Fundi CH 18: Planning Nursing Care

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. What factors does the nurse consider when prioritizing interventions? (Select all that apply.) a. Put all the patients nursing diagnoses in order of priority. b. Consider time as an influencing factor. c. Set priorities based solely on physiological factors. d. Utilize critical thinking. e. Do not change priorities once theyve been established.

ANS: A, B, D The nurse avoids setting priorities based solely on physiological factors. Consider psychosocial factors as well. Prioritizing the problems, or nursing diagnoses, will help the nurse decide which problem to address first. Time is a factor to be included in planning before continuing on to the implementation phase. Nurses use critical thinking throughout the entire nursing process. Priorities can change based on patient needs and responses to treatments. pg. 241

The nurse recognizes that another term for a collaborative nursing intervention is _____ intervention. a. Dependent b. Independent c. Interdependent d. Physician-initiated

ANS: C A collaborative, or interdependent, intervention requires the combined knowledge, skill, and expertise of multiple health care professionals. A dependent intervention requires an order from a health care professional. An independent intervention is an action that the nurse initiates. pg. 246

19. A hospitals wound nurse consultant made a recommendation for nurses on the unit to continue the patients dressing changes as previously ordered. The nurses on the unit should incorporate this recommendation into the patients plan of care by a. Assuming that the wound nurse will perform all dressing changes. b. Requesting that the physician look at the wound herself. c. Including dressing change instructions and frequency in the plan of care. d. Encouraging the patient to perform the dressing changes.

ANS: C The wound nurse clearly recommends that nurses on the unit, not the patient, should continue dressing changes. The nurses should not make a wrong assumption that the wound nurse is doing all the dressing changes. The recommendation states for the nurses to do the dressing changes. If the nurses feel strongly about obtaining another opinion, then the physician should be contacted. No evidence in the question suggests that the patient needs a second opinion. pg. 253

Which patient outcome statement includes all seven guidelines for writing goal and outcome statements? a. The patient will ambulate in hallways. b. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort. c. The nurse will monitor the patients heart rhythm continuously this shift. d. The patient will feed self at all mealtimes today without complaints of shortness of breath.

ANS: D A goal or outcome statement should be patient-centered; should address one patient response; should be observable, measurable, and time-limited; should be mutually set by nurse and patient; and should be realistic. The statement The patient will feed self at all mealtimes today without complaints of shortness of breath includes all seven criteria for goal writing. The patient will ambulate in hallways is missing a time limit. Administering pain medication and monitoring the patients heart rhythm are nursing interventions; they do not reflect patient behaviors or actions. pg. 244

A registered nurse administers pain medication to a patient suffering from fractured ribs. What type of nursing intervention is this nurse implementing? a. Collaborative b. Independent c. Interdependent d. Dependent

ANS: D The nurse does not have prescriptive authority to order pain medications, unless the nurse is an advanced practice nurse. The intervention is therefore dependent. A collaborative, or interdependent, intervention involves therapies that require combined knowledge, skill, and expertise from multiple health care professionals. An independent intervention does not require an order or collaboration with other professionals. pg.246

It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply.) 1. Using a standardized checklist for essential information 2. Asking the wife to briefly leave the room 3. Completing the hand-off without inviting questions 4. Doing prework such as checking laboratory results before giving a report 5. Including the wife in the hand-off discussion

Answer: 1, 4, 5. Using standardized forms or checklists and doing thorough pre work enhances the nurse's ability to communicate the plan of care effectively during a handoff. The other two options are barriers to an effective hand-off.

The following statements are on a patients nursing care plan. Which of the following statements is written as an outcome? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased mobility in 2 days. c. The patient will demonstrate increased tolerance to activity over the next month. d. The patient will understand needed dietary changes by discharge.

ANS: A An expected outcome is a specific and measurable change that is expected as a result of nursing care. The other three options in this question are goals. Demonstrating increased mobility in 2 days and understanding necessary dietary changes by discharge are short-term goals because they are expected to occur in less than a week. Demonstrating increased tolerance to activity over a month-long period is a long-term goal because it is expected to occur over a longer period of time. pg. 244

Which of these outcomes would be most appropriate for a patient with a nursing diagnosis ofConstipation related to slowed gastrointestinal motility secondary to pain medications? a. Patient will have one soft, formed bowel movement by end of shift. b. Patient will not take any pain medications this shift. c. Patient will walk unassisted to bathroom by the end of shift. d. Patient will not take laxatives or stool softeners this shift.

