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ACCORDING TO THE MOST recent sta-tistics from the CDC, hospital-acquiredpneumonia (HAP) accounts for nearly 15%of all hospital-acquired infections (HAIs)and is associated with the highest mortal-ity rates (20% to 33%). It’s second only tourinary tract infections as the most com-mon HAI. The American Thoracic Society(ATS) defines HAP as the development ofpneumonia, which isn’t incubating or pre-sent at the time of the patient’s admission,more than 48 hours after admission to ahealth care facility. HAP includes ventila-tor-associated pneumonia (bacterial pneu-monia that develops in patients with acuterespiratory failure who’ve been receivingmechanical ventilation for at least 48hours), post-op pneumonia, and develop-ing pneumonia in nonventilated and criti-cally ill patients.

In this article, I’ll discuss the pathophysi-

ology, risk factors, signs and symptoms,and treatment options for HAP, as well ashow to care for a patient who has it andprevent at-risk patients from developing it.

But first, let’s quickly review some gen-eral information about pneumonia.

Acute inflammation aheadPneumonia is an acute inflammation ofthe lungs caused by a bacterial, viral, my-coplasmal, fungal, protozoal, or mycobac-terial infection. In bacterial pneumonia, aninfection initially triggers alveolar inflam-mation and edema. In viral pneumonia, avirus attacks bronchiolar epithelial cells,leading to interstitial inflammation anddesquamation that spreads to the alveoli.It may be primary, resulting from inhala-tion of a pathogen, or secondary, resultingfrom lung damage caused by inhalation ofa noxious chemical or other insult or thespread of bacteria from a distant area.Types of pneumonia include:• bronchopneumonia—involves the distalairways and alveoli• lobular pneumonia—involves part of thelobe• lobar pneumonia—involves the entirelobe (see Picturing pneumonia).

Besides HAP, pneumonia can be furtherclassified as: • health care–associated pneumonia—affects patients who aren’t hospitalized butwho have close contact with the health care

32 Nursing made Incredibly Easy! September/October 2008

The essentials of

Hospital-acquired pneumonia is a growingconcern that all nurses need to be aware of.We give you the essentials, from who’s most atrisk to important nursing interventions andprevention strategies.LINDA K. GOSS, RN,C, CIC, COHN-S, BSNDirector • Infection Control and Infusion Services • University of LouisvilleHospital • Louisville, Ky.

The author has disclosed that she has no significant relationships with or financial interest in any com-mercial companies that pertain to this educational activity.

hospital-acquired

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September/October 2008 Nursing made Incredibly Easy! 33

pneumonia

system, such as those who reside in long-term-care facilities or who have regularhemodialysis • community-acquired pneumonia—occursin the community setting or within the first48 hours of admission to a health care facil-ity because of community exposure• aspiration pneumonia—can occur in thecommunity or health care facility settingand results from inhalation of foreign mat-ter, such as vomitus or food particles, intothe bronchi (most common in olderpatients, patients with a decreased level ofconsciousness [LOC], and those receivingnasogastric [NG] tube feedings); microaspi-ration, or aspiration of microbiologicorganisms, may also lead to pneumonia inhospitalized patients because they often

lack the ability to clear their own air-way, allowing colonized bacteria toenter the oropharynx and, subse-quently, the lower respiratory tract.

Now, let’s delve into HAP specifi-cally.

An unwanted deliveryHAP occurs when at least one ofthree conditions exist: host defensesare impaired, organisms reach thelower respiratory tract and over-whelm the host’s defenses, or ahighly virulent organism is pre-

sent. Certain factors may predis-pose patients to HAP, such as severe

acute or chronic illness, comorbid condi-tions such as hypotension or metabolicdisorders, supine positioning and aspira-tion, coma, and prolonged hospitaliza-

tion. Hospitalized patients are also ex-posed to potential bacteria from other

sources, such as respiratory therapy de-vices and equipment and transmission ofpathogens by the hands of health care per-sonnel. Numerous intervention-related fac-tors may play a role in the development ofHAP as well, such as therapeutic agentsleading to central nervous system depres-sion with decreased ventilation, impaired

removal of secretions, or potential aspira-tion; prolonged or complicated thoracoab-dominal procedures; endotracheal (ET) in-tubation; prolonged or inappropriate useof antibiotics; and use of NG tubes.

