Pneumonia is a respiratory disease that affects lung tissue and disrupts normal metabolism. The exudate that forms does not allow the alveoli to process regular amounts of oxygen, so respiratory failure often develops. A defining feature of pneumonia is the presence of intra-alveolar exudate with the obligatory clinically pronounced fever and intoxication due to bacterial and/or viral infection (Kallet et al., 2018). Anatomical organs affected by inflammation are the lungs, alveoli, bloodstream, and adventitious tissues (Quinton et al., 2018). It is also worth noting that the respiratory nerve center, which triggers and mediates protection through an inflammatory process, may also be impaired. In addition, the blood vessels involved, which should transfer oxygen from the lungs to the heart, begin to weaken. As a result, cardiac activity becomes less regular, and tachycardia and arrhythmia develop.
Ventilation of the lungs becomes impaired during pneumonia: Patients often experience shortness of breath. Dyspnea leads to cough with sputum of a mainly mucopurulent nature. Consequently, external respiration takes up a large expenditure of energy and resources in the patient, and their lack can lead to the worsening of the disease (Kallet et al., 2018). Externally, it will be manifested as redness and cyanosis of the nasolabial triangle and swelling of the wings of the nose due to chatty shallow breathing (Quinton et al., 2018). The characteristics of internal breathing will be as follows: fibrinous exudate will accumulate in the alveoli, which will sound like a fine bubbling crackle when listened to. In addition, the rate of exchange of carbon dioxide for oxygen is impaired; the affinity of hemoglobin for O2 drops, and blood flow becomes poor (Kallet et al., 2018). It may also lose filling capacity and volume as the alveoli fail to cope with the exudate entering them. A fluid-filled alveolus becomes a predictor of first respiratory and then cardiac failure.
Most of the patients in need of incubation tend to portray ventilation alterations. For this reason, they tend to experience bronchial secretion, which can complicate their evolution if not adequately controlled. Associated complications can lead to mucus plugs, atelectasis, and at times, super-infection, which favor the onset of nosocomial pneumonia. Research has not specified how the practice needs to be performed on adults living with endotracheal intubation. However, the institution’s protocols need to be followed and justify that the patients require aspirations depending on the secretion visualizations in the airways. Coughing attempts, agitation, shortness of breath, snoring, and anxiety is respiratory indicators of impairment. In this regard, patients need to be interrogated on whether they think aspiration is essential.
The scenario demonstrates a lack of proper guidelines on proper treatment intervention for pneumonia patients. For this reason, an appropriate treatment plan needs to be enacted and communicated to all nursing practitioners. To show the effect of saline installation and lack of it on the pneumonia risk, the following step by step plan is necessary:
The first step involves evaluating a patient on a clinical ventilator to establish the effect of instilling the saline during suction compared to its absence. This helps in testing the risk involved in pneumonia in the patient. The second step consists in searching for the best indication using abstracts to establish evidence level. The third step will look at the accuracy of the results provided. The fourth step involves incorporating evidence provided with patient preferences and clinical expertise to determine the appropriateness of saline instillation. The next step will be used to test the effect of the saline in reducing pain and anxiety for patients. Finally, EBP results need to be disseminated through educational sessions and brochures.
The saline nebulization method can be applied compared to direct installation because the solution is uniformly spread in the lungs. This method ensures less influence of distribution by gravitation, enabling it to reach the edge of the lung to a considerable degree. In addition, the use of aerosol with particular characteristics helps optimize the fluid distribution along the distribution zone (Eekholm et al., 2020). This helps achieve more standardized humidification, making saline instillation unfit for mechanical ventilation. Typical saline installation can also lead to reduced oxygen saturation making it displace bacteria in endotracheal tubes (Eekholm et al., 2020). As portrayed in this case, the difference is a result of the lack of scientific reports that support the installation of saline.
Definition of Nursing Process and Clinical Decision-Making Process
In the long term, proper oral hygiene hand wash alongside good respiratory management helps reduce the severity of pneumonia in this category of patients. There are varied approaches that can help ensure desirable secretion control that aims to evacuate the exudate and curb complications:
Respiratory Physiotherapy
In critical care practice, chest physiotherapy encompasses vibration, drainage, and percussion of the chest wall and manual insufflation.
Postural Drainage
The change in position in TR implies the placement of particular segments of lungs greater than that of carina to help move secretions and utilize this measure in therapeutic. This change is also likely to enhance ventilation, decrease breathing, increase heart volume and facilitate proper secretion drainage. Postural changes need to be done after two or cone hours in patients with special needs for ICU ventilation, while postural drainage needs to be done in 4-6 hours.
Percussion and Chest Vibration
Vibration and percussion are two practical approaches traditionally applied to enhance airway clearance through the broadcast of energy applied to the chest wall. It is essential to realize that percussion can be done with dry blows and having hands in concave shape along the wall of the trunk of the affected region (McKinley et al., 2018). The drainage can be done through vibration by acceleration and manual flow accompanied by a rhythmic shift of either hands or squashing the chest wall during non-selective expiration. Similarly, vibration and percussion can be done by using mechanical equipment.
Mechanical or Manual Insufflation
This approach involves disconnecting a patient from a ventilator and ensuring lungs are well fit with sizeable tidal volume by using the mechanical instrument. The course is usually done with deep aspiration and slow supply, inspiration pausing and fast releasing the space to attain a high expiratory flow. This is done to end the chances of pulmonary collapse lung compliance and enhance oxygenation.
Endotracheal Suction
This is also known as ETA and is one of the most performed practices among artificial airway patients. This is part of bronchial hygiene and manual ventilation made of mechanical drag of pulmonary emissions originating from the synthetic airway to reduce the chances of its obstruction (McKinley et al., 2018). Depending on the tube selected, there are two common approaches to endotracheal suction. The first method is an open aspiration which necessitates a patient to be removed from a ventilator. On the other hand, the closed approach allows aspiration tubes to be distributed through an artificial airway without removing the patient from the ventilator.
