Nursing care
Postoperative Atelectasis nursing care: what to assess and what to do first
Written and reviewed by Dana Whitfield, RN, MSN · 5 min read · Updated September 2026
Short answer
Postoperative atelectasis is collapse of alveoli from shallow breathing after surgery, and it is the commonest cause of fever on postoperative day one. The main treatment is prevention nobody carried out consistently: hourly incentive spirometry, early ambulation, and adequate pain control so the patient can actually take a deep breath.
The clinical picture
Atelectasis is collapse of alveolar units, most often affecting the lung bases after abdominal or thoracic surgery. General anaesthesia reduces functional residual capacity, incisional pain discourages deep breathing, and the patient who lies still and breathes shallowly simply does not expand the lower lobes. Secretions pool in the collapsed segments, and within 24 to 48 hours those areas become a nidus for infection if they are not reopened.
It typically presents on postoperative day one or two, before pneumonia or a wound infection has had time to develop, which makes the timing itself a diagnostic clue. Patients may report mild shortness of breath or a sense of not being able to take a full breath, and some are entirely asymptomatic aside from the fever, found only when the nurse listens to the chest.
Assessment: what to look for and in what order
Start with the vital signs trend. Atelectasis is the single most common cause of fever in the first 24 to 48 hours after surgery, so a low-grade temperature on postoperative day one should prompt a respiratory assessment before anything else, ahead of chasing a wound or line source that is far less likely this early. Tachypnoea and mild tachycardia often accompany the fever even when the patient denies feeling unwell.
Auscultate the bases first, since that is where collapse concentrates. Listen for diminished or absent breath sounds and fine crackles that may or may not clear with a cough. Check oxygen saturation, which can be normal or only mildly reduced in limited atelectasis, so a normal SpO2 does not rule it out. Ask the patient to take a deep breath and cough, and watch how far the chest actually expands and how shallow the effort is, since a guarded, splinted breath from pain is often the real finding behind the fever.
Immediate interventions
The core treatment is lung expansion, and the tool for it is the incentive spirometer that too often sits unused on the bedside table. Have the patient sit as upright as possible, seal the lips around the mouthpiece, and inhale slowly and deeply enough to raise and hold the piston or ball for 3 to 5 seconds, repeated 10 times every hour while awake. Coach through the first few attempts, because a rushed shallow breath on the device achieves nothing.
Pair spirometry with adequate analgesia, since pain is usually the reason the patient was not breathing deeply in the first place. Splinting the incision with a pillow while coughing reduces pain enough to allow an effective cough. Get the patient sitting up in bed or into a chair as soon as it is safe, and mobilise out of bed on schedule, because upright posture and movement reinflate the bases far better than lying flat. Humidified oxygen and chest physiotherapy may be added for more significant collapse.
Ongoing nursing management
Chart incentive spirometer use and volumes achieved each shift, not just whether the device was handed to the patient, and escalate if volumes are not trending upward over 24 to 48 hours. Reassess breath sounds at each set of vital signs so that persistent bibasilar crackles or a worsening fever curve is caught before it progresses to pneumonia.
Keep the pain regimen adjusted so analgesia does not become the barrier to deep breathing itself; oversedation defeats the purpose just as much as undertreated pain does. Continue scheduled ambulation, repositioning every two hours if the patient cannot yet walk, and encourage fluids to keep secretions thin enough to clear with coughing. Document the trajectory of the fever curve, since a temperature that resolves as spirometry volumes improve confirms the working diagnosis without further workup.
Patient and family education
Teach the incentive spirometer before surgery whenever possible, since a patient who already knows the technique uses it correctly and consistently afterward. Explain in plain terms that the fever they may develop on day one is very likely from small areas of lung not fully expanding, not from an infected wound, and that using the device hourly is the treatment, not an optional comfort measure.
Show family members how to remind and encourage the hourly schedule, since patients often skip it once the nurse leaves the room. Explain why sitting up and getting out of bed matters even when it hurts, and why splinting the incision with a pillow while coughing or laughing protects the wound rather than harming it. Set the expectation that the goal volume on the spirometer should be discussed with the nurse or physiotherapist and increased gradually as tolerated.
How this appears on the NCLEX
NCLEX questions commonly present a postoperative patient with a fever on day one and ask for the most likely cause; the correct answer is atelectasis, not a urinary or wound infection, which the classic mnemonic for postoperative fever causes places later in the timeline. Distractor options that jump to antibiotics or wound cultures on day one are testing whether you know this timing pattern.
Priority and intervention questions ask what the nurse should do first for a febrile postoperative patient with diminished basilar breath sounds, and the expected answer is incentive spirometry, deep breathing and coughing, and ambulation, not an immediate call to the physician for imaging. You may also see delegation items asking whether spirometer coaching can be assigned to unlicensed staff, and the answer is no, because it requires ongoing nursing assessment of technique and effort.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our med-surg practice questions are the closest set to what this page covers.
One question from the med-surg set
A client with chronic obstructive pulmonary disease has an oxygen saturation of 88% on 2 L/min via nasal cannula and is alert with no distress. What should the nurse do first?
Rationale
In COPD a saturation of 88–92% is the therapeutic target, not an emergency, and this client is alert with no distress. The first action is the independent nursing intervention that is least invasive and most likely to help: sit them up and reassess. Turning the oxygen up to 6 L/min risks blunting the hypoxic drive, and calling rapid response or drawing an ABG escalates ahead of an assessment you have not finished.
Answer: B
Common questions
What is the most common cause of fever on postoperative day one?
Atelectasis is the most common cause of fever in the first 24 to 48 hours after surgery. It results from collapsed alveoli at the lung bases from shallow breathing and reduced lung expansion under anaesthesia and pain.
How often should a patient use an incentive spirometer after surgery?
Most protocols call for 10 breaths through the device every hour while awake, with each breath held for 3 to 5 seconds at peak inhalation. Consistent, coached use is what prevents and treats atelectasis, not occasional use.
What are the signs of atelectasis on assessment?
Diminished or absent breath sounds and fine crackles at the lung bases, a low-grade fever, mild tachypnoea, and sometimes mild oxygen desaturation. Patients may also show a shallow, guarded breathing pattern from incisional pain.
Can atelectasis lead to pneumonia if untreated?
Yes, secretions pooling in collapsed alveoli create an environment where bacteria can proliferate, and untreated atelectasis can progress to pneumonia over the following days. Early spirometry, ambulation and adequate analgesia are what prevent that progression.
Why does pain control matter for preventing atelectasis?
Poorly controlled incisional pain makes patients splint their breathing and avoid deep breaths or coughing, which is exactly what allows the lung bases to collapse. Adequate analgesia, without oversedation, allows effective use of the incentive spirometer and an effective cough.
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