Alneelain University

Faculty of nursing sciences

College of under graduate studies

Title:
Assessment of the nurse’s knowledge regarding
the prevention of the ventilation associated
pneumonia in alshaab hospital in February to
April 2015
Submitted to under graduate faculty of nursing sciences - alneelain
university in Partial Fulfillment of the Degree of B. Sc.

Submitted By:
Bidour Hissain Musa

Supervisor:
Altayeb Abd ulazeem Edriss
Degree: M. Sc in medical surgical nursing
Work place: Alneelain University - Faculty of nursing sciences
Medical surgical department

2015
 ‫اآلية‬
‫بسم هللا الرحمن الرحيم‬
‫ﭧﭨ‬
‫ﮃ ﮄ ﮅ ﮆ ﮇ ﮈ ﮉ ﮊ ﮋ ﮌ ﮍ ﮎ ﮏ ﮐ‬ ‫ﭻ ﭼ‪ 0‬ﭽ ﭾ ﭿ ﮀ ﮁ‪ 0‬ﮂ‬ ‫ﭽ‪ 0‬ﭶ ﭷ ﭸ ﭹ ﭺ‪0‬‬
‫ﮧ ﮨ ﭼ‬ ‫ﮣ ﮤ ﮥ ﮦ‬ ‫ﮑ ﮒ ﮓ ﮔﮕ ﮖ ﮗ ﮘ ﮙﮚ ﮛ ﮜ ﮝ ﮞ ﮟﮠ ﮡ ﮢ‬
‫صدق هللا العظيم‬

‫سورة لقمان ‪:‬اآلية (‪)15-14‬‬

‫‪I‬‬
 Dedication

I want to dedicate this research

To my father…
Acknowledgment
To my Mother the source of love and
care…
I would like to thank all those who had helps me in the

To my sisters…
preparation of this work…
Special thanks to our teachers, colleagues and department staff
To my brothers…
for their help through the year of study…
Tothanks
Special my small
to Dr. family…
Altayeb Abdulazeem Edriss for his
guide and advice me from the beginning up to the end of this
To my friend …
project.
And finally to deep secret in my heart
keep him alla

II
Abstract:

III
Ventilation associated pneumonia is infectious disease caused by wide
spectrum of pathogens and associated with morbidity and mortality .it
account for up 27-76% of all health care association infection
The study aimed to evaluate the nurses knowledge for prevention of
ventilator associated pneumonia (VAP) in alshaab teaching hospital 2015
and the general objective of this study was done to evaluate the
knowledge of nurses working in ICU for prevention of VAP hospital
2015 .and specific objective to assess knowledge of the nurse about
nursing care for prevention of VAP also to identify the nurse’s
knowledge of the needs of mechanically ventilated patient and to
measure if there is any relation between training as well as years of
experience and knowledge of nurse for prevention of ventilation
associated pneumonia .
a descriptive cross sectional study was conducted in alsaab teaching
hospital during period extended from February to April 2015 .it involved
(30) ICU nurses staff chosen as total coverage .the data was collected
as self administrating questionnaire and analyzed by statistical package
for social sciences (SPSS) .
The result of the study was found that just (61.5%) was poor knowledge
of participants regarding prevention of ventilation association
pneumonia (VAP)
Prevention is better than cure as the saying goes. it’s recommended to
encourage the training activity in hospital and ICU to improve knowledge
on prevention of ventilation associated pneumonia which is second
nosocomial infection in ICU. It's recommended for new staff in ICU to
be included in infection control program. Continues study should be
conducted to test the knowledge level of nurses prior to and after
education program on evidence based guideline for prevention of
ventilator associated pneumonia

IV
 ‫المستخلص‬

‫االلتهاب الرئوي المصاحب للتنفس الصناعي هو من األم راض المعدي ة ال تي تس ببها العدي د من‬
‫أنواع البكتريا واسعة الطيف ومرتبطة بنسبه من األمراض والوفيات تمثل أكثر من ‪% 76-27‬‬
‫من كل األمراض المعدية‪.‬‬
‫أج ريت ه ْذه الدراس ة لتق ييم معرف ه الممرض ين والممرض ات للحماي ة من االلته اب الرئ وي‬
‫المصاحب للتنفس الصناعي في مستشفي الشعب التعليمي ‪. 2015‬‬
‫الهدف العام من هذه الدراسة هو تقييم ألمعرف ه للممرض ين الع املين في وح ده العناي ة ألمرك زه‬
‫للوقاي ة من اللته اب الرئ وي المص احب للتنفس الص ناعي واأله داف الخاص ة لتق ييم معرف ه‬
‫الممرض ين عن العناي ة التمريض ية للوقاي ة من االلته اب الرئ وي المص احب للتنفس الص ناعي‬
‫ومعرفة احتياجات المريض أثناء التنفس الصناعي وأيضا لمعرفه ما إذا ك ان هن اك أي عالق ة‬
‫ارتباطيه بين المؤهل وسنوات الخبرة أو التدريب ومستوي المعرف ة التمريض ية للحماي ة من‬
‫االلتهاب الرئوي المصاحب للتنفس الصناعي ‪.‬‬
‫أجريت هذه الدراسة الوص فية في مستش في الش عب التعليمي خالل ف تره ش هر ف براير إلي‬
‫ابريل اشتملت الدراس ة علي (‪ )30‬من الممرض ين في وح ده العناي ة المكثف ة واخت يرت العين ة‬
‫كتغطيه شامله وقد تم جمع البيانات باس تخدام اس تبيان وتم تحليله ا بواس طة حزم ه البيان ات‬
‫اإلحصائية للعلوم االجتماعية ‪.‬‬
‫والناتج من بين (‪ )30‬مشاركا‪ 0‬في الدراسة أظهرت م‪00‬ا يلي (‪ )38.5‬معرف‪00‬ه جي‪00‬ده (‪ )61.5‬معرف‪00‬ه‬
‫ضعيفة حول الوقاية من االلتهاب الرئوي المصاحب للتنفس الصناعي‬
‫التوصيات من هذه الدراسة ‪ :‬الوقاية خير من العالج كما ذكر سابقا يوصى بالتدريب للكادر‬

‫في وحدات العناية المكثفة لتحسين المعرفة بشان الوقاية من االلتهاب الرئوي المص احب لتنفس‬

‫الصناعي وهى العدوى الثانية في العناية المكثفة‪.‬‬

‫أوصت الدراسة إن تشتمل الكوادر الجديدة في برنامج الوقاية من العدوى‪.‬‬

‫وأج راء دراس ات مس تمرة الختب ار مس توى المعرف ة للك ادر التمريض ي قب ل وبع د ال برامج‬

‫التعليمي ة بش ان المب ادئ التوجيهي ة القائم ة على األدل ة للوقاي ة من االلته اب الرئ وي المص احب‬

‫لتنفس الصناعي‪.‬‬

‫‪V‬‬
 Contents
No Subject Page
1 ‫اآلية‬ I
2 Dedication II
3 Acknowledgment III
4 Abstract IV
5 ‫ملخص الدراسة‬ V
6 Contents VI
7 List of figures IX
8 List of tables X
9 Abbreviations XI
Chapter One
Introduction and literature review
1-1 Introduction 3
1-2 justification 4
1-3 Objective 5
Chapter two
Literature review
2-1 Etiology 7
2-2 Pathophysiology 9
2-3 Clinical presentation 10
2-4 Diagnosis 11
2-4-1 Clinical diagnostic criteria 11
2-4-2 Non invasive/ non Bronchoscopic methods 12
2-4-3 Bronchoscopic methods 12
2-5 Treatment 13
2-6 Impact of VAP on pt out come 14
2-7 Nursing care guideline 15
2 -7-1 Physical strategies 17
2-7-1-1 Route of endotracheal intubation 17
2-7-1-2 Frequency of ventilator circuit change 17
2-7-1-3 type of humidifiers 17
2-7-1-4 Frequency of humidifier change 17
2-7-1-5 Endotracheal suction system 18
2-7-1-6 Endotracheal suctioning system: frequency of 18
change
2-7-1-7 Subglottic secretion drainage 18
2-8-1 Positional strategies 18
2-8-2-1 Kinetic bed therapy 18
2-8-2-2 Semirecumbent positioning 19

