Vol.32 No.2 Apr. - Jun.

2015

J Prapokklao Hosp Clin Med Educat Center

173

, ..*

Nursing Care of Ventilator Associated Pneumonia in Severe Head Injury

Patients


Mahka Kittitornkul, B.N.S.*
* Department of Trauma Intensive Care Unit, Nursing Service Organization,

Prapokklao Hospital, Chanthaburi Province.
J Prapokklao Hosp Clin Med Educat Center 2015;32:173-188

Abstract

Purpose : To report the comparative study of two patients with severe head injury
who complicated with ventilator associated pneumonia.
Mode of Study : Case study report from December 21, 2013 to March 8, 2014
Results : The finding was found that there were different severities of pathology
of head injuries between two patients. Promoting factors such as alcohol
consumption and no wearing a helmet when riding a motorcycle
contributed to more severity of head injury. The second patient had more
severity of pathology of head injuries than had the first patient because of
age, underlying diseases and hypertension which affect the patient
recovery. Ventilator associated pneumonia was found the first patient
earlier than the second patient because of aspiration, delays to intubation
and contamination. The nurses must quickly, accurately and continuous
assessed and found risk factors before critical period or complication
*

174

32 2 .. - .. 2558

provides important information used in interpreting the results. The nurse's

role was extremely important because the expert nurse cognitively
manipulates many variables over a continuum of care and, if such tasks
were skillfully and successfully performed and effectively supervision
system, the incidence of complication disability deaths and length of
hospital stay were reduced.
Conclusion : The study showed that both patients received cure and nursing care and
discharge plan specifically provided for each patients problem and family.
Keywords : Severe head injury, Ventilator associatied pneumonia, Nursing care

21 .. 2556 - 8 ..
2557

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J Prapokklao Hosp Clin Med Educat Center

175

3
38.1 1
2
50.18 2
25



30
(severe head injury) 29
2

(International
nasocomial infection control consortium)

40
1,000 3

11 4
6 4
134

755
.. 2554
.. 2556 971 , 1,050
1,691 5

.. 2554 ..
2556 7.90, 8.76 5.56
1,000 5

176

(head injury)6

(maxillo-facial injuries)

32 2 .. - .. 2558

3
(minor head
injury) : GCS 13-15 ,
(moderate head injury) : GCS 9-12

(severe head injury) : GCS 3-8

2 7

1. (primary head
injury)


2. (secondary
head injury)

(epidural hemorrhage)
(subdural hemorrhage)
(subarachnoid hemorrhage)
(intracerebral hemorrhage)
(increased intracranial
pressure) 8

9
sedative, muscle
relaxants, anticonvulsants, osmotic diuretics,
steroids

10

Vol.32 No.2 Apr. - Jun. 2015

1.

6,8
1.1.
15
1-4
1.2.
30-45


1.3. valsalva
manueuver



1.4.

1.5.

ADH SIADH

2.

J Prapokklao Hosp Clin Med Educat Center

177

2.1.

2.2.



3.

tracheostomy



3, 5 1

11
(ventilator-associated pneumonia: VAP)

48

12

178

(aspiration of oropharyngeal flora)
(inhalation of infectious aerosols)

(hematogenous
spread from a distant focus of infection)

patient safety goals : SIMPLE

13

14
1) wean

2) hand
hygiene
3) aspiration precaution
30
cuff pressure 25-30 cm H2O

4) mouth hygiene
8

32 2 .. - .. 2558

3


1 3



2 2 3

2

fracture left
parieto-occipital bone with acute epidural
hemorrhage with hemorrhagic contusion right
frontal lobe size 245 cm3 with left frontal
lobe size 246 cm3 and moderate brain
swelling

craniotomy with remove
blood clot both frontal lobe and tracheostomy

E4V4M5 pupil 3 min reaction to light both eyes
2 BP 110/60 mmHg

0.9 percent
NSS 1,000 ml DTX 137 mg percent
8
E1V2M4
2 2

1 41 pupil right eye 5 mm left eye 4 mm sluggish
21 .. 2556 both eyes BP 160/80 mmHg pulse = 60/min
regular RR 26 /min
9 .. 2557

Vol.32 No.2 Apr. - Jun. 2015

craniotomy and remove

blood clot

E1VTM2 pupil
right eye 5 min left eye 4 min sluggish both
eyes 2 BP 160/100
mmHg pulse 70 /min mode
PCV RR 16-18 /min O2 saturation 99 percent
cefazolin 1 gm 6
2
losec 40 mg 12

morphine 5 mg 4
2 brain
swelling 20 percent mannitol 250 ml
3 serum potassium
2.97-3.3 mmol/L serum sodium chloride
133.5-134.6 mmol/L 0.9 percent NSS
1,000 ml add KCL 20 mEq/L
rate 80 ml/hr
elixer KCL 30 ml 30 2
Serum potassium 4.03 mmol/L, serum
sodium chloride 135.3 mmol/L


3
38C
Infiltration RLL
many klebsiella pneumoniae pseudononas
aeruginosa
ceftriazone 2 1
4 ciprofloxacin 400
mg 8 14

