Pneumonia
Ventilator-Associated
Evidenced Based-Practice
Michelle A Scarlett
FHT/UD
4/9/2013
Objective
• Review Maria’s case and new onset of Pneumonoia
• Understand the Pathophysiology of Pneumonia
• Understand Etiology, Risk Factors, Signs and
Symptoms of Pneumonia
• Understand Nursing Diagnoses of Pneumonia
• Introduce Ventilator Bundle prevention
• Understand Evidence Based Research
• Describe Treatment options
• Nurse and Patient Teachings
• NCLEX questions to test knowledge
Case Study
36 year old Maria. Came into hospital due
to an Asthma attack. 5’ 1” 359 lbs , married
with 6 yo twins. Type 2 Diabetes. Been in
the hospital since Easter and is still present
in the hospital due to catching ventilatorpneumonia. Defense mechanism became
overwhelmed with the asthma making it
hard to fight off pneumonia. Maria is
overwhelmed and upset as she misses her
family and is in the hospital longer than
expected.
Pathophysiology
Acute inflammation of lung Parenchyma (functional tissue of cells or organs) by
organism such as bacteria, viruses, mycoplasma, parasites and chemicals. Line
of defense
Upper cough reflex and mucociliary clearance
Alveolar macrophages
Release of multiple inflammatory mediators, cellular filtration, immune activation
Result-Bronchial mucous membranes become damaged
Acni and terminal bronchioles fill with infectious debris and exudates, pus and
other fluids making it hard for oxygen to reach the blood stream.
Prevalence of Pneumonia
• Until 1936 leading cause of death
• Currently leading cause of infectious
disease death
• Affects 1 out of every 100 people per
year
• Mortality rate of 10-50% if contracted
in hospital
Types
Community Acquired-people who have not been recently
hospitalized.
Streptococcus pneumonaie-high mortality in elderly
Mycoplasma pneumonaie –more in young people
especially those living in crowded conditions
Hospital acquired - (Nosocomial infection) that occurs during
more than 48 hours of an hospital stay. 2nd most common
nosocomial infection
Ventilator-Associated Pneumonia- germs enters through tune
and gets into the lungs. Ventilator is suppose to help the
patient breath through mouth pr nose infections through the
tube further impairs such ability.
Long Term Care facilities
Psuedomonas aeruginosa
Staphylococal pneumonia
Klebsiella pnuemonaie
Risk Factors
Chronic lung disease
Immunocompromised
Immobility
Altered LOC- risk of aspiration
Intubation
Tube Feeding
Some research says Meds- inhaled
corticosteroids increase risk in COPD
patients by as much as 70%. Patient is on
Budenoside and fluticasone
Clinical Presentations
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Tachycardia
Fever, leukocytes. Chills
Confusion, restlessness
Dyspnea, tachypnea
Cough
Hypoxemia
Crackles, rhonchi, wheezes
Dehydrated-maybe hypotensive
Elevated WBC
Labs/vitals
Sodium 132 lowNormal 135-145- mEq/L Possible reasons for being, excess body fluid
due to patient large consumption of water, as she stated that she loves to drink water or the fact
that her IV was infused and couldn’t be reinserted to keep her sodium levels within normal range.
Chloride 98
Normal 95-105- mEq/L Patient is within normal limits.
Calcium 9.4
Normal 9-11 mg/dL- Patient is within normal limits.
Potassium 4.4
Normal 3.5-5.0 mEq/L Patient is within normal limits.
Glucose 108 highNormal 65-99 or 70-100 mg/dL Patient is a diabetic and may have just
eaten.
BUN 18
Normal 6-20 mg/dL Patient is within normal limits.
Creatinine 0.5 low
Normal 0.6-1.2 mg/dL Patient creatinine is not that low. Possible causes
are limited mobility due to weight or not enough protein in diet.
CO2 21
Normal 35-45 Patient is within normal limits.
HGB 12.2
HCT 39.9
MCV 90
WBC 8000
PLT 339000
ALT 9
AST 13
Albumin 3.6
Troponin T 0.01
Normal 12-16 g/dL Patient is within normal limits
Normal 38-47 % Patient is within normal limits
Normal 76-100 Patient is within normal limits
Normal 5,000-10,000 Patient is within normal limits
Normal 150,000- 450,000 Patient is within normal limits
Normal 10-30 IU/ML Patient is within normal limits
Normal-7-34 U/L Patient is within normal limits
Normal 4-6 g/dL Patient is within normal limits
Normal 0-0.1 Patient is within normal limits
Admission
BP 141/80, HR-88, RR 24, Sp02- 82
chest pain10, temp 106.2
Diagnostic Test
Chest-x-ray
Sputum Gram stain and culture
Transtracheal aspiration
Bronchoscopy
CBC
ABG study
Thoracentesis
Urine sample
Serum electrolytes, BUN, creatinine,
liver function studies
Nursing Diagnoses
Ineffective breathing patterns related to
infections in the lungs as evidenced by sputum
culture.
