Incentive Spirometry: Nursing Coaching, Steps & Safety
After major surgery, nurses are often the staff who turn a plastic incentive spirometer into a repeatable breath-training habit. This page focuses on how to coach sustained maximal inspiration, when to pair it with Fowler positioning and oxygen therapy, and how to spot hypoxia symptoms or chest pain that should halt the session—without treating the device as a stand-alone substitute for mobilisation or medical review.
On this page
Quick facts
Key takeaway
Treat incentive spirometry as feedback for a deep, slow inspiration, not a talisman. Your shift wins when the patient can reproduce the manoeuvre independently, you have tied it to chest physiotherapy or mobilisation where indicated, and you escalate early if shortness of breath, pulmonary embolism features, or refractory atelectasis on chest X-ray suggests the problem is not “weak effort” alone.
Procedure summary
| Field | Details |
|---|---|
| Procedure name | Incentive spirometry (IS) |
| Also known as | Deep breathing with volume or flow feedback; “sustained maximal inspiration” coaching with a bedside incentive device |
| Category | Respiratory nursing / perioperative lung expansion |
| Clinical purpose | Encourage repeated, controlled deep inspirations to support lung expansion, secretion movement when part of a broader plan, and patient confidence after surgery or immobility—within individualised orders. |
| Who performs | Registered nurses commonly coach and supervise; respiratory therapists or physiotherapists may set targets in many services. Work within local scope and competency. |
| Typical settings | Postoperative surgical wards, medical wards with hypoventilation risk, step-down areas, and selected high-dependency environments per policy. |
| Time | Institutional protocols may vary for frequency, set size, and rest intervals; align with the written order and physiotherapy or surgical plan. |
What is incentive spirometry?
Incentive spirometry uses a handheld device that gives the patient immediate feedback (commonly a rising ball or column, or a numeric volume) while they perform a slow, deep inhalation followed by a brief comfortable breath-hold and relaxed exhalation. It supports nursing care when the goal is to maintain inspiratory effort after operations that splint breathing, when patients fear opioid analgesia-related sedation, or when pneumonia risk is being mitigated through a multidisciplinary bundle rather than a single gadget.
It does not replace antibiotics, drainage procedures, bronchoscopy, or escalation when arterial blood gas results and clinical findings show worsening gas exchange. Always interpret the device alongside respiratory assessment trends.
Evidence context: bundles beat “device alone”
Respiratory care guidelines have increasingly emphasised that nonpharmacologic airway strategies should be individualised and that incentive spirometry should not be assumed helpful for every adult simply because they had surgery. Major reviews and professional guidance instead highlight early mobilisation, adequate analgesia, and selective secretion clearance when there is real retention—exactly the environment where nurses add value by coordinating care rather than ticking a device in isolation.
If the patient can already mobilise, cough effectively, and maintain comfortable tidal volumes, redirect your time toward turning and repositioning, bronchodilator timing if prescribed for wheezing, and escalation when cough becomes productive for sputum sampling. Use incentive spirometry where the team still expects inspiratory coaching with measurable feedback.
Common ordered indications (individualise)
| Clinical context | Nursing rationale |
|---|---|
| Upper abdominal or thoracic surgery pathways | Splinted breathing and pain can reduce inspiratory volume; coaching restores rhythm when combined with multimodal analgesia and mobilisation. |
| Prolonged bed rest with hypoventilation risk | Provides a concrete target for patients who struggle to self-judge “how deep is deep enough.” |
| Adjunct within a documented respiratory bundle | Supports compliance tracking when teams still mandate inspiratory targets alongside VTE pharmacoprophylaxis and early ambulation. |
| Patients who need visual feedback | Useful for anxiety, language barriers, or cognitive impairment where simple verbal cueing fails. |
Contraindications, precautions, and pause rules
Screening should precede every session. Institutional protocols may vary; when guidance conflicts with your bedside risk assessment, choose the safer option and seek timely medical or physiotherapy review.
- Known or suspected pneumothorax that is not definitively managed.
- Haemodynamic instability, uncontrolled arrhythmia, or acute coronary syndrome without clearance.
- Massive haemoptysis or inability to protect airway.
- Inability to follow instructions because of profound encephalopathy—address cause first.
- Recent oesophageal or airway surgery where team limits inspiratory force.
- Severe baseline COPD with air trapping—watch for dizziness and prolonged exhalation need.