The common organisms responsible forHAP include the Enterobacter species,Escherichia coli, Haemophilus influenzae,Klebsiella pneumoniae, Proteus species,Serratia marcescens, Pseudomonas aeruginosa,methicillin-sensitive or methicillin-resistantStaphylococcus aureus, and Streptococcuspneumoniae. Most patients with HAP arecolonized with multiple organisms.Pseudomonal pneumonia, which accountsfor 15% of HAP cases, occurs in patientswho are debilitated, those with alteredLOC, and those with prolonged intubationor with tracheostomy. Staphylococcalpneumonia, which accounts for up to 30%of HAP cases, can occur through inhalationof the organism or spread through thehematogenous route (see Common organ-isms responsible for HAP).

Next, let’s take a look at which patientsare most at risk for HAP, the signs andsymptoms to watch for, and the diagnostictests that may be ordered for your patient.

Who’s at risk?Risk factors for HAP include:• age over 70 • admission to the hospital for burns,trauma, or disease of the central nervoussystem • previous thoracic or abdominal surgery• immunocompromise• malnutrition• decreased LOC• underlying chronic lung disease• gastric reflux.

Admission or transfer to the ICU increas-es the risk of HAP primarily due to thelikelihood of the patient requiring mechan-ical ventilation. Mechanically ventilatedpatients are at greater risk for developingHAP than nonventilated patients: Oro-pharyngeal secretions may be delivered to


Be tough onorganismsthat can

cause HAP.


Picturing pneumonia

Lobar pneumonia

Trachea

Bronchus

Horizontalfissure

Obliquefissure

Consolidationin one lobe

Bronchopneumonia

Trachea

Bronchus

Obliquefissure

Alveolus

Scatteredareas ofconsolidation

the lower respiratory tract because thepatient is unable to cough on his own dueto the artificial airway. If a patient experi-ences HAP in the ICU, his length of stay inthe ICU may be prolonged up to 6 daysand in the hospital up to 9 days, withincreased costs estimated at $40,000 perpatient.

To prevent modifiable risk factors, CDCguidelines include strict infection control,alcohol-based hand disinfection, use ofmicrobiologic surveillance, monitoring andearly removal of invasive devices such as

ET tubes, and programs to reduce or alterantibiotic prescribing practices.

It’s a signSigns and symptoms of pneumonia in-clude:• cough (often dry in older adults due todehydration; typically productive inyounger adults)• fever higher than 100° F (37.8° C)• difficulty breathing or dyspnea on exer-tion (rarely at rest)• chest pain or discomfort that may be ac-

companied by abdominal pain• heart rate of more than 100 beats/minute • rhonchi or crackles on both inspirationand expiration• overall weakness or fatigue.

Nursing assessment of a patient is criti-cal in detecting pneumonia. Fever, chills, or

night sweats in a patient who has respirato-ry symptoms such as a cough should alertyou to the possibility of pneumonia.Further respiratory assessment shouldinclude inquiry into pleuritic pain, fatigue,tachypnea, use of accessory muscles forbreathing, bradycardia, and purulent spu-tum. Monitor your patient for changes in


Common organisms responsible for HAP

Organism Epidemiology Clinical features Treatment Commentsresponsible

Pseudomonas • Incidence greatest in those with • Diffuse • Aminoglycoside • Complications include aeruginosa preexisting lung disease, cancer consolidation and antipseudo- lung cavitation