In adults, the suction tube size needs not exceed half of the inner side of the artificial airway. During the aspiration preparation, it is expected to provide 100% oxygen for close to 60-30 seconds before the aspiration (McKinley et al., 2018). This should be done mainly to patients who are hypoxemic before the process. During this procedure, the advanced pressure of the unit needs to be checked by obstructing the end of the suction tubes right before connecting the probe suction and before any suctioning act. In this regard, it is required that the suctioning pressure be as low as possible while ensuring effectiveness in secretion extraction. Although this is an essential procedure, it is necessary to realize that it is capable of causing complications such as pain, tracheal mucosa injury, infection, discouragement, and alterations in hemodynamic parameters. Other probable injuries include atelectasis, arterial gasses, amplified arterial gasses, and bronchoconstriction.
The above EBP plan will help nursing practitioners avoid the unnecessary endangering of patients in evidence-based practice. In this regard, whenever one encounters a patient in a mechanical ventilator, it is required first to ensure the person is adequately hydrated, use mucolytic agents, and encourage the patient to move around. Moreover, the plan helps in improving the level of patient care by providing necessary information that discourages saline use in the event of suction (McKinley et al., 2018). Proper application of this plan will help ensure patients recover faster by using EBP.
It is clear from the above analysis that saline has limited time on oxygen therapy, ventilators, and intensive care. The information also helps practitioners explain to other nurses the need to avoid the use of saline during suction. It is clear from this that instilling saline increases VAP chances and lowers the respiratory tract. These undesirable outcomes cause more harm to antimicrobial characteristics in respiratory hypoxemia, cardiac arrest, infection, and bronchospasm.
References
Eekholm, S., Ahlström, G., Kristensson, J., & Lindhardt, T. (2020). Gaps between current clinical practice and evidence-based guidelines for treatment and care of older patients with Community Acquired Pneumonia: a descriptive cross-sectional study. BMC infectious diseases, 20(1), 1-12.
McKinley, D. F., Kinney, S. B., Copnell, B., & Shann, F. (2018). Long-term effects of saline instilled during endotracheal suction in pediatric intensive care: A randomized trial. American Journal of Critical Care, 27(6), 486-494.
In medicine, prevention is one of the management options for controlling diseases. In the case of pneumonia, the pneumococcal conjugate vaccine (PCV 13) is endorsed for adults who are 65 years old and above, children less than two years old, and babies (John Hopkins Medicine, n.d.). Moreover, the vaccine is indicated for people aged between 2 to 64 years old who are highly susceptible to pneumonia infections because of specific medical issues. According to Grief and Loza (2018), PCV 13 has resulted in a 46% reduction of community-acquired pneumonia cases, and the protection lasts for four years. The pneumococcal polysaccharide vaccine (Pneumovax 23) is specified for cigarette smokers between 19 and 64 years, adults above 64 years old, and people between 2 and 64 years old with medical conditions.
Bacteria cause most pneumonia infections, and they are managed using antibiotics. Empirical therapy should be the best option for treating pneumonia and should be chosen depending on the etiology and efficacy (Mantero et al., 2017). The prevalence of antibiotics differs among different classes of patients, including inpatients, outpatients, and intensive care unit patients. There is a need for starting early treatment using antibiotics as it helps to reduce 30-day mortality. Antibiotics are administered via the oral route for outpatients, while the endo-venous route is preferred for inpatients until they gain clinical stability, after which oral administration is used. Clinical stability is determined by monitoring respiratory rate, fever, hemodynamic parameters, and inflammatory biomarkers.
Macrolides and doxycyclines should be used in previously healthy patients who lack risk factors for resistant Staphylococcus pneumonia. Examples of these drugs are erythromycin, azithromycin, and clarithromycin. Respiratory fluoroquinolones such as moxifloxacin and levofloxacin are indicated in cases of comorbidities such as diabetes; chronic renal, heart, liver, or lung disease; and compromised immune system. They are also used in cases of resistant Staphylococcus pneumonia, or where patients have used antibiotics within the last three months (Mantero et al., 2017). Moreover, combined therapy of macrolides and beta-lactam antibiotics is directed. High doses of cefuroxime, ceftriaxone, cefpodoxime, amoxicillin, or amoxicillin-clavulanate are used in this treatment. Patients who are allergic to penicillin are managed using respiratory fluoroquinolone. The inpatients who are not in the intensive care unit are treated using either respiratory fluoroquinolones or beta-lactams and macrolides. For intensive care patients, beta-lactams and azithromycin, and beta-lactams and fluoroquinolones are used.
Adequate antimicrobial therapy has positive outcomes; however, it is not sufficient in some cases. For instance, even with sufficient antibiotic treatment, patients with two or more of the following risk factors, arterial blood with a pH of less than 7.35, hypoalbuminemia, high urea levels, needing hospitalization, have a higher probability of 30-day mortality (Mantero et al., 2017). Such patients should be identified early and provided with supportive therapy for better management of their health. The main complication that requires supportive treatment is respiratory failure. There are several non-invasive respiratory support options. Examples include high flow nasal cannula oxygen therapy, non-invasive therapy, and Helmet Continuous Positive Airway Pressure.
Despite antibiotics being the cornerstone of pneumonia treatment, resistance limits their use. For instance, in pneumococcal pneumonia, a monotherapy using beta-lactams will not manage the infection even though the bacteria are susceptible. Staphylococcus pneumoniae has a 20% to 40% resistance against macrolides, and the resistance is still on the rise (Nayar et al., 2019). As bacteria develop resistance against antimicrobials, it may become difficult to manage them in the future. Therefore, there is a need to use the correct antibiotics and dosages to avoid increased resistance cases.
Nursing intervention, adherence to VAP prevention measures, and the correct use of equipment increase the patient’s chances of recovery. Lack of knowledge about VAP prevention strategies provokes low adherence of nurses to them. The ability of a nurse to assess risks and counteract barriers has a positive effect on the outcome for patients. Understanding how preventive measures and nursing interventions affect VAP is essential to reducing patient mortality.
