) Preventing
Prejudice: A guide for counselors and educators Sage
Publications)
There is a developmental process to understanding ourselves as
members of a society that assigns meaning to race
(social class, gender). Identity development models help
explain individual differences. Racial identity influences
how you experience the world, how you see others, and how you

7. communicate
White Racial Identity
Stage One: Pre-exposure/Pre-contact
• Whites have not begun to examine their own ethnicity
• Lack of awareness of self as a racial being
• Unaware of social expectations and role regarding race
• Unconscious identification with Whiteness
• Acceptance of stereotypes about minority groups
•
(Transition: Something Happens)
Stage Two: Conflict Stage
• Individuals begin to recognize that they live in a society that
discriminates based on race
• Awareness of realities of prejudice, discrimination, racism
• Conflict over new knowledge about race relations
• Marked by feelings of confusion, guilt, anger and depression

8. (Transition: Something Happens)
Individuals respond to their new awareness in one of two ways:
EITHER:
Stage Three: Pro-Minority/Anti-Racism
• Whites begin to resist racism /identify with minority groups
• Identification alleviates strong feelings of guilt/confusion
• Still have self-focused anger and guilt, and anger at White
culture
in general
OR:
Stage Four: Retreat into White Culture
• Retreat from situations that stimulate internal conflict
• Retreat into comfort and security of same-race contact
• Overidentification with Whiteness
• Defensiveness about White Culture
• Fear and anger toward people of color

9. •
(Transition: Something Happens)
Stage Five: Redefinition/Integration
• White people redefine what it means to be White
• Whites acknowledge responsibility for maintaining racism
• Individuals become more balanced, more open to acquiring
new
information
Minority Identity Development
Stage One: Conformity
• Preference for the values/ norms of dominant culture
• Strong desire to assimilate into the dominate culture
• Negative self-deprecating attitudes toward own group
• Attitudes toward the dominant group are positive
• Denial

10. (Transition: Something Happens)
Stage Two: Dissonance
• Individual begins to question pro-White attitude /behaviors
• Individuals alternate between self- and group-appreciation and
depreciating attitudes and behaviors
• Confusion
(Transition: Something Happens)
Stage Three: Resistance and Immersion
• Individuals embrace own racial/ethnic group completely
• Blind endorsement of one’s group and all the values/attitudes
attributed to the group
• Individuals accept racism and oppression as a reality
• Rejection of the values and norms of the dominant group
• Empathic understanding /overpowering ethnocentric bias
(Transition: Something Happens)

11. Stage Four: Introspection
• Individuals develop a security in their racial identity that
allows
questioning of rigid Resistance attitudes
• Re-direct anger/ negativity toward “White system” to
exploration of individual and group identity issues
• Conflict between allegiance to one’s own ethnic group and
issues of personal autonomy
• Individuals acknowledge there is variation amongst all groups
of
people
(Transition: Something Happens)
Stage Five: Synergetic Articulation and Awareness
• Confident and secure racial identity
• Desire to eliminate all forms of oppression
• High positive regard toward self and toward one’s group
• Respect and appreciation for other racial/cultural groups

12. • Openness to constructive elements of dominant culture
White Racial IdentityStage One: Pre-exposure/Pre-contactStage
Two: Conflict StageStage Four: Retreat into White
CultureMinority Identity DevelopmentStage One: Conformity
Summer
Homework 1
Case Study
Health History (subjective data)
• Darrell Kinsey is a 55-year old, male admitted to the hospital
with an upper gastrointestinal bleed
(UGIB). For this admission, he reported epigastric pain, melena,
fatigue, dizziness, and mild shortness
of breath with exertion for the past 2 days. His medical history
includes arthritis of the right shoulder
and hypercholesterolemia. He has an allergy to nuts which
causes hives.
• In addition, he reports a previous hospitalization 4 months ago
for UGIB in which he was newly
diagnosed with a duodenal peptic ulcer, but was negative for
Helicobacter pylori infection. He was
treated with endoscopic injection therapy and a blood
transfusion. He cannot recall his hemoglobin
level or how many units of blood he was given at that time.
• His current medications are Nexium 20 mg/day and Lipitor 20
mg/day. He has discontinued any use of