VI
2-8-3 ICU nurse’s knowledge levels on prevention of 19
vap
2-9-1 Barriers to nursing care 22
2-9-2 Contributors to nursing care 24
2-10-1 Belgian study 26
2-10-2 Viviana Paula Ribeiro Gomes.South africa 27
Johannesburg
Chapter three
Material and Methods
3-1 Study design 29
3-2 study period 29
3-3 Study setting 29
3-4 Study population 29
3-5 Inclusion criteria 29
3-6 Exclusion criteria 29
3-7 Sampling 29
3-8 Sample size 30
3-9 Tool of date collection 30
3-10 Sampling technique 30
3-11 Variable 30
3-12 Data analysis 30
3-13 Ethical consideration 31
Chapter four
Results
4-1 Results 33
Chapter five
Discussion Conclusion and Recommendations
5-1 Discussion 46
5-2 Conclusion 48
5-3 Recommendations 49
References
References 50
Appendics 53

VII
 List of figures
No Title Page
I Distribution of study group according to age 33
II Distribution of study group according to sex 33
III Years of working in ICU 34
IV Describes the Level of qualification 34
V Distribution of study group according to training course 35

VIII
 List of Tables
No Title Page
1 36
Distribution of result regarding endotracheal intubations
2
Distribution of result regarding sign and symptom of 36
pneumonia
3 37
Distribution of result regarding ventilator circuit changes
4 37
Mean of result regarding type of humidifiers
5
Distribution of result regarding type fluid used in 38
humidifiers
6
Distribution of result regarding frequency of humidifiers 38
change
7
Distribution of result regarding 0pen verse closed suction 39
systems
8
Distribution of result regarding frequency of change in 39
suction system
9 40
Distribution of result regarding daily oral care
10
Distribution of result regarding use of endotracheal
tube with extra lumen for drainage of subglottic 40
secretion
11
Distribution of result regarding bronchotracheal 41
suction
12
Distribution of result regarding patient position 41
during suction
13
Distribution of result regarding the barriers to the
implementation of scientific and proper nursing care 43
for prevention of VAP?
14
Distribution of result regarding the contributors to
the implementation of proper nursing Care for 44
prevention of VAP are availability of resource

IX
 Abbreviations

VAP Ventilation Association Pneumonia

MV Mechanical Ventilation
ICU Intensive Care Unit
EBGs Evidence Base Guideline

X
CHAPTER ONE

• introduction
• Justification
• Objectives

1
ASSESSMENT OF THE NURSES KNOWLEDGE REGARDING
THE PREVENTION OF THE VENTILATION ASSOCIATED
PNEUMONIA IN ALSHAAB HOSPITAL IN FEBRUARY TO
APRAIL 2015

2
1.1 introduction

Ventilator-associated pneumonia (VAP) is defined as pneumonia that

occurs 48-72 hours after intubation and mechanical ventilation
characterized by progressive pulmonary infiltrate ,fever, leukocytosis ,
and change in sputum (purulent sputum ) (1)
Mechanical ventilation is one major supportive modalities in intensive
care unit but it carries a lot of risk and complications ,the most common
one being ventilator associated pneumonia which can significantly affect
the outcome of critically ill patient. (1,2)
The lungs are usually highly risk organ to be involved in multiple organ
failure and thus the challenge of delivering appropriate ventilation with as
little complication as possible is extremely important to ensure the
highest standards of nursing care, nursing practice must be based on a
strong body of scientific knowledge.(4)
VAP contributes to approximately half of all cases of hospital –acquired
pneumonia.
Prolonged ventilation increases the risk of ventilation associated
pneumonia and increases hospital stay, which dramatically increases
mortality rate.
In the intensive care nurses are in the best position to apply knowledge
into practice as they are at the patient bedside 24 hours a day and there
for play important role in the prevention of ( VAP ). (7)
This study was conducted to assess the nurses knowledge regarding
prevention of ventilation association pneumonia (VAP).

3
1-2: justification:-

- Ventilation associated pneumonia is account high percentage of

infections in intensive care unit and affect mortality rate of the patient
- The ventilation associated pneumonia is second nosocomial pneumonia
in hospital
-The mortality rate for VAP is27-76% (1)
-The incidences of VAP increases with duration of mechanical
ventilation, estimate rate are 3%per day for the first five day Nurses are
conceder the first line manger contact with mechanical ventilated patient
because of spending a lot of time beside the patient this make an a great
role for the nurses to prevent ventilation association pneumonia. (19)
It is thought that ventilation association pneumonia is commonly
associated with mal practice in sectioning and may be of aspiration
during feeding so that these activities of the nurse are important to be
proper as possible to prevent ventilation association pneumonia. (7)

4
1-3: objectives
General objective
- To assess the nurses knowledge regard the prevention of ventilation
associated pneumonia
Specific objective-
- To assess knowledge of the nurse about nursing care for prevention of
VAP
- To identify the nurse knowledge of the daily living care of mechanically
ventilated patient
- To measure if there is any relation between training as well as years of
experience and knowledge of nurse for prevention of ventilation
associated pneumonia

5
CHAPTER TWO

6
Literature review

Ventilator associated pneumonia is defined as a pneumonia in a patient

receiving mechanical ventilation that was not present at the time of
admission to hospital or that occurs 48 hours after intubation and
mechanical ventilation. It is characterized by a new or a progressive
pulmonary infiltrate, fever, leukocytosis and purulent tracheobronchial
secretions (8).
VAP is the most common nosocomial infection in critically ill patients
(8 ).
who require mechanical ventilation It is an important cause of
morbidity and mortality in intensive care units. It accounts for 47% of
infections in the intensive care unit and it complicates the course of
(8).
illness of 8% to 28% of mechanically ventilated patients Mortality
rates reach 24% to 50% and 74% in high risk patients such as the elderly,
immunocompromised patients, patients with chronic obstructive
pulmonary disease, burns, neurosurgical conditions, acute respiratory
distress syndrome and witnessed aspiration ( 9). Those who are reintubated
and those who receive paralytic agents or enteral nutrition are also at high
risk for acquiring VAP.

2.1 Etiology

In critically ill patients, several factors associated with intubation and

mechanical ventilation alter normal defences against infection. The
placement of an artificial airway such as an endotracheal tube or a
tracheostomy tube alters the host defences and contributes to the
( 11).
development of pneumonia once colonization occur
Once a patient is intubated, bacteria have direct access to the lower
airways because the endotracheal tube bypasses normal filtration
mechanisms and the barrier function of the epiglottis. In addition, the

7
endotracheal tube provides a direct route for inoculation of the lungs with
bacteria. Inoculation is caused by inadequate hand washing, using the
same gloves from patient to patient and contaminated respiratory devices
such as nebulizers, spirometers, bag-valve mask devices and suction
( 13).
catheters
Endotracheal intubation also interferes with natural host mechanisms by
reducing the cough effort, interfering with mucocilliary clearance and
injuring the epithelial layer, thereby exposing thebasement membrane
(11,7).

This factor plays a key role in facilitating bacterial adherence and

colonization. Mucus is normally produced to trap bacteria, which is then
removed by mucocilliary clearance.
Endotracheal intubation may result in increased production of mucus and
stagnation of mucus in the respiratory tract. These factors combined with
an impaired mucocilliary clearance increases the risk of VAP.
The pathogens responsible for VAP originate in the patient’s endogenous
flora or in the hospital environment: other patients, staff members and
invasive devices. Most VAP results from aspiration of bacteria colonizing
the oropharynx or gastrointestinal tract. The following pathogens account
for more than half the cases of ventilator associated pneumonia:
Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacter spp, and
(11-7).
Klebsiella pneumoniae Gram negative bacteria are implicated in
more than 60% of all cases. P. aeruginosa and Acinetobacter spp have
(11-7).
been associated with higher mortality rates from VAP Pathogens
differ according to the onset of VAP. Onset of infection can be divided
into early and late phases. Early onset VAP is described as that which
occurs 1 to 4 days after endotracheal intubation. Organisms responsible
for early onset VAP are usually of oropharyngeal species and include
Streptococcus pneumoniae, S. aureus and Haemophilus influezae. Late

8
onset VAP occurs more than 4 days after endotracheal intubation and is
usually associated with gram negative bacteria. Causative agents include
P. aeruginosa, Acinetobacter spp and Enterobacter spp (11-7).