(particularly leukemia), homograft on chest X-ray monal agents • Has capacity to transplants, or burns; debilitated • Toxic appear- (ticarcillin, piperacillin, invade blood vessels, persons; and patients receiving ance: fever, chills, ceftazidime); other causing hemorrhage and antimicrobial therapy and treatments productive choices include lung infarction such as tracheostomy, suctioning, cough, relative cefepime, imipenem, • Usually requires and in post-op settings bradycardia, ciprofloxacin, hospitalization• Accounts for 15% of hospital- and leukocytosis and colistinacquired pneumonia (HAP) cases• Mortality rate: 40% to 60%

Staphylococcus • Incidence greatest in immunocom- • Severe hypoxemia • Nafcillin/oxacillin, • Complications include aureus promised patients, I.V. drug users, and • Cyanosis clindamycin, or linezolid pleural effusion, pneu-

as a complication of epidemic influenza • Necrotizing • Methicillin-resistant: mothorax, lung abscess, • Accounts for 10% to 30% of HAP infection vancomycin or linezolid empyema, meningitis, cases • Bacteremia is and endocarditis• Mortality rate: 25% to 60% common • Frequently requires

hospitalization• Treatment must be vig-orous and prolonged because disease tends to destroy lung tissue

Klebsiella • Incidence greatest in elderly patients, • Tissue necrosis Third- or fourth- • Complications include pneumoniae alcoholics, patients with chronic occurs rapidly generation cephalo- multiple lung abscesses (Friedlander’s disease (such as diabetes, heart failure, • Toxic appearance: sporins (cefotaxime, with cyst formation, bacillus- or chronic obstructive pulmonary fever, cough, sputum ceftriaxone) plus empyema, pericarditis, encapsulated disease), and patients in chronic care production, broncho- aminoglycoside, and pleural effusionGram-negative facilities and nursing homes pneumonia, and antipseudomonal • May be fulminating, aerobic bacillus) • Accounts for 2% to 5% of lung abscess penicillin, monobactam, progressing to a fatal

community-acquired and 10% to 30% • Lobar consolidation or quinolone outcomeof HAP cases and broncho-• Mortality rate: 40% to 50% pneumonia pattern

on chest X-ray


A chest X-ray can helpdetermine ifI have HAP.

temperature; pulse; amount, odor, andcolor of respiratory secretions; frequencyand severity of cough; degree of tachypnea;and lung auscultation findings.

Your strong assessment skills will comeinto play when recognizing a change inyour patient’s respiratory status. For exam-ple, an alteration in his breath sounds maylead to a decrease in tolerance for activityand a need for longer rest periods. Anincreased heart rate or tachycardia maylead to a decrease in oxygenation and achange in his mental status. And use ofaccessory muscles to breathe may lead toineffective breathing patterns.

An intubated or critically ill patient willshow signs of pneumonia as indicated byhis documented respiratory values andPaO2/FIO2 levels. Older adults and youngchildren may have symptoms that arenonspecific, such as agitation, confusion,and restlessness, which may make recog-nizing pneumonia more difficult. As ageneral rule, if your patient exhibits afever and cough, pneumonia should beconsidered.

Likely suspectThe health care provider will order a chestX-ray to determine areas of consolidation,a white blood cell count with differentialto indicate the presence and type of infec-tion and, possibly, an arterial blood gas(ABG) analysis to determine the extent ofrespiratory compromise due to alveolar in-flammation. She may also order bron-choscopy to allow for the collection ofsputum cultures to identify the specific in-fectious organism.

The diagnosis of pneumonia is made onthe findings of the chest X-ray, physicalexam, sputum specimen collection (inwhich the patient is instructed to rinse hismouth, deep-breathe, cough, and expecto-rate into a specimen container; if thepatient is already mechanically ventilated,the specimen can be collected via suction-ing), and blood cultures. The health care

provider will most likely use the ClinicalPulmonary Infection Score, which is basedon certain clinical criteria such as the pres-ence of fever and a decrease in blood oxy-genation values, to confirm the diagnosis ofHAP.

If your patient is diagnosed with HAP,his treatment will depend largely on theorganism suspected of causing it. Let’s takea closer look.

