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Public Health Nursing Practice Manual

1

Lab and X Ray Studies

see

OBJECTIVE _________________________________________________________________________

TST Date:

_________

negative

____

mm

positive

____

mm

not read

not done

previous TST

Chest x-ray:

date/location

____________________________________________________________

No CXR done

CXR result:

normal

abnormal/TB:

cavitary

non-cavitary

abnormal/ Not TB/ Other Pathology

MYCOBACTERIOLOGY

Date

Lab #

Specimen Type

Smear

Culture

Susceptibility studies:

done

not done

pending

Result:

susceptible to all first line TB drugs

resistant

TB drug resistance to:

________________________

date/specimen site/drug resistance identified:

_______________

HIV date: ____________

negative

positive

refused

not done

Liver function tests:

done

not d

one

pending

baseline results:

AST (sgot) ______

ALT (sgpt) _____

Other pertinent labs/diagnostic studies:

___________________________________________________________

None

2 Medications On TB DOT:

no yes

TB DRUGS

INITIAL REGIMEN/ DATE PRESCRIBED

CURRENT TB REGIMEN/

# PILLS/CAPS

CORRECT PILL

DATE BEGUN

ON HAND

COUNT/COMMENTS

Isoniazid Rifampin Rifamate Rifater Ethambutol Pyrazinamide Vitamin B6 All other current medications and dosages:

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

____________________________________________________________________

Comments/ Date:

____ Initial ____ Initial

______________________

Print Name/Title ______________________

Print Name/Title

_________________________ Signature/Title _________________________ Signature/Title

© 2007 LAC DPH Public Health Nursing

Date/ Initial

E 17

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