13. non-steroidal anti-inflammatory drugs (NSAID), alcohol, and
caffeine.
Physical Assessment and Diagnostic Evaluation (objective data)
Emergency department,
• Vital signs: Oral temperature 98.5°F; respiratory rate (RR) =
28 breaths/min, slightly labored; heart
rate (HR) = sinus tachycardia (ST) at 118 beats/min; blood
pressure (BP)= 98/54 mmHg; oxygen
saturation = 89% on room air; pain = 4/10 (0-10 pain scale) in
the epigastric area.
• Diagnostic results: Abnormal serum results were hemoglobin
(HB) = 7.9 gm/dL and hematocrit (HCT)
= 35%. Other serum blood counts, chemistry, and coagulation
results were within normal ranges.
Upper endoscopy revealed no active bleeding. Chest x-ray
showed clear lungs.
• Treatment: The patient was placed on 2L of oxygen via nasal
cannula, intravenous (IV) fluids were
started, and indwelling urinary catheter placed with 250 cc of
clear urine output.
Admission to the nursing floor,
• The patient was alert, oriented, and cooperative upon
admission to the medical-surgical unit and a
transfusion of 1 unit of packed red blood cells was started.
Within 30 minutes of the transfusion; the
patient called the nurse complaining of chills, dizziness, and
nausea. He appeared anxious and restless.
• His immediate vital signs were: Oral temperature 102° F; RR
= 32 breaths/min, labored; HR = ST at

14. 136 beats/min; BP= 88/50 mmHg; oxygen saturation = 87% on
2L of oxygen via nasal cannula; pain =
8/10 in the epigastric area and extending to the lower back.
• Skin, mucous membranes: Oral mucosal membranes pale. Skin
and sclera slightly jaundiced.
Sanguineous fluid oozing from the IV access site and other
venipuncture sites.
• Cardiopulmonary: Lung sounds diminished in both bases with
fine crackles. S1 and S2 auscultated.
Extremities cool with trace pedal edema, peripheral pulses 1+,
capillary refill 2-3 seconds.
• Abdomen, musculoskeletal: Slight distention, soft, tender,
hypoactive bowel sounds. Minimal dark
reddish urine in collection bag. Musculoskeletal: There was full
range of motion (ROM) and strength
in extremities except right shoulder (limited ROM, strength
4/5).
• STAT diagnostic results: Abnormal serum results were HB =
6.8 gm/dL, HCT = 30%; potassium = 5.8
mEq/L, total bilirubin = 2.6 mg/dL, blood urea nitrogen = 34
mg/dL, creatinine = 2.0 mg/dL, direct
Coombs test positive for antiglobulin; prothrombin time and
partial thromboplastin times increased.
Urinalysis positive for free hemoglobin. Chest x-ray positive for
bibasilar pulmonary infiltrates.
Summer
To answer questions 1-3, use the scenario above
1. Identify the likely disorder, the underlying pathophysiology

15. (i.e., cellular and tissue changes), and
relate the changes to abnormal findings to support your
interpretation. (20 points) Hint: We are in
2. Identify all NANDA nursing diagnoses labels (just the label!)
that apply to this patient (e.g.,
impaired swallowing). Identify the priority (#1) nursing
diagnosis label; and for the (#1) nursing
diagnosis label, explain the nursing interventions to address the
identified problem. Provide
evidence-based rationale to explain the need and/or benefit of
each intervention. For interventions,
include what the nurse should “monitor/assess”, “do”, and
“teach” to the client. (20 points)
3. Describe at least TWO medical therapies used to treat the
disorder and explain their specific
mechanism of action and intended impact at the cellular and/or
tissue level. (15 points)
To answer questions 4-5, choose ONE disorder from this week’s
reading
4. For the chosen disorder, identify the disorder and describe
the impact on the population including
incidence, prevalence, costs, morbidity, mortality, and/or other
appropriate issues. Be sure to
identify the disorder, the population associated with the data,
and the year(s) of data. (15 points)
5. For the chosen disorder, locate recommendations in a nursing
journal article or professional