ANS: A The identified problem, or nursing diagnosis, is Constipation. Therefore, the outcome should be that the constipation is relieved. To measure constipation relief, the nurse will be observing for the patient to have a bowel movement. Not taking pain medications may or may not relieve the constipation. Although not taking pain medicines might be an intervention, the nurse doesnt want the patient to be in pain to relieve constipation. Other measures, such as administering laxatives or stool softeners, might be appropriate interventions. The patient walking unassisted to the bathroom addresses mobility, not constipation. The patient may need to walk to the bathroom to have a bowel movement, but the appropriate outcome for constipation is that the constipation is relieved as evidenced by a bowel movementsomething that the nurse can observe. pg. 244

After completing a thorough database and analyzing the data to identify any problems, the nurse should proceed to what step of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: B In the five-step nursing process, the nurse should establish mutual goals with the patient and prioritize care in the planning phase, which follows the diagnosis phase. The assessment phase of the nursing process involves gathering data. The implementation phase involves carrying out appropriate nursing interventions. During the evaluation phase, the nurse assesses the effectiveness of interventions. pg. 240

The nurse describes evidence-based practice as a. Practice based on the evidence presented in court. b. Implementing interventions based on scientific rationale. c. Using standardized care plans. d. Planning care based on tradition.

ANS: B The best answer is implementing interventions based on scientific rationale. Practice based on evidence presented in court is incorrect. Practice is based on current research. Using standardized care plans may be one example of evidence-based practice, but there are many others as well. The nurse must be careful in using standardized care plans to ensure that each patients plan of care is still individualized. Planning care based on tradition is incorrect because nursing care should be based on current research. pg. 251

Which intervention is most appropriate for the nursing diagnostic statement, Impaired skin integrity related to shearing forces? a. Administer pain medication every 4 hours as needed. b. Perform the ordered dressing change twice daily. c. Do not document the wound appearance in the chart. d. Keep the bed side rails up at all times.

ANS: B The most appropriate intervention for the diagnosis of Impaired skin integrity is to perform the ordered dressing change. The other options do not directly address the skin integrity. The patient may need pain medication before dressing changes, but Acute pain would be another nursing diagnosis. Documenting all objective findings is the nurses responsibility, even if a wound or infection is a health careassociated problem. Keeping the side rails up addresses safety, not skin integrity. pg. 246

What is the first step in making a consult? a. Avoid bias by not providing a lot of information based on opinion to the consultant. b. Identify the problem. c. Provide the consultant with relevant information about the problem. d. Ensure that the right professional, with the appropriate knowledge and expertise, is contacted.

ANS: B The nurse needs to first identify the problem. Subsequent steps in order include obtaining direct consultation with the right professional, providing the consultant with relevant information, avoiding bias, and being available to discuss the consultants recommendations. pg. 253

When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by a. Ambulating in the hallway two times this shift. b. Turning side to back to side with assistance every 2 hours. c. Using the walker correctly to ambulate to the bathroom as needed. d. Using a sliding board correctly to transfer to the bedside commode as needed.

ANS: B The patient is ordered to be on bed rest; therefore turning the patient in bed is the only option that is appropriate. When determining goals, the nurse needs to ensure that the goal is individualized and realistic for the patient. pg. 243

Which of the following options correctly explains what the nurse should do with the plan of care for a patient after it is developed? a. Place the original copy in the chart, so it cannot be tampered with or revised. b. Communicate the plan of care to all health care professionals involved in the patients care. c. Send the plan of care to the administration office to be filed. d. Send the plan of care to quality assurance for review.

ANS: B The patients nursing plan of care is a dynamic piece of work that needs to be updated and revised as the patients condition changes. All health care professionals involved in the patients care need to be informed of the plan of care. The plan of care is not placed on the chart and not ever looked at again. The plan of care is not sent to the administrative office or quality assurance office. pg. 248

When planning patient care, a goal can be described as a. A statement describing the patients accomplishments without a time restriction. b. A realistic statement predicting any negative responses to treatments. c. A broad statement describing a desired change in patient behavior. d. An identified long-term nursing diagnosis.

