Skill 6-1

Teaching Deep-Breathing Exercises, Coughing, and Splinting

During surgery, the cough reflex is suppressed, mucus accumulates in the tracheobronchial passages, and the lungs do not ventilate fully. After surgery, respirations are often less effective as a result of anesthesia, pain medication, and decreased respiratory effort because of incisional, particularly thoracic and high abdominal incisions, or other pain. Alveoli do not inflate or may collapse. Along with retained secretions, this increases the risk for atelectasis and respiratory infection.

Deep-breathing exercises hyperventilate the alveoli and prevent them from collapsing again, improve lung expansion and volume, help to expel anesthetic gases and mucus, and facilitate tissue oxygenation (Hess et al., 2021; Hinkle et al., 2022). Coughing, which helps to remove mucus from the respiratory tract, usually is taught in conjunction with deep breathing. Because coughing is often painful for the patient with a thoracic or abdominal incision, it is important to teach the patient how to splint the incision when coughing. This technique provides support to the incision and helps reduce pain during coughing, deep breathing, and movement (Milotte et al., 2018). Some facilities have implemented the I COUGH program to reduce postoperative pulmonary complications (Boston Medical Center and Boston University School of Medicine, n.d.; Cassidy et al., 2013, 2020; Lumb, 2019). This multidisciplinary pulmonary care program is outlined in Box 6-1.

Delegation Considerations

Preoperative assessment and teaching are not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, preoperative teaching may be delegated to licensed practical/vocational nurses (LPN/LVNs) after an assessment of education needs by the registered nurse. 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

Small pillow or folded bath blanket
PPE, as indicated

Assessment

Identify patients who are considered at greater risk for respiratory complications after surgery, such as the very young and very old; obese or malnourished patients; patients with fluid and electrolyte imbalances; patients with chronic disease; patients who have underlying lung or cardiac disease; patients who have decreased mobility; and patients who are at risk for decreased engagement with postoperative activities, such as those with alterations in cognitive function (Hinkle et al., 2022). Depending on the particular at-risk patient, specific assessments and interventions may be warranted. Assess the patient's current level of knowledge regarding deep breathing, coughing, and splinting.

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:

Knowledge deficiency
Altered breathing pattern
Impaired mobility

Outcome Identification and Planning

The expected outcomes to achieve when teaching deep breathing, coughing, and splinting of an incision are that the patient verbalizes an understanding of the instructions and is able to accurately demonstrate the activities.

Implementation

Action	Rationale
1. Check the patient's health record for the type of surgery and review the prescribed interventions. Gather the necessary supplies.	This check ensures that the care will be provided for the right patient and any specific teaching based on the type of surgery will be addressed. Preparation promotes efficient time management and 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. Close the curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Place necessary supplies on the bedside stand, overbed table, or other surface within easy reach.	Closing the curtains and door ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. 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. Identify the patient's learning needs and the patient's level of knowledge regarding deep-breathing exercises, coughing, and splinting of the incision. If the patient has had surgery before, ask about this experience.	Identification of baseline knowledge contributes to individualized teaching. Previous surgical experience may impact preoperative/postoperative care positively or negatively, depending on this experience.
6. Explain the rationale for performing deep-breathing exercises, coughing, and splinting of the incision.	Explanation facilitates patient engagement. An understanding of the rationale may contribute to increased engagement.
7. Teach the patient how to perform deep-breathing exercises and explain their importance.	Deep-breathing exercises improve lung expansion and volume, help expel anesthetic gases and mucus from the airway, and facilitate the oxygenation of body tissues.
a. Assist or ask the patient to sit up (semi- or high-Fowler's position) (Figure 1), with the neck and shoulders supported. Ask the patient to place the palms of both hands along the lower anterior rib cage.	The upright position promotes chest expansion and lessens exertion of the abdominal muscles. Positioning the hands on the rib cage allows the patient to feel the chest rise and the lungs expand as the diaphragm descends.
b. Ask the patient to exhale gently and completely.
c. Instruct the patient to breathe in through the nose as deeply as possible and hold breath for 3 to 5 seconds.	Deep inhalation promotes lung expansion.
d. Instruct the patient to exhale through the mouth, pursing the lips like when whistling.
e. Have the patient practice the breathing exercise three times. Instruct the patient that this exercise should be performed every 1 to 2 hours for the first 24 hours after surgery, and every 2 hours thereafter (Cassidy et al., 2020), depending on risk factors and pulmonary status.	Return demonstration ensures that the patient is able to perform the exercises properly. Practice promotes effectiveness and engagement.
8. Provide teaching regarding coughing and splinting.	Coughing helps remove retained mucus from the respiratory tract. Splinting minimizes pain while coughing or moving.
a. Ask the patient to sit up (semi-Fowler's position), leaning forward. Apply a folded bath blanket or small pillow against the part of the body where the incision will be (e.g., abdomen or chest) (Figure 2).	These interventions aim to decrease discomfort while coughing.
b. Ask the patient to inhale deeply and slowly through the nose and exhale through the mouth three times.
c. Ask the patient to take a deep breath and hold it for 3 seconds (Figure 3) and then cough out three short times (Figure 4).
d. Ask the patient to take a deep breath through the mouth and strongly and deeply cough again one or two times.
e. Ask the patient to take another deep breath, then relax and breathe normally.
f. Instruct the patient that they should perform these actions every 2 hours when awake after surgery (Cassidy et al., 2020; Hinkle et al., 2022).
9. Validate the patient's understanding of the information. Ask the patient to give a return demonstration. Ask the patient if they have any questions. Encourage the patient to practice the activities and ask questions, if necessary.	Validation facilitates patient's understanding of information and performance of activities.
10. Remove PPE, if used. Perform hand hygiene.	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 verbalized an understanding of the instructions related to deep breathing, coughing, and splinting and has accurately demonstrated the activities.

