What are the appropriate discharge instructions for a 67-year-old male with rib fractures, including the use of an incentive spirometer?

Discharge Instructions for a 67-Year-Old Male with Rib Fractures

Incentive spirometry should be performed regularly (10 breaths every hour while awake) as it is a critical component of preventing pulmonary complications in elderly patients with rib fractures. 1, 2

Pain Management Instructions

1. First-line medication:

   • Regular acetaminophen (1 gram every 6 hours) 1
   • Take consistently, not just when pain is severe

2. Additional pain control options:

   • NSAIDs may be added with caution if pain persists
   • Prescribed opioids should be used at the lowest effective dose and for the shortest duration possible 1
   • Take pain medication 30 minutes before performing breathing exercises

Respiratory Care Instructions

1. Incentive spirometry:

   • Use the incentive spirometer 10 times every hour while awake
   • For each breath:
     • Sit upright if possible
     • Exhale normally
     • Place lips tightly around mouthpiece
     • Inhale slowly and deeply to raise the indicator as high as possible
     • Hold breath for 3-5 seconds
     • Remove mouthpiece and exhale normally
     • Rest for a few seconds between breaths

2. Deep breathing exercises:

   • Perform deep breathing exercises hourly when awake
   • Take slow, deep breaths, expanding the chest fully
   • Hold each breath for 3-5 seconds before exhaling

3. Coughing technique:

   • Support the injured area with a pillow or folded blanket
   • Take a deep breath and cough firmly but controlled
   • Perform this 2-3 times every few hours while awake

Activity Guidelines

1. Mobilization:

   • Get out of bed and walk at least 3-4 times daily 1, 3
   • Gradually increase activity as tolerated
   • Avoid prolonged bed rest as it increases risk of pneumonia

2. Positioning:

   • Sleep with head elevated 30-45 degrees if comfortable
   • Change positions every 2 hours while in bed
   • Avoid lying flat for prolonged periods

Warning Signs Requiring Medical Attention

Return to the emergency department immediately if you experience:

• Increasing shortness of breath or difficulty breathing
• Fever over 100.4°F (38°C)
• Increased pain not controlled by prescribed medications
• Coughing up yellow, green, or bloody sputum
• Confusion or disorientation

Follow-Up Instructions

• Schedule follow-up appointment within 2-3 weeks 1
• Continue incentive spirometry and breathing exercises until follow-up
• Bring your incentive spirometer to follow-up appointments

Important Considerations and Pitfalls

• Avoid rib belts or binders: Research shows they may increase complications including atelectasis and pleural effusions 4
• Pain control is critical: Inadequate pain management leads to shallow breathing and increased risk of pneumonia 3
• Spirometry performance, not pain level, predicts outcomes: Even if pain persists, continuing respiratory exercises is essential 5
• Early implementation of chest trauma protocols: Has been shown to significantly decrease adverse pulmonary events in older patients with rib fractures 2

The combination of adequate pain control, regular incentive spirometry, and early mobilization forms the cornerstone of successful management for elderly patients with rib fractures, significantly reducing the risk of pneumonia and respiratory failure.