Question

The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)?

-Cleaning the client's mouth with chlorhexidine daily Maintaining the client in a high Fowler's position
-Ensuring that the client remains sedated while intubated Turning and repositioning the client every 4 hours

Answer 1

To reduce the risk of ventilator-associated pneumonia, essential nursing measures include cleaning the patient's mouth with chlorhexidine, maintaining them in a high Fowler's position, and repositioning them every four hours.

Step-by-step explanation:

Reducing the risk of developing ventilator-associated pneumonia (VAP) in clients in the ICU receiving mechanical ventilation involves several important nursing measures. A key strategy includes cleaning the client's mouth with chlorhexidine daily. This practice helps to reduce the microbial load in the mouth, which in turn can diminish the risk of pathogen entry into the lower respiratory tract. In addition, maintaining the patient in a high Fowler's position whenever possible helps to promote better lung expansion and drainage of secretions, thus reducing the risk of aspiration and subsequent pneumonia. Ensuring that the client remains sedated while intubated may be important for patient comfort and safety, but does not directly reduce the risk of VAP. Finally, turning and repositioning the client every 4 hours is another vital step, as it helps to prevent stasis of secretions and improve respiratory function.