Documentation

Guidelines

Document the components of teaching related to deep-breathing exercises, coughing, and splinting that were reviewed with the patient and family/caregivers, if present. Record the patient's ability to demonstrate deep-breathing exercises, coughing, and splinting and their response to the teaching; note if any follow-up instruction needs to be performed.

Sample Documentation

4/2/25

1030 Perioperative teaching points related to deep breathing, coughing, and splinting reviewed with patient and his wife, including the rationale for each of these points. Patient verbalized an understanding of the rationale for the activities. Patient demonstrated proper technique for deep breathing, coughing, and splinting. Patient stated that he was anxious about the surgery because this will be his first time to the OR. Emotional support and reassurance were provided.

—J. Lance, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient verbalizes concern about being able to remember steps for deep breathing and coughing: Discuss with the patient why they feel this way. Offer encouragement and support. Reinforce that nurses will assist the patient with postoperative activities and reinforce the required actions. Provide written instructions as necessary to reinforce material.

Special Considerations

General Considerations

Respiratory disorders, such as pneumonia, bronchitis, asthma, and chronic obstructive pulmonary diseases increase the risk for respiratory depression from anesthesia as well as postoperative pneumonia and atelectasis (Hinkle et al., 2022).

Infant and Child Considerations

Deep breathing and coughing can be accomplished through play such as blowing bubbles or a whistle to enhance a child's participation (Kyle & Carman, 2017).

EVIDENCE FOR PRACTICE

Reducing Postoperative Pulmonary Complications

A wide variety of factors increase the risk of postoperative complications. Potential respiratory complications include pulmonary embolus, atelectasis, and pneumonia. It is important to implement ongoing postoperative interventions to decrease the risk for postoperative complications.

Related Evidence

Cassidy, M. R., Rosenkranz, P., Macht, R. D., Talutis, S., & McAneny, D. (2020). The I COUGH Multidisciplinary Perioperative Pulmonary Care Program: One decade of experience. The Joint Commission Journal on Quality and patient Safety, 46(5), 241-249. https://doi.org/10.1016/j.jcjq.2020.01.005

This study aimed to identify a long-term perspective of the implementation of a standardized postoperative program to improve care, including special challenges and factors involved in sustaining success. A multidisciplinary team developed and implemented a strategy based on comprehensive patient and family/caregiver education and a set of standardized electronic prescribed interventions to specify early postoperative mobilization and pulmonary care to reduce postoperative pulmonary complications. The I COUGH program emphasizes Incentive spirometry, Coughing and deep breathing, Oral care (brushing teeth and using mouthwash twice a day), Understanding (patient and family/caregiver education), Getting out of bed (at least three times a day), and Head-of-bed elevation. The I COUGH program was implemented for all patients undergoing general or vascular surgery. This before-after study audited clinical practices and compared them to actual and risk-adjusted pulmonary outcomes. Results revealed improvements in compliance with the I COUGH elements were initially promising, but baseline behaviors eventually returned. Adverse outcomes were inversely correlated with adherence to the program in “sawtooth” patterns. Coordinated efforts and interventions to rededicate to the use of the I COUGH program were effective and resulted in improved patient outcomes. Compliance with getting patients out of bed was initially 20%, improved to 69% after implementation, returned to baseline 2 years after implementation (29%) and increased to 60% after rededication. Availability of incentive spirometry initially increased from 53% to 77% after I COUGH, dropped to 41% two years later, but improved to 94% with redirection to the program. Immediately after introduction of I COUGH, the incidence of postoperative pneumonia decreased from 3% (preimplementation) to 1.8% but climbed to 2.2% before improving and dropping to 0.4% with rejuvenated program implementation. The incidence of unplanned intubations was 2.3% before initial implementation of I COUGH and declined to 1.4% after its introduction, rebounded to 1.8% two years later, and improved to 0% after renewed efforts to implement the program.

The researchers concluded the I COUGH program reduces postoperative pulmonary complications within institutional culture is optimized around adherence to its principles. The success and sustainability of the I COUGH program depends on the commitment and interaction of dedicated stakeholders, financial support, human resources, and a supportive organizational environment. Momentum can be sustained by establishing a commitment to quality as an essential part of an institution's culture.

Relevance for Nursing Practice

Implementation of recommended postoperative interventions to prevent pulmonary complications is an important part of patient care. Basic postoperative patient care can favorably affect patient outcomes (Cassidy et al., 2013). Nurses must include preventative nursing interventions and patient education as part of the plan of care for patients undergoing surgical procedures.

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Skill 6-1

EVIDENCE FOR PRACTICE