2.2 Path physiology

The lung is colonized by nosocomial pathogens in many ways:

microaspiration of oropharyngeal secretions, aspiration of gastric
contents, direct inoculation into the airways of intubated patients,
inhalation of infected aerosols, hematogenous spread of infection from a
distant site, andpotentially, translocation of bacteria from the
gastrointestinal tract (GIT). Most VAP is associated with the aspiration of
bacteria from the oropharynx and GIT ( 8).
Oropharyngeal secretions commonly become colonized with pathogens,
especially gram negative bacteria. Gram negative bacteria are not part of
the normal flora of the oropharyngeal tract and their presence in
oropharyngeal secretions is a predictor for the development of VAP.
Mechanical ventilation requires intubation with a cuffed endotracheal
tube or tracheostomy tube. Despite adequate inflation of the cuff,
microaspiration often occurs and bacteria from the oropharynx and the
GIT can migrate below the endotracheal tube cuff. The endotracheal tube
serves as a reservoir of bacteria with secretions that have pooled above
and around the cuff leak and enter the trachea.
The tube serves as a safe haven from antibiotics and host defence
mechanisms, in that they have no access to destroy bacteria. Bacteria
form a biofilm within the tube that may be dislodged when suctioning,
coughing or moving the tube, increasing the risk of bacterial
( 11-13).
contamination of the lower respiratory tract
Although not directly related to aspiration, nasal placement of
endotracheal tubes increases the risk for sinusitis. The sinus provides a

9
reservoir from which organisms seed the tracheobronchial tree and
bacteria causing sinusitis can colonize the upper airway, increasing the
risk of VAP. Infectious sinusitis occurs in 20% to 30% of patients who
have been intubated for at least a week ( 11).
Most intubated and mechanically ventilated patients have a decreased
level of consciousness from disease, injury or sedatives and therefore
they are not able to use protective mechanisms such as cough and gag
reflexes. The inability to cough or gag when foreign substances are
aspirated increases the likelihood of bacterial colonization and VAP.
Most critically ill patients have a nasogastric tube, which increases the
risk of aspiration through mechanisms such as reflux and translocation of
(11-7)
bacteria as the gastroeosophageal sphincter is violated
Medications and enteral feeding can alter the acidity of gastric juices,
increasing the likelihood of bacterial growth. The use of antacids and H2
receptor-antagonists has been identified as contributing factors for the
( 11-7).
development of VAP These drugs are prescribed in critically ill
patients for stress ulcer prophylaxis and they increase the pH of gastric
secretions which affects the normal flora of the gastrointestinal tract
allowing pathogens to proliferate. Duodenal reflux and gastric pH higher
than 3.5 have been associated with increased bacterial colonization of the
lower respiratory tract ( 11-7 ).
There is still controversy as to the use of antacids and H2 receptor
antagonists to prevent stress ulcers in critically ill and mechanically
ventilated patients.

2.3 Clinical presentation

Ventilator associated pneumonia (VAP) is characterized by ( 15 ) :

a) a new or a progressive pulmonary infiltrate,

10
 b) fever,
c) leukocytosis and
d) purulent tracheobronchial secretions Patients with ventilator
associated pneumonia have clinical evidence of a new and persistent
radiographic infiltrate plus two of the following:
a) a body temperature of > 38 degrees Celsius or < 36 degrees
Celsius;
b) white blood cells count > 10.000 or < 4.000;
c) macroscopically purulent tracheal aspirate; and
d) additionally it is required that patients have microbiological
confirmation by growth of >10000 colony-forming units/ml of a
microorganism on bronchoscopic culture; or
e) the isolation of a potential pathogen from the blood culture
(unrelated to another source).

2.4 Diagnosis

The diagnosis of VAP is challenging. Bedside evaluation using clinical

and radiographic criteria for the presence of VAP is neither specific or
sensitive ( 15).

2.4.1 Clinical Diagnostic Criteria

Clinical diagnosis for VAP is based on the Center for Disease Control
criteria: new or progressive pulmonary infiltrates detectable on chest
radiograph, fever higher than 38 degrees Centigrade or less than 36
degrees Centigrade, leukocytosis and purulent tracheal secretions after 48
hours of intubation and mechanical ventilation.
These criteria are often inadequate in confirming a diagnosis of VAP,
because infiltrates can occur from atelectasis and other pulmonary

11
conditions and also because in most critically ill patients, fever and
leukocytosis will develop.

2.4.2 Non invasive/non bronchoscopic methods

These techniques are used by obtaining the specimen via the endotracheal
tube, using either a specimen brush or a specially designed suction
catheter. These methods take less time to obtain and the procedure is
more cost effective to perform. The sputum is then sent for Gram’s stain
and/or culture and sensitivity tests, which facilitates the decision of what
antibiotic to use ( 15).

2.4.3 Bronchoscopic methods

These methods are invasive, have associated risks and thus have not been
adopted for the routine clinical diagnosis of VAP. There are two
bronchoscopic methods in diagnosing VAP, mainly protected specimen
brush and broncoalveolar lavage ( 11-4).
In protected specimen brush (PSB), a catheter is inserted through the
bronchoscope into the area of the lung in which pneumonia is suspected.
Using a microbiology specimen brush, a sample is obtained by expressing
and retracting the inner cannula and brush. The brush tip is placed in a
small amount of sterile, preservative-free saline and is processed.
Test results are considered positive if organisms grow at 103 colony-
forming unit (CFU)/ml or more.
Disadvantages are that the specimen must be taken from the affected
portion of the lung, the sample is not adequate for gram staining and
therefore culture results are delayed for 24 to 48 hours.
A bronchoalveolar lavage is similar to PSB, except that a larger amount
of sterile, preservative free saline is instilled in the lung area and
secretions are aspirated until an adequate specimen is obtained. Cells and

12
secretions lining the lower respiratory tract are obtained and a gram stain
can be performed on the specimen. Test results are considered positive if
organisms grow at 104 CFU/ml or more. A recently published meta-
analysis suggested that bronchoscopic techniques as compared to
endotracheal aspirates have no effect on mortality but are superior for the
( 15).
management of antibiotic therapy for VAP In the American Thoracic
Society guidelines (2004) for diagnosis and prevention of VAP, invasive
quantitative cultures are preferred over endotracheal aspirates.
In the health care institutions were this study was conducted, non
bronchoscopic methods are used to diagnose VAP. An endotracheal
specimen is collected from the patient with suspicion of VAP and the
specimen is sent for micro culture and sensitivity tests.
Bronchoalveolar lavage is done if a bronchoscopy procedure is done on a
patient in theatre. Then a specimen is collected in the manner mentioned
above and Gram’s stain is performed.

2.5 Treatment

Empiric therapy is recommended when there is clinical suspicion of

VAP(8).
Empiric therapy is defined as the initiation of antibiotic therapy at the
time of VAP suspicion, even before culture reports are available.
Antibiotics can be stopped safely after 8 days of therapy in patients who
( 15).
have received adequate initial therapy A shorter course of antibiotics
(8 day course as compared to 15 days course) is associated with a
reduction in antibiotic use and a reduction in the emergence of resistance
(15).
A higher percentage of patients treated with 8 days of antibiotic
therapy has developed recurrence of pulmonary infection secondary to
non-fermenting gram negative bacteria (eg, Pseudomonas or
Acinetobacter species), but this was not associated with worsened clinical

13
 (15).
outcomes Among patients who developed a recurrent VAP,
multiresistant organisms emerged significantly less often in the group
(15).
who received 8 days of therapy The decision to discontinue therapy
for non- fermenting gram-negative bacteria at 8 days should be based on
clinical factors.
Resolution of VAP can be defined clinically following such features as
change in fever, sputum purulence, leukocyte count, oxygenation and
radiographic pattern.

