Public Health Nursing Practice Manual
Instructions for PHN TB Class 3/5 Assessment Form
Discussion about contacts may lead to other questions depending on the individual client.
In the subjective section the information is given by the client. In the objective section, the information is obtained by site visit and evaluation which may be done by a PHN in another district.
School Exposure: (See #9 above)
Obtain as much information as possible re: the index client contacts using sections 9-10 as a guide.
Lab and X Ray – Studies:
If information is already listed on other forms/documents in the client’s medical record such as CMR, H290, H1365, H1397,hospital discharge summary, list the forms/documents on the line “see ____________”.
If the information cannot be found elsewhere in the record, check all appropriated boxes. Write in date and test results for TST, CXR, laboratory results and drug resistance / sensitivities.
Check appropriate box for DOT.
Initial Regimen: List names of medications the client was initially started on and the start date, dosage, route and frequency. Start date is the first date the client was prescribed TB medication from any source.
Current TB Regimen: List names of TB medications that the client is currently on including their start date, dosage, route, and frequency.
Number of Pills/Capsules On Hand: Count pills/capsules in each individual container and write number of pills/capsules in the # pills/caps on hand section. Use the comment section under “correct pill count” to assess and elaborate on any problem/incorrect count. List all other current medications and dosages (prescribed, street drugs, over-the-counter, herbal).
3. Physical: Physical Appearance: Cough: Affect:
Is client thin, obese, pale, ambulatory, amputee, etc? Is client coughing during visit? Characteristics of cough? Is client cooperative, friendly, hostile, confused, responds appropriately, receptive of visit, evasive?
© 2007 LAC DPH Public Health Nursing