Sampling Basic Information
To assess the role of the nurses in the prevention of VAP, it is necessary to draw up a sample that will consist of nurses and patients. Previous studies show that gender and age are not characteristics that influenced the research results (Oner Cengiz & Kanan, 2019). Patients will also not be segregated by sex and age; however, older patients are likely to be more common due to the higher prevalence of VAP in this age group. The main criterion for compiling the sample is the risks of VAP in patients and work in the intensive care unit.
Sample Size
The sample size should include a minimum of 10 patients in critical condition and a minimum of 5 nurses working in the intensive care unit. The sample size is determined by the amount of information needed for comparative analysis. The indicated number of study participants will be sufficient to analyze the nursing intervention’s role. The analysis of the specified amount of information will fit into the required time frame of the study.
The Sample’s Suitability
The established sample is suitable for the study as it meets the goals and objectives of the work. Analyzing the work of nurses in the intensive care unit meets the need to assess the role of nursing intervention and identify strengths and weaknesses. An analysis of the condition of patients will make it possible to assess the effectiveness of the work of medical personnel and develop strategies for further development.
Data Collection Process
The process of collecting information will involve monitoring the work of nurses and the condition of patients with VAP. Quantitative and qualitative methods will be used to derive the assessment. A qualitative method will imply a general analysis of nursing interventions for the well-being of patients. The work will be carried out similarly to the study of Oner Cengiz and Kanan, who assessed the average knowledge scores and VAP frequency (2019). The quantitative methods will be reflected in the structured percentage assessment of the interventions performed and the health outcomes.
The Reliability of the Measurement Tool
The data collection method chosen is consistent and reliable as it can provide a complete picture of the role of nurses in VAP prevention. The qualitative analysis method reveals how nurses act to prevent VAP and assess the need for changes. The method of quantitative analysis derives clear statistics reflecting the degree of influence of nursing intervention on the level of development of VAP, mortality and recovery rate. The reliability of the chosen data collection and analysis tool is evidenced by the fact that the study will be conducted in real medical personnel’s work conditions.
Validity
Previous researchers confirm the reliability of the chosen measurement tool. The effectiveness of combining the quantitative and qualitative methods is demonstrated by relevant results (Oner Cengiz & Kanan, 2019). Analysis of health status by intervention or non-intervention can be done based on mortality (Kumar & Raghavendran, 2021). The analysis of the interventions is carried out based on observations of the nurses’ work in the intensive care unit.
Conclusion
Research into the role of nurses in preventing the development of VAP in critically ill patients involves the collection and analysis of data. Qualitative and quantitative methods will be used for the study. The relevance of the chosen strategy is determined by the need to observe both the work of the nurses and monitor the condition of the patients. Based on the chosen strategy, accurate quantitative statistics will be obtained, which will serve as a tool for developing a practical working methodology.
References
Kumar, A., & Raghavendran, M. (2021). Ventilator-Associated Pneumonia. RGUHS Journal of Nursing Sciences, 11(2), 38–41. Web.
In modern times, one of the most common groups of diseases is a group that leads to harm to the patient’s health during treatment. For example, pneumonia can be cited as the result of artificial ventilation of the lungs of seriously ill patients. This study is aimed at finding strategies that will help nurses and medical staff to reduce or eliminate the risks of patients’ diseases. In this case, the main issue is the work of nurses contributing to protecting patients from pneumonia caused by artificial ventilation and assistance in their survival.
By providing nurses with specific instructions on how to prevent patients from contracting pneumonia, medical institutions will be able to reduce the number of deaths.
The Significance of Nursing
Patients in the intensive care unit often get pneumonia due to artificial lung ventilation. A large number of deaths gave an understanding that it is necessary to take specific measures and develop strategies to reduce the number of deaths. In addition, it is essential to reduce the number of complications in patients after treatment.
The main issue of the study is to understand how much nursing intervention affects the possibility of pneumonia in seriously ill patients undergoing artificial ventilation of the lungs. Mortality from pneumonia due to artificial lung ventilation is 10%, which is a high indicator (Papazian et al., 2020). This study is aimed at finding solutions to this problem.
An Overview of Literature Review
Various articles and studies have been selected as sources of literature related to pneumonia caused by artificial ventilation. There is no knowledge about the prevention and prevention of VAP, which leads to low awareness of the medical staff about the strategy of action.
As sources, studies were selected that summarize all the knowledge about pneumonia, artificial lung ventilation, and nursing intervention in prevention and treatment. The study by Kumar and Raghavendra (2021) aims to study the causes of VAP and find solutions to how they can be eliminated. In addition, Osti et al.((2017) assess how nursing intervention helps in the recovery of patients. These articles offer general knowledge and recommendations for working with VAP, not individual ones.
In another study, an article by Alloush (2017) was cited, which says that nurses stop following individual recommendations, which negatively impacts patients. There is a significant shortage of medical personnel in intensive care units, which reduces the quality of care and leads to harmful consequences for patients.
Other researchers have proposed, implemented, and evaluated a system for teaching intensive care unit nurses to prevent VAP. Oner Cengiz and Kanan (2019) concluded that high-quality nursing training brings positive results in preventing VAP. Alvarez-Lerma et al. (2018) suggest considering the “Zero Pneumonia” program, which is aimed at minimizing cases of pneumonia, and this program is 55.8% successful. This study is undoubtedly successful, as it brings many positive results.
A multi-criteria model has been developed and implemented, aiming to assess the risks of VAP occurrence. Drnovšek et al. (2020) evaluated this model, created a decision support system, and implemented it into the practice of medical personnel. Undoubtedly, this was a success, as it helped significantly reduce the number of cases of pneumonia in intensive care patients.
Currently, pneumonia caused by artificial lung ventilation is one of the most acute problems. The skills and knowledge of nurses aimed at preventing the appearance of the disease are essential. It is necessary to invest in training nurses of the intensive care unit working with patients connected to the ventilator, as they will know how to work with such patients. In addition, specialized nurses will learn how to prevent the development of pneumonia in patients.
