Question

A nurse is preparation to administer an intradernal tuberculin test to a client. Which of the following actions should the nurse take?

Answer 1

Answer :

TUBERCULIN TEST : it is a standard method of determining whether a person is infected with mycobacterium tuberculosis .

- tuberculin skin test is performed by injecting 0.1 ml of tuberculin purified protein derivative in to the inner surface of forearm.

- the injection should made with a tuberculin syringe ,with needle bevel facing upward .

it is a intra dermal injection.

- positive result on the skin test indicate that the patient has been exposed to the antigen ,but it does not indicate that TB is currently present .

- negative result indicate there has been no exposure or there has a depression of cell mediated immunity such as occurs in HIV infection .

nursing actions :

• To prevent the falls negative reaction ,the nurse should be certain that the injection is intradermal not subcutaneous.
• after the injection ,the sites should be circled and the patient instructed no to remove the mark .
• When charting administration of antigen ,the nurse should draw a diagram of forearm and hand and label the injection site.
• the diagram is helpful when more than one test is administered .
• when reading the test results ,the nurse should use a good light ,if induration present ,a marking pen is used to indicate the periphery on all four sides of induration .
• as pen touches rised area ,a mark should be made .
• nurse then determine the diameter of induration in millimeters .
• reddened ,flat areas are not measured .

Interpretation of tuberculin skin test with reactions :

POSITIVE REACTIONS GREATER THAN 5 mm induration

• HIV positive persons
• suspected HIV infection.
• recent close contact with TB patient .
• patient with organ transplantation and other immuno suppressed patient
• past healed TB.

POSITIVE REACTIONS GREATER THAN 10 mm induration :

• Person with clinical conditions such as diabetes ,end stage renal disease, prolonged corticosteroid therapy ,cancer of oro pharynx .
• recent immigrants from high prevalence countries.
• medically underserved groups.
• iv drug users

POSITIVE REACTIONS GREATER THAN 15 mm induration:

• All other persons who are at high risk .