Policies,Clinical,UWHC Clinical,Department Specific,Ambulatory,Clinic Specific

Ambulatory Tuberculin Bacillus (TB) Skin Testing Procedures (12.50)

Ambulatory Tuberculin Bacillus (TB) Skin Testing Procedures (12.50) - Policies, Clinical, UWHC Clinical, Department Specific, Ambulatory, Clinic Specific


12.50 Ambulatory Tuberculin Bacillus (TB) Skin Testing Procedures
Category: UWHC Departmental Policy
Policy Number: 12.50
Effective Date: September 19, 2012 (extended expiration date to December 31, 2015)
Version: Revision
Manual: Ambulatory
Section: Clinic Specific (Ambulatory)

To screen UWHC outpatient population when clinically appropriate for possible, previous infection caused by
Mycobacterium Tuberculosis.


Only Medical Assistants (MAs), Registered Nurses (RNs), Licensed Practical Nurses (LPNs) or physicians/providers who
have received training and have demonstrated competency on the Mantoux Tuberculin Skin Test (TB skin test) may
administer the tests and read results. Training for nursing staff is provided through the Nursing Education Specialists in the
Education and Development for Nursing and Patient Care Services Department or by UWHC Employee Health Department
(only for staff who will be placing and reading TB skin tests on behalf of Employee Health Services). Education and
Development for Nursing and Patient Care Services Department will maintain records of competency. Refer to UWHC
Hospital Administrative Policy 13.17 - Control of Tuberculosis, for additional information related to suspicion of pulmonary
tuberculosis, isolation procedures, and employee TB screening.


A. Sterile disposable tuberculin syringe with attached 26 to 28 gauge safety needle
B. Purified protein derivative (PPD) 5 TU/0.1mL strength multiple dose vial
C. Alcohol prep swabs
D. 2 x 2 gauze pads
E. Ruler with millimeter (mm) measurements


A. Orders - An order for TB skin testing must be obtained from a provider or by following a protocol for TB
skin testing.
B. Patient Education
1. Explain to patient or parents/guardian why the TB skin test is given and describe skin test procedure.
Inform patient that the skin test will need to be read by a RN, LPN, MA or provider that have completed a
UWHC competency 48-72 hours after the test is administered to determine test results. Ask them to
schedule their appointment before leaving the clinic.
2. Explain that mild itching, swelling, or irritation may occur and that these are normal reactions that do not
require any treatment. Instruct patient or parents/guardian to report severe reaction, e.g. extensive
erythema, vesiculation, severe itching, prior to the reading time.
3. The patient should avoid scratching the site, and avoid putting creams, lotions, or adhesive bandages on
it. Allowing the site to get wet with water is not harmful.
4. Clinical staff may provide the printable CDC Fact Sheet found in the TB Screening Smart Set.
C. Screening
1. Follow the screening questions in the TB Screening Smart Set.
2. Previous receipt of Bacillus Calmette Guerin (BCG) vaccination is not a contraindication to tuberculin
skin testing unless the patient has had a previous positive skin test.
D. Syringe Preparation

E. TB Skin
F. Readin
. PPD bottle/v
xpiration date
. Wipe the top
. Withdraw 0.
eaving exactly
n Test Admin
. Administer m
ntradermal inje
kin conditions
. Evaluate site
. Often there
ot cover the s
he test.
. Document in
ctivity entry in
a. Date
b. Nam
c. PPD
d. Site
g TB Skin Te
. The TB skin
ompetency. If
. In a well-ligh
p and down th
vial for expirat
e when opene
p of the vial w
1 mL (5 PPD
y 0.1 mL of PP
medication int
ection pp. 202
s of concern s
e for formation
of the test at
is a drop of bl
site with an ad
n the patient's
n HealthLink w
e and the time
me and manuf
D dose admini
where the te
st Results
test must be
f a TB skin tes
hted area, visu
he arm, to det
tion date, prop
ith an alcohol
units) from vi
PD solution in
radermally. R
2-206. TB skin
uch as scarrin
n of a 6 to 10
least 2 inches
lood at the inj
dhesive banda
s clinical recor
e the test was
facturer of the
istered, and
st was admin
read 48-72 h
st is not read w
ually inspect t
tect induration
per strength, a
l swab before
al. Expel all a
the syringe.
Refer to Nurse
n test is to be
ng, rash or sig
mm wheal up
s from the site
ection site. Li
age because t
rd by complet
s administered
e PPD solution
ours after pla
within 72 hou
the site, then
n. Erythema is
and clarity of
drawing up t
air and excess
es' Guide to C
given in the l
gnificant irrita
pon administr
e of the initial
ightly blot the
the adhesive
ing the Smart
n, lot number
acement by cli
urs PPD skin t
gently rub two
s not measure
solution. The
he PPD solut
s fluid from th
Clinical Proced
left forearm ro
tion, then the

ration. If no wh
blood away w
could cause
t Set progress
r and expiratio
inical staff tha
testing should
o fingers over
ed, only indur
vial is dated
e syringe and
dures (5th ed.
outinely, unles
right forearm
heal was crea
with a 2x2 gau
irritation and i
s note and the
on date,
at have compl
d be repeated
r site, both sid
with a 28 day
d needle,
), 5.12,
ss there are
m can be used
ated, repeat
uze pad. Do
interfere with
e Imm/Inj
leted a UWHC
de to side and

3. Lines drawn by a pen, on both sides of the induration, provide a visible record of the margins of
induration for accurate measurement.
4. If induration is present, measure diameter:
a. The diameter of the indurated area is measured transversely across the forearm (perpendicular
to the long axis) using a ruler with millimeter (mm) measurements. Longitudinal induration is not
b. All measurements are recorded in millimeters. If there is no induration, record result as "0 mm."
Do not use terms such as "positive," "negative," or "no reaction."
5. If 5mm or more of induration is noted, the patient’s provider must be notified, and the patient must be
evaluated by a provider immediately.
G. Documentation - Document TB skin test results in the patient's clinical record in the Enter/Edit activity. Include
the time and date the TB skin test was read and results.
H. Special Considerations
1. In some cases two step TB skin testing may be ordered. This type of TB skin testing requires that a second TB
skin test is administered 1 to 3 weeks after the initial negative TB skin test. Two step TB skin testing should be
indicated by the provider order or protocol if required.


A. CDC (2006). Mantoux Tuberculin Skin Test podcast. Accessible at:
B. CDC (2008). Division of Tuberculosis Elimination. Accessible at: http://www.cdc.gov/tb/default.htm
C. HFFY 945: Wisconsin Department of Health Services Tuberculosis (TB) Program. Accessible at:
D. Smith-Temple, J. & Young -Johnson, K. (2006). Nurse's guide to clinical procedures (5th ed.), 5.12 Administering
intradermal medications (pp.202-206). Lippincott Williams & Wilkins: Philadelphia.
E. UWHC Hospital Administrative Policy 8.17, Administration of Medications
F. UWHC Hospital Administrative Policy 13.17, Control of Tuberculosis
G. CDC (2008). Accessible at: http://www.cdc.gov/tb/?404;http://www.cdc.gov:80/tb/publications/ltb/default.htm
H. UWHC TB Skin Test Documentation Podcast. Accessible at:


Clinical Nurse Specialist, Infectious Disease and Immunology Clinics
Nursing Education Specialist, Ambulatory Clinics
Clinic Manager, General Pediatrics and Teenage Clinic-University Station


Ambulatory Policy and Procedure Committee
Clinics Administration


Deborah D. Tinker, RN, MS, Director, Ambulatory Nursing