ANS: C A goal is a broad statement that describes a desired change in a patients condition or behavior. A goal is mutually set with the patient and is time-limited, patient-centered, measurable, and realistic. pg. 242

A patients plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. The nurse should revise the plan of care first by a. Asking physical therapy to assist the patient because of the new injuries. b. Disregarding all previous diagnoses and establishing a new plan of care. c. Reassessing the patient. d. Setting new priorities for the patient.

ANS: C The nurse needs to reassess the patient after any type of change in health status. The nursing process is dynamic and ongoing. Asking physical therapy to assist the patient is premature before reassessing the patient and awaiting physician orders. The nurse may not need to disregard all previous diagnoses. Some diagnoses may still apply, but the patient needs to be reassessed first. Setting new priorities is not recommended before assessment and establishing diagnoses. pg. 241

A patients son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do? a. Individualize the care plan only according to the patients needs. b. Request that the son leave at bedtime, so the patient can rest. c. Suggest that a female member of the family stay with the patient. d. Involve the son in the plan of care as much as possible.

ANS: D Family should be included in the plan of care as much as possible. The family is a resource to help patients meet health care goals. Meeting some of the familys need as well as the patients needs will possibly improve the patients level of wellness. The son should not be asked to leave if at all possible. In some situations, it may be best that family members not remain in the room, but no evidence in the question stem suggests that this is the case in this situation. Suggesting that a female member of the family stay is not justified without a legitimate reason. No reason is given in this question stem for such a suggestion. pg.248

A nursing assessment for a patient with a spinal cord injury leads to several pertinent problems that a nurse can treat. While developing the plan of care, which nursing diagnosis is the highest priority for this patient? a. Risk for impaired skin integrity b. Risk for infection c. Spiritual distress d. Reflex urinary incontinence

ANS: D Reflex urinary incontinence is highest priority. If a patients incontinence is not addressed, then the patient is at higher risk of impaired skin integrity and infection. Remember that the Risk for diagnoses are potential problems. They may be prioritized higher in some cases, but not in this situation. Spiritual distress is an actual diagnosis, but the adverse effects that could result from not assisting the patient with urinary elimination take priority in this case. Physiological problems do not always take priority, but the greatest harm could come to this patient if urinary incontinence is not prioritized. pg. 246

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement, Risk for falls? a. Encourage patient to remain in bed most of the shift. b. Keep all side rails down at all times. c. Place patient in room away from the nurses station if possible. d. Assist patient into and out of bed every 6 hours or as tolerated.

ANS: D Risk for falls is a potential nursing diagnosis; therefore the nurse needs to implement actions that will prevent a fall. Assisting the patient into and out of bed is the most appropriate intervention to prevent the patient from falling. Encouraging activity builds muscle strength, and helping the patient with transfers ensures patient safety. Encouraging the patient to stay in bed will not promote muscle strength. Decreased muscle strength is the risk factor placing the patient in jeopardy of falling. The side rails should be up, not down, according to agency policy. This will remind the patent to ask for help to get up and will keep the patient from rolling out of bed. The patient should be placed near the nurses station, so a staff member can quickly get to the room and assist the patient if necessary. pg. 246

Which intervention is most appropriate for the nursing diagnostic statement, Impaired verbal communication related to loss of facial motor control and decreased sensation? a. Obtain an interpreter for the patient as soon as possible. b. Assist the patient in performing swallowing exercises each shift. c. Ask the family to provide a sitter to remain with the patient at all times. d. Provide the patient with a writing board each shift.

