OBSERVATION CHECKLIST ON PTB PREVENTIVE AND CONTROL PRACTICES (P.M. Veroy, RN, MAN)Profile of Family Members per Household:No. of Home Visit:_____________ Date:________________________Father (Optional)___________________ Age_______Mother (Optional)___________________ Age_______ Children Age Gender ____________________ ______ _______ ____________________ ______ _______ ____________________ ______ _______ ____________________ ______ _______Structured observation and interview of PTB Prevention and Control Practices: Client (Positive of Caretaker I - PRACTICES IN PREVENTION AND PTB) Not Not CONTROL Yes it is Yes it is practice observe observed/ observed/ practiced practiced 1. Eat at least a variety of rich food nutrient 2. Enough rest and sleep 3. Take vitamin or alternative nutritional supplement 4. Sleep in separate room 5. Avoid crowded places 6. Covers mouth when coughing (Client); Keep distance when client cough 7. Use own kitchen wares 8. Keep bed mattresses, pillows, blankets and personal belongings washed and well sun dried. 9. Keep himself in an open well ventilated room 10. Maintain good hygiene 11. Practice hand washing 12. Perform cleanliness and orderly in their home surrounding 13. Compliance of medication (Client)/
Take prophylaxis (prescribed antibiotic) 14. Do not smoke cigarette 15. Do not drink alcohol 16. Do not gamble 17. Do perform regular exercise or physical fitness Yes it is II - PRACTICES IN PREVENTION AND Not Not observed CONTROL (Children) practice Observe /practiced 1. Eat at least a variety of rich food nutrient 2. Enough rest and sleep 3. Take vitamin or alternative nutritional supplement 4. Use separate bath towel for them to use 5. Keep away from crowded places 6. Keep distance from others when coughing/sneezing/spitting discharges 7. Use separate clean kitchen wares 8. Keep bed mattresses, pillows, blankets and personal belongings washed and well sun dried. 9. Keep themselves in open well ventilated room 10. Sleep in separate room 11. Prompt consultation at clinic when present of symptoms of common illnesses observed by caretaker. 12. Child’s hands are washed (with or without soap) before and after eating meals 13. Child is bathed everyday and when necessary to maintain proper hygiene 14. Mother replaces clean utensil when it is dropped on the floor or use by others. (Client) 15. Child is kept away from hugging and kissing with member positive of PTB 16. Child is actively playing with other children 17. Child/Children were complete/update in their immunizationClient – any family member living in same household who is positive of Tuberculosis.Caretaker – any family member who is taking care of client and children and negative of PTBChildren – a young member of the family under 3 years of age who are at high risk in contacting PTB.