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Which actions are essential for the nurse caring for a mechanically ventilated toprevent ventilator-acquired pneumonia (VAP) (Select all that apply)?(a) Keep the HOB elevated at least 30 degrees(b) Perform oral care every 12 hours(c) Prevent aspiration(d) Suction every 1-2 hours around the clock(e) Turn and reposition the patient every 2 hours(f) Prevent pressure ulcers around the mouth

Question

Which actions are essential for the nurse caring for a mechanically ventilated toprevent ventilator-acquired pneumonia (VAP) (Select all that apply)?(a) Keep the HOB elevated at least 30 degrees(b) Perform oral care every 12 hours(c) Prevent aspiration(d) Suction every 1-2 hours around the clock(e) Turn and reposition the patient every 2 hours(f) Prevent pressure ulcers around the mouth

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Solution

The essential actions for a nurse caring for a mechanically ventilated patient to prevent ventilator-acquired pneumonia (VAP) include:

(a) Keeping the head of the bed (HOB) elevated at least 30 degrees: This helps to prevent aspiration, which can lead to pneumonia.

(b) Performing oral care every 12 hours: Good oral hygiene can help to reduce the amount of bacteria in the mouth, which can reduce the risk of pneumonia.

(c) Preventing aspiration: Aspiration can introduce bacteria into the lungs, leading to pneumonia. Measures to prevent aspiration can include keeping the head of the bed elevated and monitoring for signs of aspiration.

(e) Turning and repositioning the patient every 2 hours: This can help to prevent pressure ulcers and improve lung expansion, both of which can reduce the risk of pneumonia.

(f) Preventing pressure ulcers around the mouth: Pressure ulcers can provide a breeding ground for bacteria, which can increase the risk of pneumonia.

(d) Suctioning every 1-2 hours around the clock: This is not necessarily recommended as a routine practice. Over-suctioning can potentially damage the lung tissue and mucous membranes, and increase the risk of infection. Suctioning should be performed as needed, based on the patient's condition and the amount of secretions.

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