Reminder for RN: Steps of Delegation

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Reminder for RN Steps of Delegation

• 1- Ensure client care can be delegated, client
  must be stable and the outcomes for delegation
  predictable
• 2- Teach the task
• 3- Check for competency
• 4- Document
• 5- Reevaluate client if necessary
• 6- Reevaluate UAP delegated nursing task
• This module only covers 2,3,4.

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DOT Essentials
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Before we begin

• TB can be complicated and confusing.
• Many of our TB patients have complex lives.
• When in doubt
• ASK!

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• What is DOT?

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What is DOT?

• DOTDirectly Observed Therapy
• A health care worker or other designated
  individual watches the patient swallow every dose
  of the prescribed TB drugs (supervised
  swallowing).
• It is recommended that all TB suspects and cases
  be on DOT.
• DOT is not required for weekends or government
  holidays (patient may take medication on their
  own).

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Who can deliver DOT?

• TB clinic personnel (nurse or other health
  department workers).
• Staff at other health care settings, such
• as outpatient treatment centers.
• Other responsible persons (school
• personnel, clergy, social worker).
• Family and friends should not be used.

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What does the DOT worker do?

• Verify medication is given to correct person
• Deliver medication
• 3. Check for side effects
• 4. Verify correct medication is given
• 5. Watch patient take pills
• 6. Document the visit

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Where and whencan DOT be delivered?

• At any mutually agreed upon place and time (by
  patient and DOT worker).
• Examples
• -clinic, patients home, patients workplace,
• school, park or other public location
• Flexibility is one of the keys to success!

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Why do we have DOT?

• We cannot predict who will take their TB
• medications correctly!
• Anyone can forget or neglect to take their
  medications - education, age group, gender, or
  ethnicity does not matter.

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Some reasons patients dont take TB medications

• No longer feel sick
• Lack of knowledge about TB
• Not motivated
• Forgetful
• Language barriers
• Medication side effects
• Confused about what pills to take
• Have other things to dowork, drug use, etc.
• Many, many others.

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Consequences of taking TB medication incorrectly

• May develop drug resistant TB meaning longer
  treatment, medications with bad side effects,
  injections, etc.
• May be infectious longer.
• Could lead to lung damage and possibly death from
  TB.

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Is the patient swallowing the medication?

• Some tricks cheeking or hiding pill under
  tongue, keeping pill in hands, hiding in
  furniture, promising to take later, answering the
  phone, picking up a child.
• If you have a strong suspicion patient isnt
  swallowing medication consider asking the patient
  to open his/her mouth.

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Documenting the dose

• Document each dose daily after its given on the
  appropriate form.
• Any side effects and the actions taken by the DOT
  worker should also be documented.
• Record other relevant information as well.
• DOT forms are at
• http//www.oregon.gov/DHS/ph/tb/tools.shtmlCase

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Questions

• What are two negative consequences that can occur
  if a patient doesnt take TB medications
  correctly?
• What is DOT?
• What are the six main tasks involved
• in DOT?

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Medication Side Effects
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Side Effects

• Side effects are common with TB medications.
• Ask about side effects each visit.
• Some side effects that seem minor (such as nausea
  and vomiting) may not be!
• If the patient reports a side effect, do not give
  the TB medications without first consulting the
  TB nurse case manager or doctor.
• When obtaining information on side effects, ask
  the patient when the problem started, how long it
  lasted, and how often it occurs.
• Side effects should be reported immediately.

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Possible Side Effects

• Skin rash
• Blurred or changed vision
• Nausea (can indicate liver failure)
• Vomiting (can indicate liver failure)
• Abdominal Pain (can indicate liver failure)
• Dark urine (can indicate liver failure)
• Fatigue
• Flu-like symptoms
• Lack of appetite
• Yellowish skin or eyes (jaundice) (can indicate
  liver failure)
• Dizziness
• Tingling pain in hands and feet (peripheral
  neuropathy)
• And others

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Questions

• You arrive at the patients house. Hes a 24
  year old who only speaks Vietnamese (which you
  dont speak). How will you check for side
  effects?
• Your patient tells you yesterday his stomach hurt
  after he took the medication.
• What should you do?

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TB and Infectiousness
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How do people get TB?

• TB is transmitted through the air.
• Droplets containing TB are released when someone
  with TB disease coughs, sneezes, talks, or
  breaths. Other people then breath the droplets
  in.
• Droplets can stay suspended a long time.
• TB is airborne only, not in food or on things.
• Can only be infected by someone with active TB

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LTBI vs. Active TB Disease

• Latent TB Infection (LTBI)
• -Positive TB skin test or Quantiferon test
• -No symptoms of TB
• -Normal CXR
• -Not contagious
• Active TB Disease (pulmonary, typical)
• -Positive TB skin test
• -Abnormal CXR
• -Symptoms of TB
• (cough, hemoptysis, fever, weight loss)
• -Contagious

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How do I know if the patient is infectious?!?

• Ask the TB nurse case manager!
• Many TB patients are infectious initially, but
  will not be infectious after taking medication
  for awhile.
• The only way to know for sure is to look at the
  patients lab work.

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What should I do if the patient is infectious?

• You should be fit tested for a N95 mask.
• The TB Nurse Case Manager will provide you with
  education on wearing the N95 mask.

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Visiting an Infectious Patient

• Put on the N95 mask upon entering the patients
  home. Ask the patient to wear the surgical mask.
• If youre staying awhile, open and sit near a
  window if possible.
• Discuss any questions with the TB nurse case
  manager.

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Questions

• You are about to visit a new patient who is
  infectious. What should you have with you?
• The patients brother was diagnosed with latent
  TB infection. Is he infectious?
• The patients wife told you she has separate
  plates for him. Is this necessary?

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Trust andConfidentiality
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Trust

• The DOT worker sees the patient daily, often in
  the patients home.
• The patient may be sick, confused and feeling
  vulnerable.
• Consider what it would be like to have someone
  come to your house everyday.
• Developing trust is essential.

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Tips for Building Trust

• 1.Start where the patient is.
• 2. Communicate clearly
• 3. Avoid criticizing the patients behavior
• suggest behavior changes respectfully
• 4. Be on time and be consistent
• 5. Adopt and reflect a nonjudgmental
• attitude
• 6. Protect the patients confidentiality

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Protecting Confidentiality

• Confirm patients identity at first encounter.
• Dont discuss patient with anyone without
  permission (including family).
• Be discreet when making visits.
• If a message must be left on the patients door,
  place it in a sealed envelope, marked
  confidential, and address to a specific person.
• Dont leave confidential information on an
  answering machine others can access.
• Dont leave confidential information with a
  neighbor or friend.
• Dont disclose patients condition when gathering
  information on their whereabouts.

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When to ask for help

• Patient reports side effects
• You cannot find the patient
• You identify some additional contacts
• There is a situation you are uncomfortable with
  such as
• -threatening behavior
• -possible child abuse or domestic violence
• -alcohol or drug use
• -any other

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The End!

• Please take the post test now.
• Thanks to the Francis J. Curry National TB
  Center.
• This training was adapted from the
• DOT Training Curriculum for TB Control
  Programs
• at http//www.nationaltbcenter.edu/catalogue/epub
  /index.cfm?tableNameDOTE