# Situation: A public health nurse at a Rural Health Unit (RHU) in an agricultural municipality sees clients referred by the barangay health workers (BHWs). During PhilPEN risk assessment, a 52-year-old woman had seated blood pressure readings of 150/95 mmHg and 148/92 mmHg on two separate visits. She smokes and has a waist circumference of 88 cm. Under PhilPEN, what should MAINLY determine how intensively her condition is managed?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627013  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: A public health nurse at a Rural Health Unit (RHU) in an agricultural municipality sees clients referred by the barangay health workers (BHWs).

During PhilPEN risk assessment, a 52-year-old woman had seated blood pressure readings of 150/95 mmHg and 148/92 mmHg on two separate visits. She smokes and has a waist circumference of 88 cm. Under PhilPEN, what should MAINLY determine how intensively her condition is managed?

## 보기

1. The number of NCD risk factors she has, counted without the chart
2. Her total cardiovascular risk on the WHO/ISH chart **✔ 정답**
3. The higher of her two systolic blood pressure readings
4. The number of cigarettes she smokes each day at present

**정답: 2**

## 해설

Her repeated readings of 140/90 mmHg or higher confirm hypertension. PhilPEN then estimates total cardiovascular risk with the WHO/ISH chart, which combines age, sex, systolic blood pressure, smoking, diabetes, and cholesterol when available. The intensity of management follows the risk level; each single factor is only one input to that estimate.

## 심화 해설

Total risk, not a single number, sets the intensity of care
This client has two seated readings of 150/95 mmHg and 148/92 mmHg taken on separate visits. Repeated readings of 140/90 mmHg or higher confirm hypertension, so the diagnosis is no longer in question. The question asks something different: once hypertension is established, what decides how intensively the RHU manages her? Under the Philippine Package of Essential NCD Interventions (PhilPEN), the answer is her total cardiovascular risk estimated with the WHO/ISH risk prediction chart. In PhilPEN, the intensity of follow-up, counseling, and drug treatment follows the client's overall risk level, not any one reading or habit.

How the WHO/ISH chart works
The WHO/ISH chart is a color-coded table that estimates the chance of a fatal or nonfatal cardiovascular event, such as a heart attack or stroke, over the next 10 years. The nurse finds the client's cell by combining several inputs at once: age, sex, systolic blood pressure, smoking status, presence of diabetes, and total cholesterol when it can be measured. Where cholesterol testing is not available, the chart version without cholesterol is used. Each factor shifts the estimate, but none of them acts alone. A client with a moderately high systolic pressure and several other factors can land in a higher risk band than a client with a higher pressure and no other factor. That is why PhilPEN asks the nurse to plot the client on the chart rather than react to a single value.

Why the distractors fall short
Counting risk factors without the chart treats every factor as equal, but the chart weighs them differently and also accounts for age and sex, which a simple count ignores. Her waist circumference of 88 cm is above the 80 cm cutoff for women and deserves lifestyle counseling, yet it is a factor to address, not the measure that sets management intensity. The higher systolic reading and her daily cigarette count are each real inputs to the risk estimate: systolic pressure is one axis of the chart, and smoking raises her risk and calls for a brief intervention to quit. Taken alone, though, neither tells the nurse how aggressive her overall management should be.

| Item in the stem | Role in PhilPEN |
| --- | --- |
| Two readings of 140/90 mmHg or higher | Confirms the diagnosis of hypertension |
| Systolic pressure, smoking, age, sex, diabetes, cholesterol | Inputs combined on the WHO/ISH chart |
| Total cardiovascular risk level | Decides how intensively she is managed |
| Waist circumference of 88 cm | Risk factor to counsel on (lifestyle) |

Applying it at the RHU
In practice, the nurse plots the client on the WHO/ISH chart, records her risk category, and then follows the PhilPEN protocol for that category: lifestyle counseling on diet, physical activity, tobacco, and alcohol for every client, with closer follow-up and referral for drug treatment as the risk level rises. Her smoking is addressed with a brief tobacco intervention, and her waist circumference is addressed with diet and activity advice, but these actions sit inside a plan whose intensity is set by the total risk. Key point! When a PhilPEN question asks what determines how intensively a client is managed, choose total cardiovascular risk on the WHO/ISH chart. Single factors are inputs to that estimate, not substitutes for it.

## 임상 시나리오

PhilPEN Risk-Based ManagementUsing the WHO/ISH chart after hypertension is confirmed
Two seated readings of 140/90 mmHg or higher on separate visits confirm hypertension. The next step is not to react to one value but to estimate total cardiovascular risk.

Plot the client on the WHO/ISH chart using age, sex, systolic blood pressure, smoking, diabetes, and total cholesterol when available. The resulting risk level sets how often she is followed up and how intensively she is treated.

Every client still receives lifestyle counseling: a brief tobacco intervention for smokers and diet and activity advice for a waist circumference of 80 cm or more in women.

CautionDo not let a single high reading, a cigarette count, or a simple count of risk factors replace the chart. Each is only one input to the total risk estimate.

## 핵심 개념

- **PhilPEN** — The Philippine Package of Essential NCD Interventions, the DOH primary care protocol for managing hypertension, diabetes, and cardiovascular risk.
- **WHO/ISH risk chart** — A color-coded chart that estimates 10-year cardiovascular risk from age, sex, systolic pressure, smoking, diabetes, and cholesterol.
- **Total cardiovascular risk** — The combined chance of a heart attack or stroke from all of a person's risk factors taken together.
- **Waist circumference** — A measure of abdominal fat; 80 cm or more in women is the risk cutoff used for this client.

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