Impaired gas exchange related to decreased
lung function as evidenced by the need for
oxygen
Activity Intolerance related to imbalance
between supply and demand as evidence by
stopping to rest from bed to room door.
How could have VentilatorPneumonia been avoided in
Maria???
Ventilator Bundle!!!!
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Elevation of the head of the bed to 30-45°
Removal of subglottic secretions
Changing ventilator circuit no more than every 48 hours
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Peptic ulcer disease prophylaxis (preventative measures)
Deep venous thrombosis prophylaxis (heparin, Compression stockings)
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Oral care with use of chlorhexidine- oral rinse against gram positive and
negative bacteria
Strict hand hygiene no rings, nail polish, washing hands before and after caring
for patients with alcohol based solution
Checking residual volume in nasogastric tube every 4-6 hours and withholding
feeding for an hour if residual is 1 to 1.5
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All aimed to improve outcome in mechanically ventilated patients, but not all are
associated with VAP prevention.
Evidenced Based Practice 1
supporting Ventilator Bundle
Purpose To examine critical care nurses’ knowledge about the use of the
ventilator bundle to prevent ventilator-associated pneumonia. 2007
• Method Published reports were reviewed for current evidence on the use of the
ventilator bundle to prevent ventilator-associated pneumonia, and education
sessions were held to present the findings to 61 nurses in coronary care and
surgical intensive care units. Changes in the nurses’ knowledge were evaluated
by using a 10-item test, given both before and after the sessions. Changes in the
nurses’ practices related to ventilator-associated pneumonia, including elevation
of the head of the bed to 30° to 45°, were observed in 99 intubated patients.
• Results After the education sessions, the nurses performed better on 8 of the 10
items tested (P from .03 to <.001). The areas of most significant improvement
were elevation of the head of the bed (P < .001), charting of the elevation of the
head of the bed (P= .009), oral care (P= .009), checking of the nasogastric tube
for residual volume (P = .008), washing of hands before contact with patients (P <
.001), and limiting the wearing of rings (P < .001) and nail polish (P = .04). Even
after the education sessions, the nurses’ compliance with hand-washing
recommendations before contact with patients was low, though statistically some
improvement was apparent. Contraindications to elevation of the head of the bed
did not appear to affect the nurses’ practices (P= .38).
• Conclusion Education sessions designed to inform nurses about the ventilator
bundle and its use to prevent ventilator-associated pneumonia have a significant
effect on participants’ knowledge and subsequent clinical practice.
Evidence Based Practice 2
Supporting Ventilator Bundle
Background Strategies are needed to help prevent ventilator-associated
pneumonia. Jan 2009-dec 2009
Objective To develop a ventilator bundle and care practices for nurses in critical
care units to reduce the rate of ventilator-associated pneumonia.
Method The ventilator bundle developed by the Institute for Healthcare
Improvement was expanded to include protocols for mouth care and hand washing,
head-of-bed alarms, subglottic suctioning, and use of an electronic compliance
feedback tool. Compliance audits were used to provide immediate electronic
feedback.
Results Adherence to practices included in the bundle increased. Compliance rates
were greater than 98% for prophylaxis for peptic ulcer disease and deep-vein
thrombosis, interruption of sedation, and elevation of the head of the bed. The
compliance rate for the oral care protocol increased from 76% to 96.8%. Readiness
for extubation reached at least 92.4%. Rates of ventilator-associated pneumonia
decreased from 9.47 to 1.9 cases per 1000 ventilator days. The decrease in rates
produced an estimated savings of approximately $1.5 million.
Conclusion Strict adherence to bundled practices for preventing ventilatorassociated pneumonia, enhanced accountability for initiating protocols, use of a
feedback system, and interdisciplinary collaboration improved patients’ outcomes
and produced marked savings in costs.
