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Asking the Right Questions

A Visual Guide to Tuberculosis Case Management for Nurses

Reference Guide

The Francis J. Curry National Tuberculosis Center is a joint project of the San Francisco Department of Public Health and the University of California, San Francisco, funded by the Centers for Disease Control and Prevention (CDC) under CDC Cooperative Agreement U52 CCU 900454. Permission is granted for nonprofit educational use and library duplication and distribution. Suggested citation: Francis J. Curry National Tuberculosis Center. Asking the Right Questions: Reference Guide. San Francisco, CA; 2010: [inclusive pages]. This publication is available on the Francis J. Curry National Tuberculosis Center website at nationaltbcenter.edu/arq/. Design: Edi Berton Design

Asking the Right Questions: A Visual Guide to TB Case Management | Reference Guide, 2010

Contents

Contents ................................................................................................... 1 Introduction ............................................................................................. 2

About this Project........................................................................... 2 Why Are Questions Important?...................................................... 2 Why Understand the Whole TB Case Management Process?...... 3 The Right Questions Quick Reference List........................................... 5 Throughout Case Management.............................................................. 8 Understanding TB Case Management Goals and Tasks .............. 8 Ensuring that the Patient Understands TB .................................. 10 Completing the Patient's Chart .................................................... 11 Taking Special Considerations into Account ............................... 12 During Assessment............................................................................... 13 Determining the Risk for TB......................................................... 13 Knowing When to Suspect TB ..................................................... 14 Gathering Information to Evaluate the Patient's TB Disease....... 19 Determining the Patient's Infectious Period ................................. 25 Learning about the Patient's Culture and Beliefs......................... 27 Ensuring that the Patient's Basic Needs are Met ........................ 29 During Treatment .................................................................................. 30 Ensuring Completion of Therapy ................................................. 30 Monitoring the Patient's Response to Treatment......................... 33 Monitoring for Adverse Reactions................................................ 37 Determining When Treatment Is Completed ............................... 38

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Asking the Right Questions: A Visual Guide to TB Case Management | Reference Guide 2010

Introduction

About this Project

Purpose

Use the Asking the Right Questions educational toolkit to

? Prompt your critical thinking about TB case management ? Find relevant basic national training materials ? Get an overview of the full TB case management timeline

Online Educational Toolkit

Go to the Asking the Right Questions Web Guide at nationaltbcenter.ucsf.edu/ arq/ to download the Asking the Right Questions Visual Guide to TB case management, usable as a poster or smaller reference sheet. While on the website, you also can interactively review the TB case management timeline, explore the right questions list, hyperlink directly to national training materials and guidelines, and access an online glossary.

Why Are Questions Important?

No Step-by-Step Procedures

TB cannot be assessed or treated using a set of step-by-step procedures. Instead, to assess and treat TB requires applying guidelines to each patient's situation.

To assess or diagnose TB, you can use several different sets of criteria depending upon the patient's situation. Each patient can present TB signs and symptoms differently, depending upon factors such as age, immune system status, coexisting diseases, area of the body affected, and severity of the TB disease.

In assessment, for example, a standard test for pulmonary TB (acid-fast bacilli sputum smear microscopy) cannot detect the disease in its early stages, although the patient may have TB symptoms and be infectious. Sometimes a patient with TB disease may not have a cough if the immune system is suppressed or if they are under age 5, and HIV-positive patients with TB disease can have normal-appearing chest x-rays. Further, a patient can have culture-negative TB disease and be clinically diagnosed to have TB. In that case, a TB diagnosis requires starting empiric TB treatment and learning from the patient's response if he or she has TB.

Multiple factors can affect the choice of a TB treatment regimen. When planning how to treat a TB patient and when monitoring the patient while on treatment, you need to consider many aspects of the patient's situation, such as:

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Asking the Right Questions: A Visual Guide to TB Case Management | Reference Guide, 2010

? Extent and site of the TB disease ? Drug resistance ? Other conditions, such as HIV, diabetes, arthritis ? Age ? Mental health and substance abuse ? Stability of residence ? Culture and beliefs about healthcare and TB ? Language

These factors can impact the choice of treatment regimen, how it is delivered, and how you can help the patient to adhere to 6 to 12 months of treatment. Further, many of these factors can change during a patient's treatment.

Critical Thinking

Because a set of step-by-step procedures will not fit all patients, you need to gather and review the data for each patient's medical and psychosocial situation and work with your team to apply guidelines for assessment and treatment. This requires that you think critically--and the key to critical thinking is asking yourself good questions.

To recognize good questions, it helps to understand the TB case management process, be familiar with national guidelines (and local guidelines and protocols where available), and to carefully look at the data about your patient.

Why Understand the Whole TB Case Management Process?

Understanding the whole process of TB case management prompts you to ask the questions that you need to answer in order to meet TB case management goals and to understand the impact of your decisions and work throughout the TB case management process.

TB Case Management Goals

Asking good questions ensures make sure that you and the team meet TB case management goals for your patient:

? The patient is assessed, a medical evaluation is performed by a physician, and a treatment plan is established

? The patient is educated about TB and its treatment ? Treatment is promptly started with directly observed therapy and is continuous,

safe, and completed ? Contacts are identified, screened, and evaluated and those who are eligible

started on treatment for latent TB infection

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Asking the Right Questions: A Visual Guide to TB Case Management | Reference Guide, 2010

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