NURSING PATIENT CARE POLICY & PROCEDURE
April 30, 2015
Nursing Manual (Red)
Policy #: 10.11
Title: Inpatient Tuberculin Bacillus (TB) Skin
To screen UWHC inpatient population when clinically appropriate for latent
tuberculosis infection (LTBI).
A. Training and Competency
1. Staff who have received CDC education and who meet requirements for
initial and annual competency on the Mantoux Tuberculin Skin Test (TST)
may administer the TST and read results. See Related Documents listed in
UWHC Cross References.
2. Initial Mantoux TST competency (see related documents) consists of
completion of three Tuberculin Bacillus (TB) Skin Testing Procedures
assessments and the TB Skin Test Read Knowledge Verification.
3. Any UWHC TST competent staff person may sign off on performance of the
initial competency verifications.
4. The Department of Education and Development or Employee Health Services
for Nursing and Patient Care Services will maintain records of initial
B. Any patient with suspected or confirmed tuberculosis will immediately be placed
under airborne precautions in a designated negative pressure airborne infection
isolation (AII) room and all persons entering the room must comply with isolation
precautions. 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. Skin test agent, supplied in unit dose syringe, e.g., purified protein derivation
(PPD) from pharmacy and stored in refrigerator
B. Alcohol prep swabs
C. 2 x 2 gauze pads
D. Ruler with millimeter (mm) measurements
1. The provider interviewing the patient or parent/guardian will assess the need
Page 2 of 4
and appropriateness for TB skin testing.
2. The provider should ask if the patient has ever had a TST in the past or if a
severe reaction to any skin test has ever occurred.
3. The decision to administer a PPD skin test to a patient who has previously
received Bacillus Calmette–Guérin (BCG) should be made by a provider.
Previous receipt of BCG vaccination is not a contraindication to TST unless
the patient has had a previous positive skin test.
B. An order for TB skin testing must be obtained from a provider. The TST order
will generate a PPD medication administration order and a TST procedure order
to facilitate the documentation of the PPD placement and TST reading.
C. Patient Education
1. Using teach back provide education to patient or parents/guardian why the
TST is administered and describe skin test procedure.
2. The site will be examined 48 to 72 hours after the test to determine test
3. Mild itching, swelling, or irritation may occur which are normal reactions.
4. Instruct patient or parents/guardian to report anything they feel is abnormal
5. Instruct the patient to avoid scratching the site.
6. Keep the site clean and dry, and avoid putting creams, lotions, or adhesive
bandages on it.
D. Hand Hygiene
Prior to syringe preparation or test administration, appropriate hand washing
must be performed. Refer to UWHC Hospital Administrative Policy 13.08,
E. Scan medication and document according to Nursing and Patient Care Policy,
10.19 Medication Administration Using Scanning Technology
F. Syringe Preparation
1. Check the label on the unit dose syringe for proper dose and expiration date.
2. Expel all air and excess fluid from the syringe and needle, leaving exactly 0.1
mL of tuberculin solution in the syringe.
G. Test Administration
1. Administer medication intradermally. Refer to a standard clinical reference
for information about how to perform an intradermal injection.
2. The TB skin test is to be administered in the left forearm, unless there is
scarring, rash or lack of appendage on that side, then the right forearm can be
used. DO NOT perform skin test in areas with excess hair, acne or
insufficient subcutaneous tissue.
3. NOTE: If multiple skin tests are required, must be administered in
separate sites and accurately documented in patient's clinical record to
allow proper reading, e.g., PPD is placed in the left forearm and controls
(e.g., candida, mumps) in the right forearm.
4. If there is a drop of blood at the injection site. Lightly blot with a 2 x 2 gauze
pad. Do not cover the site with an adhesive bandage because the adhesive
could cause irritation and interfere with the test.
5. Document the PPD medication administration on the patient’s MAR
including the manufacturer of the injected solution, lot number, and
H. Reading Test Results
Page 3 of 4
1. The PPD (Mantoux) test must be read by a clinician who has demonstrated
competency to interpret TSTs within 48 -72 hours of PPD placement. If a
TST is not read within 72 hours the test will need to be repeated. Another
order will need to be placed by the provider
2. In a well-lighted area, observe injection site for erythema and vesiculation,
placing your two fingers over the injection site gently rub up and down over
site then side to side over injection site looking for induration. This is to be
measured. Do not measure erythema. Feel for induration.
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 Mantoux-testing
calipers. Longitudinal induration is not measured.
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. Document the TST Read in enter/edit results activity, using the following
a. Locate and highlight the TB Intradermal test in the test display
b. Enter the value of the induration measurement in the component
window in millimeters (mm)
c. Enter the date, time and status in the result detail box, right bottom
6. The provider ordering the test is responsible for interpretation. The provider
may consult an Infectious Disease physician if a positive result is suspected.
I. In immunosuppressed patients, delayed type hypersensitivity responses may
decrease or disappear. This condition is called anergy. Anergy is detected by
administering one or more delayed type hypersensitivity antigens.
1. Antigens to determine anergy are ordered by a provider, are available
through pharmacy, and are documented in the Immunization/Injection
activity in the same manner as the TB skin test.
2. UWHC uses candida for anergy testing. Persons who have a reaction
(erythema and/or induration) of greater than or equal to 3 mm are not
3. Results should be recorded in millimeters of induration, not simply positive
V. UWHC CROSS REFERENCES
A. Administering a Mantoux TB Test - Competency Verification
B. Administering & Reading Mantoux Tb Skin Test - Pre/Post Test
C. Reading a Mantoux Tuberculin Skin Test -Verification of Knowledge
D. Hospital Administration Policy 13.08, Hand Hygiene
E. Hospital Administration Policy 13.17, Control of Tuberculosis
F. Nursing Patient Care Policy 10.19, Medication Administration Using Scanning
Page 4 of 4
A. CDC (2011) TB Elimination Tuberculin Skin Testing. Accessible at:
B. CDC (2008). Division of Tuberculosis Elimination. Accessible at:
VII. REVIEWED BY
Clinical Nurse Manager, Care Initiation Unit
Infection Control Practitioner, Infection Control
Nursing Informatics Specialists, Nursing Informatics
Nursing Patient Care Policy and Procedure Committee, April 2015
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer