FUNDAMENTALS OF NURSING PRACTICE
Summative Assessment
Case: A 48 year old male is admitted to medicine ward because of hypertension. His BP upon admission is 160/100. He is conscious but with a flushed
face. His pulse is bounding, strong but with a normal rate-80 bpm; RR is 21 bpm, T- 37.1 0C per axilla. He complained of nuchal pain with a pain scale
of 4/10. What is the main problem of the patient? What is his secondary problem? Make a NCP of the main and secondary problem.
Assessment
Subjective:
The patient complained of
nuchal pain with a pain scale
of 4/10.
Objective:
BP = 160/100
PR = 80 bpm
RR = 21 bpm
T = 37.1C per axilla
Admitted due to hypertension.
Patient is conscious but has a
flushed face.
Pulse is bounding and strong.
Presence of nuchal pain.
Nursing Diagnosis
Ineffective coping related to
elevated blood pressure as
evidenced by normality in
other vital signs and
manifestation of a flushed
face, bounding and strong
pulse and neck ache.
Objective
Short term:
After an hour of nursing
interventions, the patient’s:
- BP will decrease to from
160/100 to 140/90.
- Will have less of a flushed
face.
- Pulse pressure will not be as
bounding
Long term:
At the end of the shift, the
patient’s:
- BP will lower and be
stabilized at 120/80.
- There will be no more
evidence of a flushed face
- Pulse will have stopped
bounding
- Understanding and ability to
cope will have improved.
Intervention
Independent:
1. Position patient in a
comfortable position such as
fowler’s.
2. Provide a calm
environment by limiting
unnecessary noise, dimming
bright lights, and removing
any factors that may cause
stress.
3. Demonstrate and assist
patient in doing deep
breathing exercises.
4. Encourage patient to do
relaxation techniques and
diversionary activities.
5. Provide rest periods to
promote relief, sleep and
relaxation.
6. Assess and control
present.
7. Monitor the patient’s
response to the medications
controlling the BP (Checking
for the BP and HR before and
after).
8. Educate the patient about
the disease process,
treatment regimen, possible
and changes to apply to their
diet or lifestyle.
Evaluation
After an hour, the patient’s BP
decreased to 140/90, the
pulse became less bounding
and strong, and they were
observed to have less signs of
a flushed face. Patient
verbalized improved
comfortability after position
change and practicing 15
minutes of deep breathing.
At the end of the shift, the
patient’s BP decreased and
stabilized at 120/80, the pulse
returned to normal, and they
were observed to have no
signs of flushed face. Patient
demonstrated better
knowledge in the disease, risk
factors and steps of
prevention as well as better
coping techniques.
9. Assess patient impairment
in coping.
10. Assist patient in identifying
stressors and possible
strategies for coping.
Interdependent:
1. Implement fluid restrictions
if clinically appropriate.
2. Implement dietary
restrictions, as indicated -
such as low sodium and
calories, avoiding refined
carbohydrates, high-fat foods
and highly processed foods.
3. Encourage patient to
implement regular physical
activity.
Dependent:
1. Administer medication as
ordered.
2. Refer to Attending
Physician
 Assessment Nursing Diagnosis Objective Intervention Evaluation
Subjective: Acute pain related Short term: Independent: After 45 minutes of nursing
The patient complained of ineffective coping to After 30-45 minutes of 1. Position patient in a comfortable interventions, the patient’s
nuchal pain with a pain scale primary concern nursing interventions, the position such as semi-fowler’s or pain score has decrease to
of 4/10. evidence by patient’s patient’s pain score of 4/10 fowler’s (this may aid with primary 2/10. If there is signs of
report of pain. will decrease to 2/10. If problem If it still isn’t fully addressed) elevated blood pressure due
Objective: there is signs of elevated 2. Provide a calm environment by to pain, this has lowered.
BP = 160/100 blood pressure due to pain, limiting unnecessary noise, dimming Patient also verbalized that
PR = 80 bpm this will be lowered. Patient bright lights, and removing any factors they are more comfortable
RR = 21 bpm will verbalize feelings of that may cause stress. semi-fowler’s position. They
T = 37.1C per axilla comfort. 3. Demonstrate and assist patient in have been able to practice
doing deep breathing exercises. deep breathing exercise for
Admitted due to hypertension. 4. Encourage patient to do relaxation 10 minutes.
Long term: techniques and diversionary activities
Patient is conscious but has a After the shift, the patient’s such as allowing patient to verbalize At the end of the shift, the
flushed face. pain score of 2/10 will concerns, listening to his favorite patient had no more signs or
Pulse is bounding and strong. decrease to 0/10. Any signs music, or reading his favorite book or complains of pain and
Presence of nuchal pain. of elevated blood pressure other activities the patient may find exhibited improved mood.
will be stabilized and the relaxing, to divert their attention from
patient’s mood will improve. the painful stimulus.
5. Provide rest periods to promote
relief, sleep and relaxation.
Interdependent:
1. If suitable, massage affected area.
2. Apply hot compress on the neck
area for 10 minutes.
Dependent:
1. Administer pain medication as
ordered.
2. Refer to Attending Physician