Design and Methodology
Correct prevention of VAP and in-depth nurses’ knowledge about working with patients in intensive care. To assess the role of a nurse in taking preventive measures, it is necessary to make a sample of patients and nurses. Sampling by gender and age is not adequate, even though elderly patients are more likely to become intensive care patients on ventilators.
The main criterion for the sample will be the height of the risk of VAP in patients in the intensive care unit. The sample will include at least ten patients who are in critical condition, as well as at least five nurses working in the intensive care unit. This number of patients and nurses is determined by the need for a certain amount of information.
By analyzing the work of medical personnel, it will be possible to assess how effective the profession of nursing staff in intensive care is. Examining the condition of patients will allow you to determine how correctly and effectively the work of nurses is. In addition, all the assessments made it possible to understand what measures need to be developed and taken to improve the quality of work of intensive care unit nurses.
The process of collecting information itself includes monitoring the work of nurses and the condition of patients with VAP. Qualitative and quantitative assessment methods will be used to obtain the most accurate results.
Methodology
The qualitative method includes a general analysis of the work of nurses and the well-being of patients. The basis will be the average knowledge score of the medical staff and the frequency of VAP. The quantitative method will be reflected in the percentage of interventions and results.
A qualitative method makes it possible to understand what measures nurses are taking to prevent VAP. The quantitative approach helps to obtain formulated data showing the degree of nursing influence on how often patients die recover, and how quickly VAP develops. This method is reliable because it helps to comprehensively assess the quality of nurses’ work in the field of pre-treatment of pneumonia by patients.
Ethical Considerations
The study will be conducted in actual conditions, which will give the most accurate assessment of the quality of work of medical personnel. It is imperative to monitor compliance with ethical standards when conducting research, that is, to encourage autonomous work, charitable goals, and justice. It is necessary to exclude any malice and coercion in conducting research.
The subjects may refuse to participate at any stage of the research. In addition, the persons involved in the study should not be exposed to any risk. This project completely excludes any discrimination, and the attitude of all participants is absolutely the same. In addition, the selected participants must read and sign an informed consent that confirms that they are familiar with the entire process and are ready to participate.
Research Details
One of the most successful recruitment strategies is the placement of online advertising on social networks. It is imperative that the online post contains all the necessary information about the study so that patients are fully aware. Another important detail is that participants should not be under 18 years of age, as this requires a particular organization. To collect the maximum amount of information, it is necessary to use a survey. The questionnaire will also be distributed via the Internet to gather as much information as possible about all participants.
This method of research is very convenient and gives the most accurate result. It is necessary to take into account an ethical point that is very important when conducting research.
Conclusion
In conclusion, it is necessary to develop the main ethnic considerations, as well as find ways to solve them. In addition, based on the obtained research data, it is important to track how successful the nurses working in the intensive care unit were.
Based on the data obtained, it is necessary to develop several strategies that will improve the indicators and improve the work of nurses. For example, if the knowledge indicators of nurses are at an average level and the number of rescued patients is low, it is necessary to develop a plan for teaching nurses how to prevent VAP for patients in intensive care. In any case, the proposed measures will depend on the results of the study. After developing and implementing strategies, it is necessary to re-conduct the study and determine the level of knowledge gained and how successfully patients recover. It is also required to control the proposed strategies and their possible transformation into more successful ones.
Álvarez-Lerma, F., Palomar-Martínez, M., Sánchez-García, M., Martínez-Alonso, M., Álvarez- Rodríguez, J., Lorente, L., Arias-Rivera, S., García, R., Gordo, F., Añón, J. M., Jam-Gatell, R., Vázquez-Calatayud, M., & Agra, Y. (2018). Prevention of ventilator-associated pneumonia.Critical Care Medicine, 46(2), 181–188. Web.
Osti, C., Wosti, D., Pandey, B., & Zhao, Q. (2017). Ventilator-Associated Pneumonia and Role of Nurses in Its Prevention. Journal of the Nepal Medical Association, 56(208), 461– 468.
Papazian, L., Klompas, M., & Luyt, C.-E. (2020). Ventilator-associated pneumonia in adults: A narrative review. Intensive Care Medicine, 46(5), 888–906. Web.
One of the central health problems is hospital-acquired diseases (HAI). Ventilator-associated pneumonia (VAP) is one of the leading HAI, which has become an even more severe problem with the COVID-19 pandemic. However, official policies and scientific research for preventing VAP offer a set of measures to avoid the development of the disease. These include the choice of non-invasive methods of providing oxygen, shortening the ventilation period, cleaning a patient’s oral cavity, correct positioning, and subglottic secretion suctioning. Therefore, the purpose of this paper is to define the intervention for the prevention of VAP based on the analysis of a facility’s activity and literature.
Learning Objectives
However, before researching the issue, one should define and describe the learning objectives of this assignment. Objectives are formulated based on Bloom’s taxonomy and correspond to its levels of cognitive skills as well as types of knowledge. Students must use factual, conceptual, procedural, and metacognitive knowledge specific to the nursing profession and strategic planning to meet these learning objectives. 3 At the same time, the goals include simple skills from memorizing concepts to applying them in analysis, synthesis, and evaluation necessary to formulate an intervention plan.
Background and Reasons of VAP
Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections globally and in the USA. VAP causes higher mortality and increases the length of hospital stay and the cost of treatment. The most common causes of VAP are bacterial colonization of the oral cavity, the subglottic area, and, as a consequence, the lower respiratory tract due to insufficient movement and accumulation of fluids.2 However, one of the most effective interventions is subglottic secretion suctioning, as it reduces the likelihood of VAP by 45%.2 However, most nurses have low compliance with the procedure due to insufficient knowledge or staff shortage in contrast to other preventive measures.4 Therefore, this evidence demonstrates that the intervention should be aimed at improving nurses’ knowledge in subglottic secretion suctioning.
Research Question
The problem: Insufficient knowledge and use of the subglottic secretion suctioning procedure by nurses
The problem’s importance: VAP prevention
The focus of the problem: Clinical
Scope of the problem: Institution
PICO Question: In patients requiring mechanical ventilation (P), how does the subglottic secretion suctioning applied by nurses (I) compared with no intervention (C) affect the reduction of ventilator-associated pneumonia?
