Quick question (I hope!)

Jolie, BSN · Nov 1, 2008

It is imperative to instruct the patient on when to return to have the test read.

And yes, in my experience, the test is read and interpreted by by a nurse, with the results documented and a copy provided to the patient.

mama_d, BSN, RN · Nov 1, 2008

At my facility, when an inpt receives a PPD, the nurses document at 24, 48, and 72 hours on the site. I'm assuming that the ordering MD observes the site as well, although that is probably a HUGE assumption on my part.

lainith · Nov 1, 2008

Thanks so much! :) I totally forgot about instructing the pt when to return for reading the skin test. Awesome.

Daytonite, BSN, RN · Nov 1, 2008

when doctors are ordering this test for patients they are doing it as part of a workup in doing their medical assessment of the patient. they are often either suspecting that the patient might have tb or looking to rule it out.

(from pages 1246-1249, davis's comprehensive handbook of laboratory and diagnostic tests with nursing implications, 2nd edition, by anne m. van leeuwen, todd r. kranpitz and lynette smith)

"tuberculin skin tests

(synonyms: tb tine tests, ppd, mantoux skin test)

nursing implications pretest:

inform the patient that the test is used to indicate exposure to tuberculosis.
obtain a history of the patient's complaints, including a list of known allergens, and inform the appropriate health care practitioner accordingly.
obtain a history of the patient's immune and respiratory systems and results of previously performed laboratory tests, surgical procedures, and other diagnostic procedures. obtain a history of tuberculosis or tuberculosis exposure, signs and symptoms indicating possible tuberculosis, and other skin test or vaccinations and sensitivities.
obtain a list of medications the patient is taking, including herbs, nutritional supplements and nutraceuticals. the requesting health care practitioner and laboratory should be advised if the patient regularly uses these products so that their effects can be taken into consideration when reviewing the results.
review the procedure with the patient. ensure that the patient does not currently have tuberculosis and has not had a positive skin test previously before beginning the test. do not administer the test if the patient has a skin rash or other eruptions at the test site. inform the patient that the procedure takes approximately 5 minutes. address concerns about pain related to the procedure. explain to the patient that a moderate amount of pain may be experienced when the intradermal injection is performed.
emphasize to the patient that the area should not be scratched or disturbed after the injection and before reading.
sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
there are no food, fluid or medication restrictions, unless by medical direction.

nursing implications intratest:

instruct the patient to cooperate fully and to follow directions. direct the patient to breathe normally and to avoid unnecessary movement.
observe standard precautions. . .identify the patient.
have epinephrine hydrochloride solution (1:1000) available in the event of anaphylaxis.
cleanse the skin site on the lower anterior forearm with alcohol swabs and allow to air-dry.
prepare ppd or old tuberculin in a tuberculin syringe with a short, 26-gauge needle attached. prepare the appropriate dilution and amount for the most commonly used intermediate strength (5 tuberculin units in 0.1 ml) or a first strength usually used for children (1 tuberculin unit in 0.1 ml). inject the preparation intradermally at the prepared site as soon as it is drawn up into the syringe. when properly injected, a bleb or wheal 6 to 10 mm in diameter is formed within the layers of the skin. record the site, and remind the patient to return in 48 to 72 hours to have the test read. at the time of the reading, use a plastic ruler to read the diameter of the largest indurated area, making sure the room is sufficiently lighted to perform the reading. palpate for thickening of the tissue; a positive result is indicated by a reaction of 5 mm or more with erythema and edema.
the results are recorded manually or in a computerized system for recall and postprocedure interpretation by the appropriate health care practitioner.

nursing implications post-test:

a written report of the examination will be sent to the requesting health care practitioner, who will discuss the results with the patient.
recognize anxiety related to the test results, and be supportive of perceived loss of independence and fear of shortened life expectancy. discuss the implications of abnormal test results on the patient's lifestyle. provide teaching and information regarding the clinical implications of the test results, as appropriate. educate the patient regarding access to counseling services.
reinforce information given by the patient's health care provider regarding further testing, treatment, or referral to another health care provider. . .inform the patient that the effects from a positive response at the site can remain for 1 week. educate the patient that a positive result may put him or her at risk for infection related to impaired primary defenses, impaired gas exchange related to decrease in effective lung surface, and intolerance to activity related to an imbalance between oxygen supply and demand. answer any questions or address any concerns voiced by the patient or family.
depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. evaluate test results in relation to the patient's symptoms and other tests performed."