• Encourage client to verbalize feelings and discuss how condition upset her.

=To assess the perception of the patient regarding her condition.

• Identified underlying condition involved.
=To properly assessed the patient and give the specific care based on patient's condition.
• Obtained history of condition such as the site, characteristics of lesions and duration of
problem.
• Determined degree of damage to integumentary system.
• Reviewed importance of skin
=To assess the skin layer involved such as epidermis, dermis or underlying tissue.
• Instructed the patient to keep the area clean/ dry and sopport the incision by the use of
pillow or abdominal binder and splinting when coughing.
= To prevent infecion, manage incontenence and stimulate circulation to surrounding areas
to assist body's natural process of repair.
• Use appropriate barrier dressing/ wound dressings for wound.
= To protect the wound or surrounding tissues.
• Repositioned patient on regular schedule, involved the client in reasons for and decisions
about positions.
= To enhance understanding and cooperation.
• Encourage early ambulation.
= To promote circulation and reduces risks associated with immobility.
• Continue some nursing interventions such as the appropriate wound dressings; repositioning
patient; encouraging early amdulation and instructing patient to always keep area clean and
dry and support incision with pillow or abdominal splinting when coughing.
= In continuing these interventions patient will be free from any infection, promote
circulation and prevent other complications.

Within 8 hour of nursing intervention the patient will be able to:

General:
Maintain/ increase strenght and function of affected body parts
Specific:
1. Verbalize willingness to participate
2. Demonstrate techniques that enable resumption of activities, especially ADLs.
3. Maintain position of function.

• Note emotional/ behavioral responses to altered ability

= Physical changes and loss of independence often create feeling of anxiety, anger,
frustrations and depressiomns that may be manifested as reluctance to engage activity.
• Encoureaged participation in self-care, occupational/ recreational activities
= Promotes independence and self-esteem, may enhance willingness to participate
= Improves muscle strenght and circulation, enhances client control in situation, and
promotes self-directed wellness.
• Reposiion periodically and encourage deep breathing exercises
= Prevents/ reduces incidence of skin complications (e.g., decubitus ulcer).
• Encouraged early ambulation
= To promote circulation and reduces risks associated with immobility.