The EBP Question: Does nursing training on the subglottic secretion suction improve the prevention of ventilator-associated pneumonia?
Subglottic secretion suctioning is the most problematic for nurses, since it requires knowledge of techniques and is usually performed by a respiratory therapist. Thus, the main problem is Insufficient knowledge and use of the subglottic secretion suctioning procedure by nurses. This problem could be solved by providing training for nurses to achieve sufficient competence and promote the application of the procedure. Therefore, the research question is whether nursing training on the subglottic secretion suctioning improve prevention of ventilator-associated pneumonia.
Intervention: In the first planning stage of the intervention, it is necessary to determine the most effective drainage tools and techniques. For example, Rouzé et al. highlight such devices as silver-coated tracheal tubes, low-volume low-pressure tracheal tubes, and the mucus shaver.5 The second step is to determine the level of skills and knowledge in using these techniques and devices and prepare training by a responsible person. The next stage includes direct theoretical and practical training under the supervision of the responsible person for a group of nurses.
After completing the training and implementation of the practice for the group of the nurse, it is necessary to evaluate the effectiveness of education and intervention in general. This approach will demonstrate whether there are problems in the course or barriers to knowledge application and whether the intervention, in general, is effective. At this stage, changes can also be made if there are deficiencies. However, if the intervention is effective, training should be provided for nurses in all departments to apply the subglottic secretion suctioning procedure and reduce the level of VAP in the hospital.
Responsibilities
The nurse manager can be the initiator and the main project leader, who will assemble the interprofessional team after coordination with the administration. The team must determine the best drainage techniques, as well as evaluate the quality of the training provided by a respiratory therapist. The training in the first stage will be conducted by a respiratory therapist, and in the “Act” stage, nurses who have already acquired suction skills can train colleagues. The nursing manager should also evaluate the intervention, although the director of nursing should assess its financial benefits.
Measures
These measures to evaluate the intervention were chosen because they cover three critical aspects of understanding healthcare quality, such as structure, process, and outcomes. 6(188) Nurses’ skills and treatment cost are measures of the structure and demonstrate qualitative changes in personnel qualifications. The level of VAP and the frequency of using the procedure show qualitative changes in the process of treating patients who need ventilation. At that time, the rate of mortality, development of diseases and disabilities resulting from VAP, and dissatisfaction and discomfort of the patient due to the duration of treatment are health outcomes. Therefore, the measurement of these indicators before the start of the intervention and after three and six months of its application will assess the intervention’s effectiveness.
Costs and Ethical Considerations
This project almost does not require financial investments for implementation. The only cost may be additional hours of work for the interprofessional team and a respiratory therapist involved in the design and delivery of the training. In addition, the price can also increase if the hospital does not have the equipment to perform the procedures; however, all investments are long-term and will pay off if the intervention is successful. The project does not have ethical consideration or conflict of interest because subglottic secretion suctioning is a safe procedure that requires minimal physical intervention and is acceptable to most beliefs. The choice of a nurse in the group for the first training may be a problem; however, the manager will recruit volunteers or select nurses based on their experience and teaching ability.
Conclusion
Therefore, this intervention aims to train nurses in the skills necessary to reduce the risks of developing VAP. Subglottic secretion suctioning procedures and other preventive methods will reduce the likelihood of colonization of bacteria that cause pneumonia. This intervention is low cost and easy to implement as it only requires development training for nurses. Several measures covering the structure, process, and results of health care quality will be used to assess the intervention. At the same time, the suctioning procedure is highly effective in preventing VAP. Consequently, reducing VAP development contributes to lower patient mortality, length, and cost of treatment and also increases patients’ satisfaction.
References
1. Haque M, Sartelli M, McKimm J, Abu Bakar M. Health care-associated infections – an overview. Infect Drug Resist. 2018;11:2321-2333.
2. Boltey E, Yakusheva O, Costa DK. 5 Nursing strategies to prevent ventilator-associated pneumonia. Am Nurse Today. 2017;12(6):42-43.
4. Al-Sayaghi KM. Critical care nurses’ compliance and barriers toward ventilator-associated pneumonia prevention guidelines: cross-sectional survey. Journal of Taibah University Medical Sciences. 2021;16(2):274-282.
5. Rouzé A, Martin-Loeches I, Nseir S. Airway devices in ventilator-associated pneumonia pathogenesis and prevention. Clin Chest Med. 2018;39(4):775-783.
6. Holly C. Practice-based scholarly inquiry and the DNP project. 2nd ed. New York, NY: Springer Publishing; 2019.
Ventilator-associated pneumonia is defined as pneumonia in a patient who has been mechanically ventilated for at least 48 hours or in a patient who has been extubated for at least 48 hours. According to Papazian et al. (2020), “reported incidences of VAP vary widely from 5 to 40%, and the estimated attributable mortality is around 10%, with higher mortality rates in surgical ICU patients” (p. 888).
Discussion
High severity and mortality, as well as a significant increase in the consumption of material resources in the event of VAP, contribute to the necessity of the development of clear and concise preventive measures. This research aims to provide strategies to help nurses identify the possible risks and signs of VAP and subsequently reduce them in the clinical setting. Specifically, appropriate nursing interventions should be developed to increase the success rate of preventing VAP among critically ill patients.
Thus, the prognosis type of the PICOT question is developed to address the study’s key aspects. The question is: In critically ill patients (P), how does a tailored and specific nursing intervention (I) compared to general methods of risk assessment and prevention (C) influence the possibility of the occurrence of VAP (O) during mechanical ventilation (T)? Consequently, the importance of the research question relates directly to the work of the ICU nurses; multiple life-threatening conditions require mechanical ventilation, and the risks and comorbidities vary from one case to another.
Conclusion
By providing nurses with a well-designed approach to assessing the possibility of VAP and comprehensive measures to prevent it, healthcare facilities could contribute to the overall patient survival rate. Moreover, ICU nurses’ stress levels could also be improved by the implementation of standardized measures to help them operate in the highly demanding environment of the ICU unit.
