# Situation: The father, 40, a construction worker, has bacteriologically confirmed pulmonary tuberculosis (TB) and started treatment 2 months ago at the Rural Health Unit (RHU), 12 km from home. The family of five lives in a one-room house with small windows that are kept closed. The children are 3, 7, and 12 years old. A barangay health station (BHS) with a midwife is within walking distance of the home. One objective states: "Within 1 month, the father will not miss any dose of his TB drugs." Which data should the nurse use to evaluate this objective?

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> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: The father, 40, a construction worker, has bacteriologically confirmed pulmonary tuberculosis (TB) and started treatment 2 months ago at the Rural Health Unit (RHU), 12 km from home. The family of five lives in a one-room house with small windows that are kept closed. The children are 3, 7, and 12 years old. A barangay health station (BHS) with a midwife is within walking distance of the home.

One objective states: "Within 1 month, the father will not miss any dose of his TB drugs." Which data should the nurse use to evaluate this objective?

## 보기

1. The father's weight compared with his weight last month
2. The father's own report that he feels much better
3. The treatment card with each dose taken recorded **✔ 정답**
4. The result of the follow-up sputum examination

**정답: 3**

## 해설

The objective is about taking every dose, so the direct evidence is the treatment card on which each dose taken is recorded. Feeling better, weight gain, and sputum results reflect response to treatment, which relates to the broader goal, but they do not show that no dose was missed.

## 심화 해설

The objective focuses on medication adherence, specifically whether the father completes every scheduled dose over a one-month period. To evaluate this, the nurse needs a direct, objective record of dose-by-dose intake, not indirect markers of clinical improvement.

Why the treatment card is the correct data source

The treatment card is a dose-by-dose documentation tool used in TB programs, especially under directly observed treatment (DOT) or facility-based supervision. Each time the father takes his anti-TB drugs, the health worker or midwife records the dose on the card. This creates a continuous, verifiable record that directly answers the question: Did the father miss any dose during the past month?

Adherence measurement in TB care has no single perfect gold standard, but dose documentation remains the most practical and widely used method in low-resource settings [1]. The treatment card functions as a proxy for directly observed ingestion, meaning it captures whether the dose was actually taken under supervision, not just whether the patient claims to have taken it.

| Data source | What it measures | Can it detect a missed dose? |
| --- | --- | --- |
| Treatment card | Each dose taken, recorded at the time of administration | Yes — direct evidence of adherence |
| Weight change | Nutritional and clinical response over time | No — weight may improve even with occasional missed doses |
| Patient’s self-report of feeling better | Subjective symptom improvement | No — feeling better does not confirm every dose was taken |
| Follow-up sputum examination | Bacteriological response to treatment | No — sputum conversion reflects overall treatment efficacy, not daily adherence |

Key point! Weight gain, symptom improvement, and sputum conversion are outcome indicators that reflect whether treatment is working. They belong to the broader goal of “cure” or “treatment success.” The objective in this scenario is narrower: no missed dose within one month. Only the treatment card directly measures that process indicator.

Watch out! A patient can feel better and gain weight while still occasionally skipping doses, especially early in treatment when symptom relief occurs rapidly. Conversely, a patient who takes every dose may not yet show sputum conversion at the two-month mark. Therefore, these clinical markers cannot substitute for dose-by-dose documentation.

In the Philippine Rural Health Unit (RHU) and Barangay Health Station (BHS) context, the treatment card is the standard tool for the National Tuberculosis Control Program (NTP). The midwife at the BHS, within walking distance of the home, can directly observe and record each dose. This aligns with the WHO recommendation that directly observed treatment be complemented by reliable documentation, and digital or paper-based monitoring improves adherence tracking . Video observed therapy (VOT) is an emerging alternative, but it still relies on verifiable documentation of each ingestion event, not on clinical outcomes .

Thus, when the nurse evaluates the objective “the father will not miss any dose,” the most valid and reliable data source is the treatment card showing each dose taken, with any gaps immediately visible.References (research sources)

- [1]How do we measure adherence to anti-tuberculosis treatment?Research articleValencia S, León M, Losada I, Sequera VG, Fernández Quevedo M, García-Basteiro AL (2017) · DOI: 10.1080/14787210.2017.1264270

## 임상 시나리오

TB Adherence EvaluationUse the treatment card for dose-by-dose evidence
When the objective is no missed dose, evaluate with the treatment card, which records each dose at the time of administration. This is the only direct, objective evidence of adherence.

Weight gain, feeling better, and sputum conversion reflect treatment response, not dose-by-dose intake. They may improve even with occasional missed doses.

CautionDo not rely on patient self-report or clinical improvement to confirm that every dose was taken. Check the treatment card at each follow-up visit.

## 핵심 개념

- **treatment card** — Dose-by-dose documentation tool used in TB programs to record each administered dose, serving as direct evidence of adherence.
- **medication adherence** — The extent to which a patient takes every scheduled dose of prescribed medication without omission.
- **DOT** — Directly observed treatment; a health worker watches the patient take each dose, improving adherence verification.
- **sputum examination** — Laboratory test to detect TB bacilli; used to monitor treatment response, not daily adherence.
- **evaluation** — Process of comparing actual outcomes with set objectives using measurable, objective data.

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