ANS: D The cause of the patients problem will help guide the nurse to the proper nursing intervention. If the patient has a problem with verbal communication, then the nurse should choose an intervention that will address the problem. Providing the patient with a writing board will allow the patient to communicate by writing because the patient is unable to communicate verbally at this time. Obtaining an interpreter might be an appropriate intervention if the patient spoke a foreign language. Assisting with swallowing exercises will help the patient with swallowing, which is a different nursing diagnosis from Impaired verbal communication. Asking the family to provide a sitter at all times is many times unrealistic and does not promote the patients independence, as does providing a writing board. pg.246

The nurse is caring for seven patients this shift. After completing their assessments, the nurse states that he doesnt know where to begin in developing care plans for these patients. Which of the following is an appropriate suggestion by another nurse? a. Choose all the interventions and perform them in order of time needed for each one. b. Make sure you identify the scientific rationale for each intervention first. c. Decide on goals and outcomes you have chosen for the patients. d. Begin with the highest priority diagnoses, then select appropriate interventions.

ANS: D When developing a plan of care, the nurse needs to rank the nursing diagnoses in order of priority, then select appropriate interventions. Choosing all the interventions should take place after ranking of the diagnoses, and interventions should be prioritized by patient needs, not just by time. The chosen interventions should be evidence-based with scientific rationales, but the diagnoses need to be prioritized first to prioritize interventions. Goals for a patient should be mutually set, not just chosen by the nurse. pg. 246

A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.) 1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague 4. RN's years of experience 5. Competency of patient care technician

Answer: 1, 2, 3. Many factors within the health care environment affect your ability to set priorities, including model for delivering care, a nursing unit's workflow routine, staffing levels, and interruptions from other care providers. Available resources (e.g., policies and procedures) also affect priority setting. The nurse's years of experience is not part of the environment.

Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing and intervention for enhancing the patient's sleep? (Select all that apply) 1. The intervention should be directed at reducing noise 2. The intervention should be shown to be effective in promoting sleep on the basis of research. 3. The intervention should be one commonly used by the patient's sleep partner 4. The intervention should be one acceptable to the patient 5. The intervention should be one you used with other patients in the past.

Answer: 1, 2, 4. Select interventions that alter the etiological factor, in this case noise. Choose interventions that have a research base and are acceptable to patients.

A 62-year-old patient had a portion of the large colon removed and colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care specialist. Which of the following should the nurse do? (select all that apply) 1. Assess condition of the skin before making the call 2. Rely on the nurse specialist to know the type of surgery the patient likely had. 3. Explain the patient's response emotionally to the repeated leaking of stool 4. Describe the type of bag being used and how long it lasts before leaking 5. Order extra colostomy bags currently being used.

Answer: 1, 3, 4. The nurse should have as much information available before making the call to the nurse specialist. It is also important for the nurse to interpret and explain the problem. In addition it is important to explain the patient's perspective. Assuming the nurse specialist knows the extent of the surgery is not appropriate.

A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity intolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity intolerance a patient-centered effort? 1. Engage the patient in setting mutual outcome for distance he is able to walk 2. Confirm with the patient's health care provider about ambulation goal 3. Have physical therapy assist with ambulation 4. Refer to medical record regarding nature of patient's physical problem.

Answer: 1. All goals and outcomes of care should be patient-centered whenever possible. An approach for ensuring patient-centered goals is having the patient involved so that goals can be mutually set and realistic to the patient. Confirming with the physician and checking the medical record helps the nurse understand the extent of exercise a patient can participate in. But these approaches are not examples of mutual patient-centered goal setting. Having physical therapy assistance would not make a goal patient centered.

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient is asking questions about whether his doctor is coming. Which of the following does the nurse perform first? 1. Reconnect the drainage tubing 2. Inspect the condition of the IV dressing 3. Obtain the next IV fluid bag from the medication room 4. Explain when the health care provider is likely to visit

Answer: 1. The nurse must reconnect the drainage tube for the priority of patient safety. There is no reason to suspect a problem with the IV dressing unless the fluid is not infusing on time. The nurse must prepare the next bottle of solution after reconnecting the drainage tube. At that time the nurse can check the condition of the IV dressing. As the nurse performs her care she can inform the patient about when the physician will round, unless the nurse is uncertain and needs to contact the physician.

An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals (numbers) with the appropriate outcome statement (letters). 1. Patient will ambulate independently in 3 days 2. Patient will be injury free for 1 month. 3. Patient will achieve 5-lb weight gain in 1 month 4. Patient will achieve pain relief by discharge. a. Patient expresses fewer nonverbal signs of discomfort within 24 hrs. b. Patient increases calorie intake to 2500 daily. c. Patient walks 20 feet using a walker in 24 hours. d. Patient identifies barriers to remove in the home within 1 week.