16. nursing organization. Provide a brief summary of the
information and specific recommendations
for nursing actions to improve care for patients. (15 points)
Hint: To increase the likelihood of
locating a nursing journal or organization, look for some form
of the word “nurse” in the journal
or organizational name!
Scholarly Writing: Use correct spelling, grammar, sentence
structure, formatting, professional terms,
title page, paraphrasing, citations, and references. Sources
current (<5 years old) and professional (15
points)
Homework 1 (should be approx. 3.5 pages of content, not
including title or reference page)
General Tips
· Page 1 is the title page. Last page is the reference list. Do not
include questions.
· Use scholarly writing with correct spelling and complete
sentences. Avoid nursing documentation-style writing. No direct
quotes allowed.
· If abbreviations are used, they are introduced and used
consistently afterwards
· Format using APA style
· Turnitin guidelines - your goal is <20% matching AND no
verbatim sentences/passages. Do not worry about matches of
non-content items (title page, headings, etc.)
· Support answers using current, professional/reliable sources -
sources should be published within the last 5 years (2015 or
later). Paraphrase and cite sources as needed. For any source

17. cited in the text, include full reference in reference list.
· Examples of professional/scientific/published sources:
textbooks, journal articles, government/scientific sites
· Journal articles – can be found in BSN library databases, see
SPC single-sign on page
· Government sites – e.g., Centers for Disease Control and
Prevention, National Institute of Allery and Infectious Disease,
AIDS.gov, Professional Nursing Organizations (e.g., Oncology
Nursing Society), World Health Organization, National Cancer
Institute
· Examples of inappropriate sources - should NOT use Wiki
anything, WebMD, Medscape, Health system sites (Johns
Hopkins, Mayo Clinic, Cleveland Clinic)
Question 1 (approx. 1 page)– Disease process and underlying
pathophysiology
· Identify the likely disease process - is pretty self-explanatory
· Explain underlying pathophysiology (evidence to support your
interpretation) – underlying cellular/tissue changes that lead to
abnormal findings…remember this is a pathophysiology class.
Question 2 (approx. 1 page) – Identify all appropriate NANDA
labels, identify #1 priority NANDA label, provide nursing care
interventions with rationales
· Identify NANDA labels that apply to the patient based on the
manifestations (e.g., pain, respiratory distress, etc.)
· Among the NANDAS, identify the #1 priority NANDA and
explain what the nurse should
· Assess/monitor - what should the nurse assess/monitor and
provide evidence of the benefit/need
· Do - what actions should the nurse complete to promote
improvement and provide evidence of the benefit/need
· Teach - what should the nurse teach the patient/family and
evidence of the benefit/need
Question 3 (approx. ½ page)- Medical care and intended impact

18. · Explain TWO items the nurse should expect to be ordered for
the patient and the intended impact of the treatment on the
underlying pathophysiology. Be precise and provide specific
mechanism of action at the cellular lever (e.g., medication with
specific cellular actions)
Question 4 (approx. ½ page) – Choose a disorder from immune
system chapters…and discuss impact on population. Give year
of information and use most current information available. You
will find newer statistics online than in the textbook
· Incidence = number of NEW cases
· Prevalence = number of ALL (new and old) cases
· Cost – can be anything you can find such as hospitalizations,
medications, etc. Varies depending on the disease chosen
· Mortality – those who died from a disease
· Morbidity – You may see this term used instead of
incidence/prevalence. You’ll have to read carefully to determine
if the estimate is for incidence or prevalence. If you already
addressed incidence and/or prevalence, morbidity is covered.
· Anything else?
Question 5 (approx. ½ page) – For disease in #3, find EBP
recommendations and apply them to nursing
· Find article in a nursingjournal or professional
nursingorganization. To be sure a journal is nursing (and NOT
medical/physician), look for some form of the word “nurse” in
the journal or organization name. For example, Critical Care
Nurse, Oncology Nursing Journal, etc. The biggest mistake
students make in this question is they fail to use a nursing
source.
· Describe the recommendations and how they should be applied
to improve nursing care…in other words; precisely, what should
the nurse “do” based on the information to improve care?