New Mexico Department Of Health Treatment For Latent Tb Infection Weekly Monitoring Flow Sheet printable pdf download

New Mexico Department Of Health Treatment For Latent Tb Infection Weekly Monitoring Flow Sheet

NEW MEXICO DEPARTMENT OF HEALTH

TREATMENT for LATENT TB INFECTION WEEKLY MONITORING FLOW SHEET

UTILIZING DOT AND ISONIAZID/RIFAPENTINE REGIMEN (3HP)

Name (Last, First, MI):

Birth Date:

Medication Orders:

Physician:

Medication Start Date:

Anticipated Stop Date:

ALL PATIENTS SHOULD HAVE THE FOLLOWING:

Baseline CBC and LFTs. Opt-out HIV testing. Monthly labs not indicated. See LTBI Protocol for indications for laboratory monitoring.

Face-to-face clinical evaluation at least monthly. Chart in BEHR.

Education about possible adverse drug events. STOP treatment and seek medical evaluation if serious adverse events occur.

Date:

TB symptoms? (i.e., persistent cough,

bloody sputum,

weight loss, fever,

night sweats, etc.

ADVERSE DRUG EVENTS

Loss of appetite (INH/RIF)

RUQ abdominal discomfort (INH/RPT)

Unusual/Excessive fatigue (INH/RPT)

Nausea/Vomiting (INH/RPT)

Unexplained fever > 3 days (INH/RPT)

Urine color change (dark) (INH/RPT)

Stool color change (light) (INH/RPT)

Jaundice (yellow skin/eyes) (INH/RPT

Skin rashes/Itching (INH/RPT)

Numbness/Tingling in arms/legs (INH)

Flu-like symptoms (RPT)

Unusual bleeding/bruising (RPT)

Change in urine output (RPT)

TEACHING

STOP medication and notify Nurse

adverse drug events occur

Signs/Symptoms of TB disease

Avoiding alcohol use and exposure to

other hepatotoxins

Orange discoloration of body fluids

Date of LMP: Effect on hormonal

contraceptives (RPT)

Adherence; treatment completion

Medication

INH ______mg (900mg Max) DOT

RPT ______mg (900mg Max) DOT

Health care provider’s initials:

Client’s initials:

Y = Yes

N = No

N/A = Not Applicable

P = See Progress Note

INH = Isoniazid

RPT = Rifapentine

CLIENT/DOT PROVIDER AGREEMENT:

We agree to meet at

(location) on day:________________________

(time) AM / PM for DOT medication, unless alternate arrangements are made in advance by either party.

Client’s signature:

Client’s initials:

____________

DOT provider’s signature:

___

DOT provider’s Initials:

____________

Nurse case manager’s signature:

Nurse case manager’s initials: _________________

Complete when closing case: Total # DOSES ingested: __________ Total # WEEKS on therapy: __________ Completed therapy: Yes

Note

Completion of treatment: defined as: eleven (11) or twelve (12) doses must be given within 16 weeks. Each dose must be separated by >72 hours.

TB 004B/LTBI 3HP Weekly Monitoring Flow Sheet 1/2012

New Mexico Department Of Health Treatment For Latent Tb Infection Weekly Monitoring Flow Sheet

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