Antibiotics on firstFirst, an effort is made to identifythe specific invading organismand whether your patient hasbeen infectedwith an organ-ism that’s re-sistant to mul-tiple drugs. Anantibiogram—a documentthat serves asa facility-specific,and sometimes unit-specific, guide to the preva-lence of organisms in your facility and theantibiotics that have been used to effec-tively treat them—can help. The antibi-ogram is used as part of an overall assess-ment of your patient, including time fromadmission to acquisition of pneumonia,presence of mechanical ventilation, andwhether he has recently been treated withantibiotics. If your patient’s HAP is causedby a susceptible organism, his treatmentwill be less complicated.

The ATS and the Infectious DiseasesSociety of America updated their con-sensus statement on the consistent andevidence-based treatment of HAP in 2005.This treatment guideline emphasizes usingantibiotics that are effective against a widervariety of organisms and changing theantibiotic only when the pathogen has beenidentified. It also states that antibiotic ther-apy should be as short as possible and lastno longer than 8 days because overuse and

inappropriate use of antibiotics can delaythe overall response to therapy (seeAmerican Thoracic Society treatmentalgorithm).

Antibiotic therapy is usually determinedby your facility’s antimicrobial pharma-cists, infectious diseases specialists, andmicrobiology department. Treatment mayconsist of monotherapy or combinationtherapy, depending on the risk factors

involved, the antibiotics’ mechanisms ofaction, and whether an organism has beenidentified. As mentioned in the treatmentguideline, a broad-spectrum antibiotic(such as antipseudomonal cephalosporins,carbapenems, penicillins, fluoroquinolones,and aminoglycosides) should be usedearly.

The recommended bottom line forantibiotic treatment of HAP is as follows:


American Thoracic Society treatment algorithm

Adjust antibiotic thera-py; search for other

pathogens, complica-tions, diagnoses, or

sites of infection

Consider stoppingantibiotic therapy

Search for otherpathogens, complica-tions, diagnoses, or

sites of infection

Clinical improvement at 40 to 72 hours

Days 2 and 3: Check cultures and assess patient’s response (temperature, white blood cell count,chest X-ray, oxygenation status, purulent sputum, hemodynamic changes, and organ function)

Unless there’s a low clinical suspicion for pneumonia and negative sensitivity of the sample, empiric antibiotic therapy should begin

Culturesnegative

No Yes

De-escalate antibioticsif possible;

treat selected patientsfor 7 to 8 days and

reassess

Culturespositive

Culturesnegative

Culturespositive

Obtain lower respiratory tract sample for culture and sensitivity

Suspected hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP)or health care-associated pneumonia (HCAP)

Source: American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia, http://www.thoracic.org/sections/publications/statements/pages/mtpi/guide1-29.html. Accessed May 20, 2008.


Antibiotictherapy shouldbe as short as

possible, lastingno longer than

8 days.

• choose an antibiotic that works against avariety of organisms• start the antibiotic early and stop it orchange it when an organism has beenidentified • limit the duration of therapy to 7 to 8days, depending on the patient’s response.

Other treatment measures include:• supplemental oxygen if the patient ishypoxic (in severe cases, the patient mayrequire mechanical ventilation)• adequate nutrition and fluid intake• rest (depending on the severity of thepneumonia; patients may be encouragedto get out of bed to cough and deep-breathe to expectorate secretions and aer-ate the lungs)• antitussives for cough may be pre-scribed• analgesics as needed to relieve chestpain.

What can you do when caring for apatient with HAP? Let’s take a look atnursing interventions next.

Cough, deep-breathe, repeatCare of a patient who’s diagnosed withHAP includes the following:• Adhere to standard precautions and in-stitute appropriate transmission-based pre-cautions, depending on the causative or-ganism.• Maintain a patent airway and oxygena-tion. Reposition your patient to maximizechest expansion and reduce discomfort,and give supplemental oxygen as needed. • Monitor his oxygen saturation level andABG values as ordered.• Assess his respiratory status often, ac-cording to your facility’s policy. Auscul-tate his lungs for abnormal breath sounds,such as rhonchi, crackles, or wheezes. • Encourage coughing and deep breath-ing.• Administer antibiotic therapy as or-dered.• Perform meticulous care of his oral cav-ity to prevent microorganisms from being

aspirated and decrease colonization, espe-cially in mechanically ventilated patients.• If your patient requires tube feedings,administer feedings slowly to prevent as-piration. Keep the head of the bed ele-vated at least 30 degrees at all times if notcontraindicated.

