A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.)
a. Head of bed elevation to 90 degrees at all times
b. Daily oral care with chlorhexidine
c. Cuff monitoring for adequate seal
d. Clean technique when suctioning
e. Daily "sedation vacations"
f. Heart failure prophylaxis
ANS: B, C, E
The key components of the Institute for Healthcare Improvement (IHI) Ventilator Bundle are:
Elevation of the head of the bed (HOB)—elevation is 30 to 45 degrees
Daily "sedation vacations" and assessment of readiness to extubate
Peptic ulcer disease prophylaxis
Deep venous thrombosis prophylaxis
Daily oral care with chlorhexidine
Monitor cuff pressure frequently to ensure that there is an adequate seal to prevent aspiration of secretions is also included. Sterile technique is used for suctioning when on ventilators. Heart failure prophylaxis is not a component.
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