Nursing Care for Patients with Ventilator–Associated Pneumonia : VAP

Abstract

Background : The impact of Ventilator-associated pneumonia (VAP) is an important nosocomial infection in hospital. VAPinclude increased duration of ventilation, length of hospital stay and cost of care. It is significant factor which associating with motility rate. VAP is a complex conditionsthat lead to difficult diagnosisandconstant and continuous treatment.Therefore heath care providers need todevelop knowledge and understanding about VAP. They also need to comply with preventive guidelines and to minimize VAP.

Case study 1 : A 62 - year - old female was cough and breathless for 4 days before hospitalized (diagnosed with asthma for 10 yearsESRD with CAPD 2 years. One day before hospitalization, she was had abdominal pain, ascites and mass, PDF not clear, on the first day of hospitalization, she had and was intubated endotracheal tube, Ceftriaxone 2 gram, Dexamethasone 4 milligram via vein q 6 hr., Beradual 1NB was given.After that, she was referred to Mahasarakham hospital, which was diagnosed Infected CAPD, peritonitis, pneumonia, respiratory failure. Volume ventilator with settings: CMV mode, FiO2 0.4, set TV 500 ml. RR= 20 /min was used and hervital signs were T = 37.6 , PR = 111 /min BP = 173/102 mmHg DTX = 113 mg% , O2sat = 100%. Nursing care included monitoring hypoxemia, ventilator care, monitor VAP , sepsis and respiratory tract obstruction , peritonitis, and electrolyte imbalance. Drug prescription consisted of Meropenem 500 mg IV OD, Tienam 500 mg, Meropenam 100 mg addedPDF x4 cycle.After hospitalization for 18 days, she had fever,breathless, increased secretion and found T = 38.6 ,PR = 118 /minRR = 22 /minBP = 115/84 mmHg ,Sputum C/S = Acinetobacter baumannii (A.baun.) MDR (Multidrug resistance), Colistin 150 mg. IV OD, Unasyn 3 gm. IV q 6hr. After 7 days of the treatment, she was improved, ventilator was taken off, and was referred to community Hospital for continuing treatment of infection with antibiotic. The length of stay (LOS) was 28 days and total cost of care were 170,940 baht. Diagnosis was
lobar pneumonia, Infected CAPD (E.Coli ESBL) with peritonitis, respiratory failure, septic shock, hypokalemia, Hypomagnesaemia, VAP (A.baun. MDR Septicemia) Anemia of chronic disease Case study 2 : A 70 - year - old female had fever and chill for 7 days before went to community hospital. Infection was treated with Ceftriaxone 2 gm. IV OD. NSS 1000 ml Iv rate 100 ml/hr was given, and Foley’s catheterization was retained.After one day of admission she go thigh fever, diarrhea more than 3 times, and weakness. One hour before reffered to Mahasarakham hospital, she was unconsciousand seizure, and wasintubated with endotracheal tube. At Emergency room she was unconscious and seizure with E2VTM5, Pupil 3 min both to light eye , T= 38. , PR = 112 /minRR = 20 / min BP = 75/61 mmHg.DTX = 88 mg%, O2sat = 100% Valium 10 mg. IV, Levophed 4 : 250 rate 10 ml./hr., Dopamine 2 : 1 rate 13 ml./hr. IV, Hydrocortisone 100 mg IV Stat was prescribed. The diagnosis was UTI, septic shock, electrolyte imbalance ,severe metabolic acidosis, respiratory failure. Volume ventilator with CMV mode, FiO2 0.4, set TV 500 ml. Her diagnosis was Infected CAPD with peritonitis, pneumonia, respiratory failure. As the worsen condition, volume ventilator with CMV mode, FiO2 0.4, set TV 500 ml. RR = 20 /min was applied to support her. HerVital signs was T = 37.6 c, PR =111 /min BP = 173/102 mmHg, and DTX =113 mg% , O2sat = 100%. Nursing care included evaluated hypoxemia, ventilator care, monitored VAP, septic shock,and respiratory tract obstruction, IV care, and monitoring electrolyte imbalance.Ceftriaxone 1 gm. OD was prescribed. On the 11th days of hospitalization, she had fever breathless, increased secretion, her vital signs : T = 38.4 oc, PR = 108/minRR = 20/min BP=118/82 mmHg, X - ray : Lobar Pneumonia Sputum C/S = Acinetobacter
baumannii (A.baun.).According to severe sepsis, Meropenem 1g q 8 hr, and Colistin 150 mg IV OD 8 days. Finally, her infection was improved,ventilator was taken off, and was referred to community hospital for continuing antibiotic other 8 days. The length of stay (LOS) was 18 days and total cost of care was 109,503 baht. The last diagnosis : UTI, septic shock, hypokalemia, metabolic acidosis, Acute respiratory failure, VAP (A.baun., MDR)

Nursing care for two patients focuses on the care of infectious pneumonia ventilator. The cares includes : 1) Clinical Nursing Practice Guidelines (CNPG) for prevention of VAP consisted of 7 categories; 2) improving knowledge, skill, and awareness concerning VAP prevention among health care providers; 3) Control the VAP
outbreak by following standard practice guideline.

Keyword : Ventilater - Assciated, Pneumonia