- Large pleural effusions or significant abdominal distension limiting diaphragm excursion.
- Patients on high-flow oxygen who desaturate when the mask is removed—coordinate breaks with the treating team.
- Use single-patient devices when possible; clean reusable components per manufacturer and trust policy.
- Perform hand hygiene before and after; dispose of contaminated tissues safely.
- Apply transmission-based precautions for suspected or confirmed transmissible respiratory pathogens per local isolation policy.
Coaching sustained maximal inspiration (flow vs volume devices)
Devices differ: some emphasise inhaled volume, others a target inspiratory flow with a floating indicator. Read the manufacturer insert and your trust teaching aid once—then teach the same sequence every time so patients muscle-memory the habit.
Patient sees a column or numeric goal
- Coach a slow inspiration so the patient maximises recruited lung units rather than snapping to a false high reading.
- Use the prescribed target or “best personal best”; avoid inventing millilitre goals not documented in the chart.
- Reinforce brief breath-hold only if comfortable and approved for that patient.
Ball or disc stays in a window
- Explain that “chasing” the ball with a violent sniff causes dizziness and traps less air.
- Pair with nose clips only if policy recommends—many adults manage fine without.
- Alternate coached breaths with relaxed normal breathing to prevent hyperventilation.
Postoperative lines, splints, and oxygen breaks
Surgical patients may have PCA lines, catheters, or chest dressings that make sitting upright momentarily harder—yet upright positioning usually improves the manoeuvre. Coordinate with the team when nasal cannula oxygen must be removed for mouthpiece use; document lowest SpO₂ if continuous monitoring is available.
When secretion burden rises, escalate to the plan that includes airway suctioning for artificial airways or specialist clearance—not unlimited IS repetitions alone. Compare trends with pulmonary function testing history only as background for chronic disease, not as a ward monitoring substitute.
Equipment checklist
Pre-use checks
Incentive spirometry procedure steps
Verify the order and screen risk
Match the patient to the correct pathway, confirm there is no hard contraindication, and clarify target parameters with physiotherapy or medical staff if the chart is ambiguous.
Explain in plain language and demonstrate
Show the slow inspiration, optional gentle breath-hold, and passive exhalation. Emphasise stopping for dizziness, crushing chest pain, or intolerable breathlessness.
Position and splint the incision
Sit upright or high Fowler as tolerated; support the surgical site with a pillow during inspiration to reduce fear-driven splinting.
Seal the mouthpiece and exhale gently first
Ensure lips create a leak-free seal; some protocols coach exhalation into the device first—follow manufacturer and local teaching aids.
Coach the slow deep breath to target
Use calm pacing cues; avoid competitive “higher is better” messaging that triggers rapid shallow breaths or syncope.
Complete the ordered cycle and rest
Alternate coached breaths with relaxed breathing; offer antiemetics if ordered when repeated valsalva-like efforts trigger nausea.
Reapply oxygen, reassess, and document
Return oxygen, recheck vitals and comfort, reinforce independence for hourly practice, and chart outcomes before leaving the bedside.
Sequence at a glance
Monitoring, complications, and escalation
| Finding | Possible concern | Nursing action |
|---|---|---|
| Reproducible desaturation when off oxygen for the mouthpiece | Hypoventilation, mucus plug, evolving pulmonary complication | Shorten off-oxygen intervals, notify team, prepare for escalation tests such as ABG or imaging per protocol. |
| New pleuritic pain or unilateral leg swelling | Pulmonary embolism differential | Stop repetitive valsalva-like efforts, keep patient monitored, activate urgent medical review. |
| Dizziness, perioral tingling, carpopedal spasm | Hyperventilation or electrolyte disturbance | Pause coaching, slow breathing, check recent labs if available, escalate if persistent. |
| Inability to meet targets despite adequate analgesia | Retained secretions, atelectasis, fluid overload | Escalate to medical or physiotherapy review; consider adjuncts in the existing plan rather than unsupervised repetition. |
Activate emergency response for respiratory arrest, massive haemoptysis, suspected tension pneumothorax, or sudden cardiovascular collapse during coaching.
Documentation
“15:20 IS coaching per orthopaedic pathway: upright in bed, demonstrated slow inspiration to ordered target x5 with rests between efforts per protocol. SpO₂ 96% on RA pre, 94% during mouthpiece use, 97% post. Patient reported 3/10 incision pain after pre-emptive analgesia; no dizziness. Reinforced hourly independent use and early mobilisation with physiotherapy follow-up.”