What about patient teaching? That’s nexton our list.

Anxiety-free teachingAnxiety related to hospitalization is com-mon, but in a patient with HAP it can leadto compromise of his respiratory functionsif not kept in check. If your patient isexperiencing anxiety, make sure tohelp reduce his feelings of anxious-ness before attempting to provideeducation. Explain to him the stepsyou’re taking; for example, whenencouraging him to cough anddeep-breathe, let him know thatit helps clear his airway. Ifyou’re performing oral care, tellhim it will reduce the bacterial col-onization in his mouth. And whenraising the head of the bed, explain that ithelps prevent aspiration of oral secretionsinto his lungs.

Patient teaching should include the fol-lowing:• Teach your patient and his family aboutthe prescribed antibiotic and any diagnos-tic tests that are ordered.• Show him how to cough and performdeep-breathing exercises and encouragehim to do so often.• To prevent pneumonia, advise him toavoid indiscriminate antibiotic use duringminor viral infections because this may re-sult in upper airway colonization with an-tibiotic-resistant bacteria. If he then devel-ops pneumonia, the infecting organismsmay require treatment with more toxic an-tibiotics.• Encourage high-risk patients, such asthose with chronic obstructive pulmonarydisease or chronic heart disease, to get an-


Preventive measures for pneumoniaRisk factor Preventive measure

Conditions that produce mucus or bronchial obstruction and interfere with • Promote coughing and expectoration of secretionsnormal lung drainage (such as cancer, cigarette smoking, or chronic • Encourage smoking cessationobstructive pulmonary disease)

Immunosuppressed patients and those with a low neutrophil count • Follow standard precautions and screen visitors(neutropenic)

Smoking (cigarette smoke disrupts both mucociliary and macrophage • Encourage smoking cessationactivity)

Depressed cough reflex (due to medications, a debilitated state, or weak • Reposition frequently to prevent aspiration and respiratory muscles); aspiration of foreign material into the lungs during administer medications judiciously, particularly those a period of unconsciousness (head injury, anesthesia, or depressed level that increase risk of aspirationof consciousness), or abnormal swallowing mechanism • Perform suctioning and chest physical therapy if

indicated

Nothing-by-mouth status; placement of nasogastric, orogastric, or • Promote frequent oral hygieneendotracheal tube • Minimize risk of aspiration by checking tube

placement and proper positioning of the patient

Supine positioning in patients unable to protect their airway (in very ill • Elevate the head of bed at least 30 degreespeople, the oropharynx is likely to be colonized by Gram-negative bacteria) • Decrease colonization by performing oral care with

an antiseptic or antimicrobial agent

Antibiotic therapy • Monitor patients receiving antibiotic therapy for signs and symptoms of pneumonia

• Use antibiotics only when necessary

Alcohol intoxication (because alcohol suppresses the body’s reflexes, • Encourage reduced or moderate alcohol intake (in may be associated with aspiration, and decreases white blood cell case of alcohol stupor, position the patient to mobilization and tracheobronchial ciliary motion) prevent aspiration)

General anesthetic, sedative, or opioid preparations that promote • Observe the respiratory rate and depth during respiratory depression, which cause a shallow breathing pattern and recovery from general anesthesia and before giving predispose the patient to the pooling of bronchial secretions and potential medications; if respiratory depression is apparent, development of pneumonia withhold the medication and contact the health care

provider

Advanced age (because of possible depressed cough and glottic reflexes • Promote frequent turning, early ambulation and and nutritional depletion) mobilization, effective coughing, breathing exercises,

and nutritious diet

Respiratory therapy with improperly cleaned equipment • Make sure that respiratory equipment is cleaned properly; participate in continuous quality improve-ment monitoring with the respiratory care depart-ment

Transmission of organisms from health care providers • Use strict hand hygiene along with the use of standard and/or transmission-based precautions• Implement health care provider education regard-ing stringent infection control practices

nual influenza and pneumococcal vaccina-tions.• Encourage smoking cessation programsfor patients who smoke.

