The nurse is caring for a patient on mechanical ventilation with an endotracheal tube. Which nursing interventions will help prevent ventilator-associated pneumonia (VAP)? (Select all that apply.)
a. Changing the patient's position every 2 hours
b. Keeping the head of the bed elevated 30 to 45 degrees
c. Providing oral care with a toothette every 8 hours
d. Keeping the head flat during and for 30 minutes after enteral feedings
A, B
Best practice guidelines indicate that the following interventions are advantageous in preventing VAP: elevating the head of the bed at 30 to 45 degrees to prevent aspiration, changing patient position every 2 hours to decrease risk for atelectasis and pulmonary infection, providing oral care with a toothbrush every 8 hours to remove dental plaque organisms (toothettes are not adequate to clean dental plaque, but they may be used between brushings for comfort), maintaining the endotracheal cuff pressures at 20 cm H2O to decrease movement of secretions to the lower airways, and carefully monitoring the patient for aspiration when enteral feedings are infusing.
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