Antibiotic Treatments
For patients with early-onset VAP and no risk factors for multidrug-resistant (MDR)
pathogens, currently recommended initial empiric antibiotics include 1 of the
following options:
Ceftriaxone
Fluoroquinolones
Ampicillin-sulbactam
Ertapenem
For patients with VAP and risk factors for MDR pathogens or for patients with lateonset VAP, initial antibiotic therapy may consist of 1 of the following options:
Antipseudomonal cephalosporins (eg, cefepime, ceftazidime)
Antipseudomonal carbapenems (imipenem or meropenem)
Beta-lactam/beta-lactamase inhibitors (piperacillin-tazobactam) with an
antipseudomonal fluoroquinolone (ciprofloxacin) or aminoglycoside plus linezolid or
vancomycin (if risk factors for methicillin-resistant Staphylococcus aureus are
present)
Teachings
 Nurses
 In Maria’s case poor hand washing may have been the cause of her
infection!!
 Strict hand hygiene no rings, nail polish, washing hands before and after
caring for patients with alcohol based solution
 Oral care with use of chlorhexidine- oral rinse against gram positive and
negative bacteria. Along with other bundle measures.
 Patient
 Teach importance of immunization and when to contact physician such as
chills, fever, dyspnea.
 To avoid people with respiratory infections or viruses
 Washing of hands
 Rescue inhaler reminders such alarms check list, having one in the car
 Self care- diet and exercise, support groups
 Importance of not over working lungs upon onset of a trigger so that lungs
won’t be to impaired to fight of nosocomial infections such as ventilator
pneumonia
NCLEX Questions 1
1.When auscultating the chest of a client with
pneumonia, the nurse would expect to hear
which of the following sounds over areas of
consolidation?
A. Bronchial
B. Bronchovestibular
C. Tubular
D. Vesicular
Rationale
Chest auscultation reveals bronchial
breath sounds over areas of
consolidation. Bronchiovesicular are
normal over midlobe lung regions,
tubular sounds are commonly heard
over large airways, and vesicular
breath sounds are commonly heard in
the bases of the lung fields
NCLEX 2
Which of the following organisms is the most
common cause of hospital-acquired
pneumonia in adults?
A. Haemiphilus influenzae
B. Klebsiella pneumoniae
C. Steptococcus pneumoniae
D. Staphylococcus aureus
Rationale
Pneumococcal or streptococcal pneumonia,
caused by streptococcus pneumoniae, is the
most common cause of community-acquired
pneumonia. H. influenzae is the most common
cause of infection in children. Klebsiella species
is the most common gram-negative organism
found in the hospital setting. Staphylococcus
aureus is the most common cause of hospitalacquired pneumonia.
NCLEX 3
3. Which intervention would be most appropriate to
use for an adult patient who is at risk for the
development of ventilator-associated pneumonia.
1. Change the ventilators circuits daily
2. Turn the patient from side to side every 4 hours
3. Administer prophylactic antibiotics
4. Elevate the head of the bed 30-45 degrees
Rationale
4. Recall from the ventilator bundle and
evidenced based studies, simply
elevation of the bed 30-45 degrees can
make a significant difference in the
prevention of ventilator pneumonia.
Conclusion
Ventilator- Acquired Pneumonia is preventable and it up
to the collaboration of staff in working together in
following through with the ventilator bundle in lowering,
morbidity, mortality and cost.
Preventing ventilation pneumonia is better than treating
it!!
References
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Amanullah, S., Mosenifar, Z., (2013) Ventilator-Associated Pneumonia Overview of Nosocomial Pneumonias
http://emedicine.medscape.com/article/304836-overview#a30
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http://amy47.com/nclex-style-practice-questions/airway-pneumonia-and-tb/ :Retrieved 4/8/2013
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http://www.cdc.gov/HAI/vap/vap.html: Retrieved 4/8/2013
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Osborn S.K., ‘Wraa E, C., Watson B.A., (2010). Medical Surgical Nursing: Preparation for Practice. Pg. 937943
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Sedwick, B.M Smith L.M., RN, MSN, CCRN, Reeder, J.S., Nardi, J. (2012.) Using Evidence-Based
Practice to Prevent Ventilator-Associated Pneumonia.
http://ccn.aacnjournals.org/content/32/4/41.short
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Silvestri, A. L., (2005). Comprehensive Review for the NCLEX-RN EXAMINATION. Pg.809-810.
Tolentino, F. T., Ruppert, D.S, Yum, S., & Shiao K.P., (2007). Preventing Ventilator-Associated Pneumonia:
Evidence-Based Practice: Use of the Ventilator Bundle to Prevent Ventilator-Associated Pneumonia American
Journal of Critical Care16:2027http://ajcc.aacnjournals.org/content/16/1/20.full