What can you do to preventHAP?It’s important to remember that a patientwho’s at risk for pneumonia doesn’t haveto acquire pneumonia. Because HAP has ahigh morbidity and mortality rate, effortsshould focus on prevention. PreventingHAP is a multilayered process that re-quires an understanding of risk factorsand knowledge of nursing interventionsthat serve to prevent the development ofpneumonia and promote patient safety. Asyou care for the patient at risk, you canidentify areas that may predispose him toHAP and work to prevent it (see Preven-tive measures for pneumonia).

Here are some prevention tips you canuse.• Follow the CDC’s guidelines for handhygiene and overall infection control.

• Elevate the head of the bed between 30and 45 degrees, if not contraindicated, tohelp prevent aspiration.• Verify feeding tube placement regularlyand check residual volumes to preventdistension that may result in aspiration. • Perform or assist your patient with oralcare to reduce the number of organisms inhis mouth. • Know and follow your facility’s policyfor replacing suctioning catheters or otheritems that may be used in his mouth.• Encourage deep breathing and assistwith ambulation, if not contraindicated, sohe’s better able to maintain a clear airway.• If your patient is post-op, utilize incen-tive spirometry, as indicated, to maximizehis ventilatory volume and promotecoughing to clear the airway.• Ensure your patient receives his antibi-otics as scheduled.

Got the essentials coveredKnowing the essentials of HAP will notonly help you care for a patient who has


Knowing apatient’s riskfactors can

help youprevent HAP.

Risk factors for HAP• Age over 70 • Severe acute or chronic illness• Comorbid conditions such as hypotension or metabolic disorders• Malnutrition• Immunocompromise• Decreased level of consciousness• Underlying chronic lung disease• Gastric reflux• Coma• Admission to the hospital for burns, trauma, or disease of the central nervous system • Prolonged or complicated thoracoabdominal procedures or previous thoracic or abdominal surgery• Prolonged hospitalization• Exposure to potential bacteria from respiratory therapy devices and equipment and transmission ofpathogens by health care providers’ hands• Administration of therapeutic agents leading to central nervous system depression with decreasedventilation, impaired removal of secretions, or potential aspiration• Prolonged or inappropriate use of antibiotics• Supine positioning and aspiration• Endotracheal intubation• Use of nasogastric tubes

sheetcheat

already been diagnosed with it, but alsohelp you prevent other patients from de-veloping it. Now that’s essentially goodnews! n

Learn more about itAmerican Thoracic Society. Guidelines for the manage-ment of adults with hospital-acquired, ventilator-associ-ated, and healthcare-associated pneumonia. http://www.thoracic.org/sections/publications/statements/pages/mtpi/guide1-29.html. Accessed May 20, 2008.

Centers for Disease Control and Prevention. Guidelinesfor preventing healthcare-associated pneumonia. http://www.cdc.gov/ncidod/dhqp/gl_hcpneumonia.html. Ac-cessed May 20, 2008.

Centers for Disease Control and Prevention. Overview ofpneumonia in healthcare settings. http://www.cdc.gov/ncidod/dhqp/id_pneumonia.html. Accessed May 20, 2008.

Masterton R. The place of guidelines in hospital-acquiredpneumonia. Journal of Hospital Infection. 66(2):116-122, June2007.

Craven DE. What is healthcare associated pneumonia andhow should it be treated? Current Opinion in InfectiousDiseases. 19(2):153-160, April 2006.

Cason CL, et al. Nurses’ implementation of guidelines forventilator-associated pneumonia from the Centers forDisease Control and Prevention. American Journal of Criti-cal Care. 16(1):28-36, January 2007.

