Diagnostics

Initial Evaluation.

Physical Examination. The medical team will start the assessment with a detailed review of
the symptoms and medical history. For example, factors such as whether triggers or bouts of
dyspnea occur can help distinguish COPD from similar conditions like asthma or allergies. The
healthcare provider will perform a thorough physical examination, which can identify signs of
COPD and its complications.

Vital Signs. The temperature, pulse, respiratory rate (breaths per minute), and blood pressure
will be measured. A respiratory rate above 12 to 20 breaths per minute is considered too high for
an adult and is a sign of respiratory distress or another serious illness like anemia.

Systemic Examination. The healthcare provider will observe for signs of respiratory distress.
Struggling to breathe and loud wheezing can indicate advanced lung disease. Advanced COPD
causes right heart failure, which can result in the prominence of the veins in the neck. The
practitioner will listen to the heart and lungs with a stethoscope. Lung sounds such as wheezing
can be indications of COPD or a lung infection. Extremities can show signs of advanced COPD.
Pale or bluish fingers or toes signal cyanosis, which is a sign of oxygen deprivation. And
swelling of the legs, ankles, or feet signals pulmonary hypertension and right heart failure (late-
stage complications of COPD).

Nursing Responsibilities
BEFORE
 Explain the purpose of the procedure to the patient.
DURING
 Establish rapport.
 Provide patient’s privacy.
 Position patient in a comfortable position.
AFTER
 Document pertinent findings on the patient’s chart.

Lung pulmonary function tests (Spirometry). These tests measure the amount of air that can
be inhaled and exhaled and whether the lungs deliver enough oxygen to the blood. During the
most common test, called spirometry, the patient blows into a large tube connected to a small
machine to measure how much air the lungs can hold and how fast they can blow the air out of
the lungs.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Position the patient comfortably (sit up straight).
● All equipment must be clean and a bacterial filter used for each patient to avoid cross-
contamination of equipment.
● Make sure that the patient does not take any bronchodilator medication for four hours.
● Instruct patient not to smoke, drink alcohol and eat a large meal at least four hours before
the test.
● Instruct patient not to wear tight clothing that makes it difficult for them to take a deep
breath.
● Instruct patient not to exercise heavily for at least 30 minutes before the test.

DURING
● Ensure the patient is wearing nose clips to prevent air leaks from the nose.
● Ask the patient to breathe in as fully as possible.
● Ensure they seal lips and teeth tightly around the mouthpiece.
● Make them blow out forcibly, as hard and as fast as possible until all air is expelled from
lungs.
● Patients are advised not to lean forward during the test.
● Check that an adequate trace has been achieved.
● Repeat the procedure at least twice until three acceptable and repeatable blows are
obtained. Maximum of 8 efforts.

AFTER
● Document the result of the procedure.

Lung Diffusion Test. The test is quick and harmless. Lung diffusion tests check for lung
damage by measuring how well the lungs exchange gases. During a lung diffusion test, a
person will inhale a small amount of air that contains a small amount of carbon monoxide and a
tracer gas — often methane or helium — then exhale into a tub. The doctor collects and tests
the exhaled air to see how much gas a person has breathed out. This shows how well the body
has absorbed the tracer gas. This test gives the doctor an idea of how much oxygen a person
breathes in and how well the gas exchange system is working.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Instruct patient to avoid using a bronchodilator or other inhaled medications prior to testing
● Instruct patient not to smoke, drink alcohol and not to eat a large meal for at least four hours.
● Instruct patient not to perform any vigorous exercise within 30 minutes of test.
● Instruct patient to wear loose, comfortable clothing.

DURING
● Have the patient hold the inhaled air for a count of 10 or so and quickly exhale the air
he/she is holding in his/her lungs.

AFTER
● Document the result of the procedure.

