NR 536 Week 3 Developing Critical Thinking Questions

Template for Week 3 Assignment:  Developing Critical Thinking Questions

Concept to be presented:  Protection and movement – infections

NR 536 Week 3 Developing Critical Thinking Questions

Type of learner (nursing student [identify level]; nurse [identify years of experience]; patient/or family):  Staff nurse working in an acute health care hospital with three years of experience in patient protection and management. 

NR 536 Week 3 Developing Critical Thinking Questions

Problem Recognition:
PathophysiologyPhysical AssessmentPharmacology
A 65-year-old male admitted to healthcare after chest pain due to localized inflammation of pleura. The healthcare facility has 3.8% HAP rates and possibility of developing VAP are high. Healthcare is aiming to reduce the infection rate and prevent patient from contracting VAP.Question: What led to increased VAP rate in the health care?
Answer:The major reasons for increased VAP rates include poor hygiene and waste management (Hua et al., 2016), lower inclination of head resulting in poor breathing pattern, increased aspiration event before intubation, high antibiotic exposure (Khan et al., 2017), secretion of bacteria such as Hemophilus influenzae and Streptococcus pneumoniae and failing to create a safer environment for patients (Olanipekun & Snyder, 2019). 
Question: What physical assessment procedures were used to prevent the secretion of bacteria in respiration tract?
Answer: Physical assessment included auscultation and palpation of the chest, monitoring airway pressures (Khan et al., 2017), exposure of patient to environment, and patient’s secretion production every 48 hours (Álvarez-Lerma et al., 2018). 
Question: Has resilience for antibiotics played a major role in increasing VAP rates?

Answer: Resilience for antibiotics is a major reason for increased VAP rates as previous exposure to antibiotics in older adults result in inadequate defense against the bacteria (Zampieri et al., 2015). This increases risk of bacterial secretion in trachea and respiration tract (Hua et al., 2016). 
Clinical Decision Making: 
PathophysiologyPhysical AssessmentPharmacology
The nursing staff and leader decided to adopt VAP prevention bundle to reduce VAP rates, VAP days, and cost of treatment. Question: What clinical data influenced the staff to adopt bundle intervention to reduce VAP?

Answer: Álvarez-Lerma et al. (2018) study found that bundle intervention including reduced infection rate from 9.83% to 4.34%. Pinho et al. (2020) study found that bundle treatment reduced VAP rates from 42 to 22.2 days. It increased oral hygiene level from 22% to 55%. 
Question: What is the optimal time to conduct physical assessment?
Answer: Generally, VAP occurs after 48 hours of admission. However, this increases risk of VAP if the physical assessment is not carried out within 48 hours (Fortaleza et al., 2020). The bundle program promotes initial assessment within 24 hours as it aids in assessing breathing pattern, congestion in chest, and airflow in oximetry (Pinho et al., 2020). 
Question: How will prolonged stay in hospital affect the bundle intervention?
Answer: Prolonged hospital stay will increase multidrug-resistant to pathogens and it decreases effectiveness of antibiotics (Zhao et al., 2020). Multimodal and probiotic drug intervention found effective in delaying VAP occurrence and aided in reducing drug resistance (Xie et al., 2019). 
Prioritization: 
The healthcare needed to assess whether monitoring patient 24-hour reduce VAP rate and possible effects of the new schedule on nursesQuestion: What changes can be considered as symptoms to provide increased care for patients?
Answer: Breathing tubes or endotracheal tube are susceptible to bacteria secretion. If the patients show the signs of fever, change in breathing rate, puss in the lung secretion areas (Zampieri et al., 2015), low oxygen levels, and mucus secretion, then it is important to provide extra care. Also, if there are cases of VAP in the unit, it is better to quarantine the patient and protect him in a safe environment (Álvarez-Lerma et al., 2018). 
Question: What should be the ideal inclination of mechanical ventilator to prevent patient from developing pressure ulcers, infection, and bacterial secretion. 

Answer: Physical assessment should start from complete oral hygiene, head to toe examination, and assessing the effectiveness of 30-degree inclination on patient’s safety, comfort and pain levels (Fortaleza et al., 2020). The 30-degree inclination and physical therapy aid in preventing infection formation (Zhao et al., 2020).
Question: Is prioritizing use of chlorhexidine beneficial for patients over regular oral hygiene?

Answer: Prasad et al. (2019) highlighted that use of 0.2% chlorhexidine increases oral health and aid in preventing bacterial secretion. Bardia et al. (2019) concluded in their study that chlorhexidine prevents bacterial secretion for long time. However, Vieira et al. (2020) argued that chlorhexidine damages organic sectors and cytotoxicity. As a result, further studies need to be analyzed to find an effective oral hygiene process. 
Clinical Intervention:
The healthcare considered multimodal bundle intervention to prevent the infection by including prioritized care for students who are at higher risk of contracting VAP.Question: how to determine who needs prioritized care?