Reference
Papazian, L., Klompas, M., & Luyt, C.-E. (2020). Ventilator-associated pneumonia in adults: A narrative review. Intensive Care Medicine, 46(5), 888–906.
In this scenario, health care professionals collaborate virtually to help a patient in Valley City, North Dakota. Caitlynn is a 2-year-old female hospitalized with pneumonia at the Pediatric Department of Valley City Regional Hospital (VCRH). Caitlynn had mecontal ileus at birth, and this is her second hospitalization with pneumonia in 6 months. Current symptoms are weakened breath sounds in the right base and wheezing in the upper lobes; respiration 32, shallow; temperature 101. Furthermore, the physicians suspected malabsorption due to the patient’s low weight of 20.7 pounds and decreased subcutaneous fat. Thus, Caitlynn was previously diagnosed with pneumonia and malnutrition.
After additional tests, the patient was diagnosed with Cystic Fibrosis (CF). This is a hereditary autosomal recessive disease characterized by a malfunction of the external secretion glands and respiratory organs and a decrease in the activity of intestinal and pancreatic enzymes (Sutherland et al., 2019). Caitlyn requires constant parental care and regular medical supervision. The patient is seen by pediatrician Dr. Benjamin in her hometown, and her treatment is overseen by a multidisciplinary team of specialists from VCRH. Caitlynn’s parents are separated, do not live together, and both works, consultation with social services is required to coordinate actions. One parent or both should be fully informed and trained in the care of Caitlynn and receive periodic advice from the VCRH team.
Care Plan
On admission to VCRH, a respiratory therapist administered aerosol and chest physiotherapy to Caitlynn. Dr. Copeland gave her an IV with piperacillin for cystic fibrosis before the follow-up examination. The LeCleir and Pettit study shows a high likelihood of kidney failure in pediatric patients using piperacillin-tazobactam – 55% (2017). The use of cefepime with a 13% chance of kidney failure is recommended for possible recurrence of pulmonary infection, especially in combination with vancomycin and tobramycin (LeCleir & Pettit, 2017). Aerosol therapy is one of the main treatments to promote hydration of the epithelial lining fluid (Velino et al., 2019). Moreover, aerosols are used to deliver various drugs directly to the lungs to reduce the burden on the body (Velino et al., 2019). Therefore, the patient’s parents should be trained in the use of aerosol treatment and other types of physiotherapy.
The second direction was diet therapy and malnutrition problem solving for Caitlynn. Dr. Copeland prescribed a high-calorie, high-protein, high-fat diet. A study by Sutherland et al. that such a diet protects patients from intestinal obstruction and provides them with additional energy and essential fat-soluble vitamins (2019). Particular emphasis in Caitlynn’s diet is on getting vitamins A, D, E, and K. These vitamins improve pulmonary function and positively affect the functions of the digestive organs (Sutherland et al., 2019). In addition, the patient receives pancreatic enzymes, facilitating the absorption of nutrients and reducing possible intestinal symptoms.
Evidence-Based Practice Model
Caitlyn used the evidence-based Star model or ACE to develop her care and treatment plan. This technique implies interdisciplinary collaboration, and patient-centered care, involving the patient’s family in the care process (Indra, 2018). First, the main task was to install a monitoring system for Caitlynn’s condition, given her residence in a remote city. It required a combination of the use of telemedicine with regular visits to the local pediatrician and the active involvement of nurses in parent education. Second, Caitlin’s parents needed to be provided with information and access to consultations with medical staff (Indra, 2018). Third, by working together, all participants had to introduce new treatment practices and observe how they are performed. Fourth, every new practice should be subject to rigorous analysis and risk assessment to ensure it is effective and necessary (Indra, 2018). This approach provides Caitlynn with comprehensive, evidence-based care that should improve her condition.
Interdisciplinary Collaboration Challenges
Caitlin lives in a small town 100 kilometers from VCRH and cannot be seen at the clinic all the time, given her age and condition. Being in a small town also means not having access to many quality medical resources (Gifford et al., 2021). This is why telemedicine plays such a significant role in Caitlyn’s treatment. The VCRH medical staff offered the patient’s parents various online services to educate and monitor Caitlyn’s condition. First, the doctors and nurses set up online meetings with the patient’s parents to educate them on treatment techniques, show them how to use the aerosols, and explain the diet plan. Second, VCRH staff are in touch with Caitlin’s parents and pediatrician via text messages. Third, social worker Madeline Becker helped parents find support groups for relatives of patients with Cystic Fibrosis.
Conclusion
Caitlynn’s treatment plan is evidence-based, patient-centered, and meets all the latest advances in medicine and patient care practices. The involvement of all stakeholders and various medical and social service personnel will help Caitlynn receive adequate and high-quality treatment, even in the conditions of life in a remote small town. Throughout Caitlin’s life, her parents and medical professionals will be able to help her cope with her genetic disease on her own. Proper use of telemedicine could make the patient’s life less dependent on hospital facilities in the future.
References
Gifford, A. H., Ong, T., Dowd, C., Van Citters, A. D., Scalia, P., Sabadosa, K. A., & Sawicki, G. S. (2021). Evaluating barriers to and promoters of telehealth during the COVID-19 pandemic at US cystic fibrosis programs. Journal of Cystic Fibrosis, pp. 20, 9–13.
Indra, V. (2018). A review on models of evidence-based practice. Asian Journal of Nursing Education and Research, 8(4), 549–552.
LeCleir, L. K., & Pettit, R. S. (2017). Piperacillin‐tazobactam versus cefepime incidence of acute kidney injury in combination with vancomycin and tobramycin in pediatric cystic fibrosis patients. Pediatric pulmonology, 52(8), 1000-1005.
Sutherland, R., Katz, T., Liu, V., Quintano, J., Brunner, R., Tong, C. W., Collins., E. & Ooi, C. Y. (2018). Dietary intake of energy-dense, nutrient-poor and nutrient-dense food sources in children with cystic fibrosis. Journal of Cystic Fibrosis, 17(6), 804–810.
