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.

DOT Essentials
 Before we begin…
• TB can be complicated and confusing.
• Many of our TB patients have complex
lives.

When in doubt

…ASK!
What is DOT?
 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).
 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.
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

 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!
 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.
 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.
 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.
 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.
 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.shtm
l#Case
 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?
Medication Side Effects
 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.
 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…
 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?
TB and Infectiousness
 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
 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
 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.
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.
 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.
 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?
 Trust and
Confidentiality
 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.
 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
 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.
 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
 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