Reminder for RN: Steps of Delegation

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. What is DOT? • 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? • 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

8. Where and whencan 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.shtml#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 andConfidentiality

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?tableName=DOTE