Public Health Nursing Practice Manual
Instructions for PHN TB Class 3/5 Assessment Form
1. The assessment is to be completed for all TB 3 and TB 5 clients placed on 2 or more TB drugs.
If the TB 5 client is not placed on TB medications (i.e. Alien Referral), use the PHN TB 3 or TB 5 Assessment form page 1 and the PHN Assessment form.
If the client becomes a TB 3, complete the remaining pages of the PHN TB 3 or TB 5 Assessment form. Applicable information may be transferred from the PHN Assessment form.
The assessment may be completed during several client contacts according to priority of information needed. The form should be completed within 1-2 months of initial referral depending on client variables (i.e., accessibility, cooperation). If more time is needed, PHN should confer with PHNS.
Date and initial each entry as completed. Initial, print and sign name at the bottom of each page. More than one PHN may initial and sign.
The comment section at the bottom of each page is to be used as needed.
Imprint each page (bottom right) with the client’s addressograph.
The assessment is attached to the chart under the miscellaneous section and is to replace the progress notes in documenting the initial client assessment.
1. Presenting symptoms: Indicate onset/date and duration/frequency and characteristics on symptoms checked “yes”.
2. Medical History and Past TB History: If history of hepatitis/liver disease, specify type, i.e., Hepatitis A, B, C or type of liver disease. Review of Systems – Define the problem in the remarks, i.e., diabetes – IDDM or NIDDM well or poorly controlled; GI disease, i.e., gastric ulcers, Crohn’s Disease, ileostomy; respiratory, i.e., COPD, asthma, etc.
3. Dental: Define the problem requiring care, i.e., due for exam, poor dental hygiene/caries, denture problems, mouth odor, etc.
4. Nutritional Status: Weight changes – Complete information. (May refer back to symptom/ onset info) Appetite – Complete information. (May refer back to symptom/ onset info) Review basic food groups with the client. Comments on problems found.
© 2007 LAC DPH Public Health Nursing