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Public Health Nursing Practice Manual

Instructions for PHN TB Class 3/5 Assessment Form


Subjective (Cont.)


  • 5.

    Sexual History:

    • a.

      Contraception used – Condom, vasectomy, tubal ligation, BC pills, etc.

    • b.

      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.

    • c.

      Use “None” if client is of child bearing age but not using birth control method.

    • d.

      Use “Interested” if the client is not using a BC method but wishes info.

    • e.

      Comments: Male – Does self-breast and testicular exam? Female – Does self-breast exam? Other issues – i.e., Transgender, transvestite, etc.

    • f.

      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.

  • 6.


    • g.

      It is important to assess language proficiency to determine the need for an interpreter and to choose appropriate literature.

    • h.

      Use the comments section to elaborate on any problems elicited.

    • i.

      For primary care provider, list name, address and phone of provider in comments section.

    • j.

      Specify living situation / arrangement by checking the appropriate box.

    • k.

      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.

  • 7.

    Preventive Health Measures:

    • l.

      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.

    • m.

      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.

  • 8.


    • n.

      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


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