TB-203_TB_Education-Counseling_Revised_12_06_2017v2.doc

Texas Department of State Health Services Tuberculosis Education/Counseling Record

Patient Name: ______________________________________________________ D.O.B.:______________________ Nurse Case Manager:________________________________________________ Instructions:

1. Provide appropriate Education/Counseling to ALL TB clients.

2. Each client must have an education/counseling plan based on individual assessment and need.

3. This tool serves as a guideline but education/counseling should not be limited to this information only.

4. Initial each box as education/counseling is performed.

5. The (Y) indicates when instruction should occur.

6. Standardized printed materials (in client’s preferred language, if available) are provided to client on the initial visit.

7. Staff providing client education must be familiar with reference information listed in the TB standing delegation orders.

Date(s):

Language used for education/counseling:

Interpreter Name:

Comments:

Initial each box as education/counseling is performed.

Initial Visit

RN CM

2 Mo

RN CM

3 Mo

RN CM

4 Mo

RN CM

5 Mo

RN CM

6 Mo

RN CM

7 Mo

RN CM

8 Mo

RN CM

9 Mo

TRANSMISSION/PATHOGENESIS:

· Signs/symptoms of TB disease

· Airborne disease / Shared airspace

· Infectiousness of case

· IGRA/PPD(+) 2-10 weeks after initial infection

· TB infection vs. disease

INFECTION CONTROL MEASURES:

· Instruct in proper use of masks & tissues

· Isolation/return to work after 3 negative smears, clinically improved, DOT for 2 weeks unless otherwise noted (see Standing Delegation Orders)

· Sputum collection

EVALUATION:

· IGRA/PPD testing/significance, CXR results, other tests Y

Y

Y

HIGH RISK GROUPS/FACTORS:

· Diabetics, Silicosis, HIV+, Gastric resection, hepatic renal

· Alcohol/drug abuse (IVDU), Underweight

· Corticosteroids, TNF-alpha antagonists

· Foreign born, Resident of correctional or long term care facility

MEDICATION:

· Possible side effects, actions to take if side effects occur

· Increased risk of side effects if pre or post-partum, alcohol abuse, kidney or liver disease

· Benefits = cure of disease or prevention of disease

· Administration = dosage/frequency, length of treatment, DOT/DOPT

· Ensure medication is stored appropriately

DRUG INTERACTIONS:

· INH: Tylenol, anticoagulants, valium, carbamazepines, disulfiram, haldol, ketoconazole, dilantin, theophyllin, valproate

· Rifampin: anticoagulants, antidepressants, beta-blockers, oral contraceptives, corticosteroids, protease inhibitors, delavirdine, efavirenz, digoxin, diltiazem, fluconazole, itraconazole, haloperidol, methadone, dilantin, verapamil, tetracyclines, trimethoprim-sulfa, chloramphenicol

· Non-TB medicine list obtained from patient. Physician & nurse case manager review at each office visit.

ADHERENCE:

· Case = control order, isolation, MDR-TB, death

· TBI = disease later, DOPT

RATIONALE FOR DOT/DOPT:

· Assure compliance and adherence

· DOT = prevents drug resistance & a Standard of Care

· DOPT = age <5, HIV+, contacts to MDR-TB, other high risk

Case / suspects only • = Provided at Indicated Month

Adapted from TB-203 Education/Counseling Record –8/2017; (CCHCS-Amended 12/06/2017) - Continued on Reverse

Texas Department of State Health Services

Tuberculosis Education/Counseling Record (cont.)

Date(s):

Initial

Visit

RN CM

2 Mo Date

RN CM

3 Mo Date

RN CM

4 Mo Date

RN CM

5 Mo Date

RN CM

6 Mo Date

RN CM

7 Mo Date

RN CM

8 Mo Date

RN CM

9 Mo Date

RATIONALE FOR MONTHLY MONITORING:

· Assess improvement/worsening of symptoms

· Toxicity/symptom review, LFTs/other lab per protocol

· Medication refill

LAB RESULTS:

· LFTs/other lab per protocol

· Sputum per protocol

· Evaluation of sputum conversion

HIV

· Affect of HIV infection on progression to TB disease

· HIV post test counseling Y

SPUTUM/SPECIMEN COLLECTION:

· One observed sputum initially

· Weekly, until 3 consecutive (-) smears

· Monthly, until 2 consecutive months (-) cultures, & at closure if possible

· Collect outdoors or in room with negative air pressure

CONTACT INVESTIGATION:

· Rationale = find new disease, detection and treatment of TBI

· 2nd testing of negative contacts, 8-10 weeks after break in contact

· Concentric circle approach / high, medium, & low prioritization Y

Y

CONSENTS/AUTHORIZATIONS:

· Consents explained

· Copies given to patient

· TB-209 Hurricane Questionnaire up to date, reviewed with patient Y

Y

PROVIDER INFORMATION:

· Clinic address/phone number

· Nurse case manager’s name/phone number

OTHER EDUCATIONAL MATERIALS

Collin County Health Care Services Low Cost Health Clinic

(English)

Provider Initials

Interpreter Initials

Next Appt.:

Case / suspects only • = Provided at Indicated Month

Adapted from TB-203 Education/Counseling Record –8/2017; (CCHCS-Amended 12/06/2017)