1. 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.

2. DOT Essentials

3. Before we begin… TB can be complicated and confusing. Many of our TB patients have complex lives. When in doubt …ASK!

4. What is DOT?

5. DOT=Directly 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).

6. 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.

7. What does the DOT worker do? 1.Verify medication is given to correct person 2. Deliver medication 3. Check for side effects 4. Verify correct medication is given 5. Watch patient take pills 6. Document the visit

8. Where and when can DOT be delivered? At any mutually agreed upon place and time (by patient and DOT worker). Examples: -clinic, patient’s home, patient’s workplace, school, park or other public location Flexibility is one of the keys to success!

9. 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.

10. Some reasons patients don’t 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 do…work, drug use, etc. Many, many others.

11. 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.

12. 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 isn’t swallowing medication consider asking the patient to open his/her mouth.

13. Documenting the dose Document each dose daily after it’s 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.sht ml#Case

14. Questions What are two negative consequences that can occur if a patient doesn’t take TB medications correctly? What is DOT? What are the six main tasks involved in DOT?

15. Medication Side Effects

16. 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.

17. 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…

18. Questions You arrive at the patient’s house. He’s a 24 year old who only speaks Vietnamese (which you don’t 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?

19. TB and Infectiousness

20. 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

21. 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

22. 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 patient’s lab work.

23. 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.

24. Visiting an Infectious Patient Put on the N95 mask upon entering the patient’s home. Ask the patient to wear the surgical mask. If you’re staying awhile, open and sit near a window if possible. Discuss any questions with the TB nurse case manager.

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

26. Trust and Confidentiality

27. Trust The DOT worker sees the patient daily, often in the patient’s 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.

28. Tips for Building Trust 1.“Start where the patient is.” 2. Communicate clearly 3. Avoid criticizing the patient’s behavior; suggest behavior changes respectfully 4. Be on time and be consistent 5. Adopt and reflect a nonjudgmental attitude 6. Protect the patient’s confidentiality

29. Protecting Confidentiality Confirm patient’s identity at first encounter. Don’t discuss patient with anyone without permission (including family). Be discreet when making visits. If a message must be left on the patient’s door, place it in a sealed envelope, marked confidential, and address to a specific person. Don’t leave confidential information on an answering machine others can access. Don’t leave confidential information with a neighbor or friend. Don’t disclose patient’s condition when gathering information on their whereabouts.

30. 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

31. 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?tableNa me=DOTE http://www.nationaltbcenter.edu/catalogue/epub/index.cfm?tableNa me=DOTE