2.6 Impact of VAP on patient outcome and resources utilization

Ventilator associated pneumonia is the most frequent infectious

complication amongst patients admitted in the ICU. Negative outcomes
associated with VAP includes a prolonged hospital stay, increased
(8).
mechanical ventilation and increased hospital costs VAP also
predisposes patients to other nosocomial infections and is associated with
an increased mortality.
Early-onset VAP, occurring within the first 5 days of endotracheal
intubation, generally has a better prognosis and is more likely to be
caused by antibiotic-sensitive bacteria that colonize the oropharynx, such
as Streptococcus pneumoniae, and Haemophilus influenzae. Late-onset
VAP, occurring more than 5 days after intubation, is usually caused by
nosocomial or multi-drug resistant pathogens, such as Pseudomonas
aeruginosa, Acinetobacter spp, or Klebsiella spp ( 11-7).
Health care costs associated with VAP have an impact on the economy of
the country as well. The main component of direct costs of VAP is the
prolongation of ICU and hospital length of stay not including other costs
such as ICU bed, antibiotics and doctor’s consultation’s costs which must
also be considered. Increased antibiotics costs are partially driven by the

14
increasing microbial resistance caused by the treatment of nosocomial
infections, secondary infections and complications acquired during the
increased ICU stay. In Canada, VAP is responsible for 230 deaths per
year and accounts for approximately 17000 additional ICU days per year,
which represents the equivalent to 3 to 4 ICU’s completely occupied for
( 15).
the whole year solely to treat patients with VAP From a public safety
point of view the number of deaths due to VAP can be compared to HIV
( 10).
related and motor vehicle accident related deaths This has a
significant societal impact such as loss of productivity and the
psychological and financial impact on the families of patients with VAP.
VAP is preventable and proper nursing care have been shown to reduce
its incidence and its burden on patient’s outcomes. Patient care and
outcomes are optimized through decreased nosocomial infection rates,
decreased ICU and hospital stay and furthermore decreased hospital
costs.
Failure to provide care that may result in greater morbidity and health
( 17)
care costs As the incidence of mechanical ventilation rises secondary
to medicine’s improving ability to support critically ill patients, the
impact of VAP will also rise. In South Africa, HIV related pulmonary
infections are increasing and the amount of patients being mechanically
ventilated due to such conditions is also on the increase. It is important to
prevent negative outcomes and increase quality of patient care into our
daily nursing activities.

2.7 nursing care guidelines for prevention of ventilatorassociated

pneumonia

The literature on VAP is extensive and, in some cases, conflicting and

therefore it has become increasingly difficult for critical care practitioners
to assimilate and apply best evidence into clinical practice. The synthesis

15
of large bodies of knowledge into clinical practice guidelines is one
method of improving accessibility and utility of medical literature to
health care professionals ( 15). For the management of critically ill patients,
guidelines can improve outcomes and costs of critical care to patients and
institutions.
The guidelines for the prevention of VAP were developed in 2004 by the
Canadian Critical Care Trials Group to address this problem in the
intensive care unit. However, new randomized controlled trials of
strategies to prevent VAP have been published and updating of the
guidelines was done in 2008 leading to the development of up-to-date and
comprehensive evidence-based guidelines for the prevention, diagnosis
and treatment of VAP ( 15).
A multidisciplinary and multispecialty panel was created to develop the
comprehensive VAP Evidence Based Guidelines. The panel was
composed of 20 intensivists from university affiliated and community
hospitals, four infectious disease specialists, three intensive care nurses,
an infection control nurse, an ICU pharmacist, an ICU respiratory
therapist and a representative from the Canadian Patient Safety Institute.
The panel members were experts in critical care medicine, infectious
diseases, infection control, nursing education, evidence based medicine
and guideline development.
There are 21 strategies on the guidelines for prevention of VAP band
these are divided into 10 physical strategies, three positional strategies
and eight pharmacological strategies. For the purpose of this study, only
strategies under the evidence based guidelines for prevention of VAP that
are relevant to nursing practice will be discussed as these were the
strategies included in the data collection tool.

16
2.7.1 Physical strategies
2.7.1.1 Route of endotracheal intubation

Orotracheal intubation is associated with a trend towards reduction in

VAP compared to nasotracheal intubation. Orotracheal intubation is also
associated with a decreased incidence of sinusitis and the incidence of
VAP is lower in patients who do not develop sinusitis. Therefore the
orotracheal route of intubation is recommended when intubation is
necessary.

2.7.1.2 Frequency of ventilator circuit changes

The frequency of ventilator circuit changes does not influence the

incidence of VAP.
Cost considerations favour less frequent changes. Therefore new circuits
for each patient, and changes if the circuit becomes soiled or damaged is
recommended, but no scheduled ventilator circuit changes.

2.7.1.3 Airway humidification: type of humidifier

It was concluded that there is no difference in the incidence of VAP

between patients whose airways are humidified using a heat and moisture
exchanger and those whose airways are humidified using a heated
humidifier. Therefore both types of humidifiers can be recommended.

2.7.1.4 Airway humidification: frequency of humidifier changes

daily humidifier changes and 5 to 7 days changes were compared it was

concluded that less frequent humidifiers changes may be associated with
a slightly decreased incidence of VAP. Reduction in the frequency of
humidifier changes might be considered as a cost reduction measure.
Therefore changes of humidifiers every 5 to 7 days or as clinically
indicated are recommended.

17
2.7.1.5 Endotracheal suctioning system: closed vs. open
The type of suctioning system has no effect on the incidence of VAP.
Safety considerations such as patient and health care worker exposure to
aerosolized secretions favour the use of closed systems. Therefore, the
use of closed endotracheal suctioning system is recommended.

2.7.1.6 Endotracheal suctioning system: frequency of change

scheduled daily changes and unscheduled changes of closed suctioning

systems have no effect on VAP. Cost considerations favor less frequent
changes. Therefore it is recommended that closed suctioning systems be
changed for each patient and as clinically indicated.

2.7.1.7 Subglottic secretion drainage

Based on five level 2 trials, it was concluded that subglottic secretion

drainage is associated with a decreased incidence of VAP. The
incremental cost of these tubes was considered to be reasonable given the
burden of illness associated with VAP. To increase their utility and cost-
effectiveness, these tubes should only be placed in patients expected
to require prolonged mechanical ventilation.
Therefore, the use of subglottic secretion drainage is recommended in
patients expected to be mechanically ventilated for more than 72 hours.

2.8.1 Positional strategies

2.8.2.1 Kinetic bed therapy

The use of rotating beds is associated with a decreased incidence of VAP.

However, feasibility, safety and cost concerns may be barriers to
implementation. Therefore the use of rotating kinetic beds should be
considered.

18
2.8.2.2 Semirecumbent positioning

semirecumbent positioning may be associated with a decreased incidence

of VAP.
Therefore it is recommended that the head of the bed be elevated to 45
degrees. When this is not possible, attempts to raise the head of the bed to
as near as to 45 degrees as possible should be considered.
These are the nine strategies that are relevant to nursing practice in the
guidelines for prevention of ventilator associated pneumonia. These
strategies, if implemented by intensive care nurses, have proven to
decrease the risk of VAP and therefore are important steps in increasing
positive outcomes to mechanically ventilated patients in the ICU as well
as to promote the implementation of evidence based nursing and
medicine.

