Chapter 20 - special conditions and environments

mobile radiography

radiographic procedures performed at the patients bedside

• requires a special mobile radiographic unit

• seldon routine, may need a creative and innnovative approach

• critical thinking is necessary

c-arm

• mobile fluoro unit

• dynamic imaging in real-time viewing

mobile radiography general guidelines

• call nursing station before leaving image department unless responding to a stat request

• ask nurse about patient’s condition

• confirm order in patients’ chart if applicable

• greet pt and explain procedure

• check patient ID, DOB on wristband

• inspect and prepare the room before bringing in the x-ray equipment

ICU and CCU

• ICU and CCU are use to care for very ill patients who require frequent if not constant monitoring

• chest radiographs is most common mobile exam requested

• must maneuver and work around a lot of equipment - cables, pumps, tubing, lines

• shield patient and provide aprons for personnel who cannot exit area to protect from exposure

post anesthesia care unit (PACU)

• referred to as recovery room

• located outside surgery for ease of transfer and access by surgeons and anesthesia personnel

  • check line placement

  • rule out pneumothorax or atelectasis

  • check orthopedic hardware placement

emergency trauma unit

• mobile is used

  • to avoid interruption of care for very critical patients

  • assess injured of spine, pelvis and chest without removing immobilization or risking confounding injuries to patient

• provide aprons for all essential ED personnel

• use proper protection from blood and other bodily fluid - self and equipment

neonatal intensive care unit and newborn nursery

• NICU - special unit for care of babies who are premature, low birth weight, or have health issue

• mobile exams often must be performed while the infant is in an incubator (necessary to keep baby warm)

• shielding is essential

• gowns and gloves are often required when handling infants - low immune systems

special beds and mattresses

• equipment provides continual position and pressure changes - decreases frequency requirements for turning patients

• examples:

  • alternating pressure mattresses - rocking beds, wave, floatation, bead mattresses

  • air pattresses - must inflate for xray

warming/cooling devices

• IR must be placed in front of those that use water or alcohol

• IR must be on top of reflective blankets

orthopedic traction

• provides constant pull on a part for therapeutic reasons

• do not change or alter traction

• ask patient to move as much as it is tolerable

• ask nurse if unsure of allowed movements

chest and tube lines

• endotracheal tubes (ET)

• chest tubes (thoracostomy)

• central venous lines

• pulmonary arterial lines

endotracheal tube (ET)

• placement of hollow tube un tracheal lumen

• typically inserted through translaryngeal approach

• commonly called intubation

• tip of tube place just above carina - 1-2 in above bifurcation

• chest radiograph required to verify position

• most common mispositioning places tip in right main stem bronchus due to angle of carina

endotracheal tube indications

• need mechanical ventilation or oxygen delivery

• insufficient ventilation

• inadequate arterial oxygenation

• parenchymal diseases that impair gas exchanges

• upper-airway obstruction

• shock

• impending gastric acid reflux or aspiration

• tracheobronchial lavage

• radiographic needed for placement and position

tracheostomies

• a tube in the opening in the trachea to provide an open airway

• sometimes hooked to a ventilator

nasogastric and nasoenteric tubes

• NG tubes - passed from nose to stomach

• NE tubes- passed from nose to duodenum

• OG - passed from oral cavity to stomach, often used along side ET tubes

• uses:

  • feeding

  • decompression or draining

  • radiographic examination

  • medication administration

• May also be called Naso intestinal tube (NI)

• watch for artifacts such as safety pins holding tube to patient gown
  

thoracostomy tubes

• also known as chest tubes

• drain intrapleural space and mediastinum

• fluid or air

• create negative pressure

• atelectasis

• pneumothorax

• hemothorax

• pleural effusion

• empyema

common insertion site (thoracostomy)

• vary with intrapleural substances to be removed

• usually inserted in 5th-6th intercostal space

• laterally and midaxillary line

• can be as high as 4th intercostal space and as low as 8th intercostal space

chest tubes

• follow up chest radiographs should be taken with patient upright or semi-upright

• to better demonstrate a pneumothorax, inspiration/expiration

specialty catheters

• placed to help monitor and manage critical patients and patients requiring long-term care

• placed in pulmonary artery, central vein, or peripherally

• care must be used to avoid disruption of catheter

• often requires c-arm during insertion

• mobile images are often used to verify placement

central venous line

• catheter that is inserted into a large vein - central venous catheter or venous access devices

• wide variety of clinical applications

  • administer a variety of drugs

  • manage fluid volume

  • draw blood and blood transfusions

  • monitor cardiac pressures

• sometimes referred to by developer - hickman, groshong, broviac, port-a-cath, mediport

• inserted into a major vein - subclavian vein, internal jugular vein, femoral vein

• if inserted into peripheral vein referred to as PICC line (peripherally inserted central catheter)

• may be single, double, or multi-lumen

• position should be superior vena cava, approximately 2-3cm above opening of right atrium

pulmonary arterial catheter (PA)

• swan-ganz catheters

• incorporates a small electrode at distal end, used to monitor pulmonary arterial pressure

• access to left ventricle requires arterial approach

• catheter placement in the left ventricle has major physiologic consequences

• safest way to assess left-sided heart pressure is to extrapolate its value by monitoring right-sided heart and pulmonary pressures

• distal tip will be in 1 of the 2 pulmonary arteries

• has balloon on distal end, during pressure monitoring inflates balloon and allows tip to float and wedge in pulmonary artery

• measures pressure, and then balloon deflates

AP chest radiograph showing:

(1) tip of Swan–Ganz catheter advanced into right pulmonary artery

(2) endotracheal tube

(3) nasogastric tube

(4) chest tube

(5) sternal wires from open heart surgery

(6) monitor lines (external)

pacemaker

• an electromechanical device that regulates the heart rate by providing low levels of electrical stimulation to the heart muscle

• often inserted under c-arm guidance

technologist responsibilities

• radiographic confirmation of line placement is essential at the time of insertion and thereafter as needed

• recognition of catheter malposition requires thorough knowledge of CV structures and their branches

• without any expectation of the radiographer to interpret the image from a pathological diagnostic standpoint, when mispositioning is thought to occur, alerting the appropriate authority is both appropriate and beneficial to patient