Tehran University of Medical Sciences Nursing Practice Today 2383-1154 0 0 2026 07 13 4410 4410 EN Elham Saberi Noghabi Department of Community Health Nursing and Nursing Management, School of Nursing, Nursing Research Center, Gonabad University of Medical Sciences, Gonabad, Iran Fatemeh Mohammadzadeh Department of Epidemiology & Biostatistics, School of Health, Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran 2025 11 10 2026 07 04 Background & Aim: Post-discharge follow-up is essential to prevent exacerbation in patients with COPD. This study examined the impact of a 3-month nurse-led follow-up program on early symptom worsening and severe post-discharge outcomes. Methods & Materials: A single-center, parallel-group randomized clinical trial was conducted among 88 hospitalized COPD patients in Gonabad, Iran, in 2022. The intervention group received a structured nurse-led follow-up program for three months, including planned education, telephone-based symptom monitoring, and zone-based triage with referral when needed. The control group received usual post-discharge care without scheduled follow-up. Primary outcomes were the Modified Borg Dyspnea Scale and the COPD Assessment Test at baseline and three months. Secondary outcomes included unplanned emergency department visits, readmissions, and post-discharge physical complications. Data analysis was performed in SPSS 21.0 using the Chi-square test, Fisher’s exact test, ANCOVA, and paired t-test. Results: Modified Borg Dyspnea Scale and COPD Assessment Test scores decreased in the intervention group from 3.31 (SD=2.32) to 2.71 (SD=2.84) and 14.91 (SD=10.91) to 12.65 (SD=11.04), respectively, while they increased in control group from 4.08 (SD=2.56) to 4.43 (SD=2.72) and 16.27 (SD=11.22) to 18.36 (SD=11.70) (adjusted p=0.002 for both outcomes. Clinically meaningful improvement was more frequent in the intervention group for both Modified Borg Dyspnea Scale (p=0.013) and CAT (p=0.007). Physical complications were lower in the intervention group (25.6% vs 48.9%; p=0.024), but emergency department visits and readmissions did not differ significantly. Conclusion: A structured nurse-led follow-up program improved symptoms and reduced complications among patients with COPD. Its integration into transitional care is recommended to enhance recovery after hospitalization. https://npt.tums.ac.ir/index.php/npt/article/view/4410