Answer: 1c, 2d, 3b, 4a. In each case the outcome is a measurable behavior or perception that reflects goal achievement.

Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (Select all that apply) 1. Numbered order of diagnosis on the basis of severity 2. Notion of urgency in nursing action 3. Symptom pattern recognition suggesting a problem 4. Mutually agreed on priorities set with patient 5. Time when a specific diagnosis was identified

Answer: 2, 3, 4. All factors are considered in setting priorities for a patient's nursing diagnoses or collaborative problems. The numbered order of diagnosis based on severity is inappropriate as a numbering system holds little meaning when a patient's condition changes.

A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply) 1. Providing mouth care every 4 hours 2. Maintaining intravenous (IV) infusion at 100 mL/hr 3. Administering prochlorperazine (Compazine) via rectal suppository 4. Consulting with dietician on initial foods to offer patient 5. Controlling adverse odors or unpleasant visual stimulation that triggers nausea.

Answer: 2, 4. The options "Provide mouth care every 4 hours" and "Control aversive odors or unpleasant visual stimulation that triggers nausea" are independent nursing interventions. The option "Administer prochlorperazine (Compazine) via rectal suppository" is a dependent intervention.

A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient? 1. Achieving wound healing of the foot ulcer 2. Enhancing the patient knowledge about the effects of diabetes 3. Providing a dietician consult for diet retraining 4. Improving patient adherence to diabetic diet

Answer: 2. The high priority for this patient is wound healing. If the ulcer is left untreated it will cause more serious harm; an infection is likely and it could spread. Providing a diet consult is an intervention. Improving patient adherence to her diet is an intermediate outcome. Adherence to the diet is important but not life threatening when unmet. Since the patient has had diabetes for 10 years, enhancing knowledge is important because of her poor adherence but a lower priority than the others.

A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5-1/2NS infusing in the right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted". If the nurse's goal for Mr. Roarke was to improve activity intolerance, which expected outcomes were shared in the hand-off? (Select all that apply) 1. IV site not tender 2. Uses cane two walk 3. Walked to end of hall 4. No shortness of breath 5. Slept better during night

Answer: 3, 4. The goal for improving activity tolerance will require an outcome that is a measure of changes in activity tolerance, such as no shortness of breath during exercise or walking a set distance.

A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. the patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? 1. Giving the enema on time. 2. Talking with the patient about her past experiences with illness 3. Talking with the patient about her concerns and acknowledging her sense of unfairness 4. Beginning instruction on postoperative procedures.

Answer: 3. The patient is obviously emotionally upset. Her concerns, whether they be about surgery or cancer or both, need to be addressed first for her to be able to be instructed and to be comfortable for the enema. Talking with the patient about her past experiences may be appropriate in the long term, but is less important than the other three priorities.

A nursing student is reporting hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5-1/2NS." Which intervention is a dependent intervention? 1. Reporting hand-off at change of shift 2. Ambulating patient down hallway 3. Sleep hygiene 4. IV fluid administration

Answer: 4. Administering IV fluids required a physician's order. The other three interventions are independent nursing activities.

The nurse writes an expected outcome statement in measurable terms. An example is: 1. Patient will has normal stool evacuation. 2. Patient will have fewer bowel movements 3. Patient will take stool softener every 4 hours 4. Patient will report stool soft and formed with each defecation

Answer: 4. Stool that is soft and formed at each defecation is measurable upon observation. "Patient will have normal stool evacuation" is a goal. "Patient will take fewer bowel movements" is not specific enough for measuring improvement. "Patient will take stool softener every 4 hours" is an intervention.

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? 1. Patient will be turned every 2 hours within 24 hours 2. Patient will have normal bowel function within 72 hours 3. Patient's skin integrity will remain intact through discharge 4. Erythema of skin will be mild to none within 48 hours

Answer: 4. The statement "Patient will be turned every 2 hours within 24 hours" is an intervention. The statements "Patient will have normal bowel function within 72 hours" and "Patient's skin integrity will remain intact through discharge" are goals.