Article contributed by AAPACN Business Partner Limitlessli
By Mary-Beth Newell, RN, BSN, MS, SVP of Clinical Reimbursement
In skilled nursing facilities, the most effective clinical interventions are not always the most complex. Often, they are the ones that are appropriately assessed, clinically justified, and consistently documented. Incentive spirometry is one such intervention.
When used in the right clinical context, incentive spirometry supports respiratory function during recovery while reinforcing disciplined nursing assessment and documentation. When used reflexively or without reassessment, however, it can raise questions about medical necessity and skilled involvement.
This article explores incentive spirometry through a clinical and documentation lens, focusing on resident care, nursing judgment, and alignment with PDPM documentation expectations—without overstating outcomes or reimbursement impact.
Clinical Purpose of Incentive Spirometry in Skilled Nursing
Incentive spirometry is a respiratory intervention intended to promote deep, sustained inhalation. Its purpose is to support lung expansion and reduce the risk of complications such as atelectasis, particularly in individuals with reduced ventilation due to pain, immobility, or recent illness.
In the skilled nursing setting, incentive spirometry may be appropriate for residents who are recovering from:
- Surgical procedures
- Acute respiratory illness
- Periods of prolonged immobility or bedrest
Its clinical value depends on several factors, including:
- Resident-specific risk factors
- Cognitive and physical ability to follow instructions
- Ongoing assessment of effectiveness
Incentive spirometry is not appropriate for routine or blanket use. Orders should be supported by individualized assessment and revisited as the resident’s condition changes.
Resident-Centered Considerations
For residents with identified respiratory risk factors, incentive spirometry may help support respiratory function during recovery when incorporated into a broader, individualized plan of care.
Potential clinical considerations include:
- Supporting lung expansion during post-operative recovery
- Assisting residents with impaired ventilation related to pain or guarding
- Complementing mobility and therapy interventions by supporting respiratory endurance
It is important to note that incentive spirometry does not replace medical treatment for acute respiratory conditions and should not be used as a stand-alone intervention. Its role is adjunctive and time-limited, guided by reassessment.
Common Clinical Scenarios in Skilled Nursing
Incentive spirometry is most effective when applied thoughtfully to specific clinical situations. The following examples illustrate how nursing judgment guides appropriate use.
Scenario 1: Post-Operative Orthopedic Admission
A resident is admitted to a skilled nursing facility following hip fracture repair. On admission, the resident demonstrates limited mobility, incisional pain, and shallow respirations related to guarding.
In this scenario, incentive spirometry may be clinically appropriate as part of a short-term respiratory support strategy. Nursing assessment should focus on:
- Respiratory effort and depth
- Pain control and timing of interventions
- Ability to follow instructions and perform the technique
As pain decreases and mobility improves, ongoing reassessment is necessary to determine whether continued use remains appropriate.
Scenario 2: Recovery Phase Following Pneumonia
A resident admitted after hospitalization for pneumonia presents with reduced endurance and diminished breath sounds but is clinically stable.
In this case, incentive spirometry may be used during the recovery phase to support lung expansion. Nursing documentation should reflect:
- The rationale for use during recovery
- Monitoring of tolerance and effectiveness
- Reassessment as respiratory status stabilizes
If the resident demonstrates improved ventilation and no longer requires respiratory support, discontinuation may be clinically appropriate.
Scenario 3: Prolonged Immobility With Functional Decline
A resident with limited mobility following an acute illness has spent several days on bedrest and exhibits decreased respiratory effort.
Incentive spirometry may be considered if the resident can participate meaningfully. Nursing involvement includes instruction, cueing, and monitoring for fatigue or distress. If the resident cannot perform the intervention effectively despite support, discontinuation should be considered and documented.
Nursing Judgment and Medical Necessity
From a nursing perspective, incentive spirometry represents a skilled intervention only when medical necessity is clearly established and reassessed.
Clinically appropriate use may include residents who:
- Are newly admitted or readmitted following surgery or acute illness
- Are recovering from pneumonia or respiratory infection
- Experience impaired ventilation due to pain, immobility, or prolonged bedrest
- Are assessed to be at risk for atelectasis
Incentive spirometry may not be appropriate when residents:
- Are unable to follow instructions despite repeated cueing
- Demonstrate no therapeutic benefit upon reassessment
- Receive the intervention without identified respiratory risk
Sound nursing judgment includes not only initiation, but also timely reassessment and discontinuation when appropriate.
Care Planning and Skilled Nursing Interventions
When incentive spirometry is incorporated into the plan of care, nursing documentation should reflect assessment, instruction, monitoring, and reassessment.