2.8.3 ICU nurse’s knowledge levels on prevention of VAP

Intensive care nurses are in the best position as they are at the patient’s
bedside 24 hours daily providing nursing care and therefore play an
( 5).
important role in the prevention of VAP Nevertheless nurses need to
have an awareness of the problem as well as knowledge on current
research evidence so as to adhere to such practice Various measures to
prevent VAP have been reported in the literature, however there are very
few data concerning nurse’s knowledge of VAP prevention strategies and
the degree of adherence to them, as well as factors that may influence
their application at the bedside. While knowledge may not ensure
adherence to nursing process, a lack of knowledge may be a barrier to
( 14).
adherence Understanding the importance of recommended practices
increases the likelihood of adherence and overcome barriers such as lack
( 12).
of knowledge If the nurse does not have enough knowledge on

19
measures proven to decrease VAP rates she may not have the necessary
confidence to take action and make decisions regarding such practices.
Patient recovery may be delayed and not to mention the increased risks of
complications from mechanical ventilation such as ventilator associated
pneumonia, which are risks that can be prevented.
Most nurses practice nursing according to what they learned in nursing
school as well as their experiences in practice. If one takes into
consideration the number of changes that occur in nursing practice on a
regular basis, it is essential to keep updated and have knowledge of the
best current practice.
The prevention and control of VAP in intensive care units are dependent
on the education and sensitisation of ICU staff members towards the
problem and on the application of measures to prevent its occurrence.
Critical thinking is needed for appropriate decision making, as one needs
to be able to evaluate their actions and their possible outcomes.
(5),
Data from an Italian study carried out at Cisanello Hospital by.
indicated that nurses tend to apply measures automatically by simply
following protocols and instructions given by physicians or colleagues
without being fully aware of what and why they actually do. Preventive
strategies are widely applied by nurses, but not in a responsible and
informed manner. This study demonstrates the importance of education
and continuous career development and update so as to be able to
rationale actions taken. As intensive care nurses, we are responsible for
lives of critically ill patients and advanced knowledge is needed to
prevent complications and for provision of quality patient care. We are
responsible and liable for our acts and omissions towards the patient and
knowledge is important to ensure responsible nursing practice.
However, education alone is insufficient to ensure compliance with
clinical guidelines (17). Failure of opinion leaders to endorse the guidelines

20
and lack of representation of important stakeholders in the groups that
develop guidelines can limit their implementation. It is important that
users participate in the development of the guidelines/protocols that will
eventually be used by them. Intensive care nurses that occupy leadership
roles are essential in motivating staff to follow guidelines as well as in
providing reasoning as to the need and the use of guidelines. They are
needed to support staff members and empower them with knowledge to
provide quality nursing care in the intensive care unit.
Nurses need to be made aware of their important role in preventing
morbidity and mortality due to complications and nosocomial infections
in their work environment.
Empowering nurses with knowledge and skills is very important to
increase their decision making ability in the workplace as well as to
provide patients with the best standard of care possible. This is needed so
that nurses are not viewed as robots available to carry orders and follow
protocols but rather seen as health care professionals that have the
capability of carrying out their duties in a responsible manner. Nurses can
have an active voice in their practice by giving their input regarding
patient care and suggestions for improvement in the workplace.
Prevention and control of ventilator associated pneumonia are dependent
on education and bawareness of ICU staff towards the problem and on the
application of evidence based strategies ( 5).
Adherence to the nursing process guidelines on prevention of ventilator
associated pneumonia will only occur once staff involved directly with
the patient’s care has knowledge of such guidelines and can understand
why it is important to put them into practice.

21
2.9 barriers and contributors to the implementation of nursing
process guidelines for prevention of VAP
2.9.1 Barriers to nursing care

Nursing process is an opportunity for intensive care nurses to become

involved in making significant changes in nursing care. It is essential that
nurses become empowered to use the knowledge available to implement
evidence based nursing practice. Motivation of nurses to get involved in
the process is needed and it is important to be aware of barriers
preventing this process to occur.
Barriers to effective implementation of evidence nursing process exist at
both the institutional and individual levels. They may include time
factors, limited access to the literature, lack of confidence in the staff’s
ability to critically evaluate empirical research, limited interest in
scientific enquiry, a work environment that does not support or value
evidence based nursing, inadequate research resources and limited
( 12).
authority or power to change practice based on research findings
Both information and the tools to obtain it are necessary components of
Nursing process , which is the use of the best evidence currently available
for clinical decision making. Appropriate resources must be made
available for the implementation of evidence based nursing practice.
Resources such as computer and internet access should be available in
(17)
intensive care units for online research and journals access. dentified
other barriers to implementation including failure of dissemination
strategies, lack of agreement amongst staff with some recommendations,
lack of outcome expectancy and lack of self-efficacy. External barriers
were also found such as perceptions that guidelines are difficult to use.
Patient barriers such as discomfort and potential adverse effects play an
important role in nurses’ reluctance to apply nursing process into
practice.

22
Job satisfaction surveys completed by nurses cite the lack of autonomy,
authority, decreased resources for patient care (including support and
nursing staff), poor work environment and lack of respect by practicing
colleagues as factors in the overall dissatisfaction with the nursing
( 12).
profession Nurses at all levels should be motivated to get involved in
the evidence based process and nursing administrators, clinical
facilitators, tutors and interested clinical staff must work together to
decide on how to best involve the entire nursing staff in the evidence
based process.
In the study, . ( 5)
a lack of human resources such as professionally trained
and dedicated personnel was also found to prevent the application of
VAP containing strategies, despite the fact that these strategies have been
indicated as fundamental means of reducing the rate of pneumonia in
mechanically ventilated patients. Strict working rhythms and insufficient
staff numbers were identified as reasons for not using the strategies, such
as regularly changing the posture of patients in order to allow the
drainage of bronchial secretions or the hourly removal of condensation
from ventilator circuits. These findings are important because ICU nurse/
patient ratio has been identified as factor potentially affecting the
incidence of VAP ( 5).
Lack of human resources may also affect the implementation of
prevention strategies in South African hospitals, as the shortage of trained
( 5)
and dedicated intensive care nurses is huge and, findings, it may be a
potential risk in increasing the incidence of VAP.
Another important resource needed is time. The world wide nursing
shortage has a toll on issues such as time allocation for patient care,
education and training. A lack of time has frequently been identified as an
(16).
important barrier to applying research into practice At time of
universal cost containment policies, there is growing evidence that high

23
workload or low staffing level increases the risk for negative patient
outcomes such as ventilator associated infections ( 10). In the Sudan
context where shortage of nursing staff is a major issue, skilled and
knowledgeable nurses are extremely important and needed to make
appropriate decisions in patient care and minimize risks to patients.
Knowledge should bring confidence to intensive care nurses to make
appropriate decisions and prevent delay in recovery of mechanically
ventilated patients.
2.9.2 Contributors to nursing care

Little is known about the contributors to effective implementation of

nursing care, but a few factors have emerged in previous studies.
Education seems to be the core factor towards application of sufficient
nursing care. Nursing education that motivates young professionals
entering the profession to think critically and value research is extremely
( 5).
important. Lack of critical thinking has been pointed out Nurses tend
to apply measures automatically without thinking about the reason as to
why they are doing it. It is also essential to stress the importance of
information seeking and information literacy to students along with the
professional obligation to career long literature searching, faculty to
believe it and live it themselves ( 16).
Nurses need to be encouraged to search for answers for questions
regarding nursing care not only with senior colleagues, but also and rather
on electronic resources and recent journal articles. Therefore there is a
need that they become familiar with such modern databases and
( 8)
resources. recommends that all hospitals institute educational training
programs for their staff to heighten awareness of VAP prevention and to
improve adherence to evidence based guidelines. They also recommend

