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Public Health Nursing Practice Manual

ASSESSMENT

Date/ Initial

1TB 3 symptomatic for TB 5 (on TB Rx) Sites: __________________ asymptomatic for TB

Other TB 5 (deferred TB Rx, pending cultures)

2 Priority in PHN practice manual:

II

III

IV

V

VI

3 Risk of transmission: Home isolation indicated:

non

e

low no

high Due to: yes

AFB smear

CXR

if yes, instructions given

clinical symptoms

4

5On TB medications currently:

no

yes

On DOT

self-administered

deferred by clinician

6Liver function test results:

WNL

elevated

7Hx of latent TB infection (LTBI):

8Hx of treatment for LTBI:

no

no yes, date/location:

_ _ _ _ _ _ _ _ _ _ _ yes, date: ____________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ unknown

9Likelihood of adherence to TB regimen:

poor

questionable

good

10Barriers to adherence to TB regimen:

none

yes (list):

11Language or cultural barriers to care:

none

yes (list)

12Able to care for self:

no (explain below)

yes

13Living space/environment safe for client:

no (explain)

14Living space/environment safe for staff:

no (explain)

yes

yes

15Psychosocial situation :

stable

unstable (explain)

16Health Need/Goal:

Health Need/Goal:

Health Need/Goal:

Health Need/Goal:

Health Need/Goal:

Comments/ Date:

_____ Initials

______________________________ Print Name/ Title

___________________________ Signature/ Title

_____ Initials

______________________________ Print Name/ Title

___________________________ Signature/ Title

© 2007 LAC DPH Public Health Nursing

E 19

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