J Prapokklao Hosp Clin Med Educat Center

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6
2 on tracheostomy
mask

E4VTM6 pupil right
eye 5 mm left eye 4 mm sluggish both eyes
2 BP 110/70-130/80 mmHg
pulse 70-90 /min regular RR 20-24 /min
temperature 37-37.5 C
400 4


18

2 71
8 .. 2557
8 .. 2557

30



10

5


pupil 2 mm reaction both
eyes
2
linear fracture right temporal
bone with acute subdural hematoma right
temporal region diameter size 1.5 cm with
hemorrhagic contusion left frontal lobe
diameter size 2.5 cm and left temporal lobe
size 953.5 cm3 and marked brain swelling

180

craniectomy with remove
blood clot right temporal lobe and left
frontotemporal lobe and trachesotomy

E2V4M6
pupil 2 mm reaction both eyes 2
BP 130/80 mmHg pulse 116 /min
regular RR 20 /min 30
E1V1M3 pupil right eye 4 mm sluggish
left eye 2 mm reaction 2 flexion
2 extention
craniectomy with remove blood clot right
temporal region
2 E1VTM4 pupil
right eye 4 mm left eye 5 mm no reaction
hemorrhagic contusion left frontotemporal
lobe craniectomy with remove blood
clot left frontotemporal lobe 2
marked brain swelling E1VTM4
pupil right eye 2 mm reaction left eye 4 mm
no reaction

mode PCV RR 12-16 /min O2 saturation 99
percent cefazolin 1 gm
6 7

morphine 3 mg 4
Hct 27 percent
PRC 3 Unit Hct 37 percent
Vit K 30 mg stat 10 mg
1 3

serum potassium 3.04 mmol/L

32 2 .. - .. 2558

KCL 30 mEq 0.9 percent NSS 1,000

ml rate 80 ml/hr infusion pump
serum potassium 3.54 mmol/L
5 serum potassium 3.46 mmol/L
Elixer KCL 30 ml serum
potassium 4.62 mmol/L serum sodium
chloride 134.5 mmol/L 0.9 percent NSS
1,000 ml rate 80 ml/hr serum
sodium chloride 139.2 mmol/L
3 MOM
30 ml unison enema

12

38-39 C infiltration
RLL many
klebsiella pneumoniae
trazocin 4.5 gm
8 14 4
37 C
(16 )
12
on tracheostomy mask

enterobactor cloacae

serum albumin 2.6-3.0 gm/dl
BD 1.2: 300 4 90

E2VTM4

pupil right eye 2 mm reaction left eye

Vol.32 No.2 Apr. - Jun. 2015

J Prapokklao Hosp Clin Med Educat Center

181

4 mm no reaction BP 130/90-150/90 mmHg

pulse 88-90 /min regular on tracheos-
tomy tube with mask FiO2 0.4 O2 10 L/min 27
RR 20-22 /min

1 2

1 . 41

71

10

15

2.
E4V4M5 Pupil 3 mm
reaction both eyes
2

E 1V 1M 5 pupil
right eye 4 mm left
eye 3 mm reaction
both eyes 2
2

E2V4M6 Pupil 3 mm
reaction both eyes
2 30

E1V1M3 pupil right eye
4 mm sluggish left
eye 2 mm reaction
2 Flexion
2 Extention
2

E1VTM4pupil right eye
3 mm left eye 5 mm
no reaction both eyes

Primary head injury

secondary head injury
Primary secondary
8 30

2
GCS 6

182

32 2 .. - .. 2558

1 2 ()

2 No
response

16

3. - -
Craniotomy with Craniectomy with
remove blood clot remove blood clot

and Tracheostomy both frontal lobe

- Mannitol and Trachesotomy
- Mannitol

Osmotic diuretics
10

4. - -

4.1

- -
30
30
-

- -

-
-
0.9%NSS

2



IICP

IICP

2.

()

E 1V 2M 4 pupil
right eye 5 mm left
eye 4 mm sluggish
both eyes 2

Vol.32 No.2 Apr. - Jun. 2015

J Prapokklao Hosp Clin Med Educat Center

183

1 2 ()

4. -

8
4.1 -
()

- Thiamine
100 mg Vein OD 3
day

-
0.9%NSS
-
8
-

- Vit K 10 mg
OD 3 day
- PRC 3 unit
-

-

2

4.

4.2

- -

184

32 2 .. - .. 2558

1 2 ()

4. -

4.2 Morphine 5 mg
()

-

Morphine 3 mg

17
45

3
7
2 10

18
6
2





-
2

3000

Vol.32 No.2 Apr. - Jun. 2015

J Prapokklao Hosp Clin Med Educat Center

185

1 2 ()

4.

4.2
()

4. - -

4.3

-
-
-
- ,

-
-

-
morphine

-
2



2

7
2

186

32 2 .. - .. 2558

1 2 ()

4.

4.3

-
-

-
()

-
-
-



-

-

-

-
-
-



-

Vol.32 No.2 Apr. - Jun. 2015

Glasgow Coma Scale

(GCS)


early detect

J Prapokklao Hosp Clin Med Educat Center

187

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