Bronchodilator Reversibility Test. This test combines spirometry with the use of a
bronchodilator, which is medicine to help open up your airways. For this test, the patient will
undergo a spirometry test to get a baseline measurement of how well the lungs are working.
Then, after about 15 minutes, the patient will take a dose of bronchodilator medication and
repeat the spirometry test. This screening is also helpful in monitoring people already diagnosed
with COPD, asthma, or both. Test results can help a doctor determine whether the current
bronchodilator therapy is working or if it needs to be adjusted.
Nursing Responsibilities:
BEFORE
● Explain the purpose of the test to the patient.
● Inquire and record the time of last bronchodilator inhaler use. Before the test, patient will be
instructed not to take his/her normal bronchodilator medicine.
● The patient should be in a comfortable state and, ideally, should have just emptied their
bladder because the procedure can result in urinary incontinence.
● The procedure should be performed while the patient is seated because standing increases
the risk of syncope.

DURING
● Patient will be asked to take a deep breath and then blow into the spirometer as hard as
he/she can. The spirometer records the results. This is called a baseline measurement.
● Give patient a dose of bronchodilator medicine using an inhaler or nebulizer.
● Patient will be asked to blow into the spirometer more than once. This is done to get the
best reading.

AFTER
● Document the result of the procedure.

Chest X-ray. A chest x-ray may not show COPD until it is severe, the images may show
enlarged lungs, air pockets (bullae) or a flattened diaphragm. A chest x-ray may also be used to
determine if another condition may be causing symptoms similar to COPD. A chest X-ray can
show emphysema, one of the main causes of COPD. An X-ray can also rule out other lung
problems or heart failure.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Remove all metallic objects. Items such as jewelry, pins, buttons, etc. can hinder the
visualization of the chest.
● Fasting or medication restriction is not needed unless directed by the health care provider.
● Ensure the patient is not pregnant or suspected to be pregnant. X-rays are usually not
recommended for pregnant women unless the benefit outweighs the risk of damage to the
mother and fetus.
● Assess the patient’s ability to hold his or her breath. Holding one’s breath after inhaling
enables the lungs and heart to be seen more clearly in the x-ray.
● Provide appropriate clothing. Patients are instructed to remove clothing from the waist up
and put on an X-ray gown to wear during the procedure.
● Coordinating care between radiology and other departments.

DURING
● Instruct patient to cooperate during the procedure. The patient is asked to remain still
because any movement will affect the clarity of the image.

AFTER
● Note that no special care is required following the procedure.
● Provide comfort. If the test is facilitated at the bedside, reposition the patient properly.
● Obtain result immediately and relay to the physician.
CT scan. Unlike a standard X-ray, which provides a flat, one-dimensional picture, CT scans
provide a series of X-ray images taken from different angles. It gives doctors a cross-section
look at the organs and other soft tissue. A CT scan gives a more detailed view than a regular X-
ray. It can be used to check for blood clots in the lungs, which a chest X-ray can’t do. A CT scan
can also pick up much smaller detail, identifying problems, like cancer, much earlier. A CT scan
of the lungs can help detect emphysema and help determine if it might benefit from surgery for
COPD. CT scans can also be used to screen for lung cancer.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Obtain informed consent before the procedure.
● If the patient has a history of allergy to contrast material (such as iodine or shellfish), the
requesting physician and radiology staff should be notified.
● Check BUN and Creatinine prior to a CT scan because IV contrast can be hard on the
kidneys and can put certain people into acute renal failure. A creatinine below a certain
level assures them that the kidneys can take the "contrast"
● Ask the patient about any recent illnesses or other medical conditions and current
medications being taken. The specific type of CT scan determines the need for an oral or
I.V. contrast medium.
● Check for NPO status. Instruct the patient to not to eat or drink for a period amount of time
especially if a contrast material will be used because the injection may cause stomach
upset.
● Remove any metal objects, such as a belt or jewelry, which might interfere with image
results.
● Assess for the presence of implanted metal devices such as aneurysm clips or a cardiac
pacemaker/defibrillator.
● Provide information about the contrast medium. Tell the patient that a mild transient pain
from the needle puncture and a flushed sensation from an I.V. contrast medium will be
experienced.
● Instruct the patient to wear comfortable, loose-fitting clothing during the exam.
● The patient is positioned on an adjustable table inside an encircling body scanner (gantry);
straps and pillows may be used to help in maintaining the correct position.