Velino, C., Carella, F., Adamiano, A., Sanguinetti, M., Vitali, A., Catalucci, D., Bugli, F. & Iafisco, M. (2019). Nanomedicine approaches for the pulmonary treatment of cystic fibrosis. Frontiers in Bioengineering and Biotechnology, 7, 406.
Pulmonary inflammation or pneumonia is a viral disease that affects lung tissue. It prevents normal oxygen exchange between the air and blood. Inflammatory secretions that enter the alveoli prevent the body from getting enough oxygen. Moreover, if the disease takes over most of the lungs, acute respiratory failure develops. When the disease occurs, the person’s body temperature rises, which can reach 38°, there is a general weakness in the whole body, headache, the patient wants to lie down and relax (Lunenfeld et al., 2015). After a few days, a severe coughing fit occurs, and sputum appears. Pain in the chest, especially in the center of inflammation and shortness of breath, indicates the severity of the situation and clearly stipulates pneumonia (Agency for Healthcare Research and Quality, 2014). The patient in question has bacterial pneumonia, as this is the case when antibiotics are prescribed. With viral pneumonia, antibiotics are not effective, so antiviral medications are prescribed. As the patient’s general condition improves and the fever drops, my clinical recommendation would be to continue taking antibiotics. Vitamins and immunomodulators such as Broncho-Vaxom may be prescribed as adjuvants.
The patient’s medical needs also include management of nausea and a change in diet. Nausea and vomiting can be assumed to be caused by intoxication from pneumonia as well as an unsuitable diet. Minerals and vitamins should be affixed to the diet for conservative relief of symptoms, the effect of which on immune performance is essential. In addition to proteins and fats, a number of vitamins, especially fat-soluble (A, D, E, and K) and water-soluble (C, B1, B12), and minerals have immunogenic potential (Montaner et al., 2014). Significant attention in the diet should be given to the protein component. It consists primarily of dairy products and eggs, the protein of which is easily digested. In second place – lean meat, beef, chicken, lean pork, which can be boiled, stewed, and baked.
In patients with lung diseases, proteins are broken down faster, which explains their high content in the diet. At the same time, proteins should be easily digestible and complete. Protein is a source of energy for muscle tissues, and acts as neurotransmitters, and contributes to the normal absorption of minerals and vitamins (Roberts & Hickey, 2016). Regarding drugs to suppress the vomiting syndrome, I would recommend broad-spectrum drugs, namely levomepromazine. It should be taken in a dosage of 6-6.25 mg at night and as needed.
An important component of quality treatment is educating the patient to fill their health needs. The primary strategy is to educate the patient about the disease and treatments using videos and printed guides. It is also vital to acquaint the patient with the positive effects of sleep habits, diet, and avoidance of bad habits, particularly given the tropism of the disease to the respiratory system and tobacco smoking. Of no small importance in the course of treatment is maintaining the physical activity of the patient, which contributes to speeding up the recovery process. It is worth informing the patient about the possibilities of undergoing therapeutic physical training and breathing exercises. The intensity of physical activity should not be accompanied by a feeling of fatigue of the patient the next day. The frequency of exercises should be two times a day for 15-45 minutes, 1 hour after meals. In this way, the patient’s treatment will be complete and provide a good chance of recovery and recovery.
Lunenfeld, B., Mskhalaya, G., Zitzmann, M., Arver, S., Kalinchenko, S., Tishova, Y., & Morgentaler, A. (2015). Recommendations on the diagnosis, treatment, and monitoring of hypogonadism in men. Aging Male, 18(1), 5–15. 10.3109/13685538.2015.1004049
Ventilator Associated Pneumonia (VAP) is the infection of the lungs seen in patients within 2 days after intubation with an endotracheal tube or any other ventilator aid, for instance, the tracheostomy tube that was not there before. It has been regarded as the most common infection in the Intensive Care Unit (ICU) and also the most fatal (Wagh & Acharya, 2009).
Etiology
VAP is a nosocomial infection that is very common. Patients especially those in ICU are at high risk of acquiring VAP. The mechanical ventilators are inserted into the respiratory tree and therefore if contaminated, they can inoculate causative agents into the lower respiratory tract. The causative agents are those common in causing hospital acquired infections like pseudomonas aeruginosa, staphylococcus aureus, Haemophilus influenza, Klebsiella pneumonia and Escherichia coli. The strains of these bacteria are usually drug resistant this being a hospital setting. Infection may also be due to contaminated ventilator equipment and lack of hand washing or using the gloves on multiple patients thus transmitting the disease.
Risk factors include those which increase exposure to these agents or those which reduce host defense mechanisms like longer duration in hospital, mechanical ventilation for long hours, old age, low score in the Glasgow Coma Scale (GCS), other forms of pre-existing pulmonary infection or disease, immunosuppression and poor nutrition (Torpy, 2008).
The aetiology of ventilator associated pneumonia is affected by many factors including time of hospitalization, flora change due to hospital stress, flora change due to various medications including immunosuppressant drugs or antibiotics, presence and amount of nosocomial pathogens and other interventions of the patient (Wagh & Acharya, 2009).
Pathology
Pathogenesis
The pathogenesis of VAP involves destruction of the respiratory parenchyma by the colonies of bacteria that gain access to it through intubation of the ventilators. Infection by bacteria triggers an inflammatory response with infiltration by neutrophils at first and other inflammatory cells later. The inflammatory process is responsible for the purulent sputum seen in these patients. Early onset VAP is that which occurs within 48 hours of intubation and that which occurs after 48 hours, that is, late onset.
They arise from aspiration during the intubation process. Intubation reduces the cough reflex which is a primary defense mechanism; it impairs mucociliary escalator and damages the mucosal lining facilitating colonization by bacteria. Mucous secretion is increased in an attempt to trap the bacteria, further deteriorating the condition. Colonies of bacteria form in the upper respiratory or upper digestive tract, from where they are inoculated into the lower respiratory tract during intubation. Contaminated secretions may also be aspirated. The causative agents can also be the patient’s normal flora especially in gastric aspirations (Augustin, 2007).
