Running head: NOSOCOMIAL PNEUMONIA 1

Evidence-Based Practice: Nosocomial Pneumonia Prevention

Jennifer Barnett
University of South Florida












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Prevention of Nosocomial Pneumonia
Pneumonia is a lower respiratory tract infection that is caused by fungi, viruses, bacteria,
parasites, or protozoa. Pneumonia is so prevalent that it is the sixth leading cause of death in the
United States. Risk factors include; old age, compromised immunity, smoking, underlying lung,
cardiac, or liver disease, endotracheal intubation, immobilization, malnutrition, poverty, altered
consciousness, and impaired swallowing (Huether and McCance, 2012). There are three main
ways individuals can acquire pneumonia: nosocomial (hospital acquired), community acquired
(the most common), and immuno-compromised pneumonia. Different microorganisms are
associated with each of the different ways it can be acquired. Those infected with pneumonia
through being in the hospital and or being immuno-compromised have a higher mortality rate
than those individuals who acquire it in the community. Nosocomial pneumonia is the second
most common hospital acquired infection (Huether and McCance, 2012). For the purpose of this
paper, I will be focusing on nosocomial pneumonia, the pathology of the infection, and evidence
based practices that have been proven to help reduce the risk of acquiring the disease.
The two microorganisms most often associated in the infection of individuals diagnosed
with nosocomial pneumonia are pseudomonas aeruginosa and staphylococcus aureus, including
methicillin resistant staphylococcus aureus (MRSA). The routes that the microorganisms may
take to invade the individual include aspiration of oropharyngeal secretions, inhalation of the
microorganisms that have been released into the air when an infected person sneezes, coughs, or
talks, or from aerosolized water from, for instance, contaminated respiratory therapy equipment
(Huether and McCance, 2012). In the lower respiratory tract, the alveolar macrophage is the
most important cell because they recognize pathogens through pattern-recognition receptors
which then activate the innate and adaptive immune responses. The inflammatory response that
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results from the introduction of these pathogens can cause damage to the bronchial mucous
membranes and alveolocapillary membranes. The damage to these membranes causes the acini
and terminal bronchioles to fill with infectious debris and exudate. Some of the infectious
microorganisms release toxins from their cells walls that can cause further damage to the lungs
as well as consolidation of the lung tissue (Huether and McCance, 2012). Accumulation of the
exudates leads to dyspnea and hypoxemia.
Nosocomial pneumonia is a common complication in the intensive care unit, most often
in patients placed on mechanical ventilation (Huether and McCance, 2012). Ventilator
associated pneumonia (VAP) has a mortality rate of 15% to 70% depending on the underlying
condition of the affected individual. Soon after an endotracheal tube (ET) is placed, bacterial
colonization of the oropharynx occurs with subsequent aspiration and pooling of bacteria by the
ET tube cuff. Bacteria are capable of forming a biofilm on the surface of the tube that
contributes to replication of the bacteria which can then make the microorganisms less
vulnerable to antibiotics (Huether and McCance, 2012). There are various interventions and
treatment protocols that have been shown to improve the outcomes regarding VAP prevention
and the reduction in mortality rates related to VAP.
Treatment protocols that have been implemented to reduce the chances of acquiring VAP
include improving oral hygiene pre and post operation. According to Colaianne (2010),
chlorhexidine is an antimicrobial oral rinse that has shown positive results in the prevention of
VAP. Keeping the head of the patients bed elevated as well as providing continuous
suctioning of subglottic secretions in the ET tube have been shown to decrease the risk of
acquiring VAP. Ambulation of the patient and patient repositioning while in bed are also
essential parts of the prevention of nosocomial pneumonia. Education of physicians, nurses, and
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staff as well as effective team communication is an important component of lowering patients
risks of infection. Lastly, incentive spirometry is part of the postoperative respiratory care
protocol for most surgical patients hospitalized longer than 24 hours, according to Lamar (2012).
An incentive spirometer is a medical device that is used to help keep patients lungs
healthy and functioning properly post operatively. Nurses must teach their patients to use their
incentive spirometer as often as possible, using it usually 10 times every 1-2 hours while they are
awake. To use an incentive spirometer, the patient must first exhale, then place their lips around
the mouthpiece and inhale slowly and deeply. The goal is to keep the ball piece in the center of
the chamber during inhalation. In a study done in 2007 by the Institute for Healthcare
Improvement, they used what they call the respiratory bundle (interventions provided above)
to test for decreasing the risk of acquiring nosocomial pneumonia. According to the study in
Lamar (2012), rapid response team calls for respiratory reasons decreased by 13% during the
12-month intervention period in the study of the general practice unit, while calls in the control
GPU increased by 10% over the same time period. The article explains that the nursing staff
found the easiest and most basic nursing interventions sometimes have the most impact on
patient safety. For instance, reminding medical patients to use their incentive spirometers every
1 to 2 hours and providing them with good oral hygiene daily requires very little additional time
and has shown positive results (Lamar, 2012).
The protocols and prevention methods for nosocomial pneumonia are an essential part of
nursing practice and patient safety. Because of its frequency and high mortality rates in hospitals
and other inpatient facilities, it is important for healthcare staff to be educated and aware of how
to prevent and decrease the risk for this disease. Following and keeping up with new research
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and techniques associated with nosocomial pneumonia will help us keep our patients safe and
lower their chances for future infection and disease.





















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References
Colaianne, B. (2010). Prevention of post-op pneumonia utilizing pre-operative oral care. AJIC:
American Journal of Infection Control, 38(5), e32-e33. doi:10.1016/j.ajic.2010.04.040
Huether, E. Sue, & McCance, L. Kathryn. (2012). Understanding Pathophysiology. (5
th
ed.). St.
Louis, Missouri: Elsevier Mosby.
Lamar, J. (2012). Relationship of respiratory care bundle with incentive spirometry to reduced
pulmonary complications in a medical general practice unit. MEDSURG Nursing, 21(1),
33-37.