DURING
● Inform patients that they will be required to remain supine and still for a short period,
typically less than 30 minutes, while a body scanner surrounds them and takes multiple
images.
● Instruct paient to hold his/her breath during the scanning.

AFTER
● Patient is assessed carefully for adverse effects to the contrast medium.
● Instruct the patient to resume the usual diet and activities unless otherwise ordered.
● Encourage the patient to increase fluid intake (if a contrast is given). This is so to promote
excretion of the dye.

Electrocardiogram (ECG or EKG). To determine if the shortness of breath is being caused by

a heart condition as opposed to a lung problem. Over time, though, the breathing difficulties
associated with COPD can lead to cardiac complications, including abnormal heart rhythms,
heart failure, and heart attacks. An EKG measures the electrical activity in the heart and can
help diagnose a disturbance in your heart rhythm.

Nursing Responsibilities:
BEFORE
● Verify the order for the ECG in the client's chart.
● Provide privacy and explain the procedure to the patient.
● Tell who will perform the test, where it will take place, and that it’s safe, painless, and is
noninvasive.
● Advise the patient that he doesn’t need to restrict food and fluids for the test.
● Ensure to empty the bladder. Instruct patient to void prior and to change into a gown.
● Explain to the patient the need to lie still, relax, and breathe normally during the procedure.
● Note current cardiac drug therapy on the test request form as well as any other pertinent
clinical information, such as chest pain or pacemaker.
● Explain that the test is painless and takes 5 to 10 minutes.
● Explain the need to darkened the examination field.

DURING
● Place the patient in a supine or semi-Fowler’s position.
● Expose the chest, ankles, and wrists.
● Place electrodes on the inner aspect of the wrists, on the medical aspect of the lower legs,
and on the chest.
● After all electrodes are in place, connect the lead wires.
● Press the START button and input any required information.
● Make sure that all leads are represented in the tracing. If not, determine which electrode
has come loose, reattach it, and restart the tracing.
● All recording and other nearby electrical equipment should be properly grounded.
● Make sure that the electrodes are firmly attached.

AFTER
● Disconnect the equipment, remove the electrodes, and remove the gel with a moist cloth
towel.
● If the patient is having recurrent chest pain or if serial ECG’s are ordered, leave the
electrode patches in place.
● Inform the patient that the study will be interpreted by the physician. An official report will be
sent to the requesting physician, who will discuss the findings with the patient.
● Instruct patient to resume regular diet and activities. There is no special type of care given
following the test.

Fractional exhaled nitric oxide (FeNO) test. It measures the amount of nitric oxide that is
exhaled from a breath. Increased levels of nitric oxide are associated with swelling of lung
airways. FeNO is a marker of endogenous inflammation which can be used to monitor
inflammatory changes in the airway.

Nursing Responsibilities:
BEFORE
 Explain the purpose of the test to the patient.
 Instruct patient not to smoke, drink alcohol and eat a large meal before the test.
  Nitrate rich food, such as green leafy vegetables and beetroot, caffeine and alcohol can
also affect the result, so instruct patient not to eat or drink these for an hour or so before
the test.
 Instruct patient to wear loose, comfortable clothing.
 Instruct patient not to perform any vigorous exercise within 30 minutes of test.
DURING
 Instruct patient to breathe into a plastic mouthpiece or a cardboard tube attached to a
monitor. The monitor shows the reading on its screen.
 Instruct patient to breathe in deeply, with mouth open, and then breathe out little by little
until lungs are empty. The breath out will normally take 10 seconds in adults (6 seconds
in children).
AFTER
 Document the result of the procedure.

Sputum Examination. Analyzing the sputum can help identify the cause of breathing difficulties
and may help detect some lung cancers. If there is a bacterial infection, it can also be identified
and treated.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● The patient can rinse their mouth with water prior to the procedure, but avoid mouthwash or
toothpaste because these products can affect the microorganisms in the sample.
● Collect the specimen before patient begins antibiotic therapy.