Pathophysiology Made Incredibly Visual! Philadelphia, Pa.,Lippincott Williams & Wilkins, 2008:61.

Pruitt B, Jacobs M. Best-practice interventions: How canyou prevent ventilator-associated pneumonia? Nurs-ing2006. 36(2):36-41, February 2006.

Respiratory Care Made Incredibly Easy! Philadelphia, Pa.,Lippincott Williams & Wilkins, 2005:151-157.

Smeltzer SC, et al. Brunner and Suddarth’s Textbook ofMedical-Surgical Nursing, 11th edition. Philadelphia, Pa.,Lippincott Williams & Wilkins, 2007:628-643.


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1. Which statistic about HAP is correct?a. HAP accounts for 30% of all hospital-acquired infections

(HAIs).b. HAP has the highest mortality rate of all HAIs.c. HAP is the most common HAI.

2. Which type of pneumonia involves the distal airways andthe alveoli?a. lobular pneumoniab. lobar pneumonia c. bronchopneumonia

3. Staphylococcal pneumonia accounts for up to a. 30% of HAP cases.b. 45% of HAP cases.c. 50% of HAP cases.

4. Which of the following is a risk factor for HAP?a. age older than 60b. hospital admission for heart failurec. gastric reflux

5. Which statement about length of stay (LOS) related toHAP is correct?a. LOS in the ICU may be prolonged up to 6 days.b. LOS in the ICU isn’t generally affected.c. LOS in the hospital is often prolonged by 2 weeks or more.

6. Clinical signs of pneumonia includea. persistent dyspnea at rest.b. temperature of 100o F (37.8o C). c. rhonchi or crackles on both inspiration and expiration.

7. Which assessment finding may indicate a worsening inthe patient’s respiratory status?a. decreased heart rateb. decreased activity tolerancec. decreased use of accessory muscles

8. Treatment for HAP will largely depend on thea. Clinical Pulmonary Infection Score.b. organism suspected of causing it.c. chest X-ray results.

9. An antibiogram includes all of the following excepta. recent antibiotic treatments.b. time from admission to acquisition of pneumonia. c. time to first dose of antibiotics.

10. According to current guidelines, which statement aboutantibiotic therapy is correct?a. Initial antibiotic therapy should be organism specific.b. Antibiotic therapy should be ordered for 7 to 14 days.c. Antibiotic therapy should last no longer than 8 days.

11. Which type of antibiotic should be started early?a. tetracyclineb. vancomycin c. broad-spectrum antibiotic

12. Which therapy is needed by all patients with HAP?a. adequate nutrition and fluid intakeb. supplemental oxygenc. analgesics

13. Which of the following is an effective prevention strategyfor HAP?a. Elevate the head bed between 60 and 90 degrees for all at-

risk patients. b. Perform or assist with appropriate oral hygiene. c. Use only parenteral nutrition for high-risk patients.

14. The American Thoracic Society guidelines recommendchecking the patient’s response to therapy after 2 or 3 daysusinga. the patient’s temperature.b. arterial blood gas values.c. a computed tomography scan.

15. Diagnostic cultures should be obtained from thea. nares.b. upper respiratory tract.c. lower respiratory tract.

16. Which preventive measures are geared specificallytoward the patient with adepressed cough reflex? a. Use strict hand hygiene. b. Encourage smoking cessation

and reduced alcohol intake.c. Frequently reposition and suc-

tion as needed.

17. Which organism is acommon cause of bac-teremia in pneumonia?a. Staphylococcus aureusb. Klebsiella pneumoniaec. Pseudomonas aeruginosa

The essentials of hospital-acquired pneumoniaGENERAL PURPOSE: To provide the professional nurse with an overview of hospital-acquired pneumonia (HAP). LEARNINGOBJECTIVES: After reading this article and taking the test, you should be able to: 1. Discuss the incidence and pathophysiology ofHAP. 2. Describe the risk factors and signs and symptoms of HAP. 3. Explain the treatment and prevention strategies for HAP.

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