Mantoux Tuberculin skin testing Andrea Jurgrau, CPNP Joan Coetzee CPN, PN Field Representatives for the P1078 team CDC TST guidelines P1078 uses CDC guidelines for TST technique The guidelines can be found at the CDC website, as can training material and supplies: http://www.cdc.gov/tb/education/Mant oux/default.htm The P1078 MOP has an overview of these guidelines. What is a TST? A tuberculin Skin Test (TST) The technique we are using in the Mantoux TST This is a intradermal injection of Protein Purified Derivative (PPD) It tests for exposure to Tuberculosis (TB) also known as latent TB Because it is a delayed immune response, it takes 48-72 hours for the reaction to take place and the TST to be read and interpreted Materials for administering the TST PPD 5tu* unit dose vials for intradermal administration. Single use, disposable TB syringe and ½ inch 27 gauge short bevel needle. Alcohol pads. Tuberculin skin test ruler (plastic ruler with mm rule.) Refrigerator for long-term storage at 2-8 degrees C and a cooler for use in the clinic if vial can’t be returned to refrigerator quickly. Preparing to Place TST Wash hands and put on gloves. If no water is available, use an appropriate skin- cleaning product (e.g., an alcohol based hand cleaner). Check PPD vial’s expiration/opening date. If it has been open for more than 30 days, discard the vial and get a new one. Be sure you review proper storage for vials between use. Place patient’s arm on a flat surface, exposing the volar (inside) surface of the forearm. Locate site for the injection (2-4 inches below elbow, where no scars, bumps or veins are located). Clean the injection site with an alcohol swab and allow it to dry before applying test. Wipe the top of the PPD vial with a second alcohol swab and place the vial on a flat surface. Prepare the syringe by inserting it into the vial. Inject 0.1 ml of air into the airspace in the vial. Do not inject air into the PPD solution. Invert the vial, keeping the needle tip below fluid level. Pull back on the plunger of the syringe and draw slightly more than 0.1 ml of PPD solution. Remove the syringe from the vial and tap the syringe lightly to dispel air bubbles. Hold the syringe point up and expel air and/or excess fluid, leaving exactly 0.1 ml of PPD solution in the syringe. Return the PPD vial to the refrigerator when not in use and place on a cooling pad when in use. Protect the vials from light. Placing TST NOTE! interferon gamma blood collection has to happen first before TST placement for P1078 Stretch the skin of the injection site with the thumb of the non-dominant hand (e.g., left hand for right-handed persons). Hold the syringe between the thumb and forefinger of the dominant hand, (e.g., right hand for right-handed persons) with the bevel of the needle pointing upward. Insert the needle intradermally (just under the top layer of skin) at a 5°-15° angle, with the bevel up. The bevel should be just below the skin, and the needle should be inserted about 3mm so the entire bevel is covered. Release the stretched skin, inject the PPD solution slowly. A firm resistance should be felt as the tuberculin solution enters the skin. Remove the needle from the injection site (DO NOT RECAP). Discard the syringe immediately in a sharps container. Measuring TST after Placing Once you place the TST you must measure it right away to make sure it was done properly Use your ruler to measure the wheal. It should be at least 6mm in diameter. If it is not, repeat the TST at a new site at least 2 inches away from first site. Be sure you document the test was repeated. TST Patient Teaching Educate the patient on the possible reactions to the TST (e.g., mild itching, swelling, irritation). Instruct patient not to rub, scratch or put an adhesive bandage or lotion on the test site. The area may be washed and patted dry. Document the test in the patient’s CRF (including second test if done). Be sure to include location of test site in your documentation. Schedule reading date and explain the importance of the patient returning for reading in 48 to 72 hours. Materials for reading TST Tuberculin skin test ruler (plastic ruler with mm rule.) Felt-tip pen Alcohol pads to remove pen marks Reading TST Read the result 48 to 72 hours after administering the test. Inspect the injection site for raised areas. Palpate the arm for a hard, raised area known as an induration. Feel the edges of the induration with the index finger Mark the 2 edges of the induration with a dot, using a black, watermark or felt-tip pen. Measure the induration (not redness) at its widest point transversely, from 1 marked edge to the other, using a flexible TST ruler. If the reading is between 2 points, the lower value should be used. Swollen areas, if they feel hard, (but not red areas) should be palpated and included in the measurement. Record the size in millimeters and not simply as “positive” or “negative”. If there is no induration, record the result as “00 mm.” Interpret the reaction as positive or negative based on the size of the induration being ≥5mm (for HIV+ study subjects) Explain the meaning of a positive or negative reaction to the individual and refer for follow-up evaluation, if needed. Caveats Vaccination with live attenuated viral vaccines such as measles, mumps and/or rubella (MMR) can cause a false-negative reaction to the TST. The TST can be administered on the same day as the live vaccine. If a skin test is needed, and was not given in conjunction with the vaccination, wait 4-6 weeks before administering a TST. Caveats If the patient fails to return for the scheduled reading but returns up to a week (7 days) after the test, examine the test site and measure any induration present; if it is large enough to be classified as positive, record the result. No further testing is needed. If there is no reaction, or the induration is too small to be classified as positive, repeat the test. A repeat test can be given immediately.
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