Answer: The patients who are bed-ridden for longer period of time are at high risk of contracting infection (Álvarez-Lerma et al., 2018). Further, patients with resistance to antibiotics with endotracheal tube are at high risk of developing infections. It is important to monitor such patients at least once a day. However, it is recommended to monitor twice a day to reduce infection occurrence (Pinho et al., 2020). 
Question: How to evaluate the effectiveness of the twice a day head to toe assessment intervention?

Answer:By adopting a evidence-based practice model such as Iowa model, it is possible to evaluate the effectiveness of the intervention by comparing pre-intervention VAP rates and post-intervention VAP rates. The interventions can be applied at local level to test its effectiveness and change the intervention based on the outcome. 
Question: What measures will help in optimizing sedation period?

Answer:Continuous sedation will result in lower body movement and increases chances of morbidity and infection rise (Álvarez-Lerma et al., 2018). As a result, protocolized sedation, daily spontaneous breathing trials (SBT), and daily sedation interruption (DSI) allows the staff nurse to manage the patient better. This helps in keeping the patient active (Hellyer et al., 2016). 

NR 536 Week 3 Developing Critical Thinking Questions

References

Álvarez-Lerma, F., Palomar-Martínez, M., Sánchez-García, M., Martínez-Alonso, M., Álvarez-Rodríguez, J., & Lorente, L. et al. (2018). Prevention of ventilator-associated pneumonia. Critical Care Medicine46(2), 181-188. https://doi.org/10.1097/ccm.0000000000002736

Bardia, A., Blitz, D., Dai, F., Hersey, D., Jinadasa, S., Tickoo, M., & Schonberger, R. (2019). Preoperative chlorhexidine mouthwash to reduce pneumonia after cardiac surgery: A systematic review and meta-analysis. The Journal Of Thoracic And Cardiovascular Surgery158(4), 1094-1100. https://doi.org/10.1016/j.jtcvs.2019.01.014

Fortaleza, C., Filho, S., Silva, M., Queiroz, S., & Cavalcante, R. (2020). Sustained reduction of healthcare-associated infections after the introduction of a bundle for prevention of ventilator-associated pneumonia in medical-surgical intensive care units. The Brazilian Journal Of Infectious Diseases24(5), 373-379. https://doi.org/10.1016/j.bjid.2020.08.004

NR 536 Week 3 Developing Critical Thinking Questions

Hellyer, T., Ewan, V., Wilson, P., & Simpson, A. (2016). the intensive care society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. Journal Of The Intensive Care Society17(3), 238-243. https://doi.org/10.1177/1751143716644461

Hua, F., Xie, H., Worthington, H., Furness, S., Zhang, Q., & Li, C. (2016). Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Of Systematic Reviews. https://doi.org/10.1002/14651858.cd008367.pub3

Khan, Z., Ceriana, P., & Donner, C. (2017). Ventilator-associated pneumonia or ventilator-induced pneumonia. Multidisciplinary Respiratory Medicine12. https://doi.org/10.4081/mrm.2017.224

Olanipekun, T., & Snyder, R. (2019). Mortality risk in ventilator-acquired bacterial pneumonia and nonventilator icu-acquired bacterial pneumonia. Critical Care Medicine47(10), e851-e852. https://doi.org/10.1097/ccm.0000000000003662

NR 536 Week 3 Developing Critical Thinking Questions

Pinho, R., Tanure, L., Pessoa, J., Santos, L., Couto, B., & Starling, C. (2020). Impact of each component of a ventilator bundle on preventing ventilator-associated pneumonia and lower respiratory infection. Infection Control & Hospital Epidemiology41(S1), s259-s260. https://doi.org/10.1017/ice.2020.824

Prasad, R., Daly, B., & Manley, G. (2019). The impact of 0.2% chlorhexidine gel on oral health and the incidence of pneumonia amongst adults with profound complex neurodisability. Special Care In Dentistry39(5), 524-532. https://doi.org/10.1111/scd.12414

Vieira, P., de Oliveira, R., & da Silva Mendonça, T. (2020). Should oral chlorhexidine remain in ventilator-associated pneumonia prevention bundles?. Medicina Intensiva. https://doi.org/10.1016/j.medin.2020.09.009

Xie, X., Lyu, J., Hussain, F., & Li, M. (2019). Drug prevention and control of ventilator-associated pneumonia. Front Pharmacol10(298). https://doi.org/10.3389/fphar.2019.00298

Zampieri, F., Nassar Jr, A., Gusmao-Flores, D., Taniguchi, L., Torres, A., & Ranzani, O. (2015). Nebulized antibiotics for ventilator-associated pneumonia: a systematic review and meta-analysis. Critical Care19(1). https://doi.org/10.1186/s13054-015-0868-y

NR 536 Week 3 Developing Critical Thinking Questions

Zhao, J., Li, L., Chen, C., Zhang, G., Cui, W., & Tian, B. (2020). Do probiotics help prevent ventilator-associated pneumonia in the critically ill patients? A systematic review with meta-analysis. ERJ Open Research, 00302-2020. https://doi.org/10.1183/23120541.00302-2020

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