Public Health Nursing Practice Manual
Instructions for PHN TB Class 3/5 Assessment Form
Contraception used – Condom, vasectomy, tubal ligation, BC pills, etc.
Use “N/A” if client is post-menopausal, has had hysterectomy, had permanent BC method such as tubal ligation or partner with vasectomy. Indicate in the blank space the applicable reason.
Use “None” if client is of child bearing age but not using birth control method.
Use “Interested” if the client is not using a BC method but wishes info.
Comments: Male – Does self-breast and testicular exam? Female – Does self-breast exam? Other issues – i.e., Transgender, transvestite, etc.
May go to “Preventive Health Measures” if appropriate (i.e. Discussion re: preventive measures have evolved during information gathering), to address sexual activities and safer sex practices.
It is important to assess language proficiency to determine the need for an interpreter and to choose appropriate literature.
Use the comments section to elaborate on any problems elicited.
For primary care provider, list name, address and phone of provider in comments section.
Specify living situation / arrangement by checking the appropriate box.
Length of time at current residence: If less than 6 months, list previous living arrangement, # living in home now, and in the past 6 months including frequent daytime, evening or overnight visitors in the past 2 to 4 months.
Preventive Health Measures:
This section is designed per the PHN Assessment Form. When completing the PHN Assessment Form, information about the index client can be obtained for inclusion on the PHN Assessment form.
The PHN may wish to address sexual activity and safer sex practices at this time from a preventive health approach. Use the comments section to elaborate on problems.
It is important to get feedback from the client regarding her/his understanding and acceptance of the diagnosis. It may take 2 or more visits before the client truly understands and accepts her/his TB diagnosis and is willing to adhere to the medical and nursing regimen.
© 2007 LAC DPH Public Health Nursing