Effective Date: 
Sun, 04/01/2001
Sat, 08/27/2011
Sat, 08/27/2011

SUBJECT: Tuberculosis Test Results

PERSONNEL: RN, LVN who has demonstrated competency

EQUIPMENT/LOCATION: Millimeter ruler , ball point pen, patient chart, and good light are needed. Any location including Triage, Same Day Clinic, AIT

The RN or LVN observes the volar surface of the patient’s lower arm with the arm slightly flexed.
Observation is done both directly and looking from the side and palpation is also done.
Induration is measured in millimeters transverse from the long axis of the arm and noted in the medical record. 
Ball point ink method of defining edge of induration is suggested in ill defined reactions.
Erythema is not significant.

A positive reaction is measured in millimeters of induration and significance is defined by circumstances of patient condition and risk of exposure:

  • 5 mm in immune compromised patients, close contacts and those with abnormal CXR.
  • 10 mm is considered positive in the state of California, which overrides CDC recommendation for interpretation of positives.
  • Note: BCG immunization will not cause a large or sustained reaction

Action taken is based on above results criteria:
The nurse documents the size of reaction as noted above.
If the reaction is less than 10 mm, the nurse completes the documentation and the patient is given a completed copy of their results.
If two stage testing is required, schedule follow-up visit in about 2 weeks. Second result is final result.
Students who are traveling to high risk area are reminded to be tested upon their return.
Patients referred by a clinician for testing are referred back to that clinician.
Patients who have a positive test on routine screening are assessed for active symptoms of TB.  If negative, they are  referred for a 1 view CXR to be read by radiologist and an appointment made with a clinician for evaluation and counseling.  If positive for symptoms of active TB,  a mask is applied, a 1 view CXR is ordered, and the student is made a Same DAy appointment for clinician evaluation.
If any question about disposition of particular case, nurse is to consult with DOC or Patient Care Coordinator.