Care plans may address:
- Risk for impaired respiratory function
- Post-operative status or effects of anesthesia
- Pain-related limitations to deep breathing
- Reduced mobility contributing to respiratory risk
Skilled nursing interventions often include:
- Instructing and cueing residents on proper technique
- Positioning residents upright during use
- Coordinating IS sessions with pain management
- Encouraging coughing and deep breathing following sessions
- Monitoring tolerance, including dizziness or shortness of breath
For residents with cognitive impairment, skilled involvement may include simplified instructions, visual demonstration, and ongoing evaluation of the resident’s ability to participate effectively.
The Importance of Reassessment
Reassessment is a critical component of skilled nursing care. Incentive spirometry orders should not continue indefinitely without evaluation of ongoing benefit.
Reassessment considerations may include:
- Improved respiratory depth or effort
- Increased mobility or functional endurance
- Improved pain control
- Resident fatigue, intolerance, or inability to participate
Discontinuation of incentive spirometry, when clinically appropriate, reflects sound nursing judgment and should be documented clearly. This documentation is as important as documentation supporting initiation.
Documentation Considerations Under PDPM
Incentive spirometry documentation should support clinical appropriateness and skilled nursing involvement, rather than frequency or volume alone.
Clear documentation often includes:
- Resident education and return demonstration
- Positioning and technique used
- Breath-hold duration and volumes achieved
- Resident tolerance or adverse responses
- Clinical rationale for continuation or discontinuation
Documentation Examples in Practice
Rather than generic statements such as “incentive spirometry completed as ordered,” documentation should reflect skilled involvement.
Examples include:
Education provided on incentive spirometry purpose and technique. Resident demonstrated correct use with return demonstration. Achieved 1,250 mL × 10 breaths. Tolerated well with no dizziness or shortness of breath.
Resident requires verbal reminders and demonstration to use incentive spirometer correctly. Able to follow simple instructions and complete session with staff cueing. Achieved 900–1,000 mL. Continued incentive spirometry indicated due to post-operative status and limited mobility.
Resident unable to follow instructions for incentive spirometry despite repeated cueing and demonstration. No effective inspiratory effort noted. Provider notified. Incentive spirometry discontinued as resident unable to benefit therapeutically.
This level of documentation reflects assessment, skilled intervention, and clinical reasoning.
Survey and Audit Considerations
During audits, reviews, or surveys, incentive spirometry is evaluated not only based on clinical rationale and documentation consistency, but also on staff competency and training.
Surveyors may ask facilities to demonstrate that licensed nursing staff performing respiratory-related interventions are competent to do so. This includes both initial competency validation and ongoing or annual competency review.
Surveyors may look for evidence of:
- Initial competency validation at orientation
- Ongoing or annual competency review
- Task-specific skills checklists or competency forms
- Documentation that staff performing respiratory interventions have demonstrated proficiency
Facilities may be at risk for citation if a nurse is performing respiratory therapy–related services without documented competency or training.
Suggested Competency Areas for Licensed Nursing Staff
Facilities may consider including the following respiratory-related skills in orientation and annual competency programs:
- Oxygen administration and safety
- Nebulizer treatment setup and monitoring
- Tracheostomy care and suctioning (if applicable)
- Pulse oximetry use and interpretation
- Incentive spirometry instruction and monitoring
- Identification and assessment of breath sounds
These competencies may be validated during:
- Licensed nurse orientation
- Task-specific skills checkoffs
- Annual skills fairs or competency reviews
Incorporating respiratory skills competency validation helps support safe care delivery and demonstrates regulatory preparedness during survey review.
Supporting Alignment Between Care and Documentation
Facilities benefit when clinical care, assessment findings, and documentation tell a consistent story. Incentive spirometry serves as a useful example of how targeted interventions, when guided by clinical judgment, support documentation integrity.
PDPM accuracy is best supported by:
- Individualized care planning
- Ongoing reassessment
- Documentation that reflects clinical reasoning rather than routine task completion
Incentive spirometry does not independently determine PDPM classification. Instead, it contributes to an accurate clinical picture when medically necessary and properly documented.
Conclusion
Incentive spirometry, when used appropriately, supports resident care while reinforcing disciplined nursing practice and documentation integrity. Its value lies not in routine use, but in clinical judgment, ongoing assessment, and accurate documentation.
By approaching incentive spirometry as a targeted, reassessed intervention rather than a default order, skilled nursing facilities can support resident safety, nursing accountability, and accurate representation of care under PDPM.
Copyright © 2026 Limitlessli. All rights reserved. This article is based on clinical education presented during the Panacea Education Call led by Mary-Beth Newell, RN, BSN, MS, Senior Vice President of Clinical Reimbursement.