24
that hospitals encourage staff involvement in educational advancement
and performance improvement projects.
Having protocols in place describing interventions related to prevention
(5),
of VAP may contribute to implementation of nursing care . nurses
apply interventions in protocols even if they are not fully aware of what
and why they actually do so. Ideally, nurses should understand the
rationale and reasons as to why certain interventions are needed.
Unfortunately, the large number of untrained staff members leads to the
use of protocols without using critical thinking. Nevertheless, the
presence of protocols in the units allows for a greater possibility of
( 8).
measures being implemented Therefore hospitals should implement
protocols for preventing VAP that includes each of the practices
recommended. Units implementing prevention protocols should evaluate
(8)
the effects of nursing actions on VAP rates and disseminate the results.
also found a direct relationship between hand washing responses and
participation in infection control projects. Increased hand washing
frequency was found amongst those participating in such projects, which
may stem from heightened awareness about infection control measures.
One could predict that if ICU nurses were involved in the development of
protocols in the unit aiming at preventing VAP, then frequent use of such
(17)
measures would occur.. found, guidelines are more likely to be
adopted if users have participated in their development.
Years of experience and age may also affect the degree as to which
( 8),
nurses apply prevention measures. In the same study mentioned above
which evaluated the extent to which nurses working in ICU’s implement
best practices when managing adult patients receiving mechanical
ventilation, older respondents and those with more years of critical care
experience reported that they kept the head of the bed elevated at 30 to 45
degrees from horizontal 75% or more of the time, whereas younger

25
respondents and those with fewer years of critical care experience did not
do so.
Patient/nurse ratio is also another important variable that may influence
( 17).
the incidence of nosocomial infection A well staffed unit allows for
time to perform important measures. Increased workloads results in non
compliance to basic hygiene measures and infection control
(10).
recommendations All the above factors need to be taken into
consideration when aiming at implementation of Effective and sufficient
nursing care , which ultimately leads to increased positive patient
outcomes. The starting point for application of guidelines is education
and from there stems all other factors.

2.10 Previous Study

2.10.1 Belgian study
. ( 6-14)
was conducted during November 2005 at the annual congress of the
Flemish Society for Critical Care Nurses in Belgium.
Results of the Belgian study The questionnaire was distributed to 855
nurses during the annual congress of the Flemish Society for Critical Care
Nurses. Of the 855 participants, 638 completed the questionnaire.
The average score was 3.7 on nine questions. Nurses with < 1 year
experience performed worse than nurses with > 1 year experience. Nurses
holding the degree had significantly better scores than those not holding
it.
Linear regression analysis identified years of experience and degree to be
independently associated with better knowledge.

2.10.2 Viviana Paula Ribeiro Gomes.South africa Johannesburg,

2010
26
The purpose of this study was to determine the knowledge of nurses
working in ICU with respect to evidence based guidelines for prevention
of ventilator associated pneumonia. A non experimental, descriptive,
correlational research design was used. Knowledge of ICU trained and
non ICU trained nurses working in ICUs of the three hospitals was found
to be lacking in the evidence based guidelines for prevention of ventilator
associated pneumonia. Of the 83 participants, 18 (21.69%; CI 95% 13.4%
; 32.1%) achieved a pass mark of 70% on the multiple choice part of the
questionnaire and were considered to have adequate knowledge on the
evidence based guidelines for prevention of VAP. The difference in the
mean average score of ICU trained nurses and non ICU trained nurses
was very similar demonstrating no statistically significant difference in
the knowledge of the two groups of nurses. A weak correlation between
years working in ICU and knowledge was found, but this correlation may
be clinically insignificant.

Recommendations to address this lack of knowledge of ICU nurses were

given for clinical nursing practice, nursing education as well as for
nursing research.

27
 CHAPTER THREE
 Research methodology

3-1: study design:-

28
This study design as descriptive cross sectional hospital based study.
3-2: study period:-

This study was conducted from February to April 2015

3-3: study setting:-

Alshaab teaching hospital is one of the establish typical hospital in

Khartoum state since of 1959 to fullfil special care for patient with
general heat disease –cardio-thoracic surgery and respiratory disease and
contain three ICU (cardiothoracic –intermediate and respiratory ICUs )
It is one of the public service institute , located in Khartoum center south
to facility of nursing science university of Khartoum , elmik nimir
street from east and Khartoum teaching hospital from west

3-4: study population:-

The target population of the study wereall intensive care nurse’s
distribute in to ICU. ICU staff about 48 nurse’s, 10 traning, 38 bacher.

3-5: inclusion and exclusion:-

Inclusion criteria:-

All of qualified either diploma ,bachelor ,and master

All ICU working in either cardiothoracic or intermediate

3-6 : exclusion criteria:-

Practitioners nurse
3-7: sampling:-

In this study was used total coverage of all intensive care nursing.

3-8: sample size:-

29
  30 nurses.

3-9: tools of data collection:-

Questionnaire was used to collect the data from subjects

3-10: sample technique :-

Self administrer questionnaire

3-11: variable :-

- Age
- Sex.
- Expérience year
- Training course in intensive care nursing
- Route of intubation
- Infection controls
- Technical of section
- Type of humidifiers
- Dialy living care of mechanical ventilation patient

3-12: data analysis:-

 The data were analyzed by SPSS version 17

30
3-13: ethical consideration:-

-verbal consent were obtained from all participants.

-any participants has right to discontinue at any time .
-participants informed about the result and the aim of this study
-participants name in this study was not used
-letter was taken from university of neelian faculty of nursing science
was taken to alshaab teaching hospital
-approval from administrative authorities of alshaab teaching hospital
was taken

31
CHAPTER FOUR

 Result

32
33
34
35
 Table no (1) distribution of result regarding end tracheal intubations

Frequency Percent Valid Cumulative

Percent Percent
Valid Oral intubation 19 65.5 65.5 65.5
can be
recommend
Nasal 2 6.9 6.9 72.4
intubations can
be recommend
Both route of 7 24.1 24.1 96.6
intubations can
be recommend
I don’t know 1 3.4 3.4 100.0
Total 29 100.0 100.0

Table no (2) distribution of result regarding sign and symptom of

pneumonia are

Frequency Percent Valid Cumulative

Percent Percent
Valid good 5 17.2 17.2 17.2
Fair 10 34.5 34.5 51.7
poor
14 48.3 48.3 100.0

Total 29 100.0 100.0

4 2-3 1 Points
good Fair poor Knowledge
degree

36
Table no (3) distribution of result regarding ventilator circuit changes

Frequency Percent Valid Cumulative

Percent Percent
Valid It is 2 6.9 6.9 6.9
recommended
to change
circuit every 48
hours ( or when
clinically
indicated)
B- It is 2 6.9 6.9 13.8
recommended
to change
circuit every
week ( or when
clinically
indicated)
It is 25 86.2 86.2 100.0
recommended
to change
circuit every
new patient ( or
when clinically
Indicated )
Total 29 100.0 100.0

Table no (4) distribution of result regarding type of humidifiers

Frequency Percent Valid Cumulative

Percent Percent
Valid Heated 3 10.3 10.3 10.3
humidifiers
Heat and 9 31.0 31.0 41.4
moisture
exchangers
Both type of 14 48.3 48.3 89.7
humidifiers are
used
I don’t know 3 10.3 10.3 100.0
Total 29 100.0 100.0

37
 Table no (5) distribution of result regarding type fluid used in
humidifiers

Frequency Percent Valid Cumulative

Percent Percent
Valid Normal saline 3 10.3 10.3 10.3
can be used
Distal water 22 75.9 75.9 86.2
can be used
Pure water can 4 13.8 13.8 100.0
be used
Total 29 100.0 100.0

Table no (6) distribution of result regarding frequency of humidifiers change

Frequency Percent Valid Cumulative

Percent Percent
Valid It 13 44.8 44.8 44.8
recommended
to change
humidifiers
every 48 hours
( or when
clinically
indicated)
It is 3 10.3 10.3 55.2
recommended
to change
humidifiers
every 72 ( or
when clinically
indicated)
It is 9 31.0 31.0 86.2
recommended
to change
humidifiers
every week ( or
when clinically
indicated)
I don’t know 4 13.8 13.8 100.0
Total 29 100.0 100.0

38
 Table no (7) distribution of result regarding open verse closed
suction systems

Frequency Percent Valid Cumulative

Percent Percent
Valid Open systems are 5 17.2 17.2 17.2
recommend
Close suction 6 20.7 20.7 37.9
system is
recommend
Both system can 16 55.2 55.2 93.1
be recommend
I don’t know 2 6.9 6.9 100.0
Total 29 100.0 100.0