DURING
● Obtain sputum samples in the early morning because secretions accumulate overnight.
● Instruct the client to take several deep breaths and then cough deeply to obtain sputum.

AFTER
● Transport the specimen immediately tp the laboratory.
● Assist the client with mouth care.

Laboratory tests. Lab tests aren't used to diagnose COPD, but they may be used to determine
the cause of the symptoms or rule out other conditions.

Arterial blood gas analysis. This blood test measures how well the lungs are bringing oxygen
into the blood and removing carbon dioxide. It can also determine the acidity (pH) of the blood.
Imbalances in the amount of oxygen, carbon dioxide, or pH can serve as a way to evaluate
respiratory diseases, kidney function, and the body’s metabolism (the process by which our
body converts food into energy that can be used right away or stored in the liver, muscles and
body fat). Results of the test can show the severity of COPD and whether a person needs
oxygen therapy. Patients with mild COPD have mild to moderate hypoxemia without
hypercapnia. As the disease progresses, hypoxemia worsens and hypercapnia may develop,
with the latter commonly being observed as the FEV1 falls below 1 L/s or 30% of the predicted
value. Lung mechanics and gas exchange worsen during acute exacerbations.
Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Prior to arterial puncture, Allen’s test should be done.
● Explain the arterial blood gas analysis evaluates how well the lungs are delivering the
oxygen to the blood and eliminating carbon dioxide.
● Tell the patient that the test requires a blood sample.
● Explain to the patient, who will perform the arterial puncture, when it will occur, and where
the puncture site will be; radial, brachial, or femoral artery.
● Inform the patient that he/she may not need to restrict food and fluids.

DURING
● Instruct the patient to breathe normally during the test and warn him that he may experience
a brief cramping or throbbing pain at the puncture site.

AFTER
● After applying pressure to the puncture site for 3 to 5 minutes and when bleeding has
stopped, tape a gauze pad firmly over it.
● If the puncture site is on the arm, don’t tape the entire circumference because this may
restrict circulation.
● If the patient is receiving anticoagulants or has a coagulonopathy, apply pressure to the
puncture site longer than 5 minutes if necessary.
● Monitor vital signs and observe for signs of circulatory impairment.
● Document the result of the procedure.

Complete blood count (CBC). A complete blood count (CBC) may alert the healthcare
provider if the patient has an infection. High levels of hemoglobin may suggest the body's
compensation for chronic hypoxemia related to COPD.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Explain that slight discomfort may be felt when the skin is punctured.
● Encourage to avoid stress if possible because altered physiologic status influences and
changes normal hematologic values.
● Explain that fasting is not necessary. However, fatty meals may alter some test results
because of lipidemia.

DURING
● Advise patient to feel relaxed as possible while blood is being drawn out.

AFTER
● After applying pressure to the puncture site for 3 to 5 minutes and when bleeding has
stopped, tape a gauze pad firmly over it.
● If the puncture site is on the arm, don’t tape the entire circumference because this may
restrict circulation.
● If the patient is receiving anticoagulants or has a coagulonopathy, apply pressure to the
puncture site longer than 5 minutes if necessary.
● Monitor the puncture site for oozing or hematoma formation.
● Document the result of the procedure.
Alpha-1-antitrypsin deficiency screening. AAT deficiency is a genetic condition that can lead
to COPD. This test may be done if the patient has a family history of COPD and develops it at a
young age. A patient might also have this blood test if they are diagnosed with COPD before
age 45. If the patient has a high risk of AAT deficiency, the World Health Organization (WHO)
recommends that the patient be tested for this disorder with this simple blood test.

Nursing Responsibilities:
BEFORE
● Explain the purpose of the procedure to the patient.
● Tell the patient that the test requires a blood sample and usually takes less than five
minutes.
● Inform the patient that he/she may not need to restrict food and fluids.

DURING
● Advise patient to feel relaxed as possible while blood is being drawn out.

AFTER
● Apply pressure on the punctured site.
● Document the result of the procedure.