Oxygenation: Respiratory : Deep Breathing, Splinting, and Coughing

Teaching Deep Breathing

Purpose

1. Facilitate respiratory functioning by increasing lung expansion and preventing alveolar collapse.
2. Encourage expectoration of mucus and secretions that accumulate in the airways after general anesthesia and immobility.

Assessment

• Assess client's risk factors for development of respiratory complications (e.g., general anesthesia, history of pulmonary disease or smoking, chest wall trauma, cold or respiratory infection within past week).
• Assess quality, rate, and depth of respiration.
• Auscultate breath sounds.
• Inspect placement of incision and evaluate whether or not it interferes with chest expansion.
• Evaluate client's physical ability to cooperate and perform pulmonary exercises:
  • Level of consciousness
  • Language or communication barriers
  • Ability to assume Fowler's position
  • Pain level (medicate as ordered)

Procedure

1. Assist client to Fowler's or sitting position.
   Rationale: Upright position allows increased diaphragmatic excursion secondary to downward shift of internal organs from gravity.
2. Have client place hands palm down, with middle fingers touching, along lower border of rib cage (Fig. 1).
   Rationale: This position allows client to feel movement of diaphragm, indicating a deep breath.


Fig. 1: Instruct client to place hands along lower ribcage to feel
diaphragm movement.

3. Ask client to inhale slowly through the nose, feeling middle fingers separate. Hold breath for 2 or 3 seconds (Fig. 2).
   Rationale: Inhaling through the nose allows air to be filtered, warmed, and humidified. Holding breath allows lungs to expand fully.


Fig. 2: Encourage client to inhale slowly and deeply through the
nose, holding breath for 2 to 3 seconds.

4. Have client exhale slowly through mouth (Fig. 3). Repeat three to five times.
   Rationale: Slow expulsion of air frequently initiates the coughing reflex, which facilitates expectoration of mucus and prevents hyperventilation.


Fig. 3: Instruct client to exhale slowly through the mouth.

5. Instruct, reinforce, and supervise deep-breathing exercises every two to three hours postoperatively.
   Rationale: Performing these exercises every two to three hours will facilitate pulminary ventilation and promote airway clearance without overtiring the client.
6. Document procedure.
   Rationale: Maintains legal record and communicates with healthcare team.

Sample Documentation
04/26/10	1700	Crackles and diminished breath sounds. Instruction on DB & C given, needs encouragement as respiration is shallow and has weak cough. Importance explained and wife is encouraged to remind him to perform hourly. Will get order for IS. S. Roberts, RN

Lifespan Considerations

Infants and Children

• Infants cannot cooperate with coughing and deep-breathing exercises, but crying is thought to hyperinflate the lungs.
• Young children learn through games and imitation. A preoperative game of "Simon Says" is one way to teach them lung exercises: "Simon says touch your nose," "Simon says stick out your toungue," "Simon says take a deep breath."

Collaboration and Delegation

• Unlicensed nursing personnel can remind and assist clients to deep breathe and cough. Identify clearly to such personnel those clients who need deep breathing to promote optimal pulmonary status.