Table no (8) distribution of result regarding frequency of change in

suction system

Frequency Percent Valid Cumulative

Percent Percent
Valid Daily change is 8 27.6 27.6 27.6
recommended
( or when
clinically
indicated )
Weekly change 3 10.3 10.3 37.9
is recommended
( or when
clinically
indicated)
It recommends 18 62.1 62.1 100.0
changing system
for every new
patient ( or when
clinically
indicating)
Total 29 100.0 100.0

39
 Table no (9) distribution of result regarding daily oral care

Frequency Percent Valid Cumulative

Percent Percent
Valid Every 12 hours 5 17.2 17.2 17.2
oral care
recommend ( or
when patient
indicate)
It recommend to 1 3.4 3.4 20.7
oral care at any
time patient
needed ( or when
patient indicate)
Every 8 hours care 23 79.3 79.3 100.0
recommend ( or
when the patient
indicate)
Total 29 100.0 100.0

Table no (10) distribution of result regarding use of endotracheal

tube with extra lumen for drainage of subglottic secretion

Frequency Percent Valid Cumulative

Percent Percent
Valid This endotracheal 12 41.4 41.4 41.4
tube reduce the
risk for VAP
This endotracheal 6 20.7 20.7 62.1
tube increase the
risk for VAP
This endotracheal 6 20.7 20.7 82.8
tube don’t
influence for VAP
I don’t know 5 17.2 17.2 100.0
Total 29 100.0 100.0

40
 Table no (11) distribution of result regarding bribcgitracgeak suction

Frequency Percent Valid Cumulative

Percent Percent
Valid 3 10.3 10.3 10.3
Use aseptic 21 72.4 72.4 82.8
technique for
suction
Use clean 5 17.2 17.2 100.0
technique for
suction
Total 29 100.0 100.0

Table no (12) distribution of result regarding patient position during

suction

Frequency Percent Valid Cumulative

Percent Percent
Valid Supine position is 11 37.9 37.9 37.9
recommended
Semirecombent is 13 44.8 44.8 82.8
recommended
The position of the 4 13.8 13.8 96.6
patient dose not
influence
I don’t know 1 3.4 3.4 100.0
Total 29 100.0 100.0

41
 Table no (13) distribution of result regarding the barriers to the
implementation of scientific and proper nursing care for prevention
of VAP?

Frequency Percent Valid Cumulative

Percent Percent
Valid 29 100.0 100.0 100.0

A- LACK of knowledge

Frequency Percent Valid Cumulative

Percent Percent
Valid 1 1 3.4 3.4 3.4
yes 25 86.2 86.2 89.7
no 3 10.3 10.3 100.0
Total 29 100.0 100.0

B-Unavailability of material and cost constraints

Frequency Percent Valid Cumulative

Percen Percent
t
Valid yes 23 79.3 79.3 79.3
no 6 20.7 20.7 100.0
Total 29 100.0 100.0

C-Unforeseen in departmental protocol

Frequency Percent Valid Cumulative

Percent Percent
Valid yes 20 69.0 69.0 69.0
no 9 31.0 31.0 100.0
Total 29 100.0 100.0

42
 D-Shortage of staff
Frequency Percent Valid Cumulative
Percent Percent
Valid yes 18 62.1 62.1 62.1
no 11 37.9 37.9 100.0
Total 29 100.0 100.0

E-Training of staff member

Frequency Percent Valid Cumulative

Percent Percent
Valid yes 26 89.7 89.7 89.7
no 3 10.3 10.3 100.0
Total 29 100.0 100.0

Table no (14) distribution of result regarding the contributors to the

implementation of proper nursing Care for prevention of VAP are
availability of resource

Frequency Percent Valid Cumulative

Percent Percent
Valid 28 96.6 96.6 96.6
1 1 3.4 3.4 100.0
Total 29 100.0 100.0

A- Training of staff

Frequency Percent Valid Cumulative

Percent Percent
Valid yes 27 93.1 93.1 93.1
No 2 6.9 6.9 100.0
Total 29 100.0 100.0

43
 B Staff motivation and compliance

Frequency Percent Valid Cumulative

Percent Percent
Valid yes 23 79.3 79.3 79.3
No 6 20.7 20.7 100.0
Total 29 100.0 100.0

C-Team work

Frequency Percent Valid Cumulative

Percent Percent
Valid yes 21 72.4 72.4 72.4
No 8 27.6 27.6 100.0
Total 29 100.0 100.0

14-pdated protocols

Frequency Percent Valid Cumulative

Percent Percent
Valid yes 25 86.2 86.2 86.2
No 4 13.8 13.8 100.0
Total 29 100.0 100.0

Table no (15) distribution of result regarding prevent ventilation

association pneumonia

Frequency Percent Valid Cumulative

Percent Percent
Valid Good 1 3.4 3.4 3.4
Fair 12 41.4 41.4 44.8
poor 16 55.2 55.2 100.0
Total 29 100.0 100.0

4 2-3 1 Point
Good Fair poor Knowledge
degree

Bar Chart

44
CHAPTER FIVE
 Discussion
 Recommendation
 Conclusion

45
5-1: Discussion:-
Ventilation association pneumonia is infectious disease caused by wide
spectrum of pathogens and associated with morbidity and mortality .it
account for up 27-76% of all health care association infection .prevalence
estimate of VAP 3%
This is cross sectional study was conduct in alshaab hospital during
(April 2015 ) to assess the (ICU ) nurses knowledge about prevention of
ventilation association pneumonia .this study was aimed to assess(ICU)
nurses about prevention of (VAP).
The result showed most age group between 21-30 years show in figure (I)
In this study the female more than showed in figure(II) .in figure No (III)
distribution the result regard the years of experience . the qualification
level in candidates vary from bachelor and master this definitely affect
different aspect of knowledge to word the prevention of (VAP)in figure
(IV). (52)% of participants have training course in (ICU) nursing this is
represent in figure (V). Table No(1) distribution the result regarding
endotracheal intubation ,just (24)%o f candidates denote about
endotracheal intubation .in table No (2) according to scale from the
result was regarding sign and symptoms of ventilation association
pneumonia
Approximate ( 86)%of participants reveal good knowledge regarding the
circuit change this showed in table No (3).in table No (4) distribution the
result regarding type of humidifiers about (51)%of nurses not know
about type of humidifiers .the table No(5) distribution the result
regarding the type of fluid used in humidifiers about (75)%of candidates
reflect the good knowledge of accurate type of fluid . in table No (6)
distribution the result regarding frequency of humidifiers change just
about (44)% of participants know about the frequency of change
.unfortunately just (20)%of the candidates know about the type of

46
suction used to the ventilated patient this result represent in table No (7).
In table No (8) distribution the result regarding frequency of change in
suction system (62.1)%of candidates donate good knowledge about
frequency of change .approximate (79.3)%of participants reveal good
knowledge regarding the frequency of daily oral care and this prevent the
patient from (VAP)this represent in table No (9).
Just (41.4)%of candidates know about the used of endotracheal tube with
extra lumen for drainage of subglottic secretion ,because this secretion
increased the risk of (VAP)this showed in table No (10) .
In table No (11) distribution the result regarding the broncho tracheal
suction just (17)%of candidates know about it , so that increased the
incidence of (VAP) .approximate about (55.2)% of participants not know
about the position of patient during the suction this showed in table No
(12) .

Unavailability of resource as well as cost represent barrier to the

implementation of proper and scientific nursing care prevention of
(VAP).the above finding have implications for patient safety and quality
of care as well as on nursing education and training of (ICU)nurse this
showed in table No(13). According to participants availability of
resources ,training staff ,staff motivation and compliance team work
,update protocols and more nursing staff would contribute in
implementing the proper and scientific nursing care for prevention of
(VAP) this represent in table No (14). In table No (15) according to scale
from the result was regarding prevent ventilation association
pneumonia.

