32 RESPIRATORY MANAGEMENT FOLLOWING SPINAL CORD INJURY V . All oxygen orders or changes in therapy are recorded in the physician’s orders. A. A bedside spirometry may be done with the physician’s approval. B. The physician should be contacted for further direction in treating patients who show no response to therapy or improvement in clinical status within 48 hours. II. Medication Nebulizers—Inhaled medications delivered by nebulizer. M E D I C AT I O N U S E D 1. Albuterol 0.5cc (2.5mg) solution with 2.5cc NaCI may be ordered by the therapist. 2. Patients using home nebulizer therapy may be ordered to receive the same medications as at home at the same prescribed dosage. 3. Other medications may be used upon orders from the ordering physician. I N D I C AT I O N S Other Respiratory Therapies That May Be Used I. Incentive Spirometer (IS)—Instruction and aiding of a patient to cough and deep breathe providing a means of measuring volume displaced. 1. Postoperative patients who are unable or unwilling to take a deep breath because of pain. 2. Postoperative patients with documented acute or chronic lung disease. 3. A temperature of 38 degrees C (100.4 degrees F) or greater in a patient who is unable or unwilling to take a deep breath unassisted. 4. Breath sounds are decreased, possibly indicating a postoperative atelectasis. 5. Patient has radiolotic confirmation of atelectasis. 6. Other conditions that prevent deep inspiration. GOALS 1. Bronchospasm as evidenced by wheezing. 2. For subjective or objective improvement of airway obstruction as documented by a pulmonary function test or recent diagnosis. 3. Patients having purulent secretions that they are unable to clear by coughing. GOALS I N D I C AT I O N S 1. Relieve bronchospasm. 2. Improve airway obstruction. 3. Mobilize secretions. DISCONTINUANCE 1. Bronchospasm is relieved as evidenced by clear breath sounds. The therapist may continue the therapy on a prn basis for 24 hours to assess patient tolerance and then discontinue. 2. COPD patients may be discontinued 2–3 days before discharge if they are not on home therapy. 3. COPD patients may be changed to their home care level of therapy 2–3 days before going home. This may include changing a nebulizer to a metered dose inhaler. The patient’s physician should be contacted to ensure agreement. 4. Patient is able to clear secretions. 5. Pulmonary rehabilitation may be suggested to the physician if the therapist evaluates that the patient may benefit from home therapy and education. III. Intermittent Positive Pressure Breathing (IPPB)—Use of a mechanical device to deliver a positive pressure breath upon triggering of the machine by the patient. M E D I C AT I O N S 1. Promote distribution of ventilation. 2. Promote improvement of VC to optimize coughing. 3. Prevent and treat postoperative atelectasis. DISCONTINUANCE 1. Patient achieves a minimum of 80% of the predicted inspiratory capacity according to nomograms for age and height. 2. Patient is able to do IS on his or her own and is motivated to continue treatment without direct supervision. 3. Patient’s temperature is <38 degrees C; patient is ambulating; breath sounds are clear; CXR is clear. See Medication Nebulizers