Skill Assessment - Incentive Spirometry (IS)

Student Name:

Credentials:

Date:

Location:

Laboratory Simulation

Clinical Environment

Device:

Step	Pass	Unsatisfactory
Knowledge
States Contraindications and Relative Contraindications of procedure.
Preparation
Clinical Standards for Procedures and Interventions.
Verifies provider order or protocol; reviews chart for indications, goals, contraindications, and recent response to therapy.
Identifies and gathers required equipment: incentive spirometer (volume-oriented preferred), mouthpiece or mask, nose clips if indicated, pillow for splinting incision.
Assessment
Assesses Vital Signs.
Calculates pre-procedure inspiratory capacity and risk factors for postoperative atelectasis.
Implementation
Explains technique and demonstrates proper use; sets individualized volume goal.
Instructs patient to perform a slow, sustained maximal inspiration (SMI) with a 3 to 5 second inspiratory hold; repeats 10 breaths per hour while awake or as per protocol.
Encourages cough and splinting after sets to mobilize secretions.
Monitoring & Modifications
Monitors patient tolerance, work of breathing, and oxygenation/ventilation response during the intervention.
Adjusts technique/device settings per patient response; discontinues treatment and notifies provider if adverse reactions occur.
Encourages cough and assesses secretion clearance as indicated.
Post-Intervention
Post-Intervention Management Steps.

Student Signature

Complete all required fields, assessment responses, and both signatures before creating the PDF.

Assessment ID Created The unique identifier is included in the generated PDF report.