NR 451 Week 2 Incentive Spirometer Problem Proposal Example

Incentive Spirometer Use After Open Abdominal Surgery: A Practice Problem Proposal

Student Name

College of Nursing, Chamberlain University

NR 451: RN Capstone Course

Instructor Name

Month Day, Year

Incentive Spirometer Use After Open Abdominal Surgery: A Practice Problem Proposal

The Problem as a Measurable Gap

On a composite 30-bed general surgical unit, adults recovering from open abdominal surgery are ordered to use an incentive spirometer ten times an hour while awake, but a two-week spot check of 40 patients on postoperative days one and two found that nurses documented spirometer use at least once per shift for 17 of them, and only 9 could demonstrate correct technique when asked. The current state, then, is that fewer than half of these patients have any documented spirometer use each shift and about one in four can use the device correctly. The desired state is that at least 80 of every 100 patients have spirometer use documented every shift on postoperative days one through three and can demonstrate correct technique by the end of postoperative day one. The distance between those two states is the gap this project proposes to close.

The gap matters because of what it may contribute to. Postoperative pulmonary complications such as atelectasis and pneumonia are among the most common complications after abdominal surgery, and they lengthen stays and raise costs. The evidence that incentive spirometry by itself prevents these complications is limited; a Cochrane review found no clear benefit of incentive spirometry over other or no physiotherapy after upper abdominal surgery (do Nascimento Junior et al., 2014). The American Association for Respiratory Care (Restrepo et al., 2011) recommends incentive spirometry only together with deep breathing, directed coughing, early mobilization and adequate pain control, not alone. The problem this project addresses is therefore not that spirometers are missing, but that the unit orders a device and then neither teaches it nor pairs it with the rest of the lung expansion bundle.

Population and Setting, Defined

The population is adults aged 18 and older who have had an open abdominal operation through a midline or subcostal incision, including bowel resection, open cholecystectomy and exploratory laparotomy, and who are admitted to the unit for at least 48 hours afterward. Excluded are patients who are intubated or return to intensive care, patients who cannot follow two-step commands because of cognitive impairment or sedation, and patients having laparoscopic procedures, whose pulmonary risk is lower and whose stays are usually shorter. The setting is one 30-bed surgical unit staffed by registered nurses carrying five or six patients each and patient care technicians, with respiratory therapy available by consult but not assigned to the unit. On an average weekday the unit receives four to six patients who meet the definition.

Current Practice and Why It Persists

Current practice has a clear history. The spirometer arrives in the admission kit from the recovery room and is placed on the bedside table, often still in its wrapper. Teaching, when it happens, is a sentence at handoff from the recovery nurse or a line in the printed discharge packet, and patients who were given the device while drowsy from anesthesia often do not remember being shown how to use it. Nurses on the unit describe the device as the patient's job, and the electronic record has a single yes or no field for spirometer use that does not ask for a volume, so a check mark can mean anything from ten good breaths to a device that has never been touched.

Three conditions keep this practice in place. The order is written by the surgical team, so nurses see it as a medical task that has already been handled. Respiratory therapy is not assigned to the unit and sees surgical patients only on consult, so no discipline owns lung expansion by default. And the outcome nurses would notice, a patient developing pneumonia on day four, is rare enough on any one shift that the link to missed breathing exercises is never made. Each of these conditions is something a nurse-led routine could address without new staff or equipment.

Significance

Pulmonary complications after abdominal surgery are common and expensive, and lung expansion is one of the few things bedside nurses can influence hour by hour. The unit already pays for spirometers and already writes the order, so a practice that neither teaches nor documents the device wastes a resource while giving the appearance of prevention. Nursing documentation also matters for handoff: if the day nurse cannot see whether a patient used the spirometer overnight, the chance to intervene early with a patient who is splinting and breathing shallowly is lost.

The Proposed Change

The change is a nurse-led lung expansion routine that pairs the spirometer with the other elements recommended by Restrepo et al. (2011). On return from surgery, the admitting nurse will teach spirometer use with a splinting pillow and have the patient demonstrate it, then record the demonstration. At each hourly rounding visit while the patient is awake, the nurse or technician will prompt ten breaths, a directed cough with pillow splinting, and a check of pain, recording the volume achieved on a bedside card. Every shift, the nurse will document the highest volume and whether the patient needed coaching. Patients who cannot reach half of their predicted volume by the end of postoperative day one will prompt a respiratory therapy consult. The routine will be written into the existing surgical order set as a nursing task rather than as a physician order.

Scope and Feasibility

The project will not attempt to show that the routine reduces pneumonia or atelectasis. Those outcomes are too infrequent on one unit to change measurably in the weeks remaining, and the evidence above suggests the device alone may not change them. Instead, the project will measure whether the practice happens: the percentage of eligible patients with spirometer use documented every shift and the percentage who can demonstrate correct technique by the end of postoperative day one. Both can be collected by a weekly chart audit of ten patients and a short bedside check, which the student can do without special data access. The project will not change the surgical order set itself during the term; instead, it will pilot the bedside card and teaching script and bring results to the unit practice council.

The work fits the time available because it relies on supplies already stocked, a routine that fits into hourly rounding already in place, and an audit that takes about an hour a week. The main risk is staff time on busy shifts, which the pilot will measure directly by asking technicians how long the prompts take. Melnyk and Fineout-Overholt (2023) recommend beginning practice change with a pilot on one unit precisely so that feasibility can be tested before anything is scaled.

References

do Nascimento Junior, P., Módolo, N. S. P., Andrade, S., Guimarães, M. M. F., Braz, L. G., & El Dib, R. (2014). Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database of Systematic Reviews, 2014(2), Article CD006058. https://doi.org/10.1002/14651858.CD006058.pub3

Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-based practice in nursing and healthcare: A guide to best practice (5th ed.). Wolters Kluwer.

Restrepo, R. D., Wettstein, R., Wittnebel, L., & Tracy, M. (2011). Incentive spirometry: 2011. Respiratory Care, 56(10), 1600-1604. https://doi.org/10.4187/respcare.01471