47
5-2: recommendation:-

- Prevention is better than cure as the saying goes

- It’s recommended by training activity into hospital and ICU to
improve knowledge on prevention of ventilation association
pneumonia which is second nosocomial infection in ICU.
- It's advised to initiate an ICU protocols on how to prevent VAP
and should be reviewed regular as update
- It's recommended for new staff in ICU being included in infection
control program.
- Continues study is recommended conducted to test the knowledge
level of nurses prior to and after education program on evidence
based guideline for prevention of ventilator associated pneumonia.

48
5-3: conclusion:-

Nurses have poor knowledge for prevention of (VAP) and without this
knowledge, patient will be under grater hazard
It can be clear that the nurse's who included in teaching program and who
not included was of poor knowledge, and this may reflect the importance
of refreshing program in ICU

49
References:-

-Augustyn, B. 2007. Ventilator associated pneumonia: risk factors and

prevention. Critical Care Nurse, vol. 27, no. 4, pp. 32 – 39.
-Biancofiore, G., Barsotti, E. & Catalani, V., et al. 2007. Nurses’
knowledge and application of evidence-based guidelines for preventing
ventilator associated pneumonia. Minerva Anestesiologica, vol. 73, no. 3,
pp. 129 – 134.
-Blot, S.I., Labeau, S. & Vandijck, D., et al. 2007. Evidence based
guidelines for the prevention of ventilator associated pneumonia: results
of a knowledge test among intensive care nurses. Intensive care medicine,
vol. 33, pp. 1463 – 1467.
-Couchman, B.A., Wetzig, S.M. & Coyer, F.M., et al. 2007. Nursing care
of the mechanically ventilated patient: What does the evidence say? Part
one. Intensive and Critical Care Nursing, vol. 23, pp. 4- 14.
-Cason, C.L., Tyner, T. & Saunders, S., et al. 2007. Nurses’
implementation of guidelines for ventilator-associated pneumonia from
the centres for disease control and prevention. American Journal of
Critical Care, vol. 16, no. 1, pp. 28- 36.
-Grap, M.J., Munro, C.L., Ashianti, B. & Bryant, S. 2003. Oral care
interventions in critical care: frequency and documentation. American
Journal of Critical Care, vol. 12, no. 2, pp. 113 – 118.
-Hugonnet, S., Uckay, I. & Pittet, D. 2007. Staffing level: a determinant
of late onset ventilator associated pneumonia. Critical Care, vol. 11, no.4.
-Hixon, S., Lou Sole, M. & King, T. 1998. Nursing strategies to prevent
ventilator associated pneumonia. AACN Clinical issues: Advanced
Practice in Acute and Critical Care vol. 9, no. 1.

50
-Hockenberry, M., Wilson, D. & Barera, P. 2006. Implementing evidence
based nursing practice in a pediatric hospital. Pediatric Nursing, vol.32,
no.4. pp. 371 – 377.
-Hugonnet, S., Uckay, I. & Pittet, D. 2007. Staffing level: a determinant
of late onset ventilator associated pneumonia. Critical Care, vol. 11, no.4.
-Kaynar, A.M., Mathew, J.J. & Hudlin, M.M., et al. 2007. Attitudes of
Respiratory Therapists and Nurses About Measures to Prevent Ventilator-
Associated Pneumonia: A Multicenter, Cross Sectional Survey Study.
Respiratory Care, vol. 52, no. 12, pp. 1687 – 1694.
-Labeau, S., Vandijck, D.M. & Claes, B., et al. 2007. Critical care nurses’
knowledge of evidence based guidelines for preventing ventilator
associated pneumonia: an evaluation questionnaire.
-Muscedere, J., Dodek, P. & Keenan, S., et al. 2008. Comprehensive
evidence- based clinical practice guidelines for ventilator-associated
pneumonia: Prevention. Journal of Critical Care, vol. 23, pp. 126 -137.
-Pravikoff, D., Tanner, A. & Pierce, S. 2005. Readiness of U.S nurses for
evidence based practice. American Journal of Nursing, vol. 5, no. 9, pp.
40 -51.
-Ricart, M., Lorente, C. & Diaz, E., et al. 2003. Nursing adherence with
evidence-based guidelines for preventing ventilator-associated
pneumonia. Critical Care Medicine, vol. 31, no. 11, pp. 2693 – 2696.

51
Appendcis

52
 UNVERSITY OF NEELAIN
UNDER GRADUATE COLLEG
FACULTTY OF NURSING
MEDICAL AND SURGICAL NURSING DEPARTMENT

QUESTIONNAIRE ABOUT ;-
EVAULATION OF INTENSIVE CAER NURSES KNOWLEDGE FOR
PREVENTION OF VENTILATION ASSOCIATION PNEUMONA

THIS QEUSTIONNAIRE ANONYMOUSE PLEASE DON’T WRITE

YOUR NAME
Age: ------------------------------- sex:
---------------------------------------
Years of work in ( ICU):-------------------------------------
Level of qualification :
-Diploma
-Bachelor
-master
Did you have training course in( ICU ) nursing ?
Yes:------------------------- no: -------------------------
-PLEASE PUT THE CORRECT NUMBER OF ANSWER IN BOX

1-oral verses nasal route for endotracheal intubations

a-oral intubation can be recommend
b-nasal intubations can be recommend
c-both route of intubations can be recommend
d- I don’t know

2-the sign and symptom of pneumonia are:

a- mild fever
b- productive cough
c- chest pain during deep breathing and cough
d-I don’t know

3-frequency of ventilator circuit changes

a- it is recommended to change circuit every 48 hours (or when
clinically indicated )
b- it is recommended to change circuit every week (or when clinically
indicated)
c- it is recommended to change circuit every new patient (or when
clinically indicated)
d- I don’t know

53
4-type of humidifiers
a-heated humidifiers
b- heat and moisture exchangers
c- both type of humidifiers are used
d- I don’t know

5-the type fluid used in humidifiers

a- normal saline can be used
b- distal water can be used
c- pure water can be used
d- I don’t know

6-frequency of humidifiers change

a-it is recommended to change humidifiers every 48 hours (or when
clinically indicated )
b- it is recommended to change humidifiers every 72 (or when
clinically indicated)
c- it is recommended to change humidifiers every week (or when
clinically indicated)
d- I don’t know

7- open verses closed suction systems

a- open suction system are recommend
b-close suction system are recommend
c-both system can be recommend
d- I don’t know

8-frequency of change in suction system

a-daily change are recommend (or when clinically indicated )
b- weekly change are recommend (or when clinically indicated )
c- it recommend to change system for every new patient (or when
clinically indicate )
d- I don’t know

9-frequency of daily oral care

a-every 12 hours oral care recommend ( or when patient indicate )
b-every 8 hours oral care recommend (or when the patient indicate )
c-it recommend to oral care at any time patient needed ( or when
patient indicate )
d- I don’t know

54
10-endotracheal tube with extra lumen for drainage of subglottic
secretion
a- this endotracheal tube reduce the risk for VAP
b-this endotracheal tube increase the risk for VAP
c-this endotracheal tube don’t influence for VAP
d- I don’t know

11 –bronchotracheal suction
a- use aseptic technique for suction
b- use clean technique for suction
c- done any way
d- I don’t know

12- patient position during suction

a-supine position is recommended
b- semirecombent is recommended
c- the position of the patient dose not influence
d- I don’t know

13- did you think the barriers to the implementation of scientific and
proper nursing care for prevention of VAP

a- lack of knowledge
b- unavailability of material and cost constraints
c- unforeseen in departmental protocol
d- shortage of staff
e- training of staff member
14 –did you think the contributors to the implementation of proper
nursing care for prevention of VAP are

a- availability of resource
b- training of staff
c- staff motivation and compliance
d- team work
e- updated protocols

15-t0 prevent ventilation association pneumonia it recommended for

nurse to:
a-check vital sign is recommended
b- proper suction is recommended
c- chest physiotherapy is recommended
d-it recommended by early post extubatin mobilization

55