Oxygenation: Respiratory : Deep Breathing, Splinting, and Coughing

Teaching Splinting and Coughing

Purpose

1. Spinting: To minimize pain while moving and coughing.
2. Coughing: 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)

Equipment

• Pillows for positioning and to splint incision

Procedure

1. Assist client to Fowler's or sitting position.
   Rationale: Upright position allows increased diaphragmatic exursion secondary to downward shift of internal organs from gravity.
2. If adventitious breath sounds or sputum is present, have client take a deep breath, hold for 3 seconds, and cough deeply two or three times. Stand to the client's side to ensure the cough is not directed at you. Client must cough deeply, not just clear the throat.
   Rationale: Several consecutive coughs are more effective than one single cough at moving mucus up and out of the respiratory tract.
3. If the client has an abdominal or chest incision that will cause pain during coughing, instruct the client to hold a pillow firmly over the incision (splinting) when coughing (Figs. 1 and 2).
   Rationale: Coughing uses abdominal and accessory respiratory muscles, which may have been cut during surgery. Splinting supports the incision and surrounding tissues and reduces pain during coughing.


Fig. 1: Instruct client to hold pillow firmly over incision.



Fig. 2: Encourage client to splint with pillow during coughing to promote comfort.

4. Instruct, reinforce, and supervise deep-breathing and coughing exercises every 2 to 3 hours postoperatively.
   Rationale: Performing these exercises every 2 to 3 hours will facilitate pulmonary ventilation and promote airway clearance without overtiring the client.
5. 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 cough."

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 aggressive coughing to promote optimal pulmonary status.