Epidemiology
VAP occurs more commonly in patients who stay longer in hospitals and on those with invasive ventilation. Haemophilus influenza and streptococci are very common agents of VAP. Gram negative bacteria are seen when patients stay for prolonged periods on ventilator equipment. Mortality and morbidity are highest in patients with VAP caused by Pseudomonas aeruginosa. Anaerobic bacteria cause VAP following orotracheal intubation more commonly than following nasotracheal intubation.
Diagnosis
Any patient receiving ventilator support is at risk of VAP. Diagnosis may be based on observation of clinical features like fever, elevated white blood cell count, new or progressive infiltrations in the chest radiograph, and purulent sputum production. Chest radiographs may show other related features like atelectasis, pulmonary emboli, pulmonary infarction, pulmonary edema, gastric aspirations, alveolar hemorrhage and even Acute Respiratory Distress syndrome. These are non-specific features hence the need for more specific diagnostic criteria; bacteria culture being the most valuable.
Bronchoscopic methods and nonbrochoscopic techniques have been used in diagnosis. Nonbrochoscopic techniques include Bronchoalveolar Lavage (BAL), Mini-bronchoalveolar Lavage (mini-BAL), Blind Bronchial Sampling (BBS) and Protected Specimen Brush (PSB). The sensitivity of BBS is higher than PSP (Anon, 2007).
Attempts have been made to increase the speed and accuracy of diagnosis. Presence of microbes triggers the alveolar macrophages to release mediators such as tumor necrosis factor alpha (TNF alpha), interleukin-1β and other mediators, making them have diagnostic and prognostic values. Reference ranges for this have not been set and they may be non-specific, making them less valuable in diagnosis.
Several biomarkers have been studied in diagnosis. Elastin Fiber (EF) is released in cases of parenchymal destruction of the lung mucosa, thus it may be useful in differentiating infection, when EF levels are elevated from colonization when its levels are low. Low sensitivity of EF testing makes it less popular in diagnosis. Procalcitonin (PCT) has high sensitivity (87%) in VAP and high specificity (88%). C-reactive protein may also be useful.
BAL fluid may be tested for levels of Soluble Triggering Receptor Expressed on Myeloid cells (sTREM)-1 as this can be useful in differentiating bacterial from fungal infections. Levels of endotoxin in BAL can be invaluable, since it is elevated in patients with Gram-negative bacteria rather than Gram-positive. It can also differentiate colonization from infection of the pulmonary tissue. STREM, PCT and CRP are potentially useful in diagnosis. EF and endotoxin are less reliable (Rea-Neto et al., 2008).
Treatment
Being a bacterial infection, administration of antibiotics is the mainstay in treatment for VAP. Results from the culture sensitivity lab are important in choosing the type of antibiotic to use. VAP is acquired in hospitals, which means that most of the causative agents are Multi-Drug Resistant, and therefore antibiotics normally chosen are those with activity against Multi-Drug Resistance bacteria. VAP is a debilitating disease and it usually requires palliative care, intensive care with mechanical ventilator aid. The risk for Antibiotic resistant bacteria is increased if the patient was receiving antibiotics previously.
A combination of piperacillin, tazobactam and amikacin are commonly used in treatment. Studies have shown that a combination of cefepime and levofloxacin are more effective, but there are concerns about their use especially in patients with Acute Renal Failure (Ahmed et al., 2007).
Prevention
Prevention of VAP is achieved primarily by reducing the risk factors. Vaccination also is very valuable in prevention. People handling patients especially in ICU, nurses and doctors should play a major role in reducing the risk factors. They should aim at reducing bacterial colonization on the oro-pulmonary tracts by observing hygiene. Hand washing with soap and a lot of water is helpful immediately before attending to the patients. They should always wear gloves and avoid using them on multiple patients. This may be achieved by placing it on notice boards and doors in ICUs that they should observe these basic and cost-effective strategies. Protective attire should be worn especially when drug-resistant strains have been isolated in cultures.
Mechanical interventions can be used to reduce colonization in the mouth and upper part of the respiratory tree. These include effective and regular tooth brushing and thorough rinsing with clean water. The secretions can be suctioned using relevant equipment as this is invaluable in reducing colonization of bacteria.
Colonization in the oropharynx can also be decreased by applying pharmacologic interventions like use of chlorhexidine oral rinse twice daily. Other solutions have also been used e.g. colistin, vancomycin (especially where drug-resistant strains are suspected) and gentamicin. Stress ulcer prophylaxis can also be done to reduce bacterial colonization of the stomach since risk of aspiration is high in ICU patients.
Accumulated mucus can home many colonies of bacteria hence the need for aseptic methods when performing intubations. Saline lavage should be avoided since its risks outweigh the benefits. It transports bacteria from the endotracheal tubes to the lower airways and has been shown to increase the incidence of VAP. Prophylactic administration of antibiotics does not reduce the incidence of VAP and it should be avoided because it leads to development of the drug-resistant strains.
Turning patients every 1 hour or so has been shown to reduce the incidence of VAP. Special beds are available for this purpose but are not cost-effective in most clinical settings. These methods act by increasing drainage of the lungs. Infection from contaminated ventilator circuits or those with bacterial colonies can be minimized by changing them frequently and cleaning them thoroughly. VAP caused by aspiration can be minimized by monitoring and preventing incidences of weaning or extubation.
Aspiration can also be prevented by elevating the head of the patient up to about 35° and also facilitating gastric emptying. Thorough suctioning of the upper respiratory tract is very useful in decreasing the risk of aspiration. Cuff pressure should be high to reduce aspiration of secretions. There are various studies underway to investigate the possibility and cost effectiveness in using endotracheal tubes that are coated with silver nitrate as this has been shown to reduce colonization in other animals (Augustin, 2007).
References
Ahmed et al. (2007). Treatment of ventilator-associated pneumonia with piperacillin-tazobactum and amikacin vs cefepime and levofloxacin: A randomized prospective study. Web.