- Date, time, credentials, and order or protocol reference.
- Device type, targets, number of coached cycles, and patient’s best effort.
- SpO₂ and oxygen delivery before, during, and after if applicable.
- Pain score, antiemetics, bronchodilators, or suction interventions linked to the session.
- Adverse events, notifications, and follow-up tasks.
Patient and family education
Clinical Judgment Practice
NCLEX-style clinical judgment practice — Splinting after upper abdominal surgery limits deep breaths—spirometry coaching scenarios for incentive spirometry, including a priority action, select-all-that-apply cue recognition, trend interpretation after intervention, and matrix escalation matching (recognise cues → analyse → prioritise → act → evaluate outcomes).
Unfolding case — surgical ward, day 1 post-op. Ms. Nguyen, 54, had open cholecystectomy 18 hours ago. She splints her right upper quadrant when coughing and reports incision pain 6/10. SpO2 94% on room air, respiratory rate 22, mild bibasal crackles. The respiratory plan orders incentive spirometry every hour while awake with a target of 1,250 mL per coached breath, plus early mobilisation and multimodal analgesia. A flow-oriented IS device is at the bedside.
Answer key & rationale
Frequently asked questions
Is incentive spirometry still used if guidelines question routine prophylaxis?
Many respiratory therapy sources caution against using incentive spirometry alone as a universal preventive measure. It can still be clinically useful when ordered as part of a bundle that includes mobilisation, adequate analgesia, and other airway strategies for patients at meaningful risk or with demonstrated poor inspiratory effort.
How is incentive spirometry different from simple deep breathing?
Incentive spirometry adds visual or numeric feedback so the patient can see whether each breath reaches an inspiratory target. The underlying physiological goal is still a sustained, controlled deep breath; some patients achieve similar effort without a device when well coached.
What symptoms mean I should stop coaching and escalate?
Stop for syncope or near-syncope, new or worsening pleuritic chest pain, sustained desaturation, massive haemoptysis, suspected pneumothorax, or signs of pulmonary embolism, and activate local emergency or rapid-response pathways per policy.
Can patients use incentive spirometry lying flat?
Upright or high Fowler positioning is usually easier for diaphragmatic excursion and reduces aspiration risk after abdominal or thoracic surgery. If flat positioning is unavoidable, modify technique with physiotherapy input and monitor tolerance closely.
How should nurses document a session?
Record time, order reference, pre- and post-session observations such as SpO₂ and pain scores, number of coached breaths or cycles, best target achieved if tracked, adverse events, and patient understanding.
Who is responsible for target volumes or frequency?
Targets and frequency should come from the surgical or respiratory plan, physiotherapy, or written protocol. Nurses coach to those parameters and escalate when goals are repeatedly missed or the patient cannot comply.
References
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Restrepo RD, Wettstein R, Wittnebel L, Tracy M. Incentive spirometry: 2011. Respir Care. AARC Clinical Practice Guideline.https://doi.org/10.4187/respcare.01471
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Strickland SL et al. AARC Clinical Practice Guideline: effectiveness of nonpharmacologic airway clearance therapies in hospitalized patients. Respir Care. 2013;58(12):2187–2208.https://rc.rcjournal.com/content/58/12/2187
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American Association for Respiratory Care (AARC). Clinical practice guidelines index.https://www.aarc.org/resource/clinical-practice-guidelines/
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The Royal Marsden Manual of Clinical Nursing Procedures — official procedures hub (RMM Online).https://www.rmmonline.co.uk/contents/procedures
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Cambridge University Hospitals NHS Foundation Trust. Patient information: incentive spirometer.https://www.cuh.nhs.uk/patient-information/incentive-spirometer/
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OpenStax. Clinical Nursing Skills (open educational resource).https://openstax.org/details/books/clinical-nursing-skills
Editorial standards & medical review
About the author: Sid A. Abdala Balal, RN, writes evidence-based nursing education focused on practical bedside skills, patient safety, and clinical decision support for nurses.
Medical review: This guide is reviewed by Dr. Adam Sayedi, MD, for clinical accuracy, clarity, and alignment with current nursing standards for incentive spirometry.
Policies: Medical Review Process · Editorial Policy · Correction Policy