Teaching a Patient to Use an Incentive Spirometer

Skill 14-3

Teaching a Patient to Use an Incentive Spirometer

Incentive spirometry provides visual reinforcement for deep breathing by the patient (Hess et al., 2021). It assists the patient to breathe slowly and deeply, and to sustain maximal inspiration (Eltorai et al., 2019), while providing immediate positive reinforcement. Use of an incentive spirometer encourages the patient to maximize lung inflation and prevent or reduce respiratory complications (Kotta & Ali, 2021). Evidence is conflicting in regard to the actual effectiveness of routine use of incentive spirometry, including routine postoperative use; deep breathing without mechanical aids may be as beneficial (Adams, 2018; Eltorai et al., 2018; Moore et al., 2018). Use of incentive spirometers is not recommended for routine use in postoperative care (Adams, 2018; Eltorai et al., 2018; Hess et al., 2021) but may be of more benefit in higher-risk patient populations (Kotta & Ali, 2021). If the use of incentive spirometry is prescribed for a patient, before use, the patient needs instructions on using the equipment properly. Validate the patient's correct use of this equipment in both health care and community-care environments.

Delegation Considerations

Patient teaching related to the use of an incentive spirometer is not delegated to assistive personnel (AP) or to licensed practical/vocational nurses (LPN/LVNs). Depending on the state's nurse practice act and the organization's policies and procedures, the LPN/LVN may reinforce and encourage the use of the incentive spirometer by the patient. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Incentive spirometer
Stethoscope
Folded blanket or pillow for splinting of chest or abdominal incision, if appropriate
PPE, as indicated

Assessment

Assess the patient for pain and administer pain medication, as prescribed, if deep breathing may cause pain. The presence of pain may interfere with learning and performing the required activities. Assess lung sounds before and after use to establish a baseline and to determine the effectiveness of incentive spirometry. Incentive spirometry encourages patients to take deep breaths, and lung sounds may be diminished before using the incentive spirometer. Assess vital signs and oxygen saturation to provide baseline data to evaluate patient response. Oxygen saturation may increase due to reinflation of alveoli. Assess the patient's understanding of the use of an incentive spirometer.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Impaired gas exchange
Altered breathing pattern
Knowledge deficiency

Outcome Identification and Planning

The expected outcome to achieve when teaching a patient to use an incentive spirometer is that the patient accurately demonstrates the procedure for using the spirometer. Other outcomes that may be appropriate include that the patient demonstrates increased oxygen saturation level, reports adequate control of pain during use; demonstrates increased lung expansion with clear breath sounds, and verbalizes an understanding of and engages in the plan of care.

Implementation

Action	Rationale
1. Review the patient's health record for any health problems that would affect their oxygenation status. Gather equipment.	Identifying influencing factors aids in interpretation of results. Assembling equipment provides for an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the overbed table or other surface within reach.	Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why. Using the chart provided with the device by the manufacturer, note the patient's inspiration target based on their height and age and/or volume of flow they generated preoperatively or prior to their change in health status (Hess et al., 2021).	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement with care. The target for inspiration is based on the patient's height and age and/or returning to preoperative/preprocedure volume (Hess et al., 2021) and provides an individualized target for each patient.
6. Assist the patient to an upright or semi-Fowler position, if possible. Remove any dentures present if they fit poorly. Assess the patient's level of pain. Administer pain medication, as prescribed, if needed. Wait the appropriate amount of time for the medication to take effect. If the patient has recently undergone abdominal or chest surgery, place a pillow or folded blanket over a chest or abdominal incision for splinting.	An upright position facilitates lung expansion. Dentures may inhibit the patient from taking deep breaths if the patient is concerned that dentures may fall out. Pain may decrease the patient's ability to take deep breaths. Deep breaths may cause the patient to cough. Splinting the incision supports the area and helps reduce pain from the incision (refer to Chapter 6, Skill 6-1).
7. Place the spirometer on a flat surface, like the overbed table, or have the patient hold it in an upright position. Have the patient hold the device steady with one hand and hold the mouthpiece with the other hand (Figure 1). If the patient cannot use their hands, assist the patient with the incentive spirometer.	This allows the patient to remain upright, visualize the volume of each breath, and stabilize the device.
8. Instruct the patient to exhale normally and then place their lips securely around the mouthpiece.	The patient should fully empty their lungs so that the maximum volume may be inhaled. A tight seal allows for maximum use of the device.
9. Instruct the patient not to breathe through the nose. Use a nose clip if necessary. Instruct the patient to inhale slowly and as deeply as possible through the mouthpiece without using their nose. Note the movement of the inhalation indicator on the spirometer.	Inhaling through the nose would provide an inaccurate measurement of inhalation volume. The inhalation indicator on the spirometer moves during inhalation, to gauge lung expansion.
10. When the patient cannot inhale anymore, the patient should hold their breath for 3 to 5 seconds (Hess et al., 2021). Check the position of the gauge to determine progress and level attained. If the patient begins to cough, splint an abdominal or chest incision.	Holding the breath for 3 to 5 seconds helps the alveoli to reexpand. The volume on the incentive spirometry should increase with practice.
11. Instruct the patient to remove their lips from the mouthpiece and exhale normally. If the patient becomes lightheaded during the process, tell them to stop and take a few normal breaths before resuming incentive spirometry.	Deep breaths may change the CO₂ level, leading to lightheadedness.
12. Encourage the patient to perform incentive spirometry 5 to 10 times every 1 to 2 hours, if possible.	This helps to reinflate the alveoli and prevent atelectasis due to hypoventilation.
13. Clean the mouthpiece with water and shake to dry. Remove PPE, if used. Perform hand hygiene.	Cleaning the equipment deters the spread of microorganisms and contaminants. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient has demonstrated the steps for use of the incentive spirometer correctly and exhibited clear lung sounds and equal in all lobes, has demonstrated an increase in oxygen saturation levels, has verbalized adequate pain control and an understanding of the plan of care, and has engaged in the plan of care.

Documentation

Guidelines

Document that the incentive spirometer was used by the patient, the number of repetitions, the average volume reached, length of time the breaths were held, and how many times the patient succeeded in meeting their volume goal (Hess et al., 2021). Document patient teaching and patient response, if appropriate. If the patient coughs, document whether the cough is productive or nonproductive. If productive cough is present, include the characteristics of the sputum, including consistency, amount, and color.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Volume inhaled is decreasing: Assess the patient's pain and anxiety level. The patient may have pain and not be inhaling fully, or they may have experienced pain previously during incentive spirometry and have an increased anxiety level. If prescribed, medicate the patient when pain is present. Discuss fears with the patient and encourage them to inhale fully or to strive to increase the volume by 100 each time incentive spirometry is performed.
Patient attempts to blow into incentive spirometer: Compare the incentive spirometer to a straw. Remind the patient to exhale before beginning each time.

Special Considerations

General Considerations

Incentive spirometers are not recommended for routine prophylactic use in postoperative adult and pediatric patients (Adams, 2018; Eltorai et al., 2018).
The use of an incentive spirometer is not a viable therapeutic option for the obtunded, confused, or uncooperative patient because it requires patient engagement and the ability to understand and demonstrate proper use of the device (Hess et al., 2021).

Older Adult Considerations

Older adults have decreased muscle function and fatigue more easily (Eliopoulos, 2018). Encourage rest periods between repetitions.

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Skill 14-3