Patient Care for CT - Ethical, Legal, and Clinical Monitoring

Ethical and Legal Aspects of Informed Consent

  • Definition of Valid Consent: Informed consent involves several criteria that must be met for the process to be legally and ethically sound:
    • Patient Identification: Verification of the patient's identity is the first mandatory step.
    • Documentation: Consent forms must be signed by the patient or their legal guardian, witnessed, and dated.
    • Competency and Age: The patient must be mentally competent and of legal age.
    • Voluntary Participation: Consent must be offered voluntarily by the patient without coercion.
    • Level of Information: The patient must be adequately informed of the procedure. While they do not need to understand every technical aspect, the Technologist or Radiologist must explain all aspects of the procedure and associated risks.
    • Lay Terms: Explanations must be provided in language that the patient can understand.
  • Medical Records and Charts: The patient's chart serves as a record of medical care and include the date, time of entry, and electronic signatures (often managed via systems like EPIC).
    • Review Policy: Charts are typically reviewed with a doctor only upon the patient's specific request.
    • Requests: Any contradictory information found in a request must be verified by a physician.
  • Authority Over the Body:
    • As long as a patient is conscious and competent, they are the only individual with authority over their own body.
    • Consent is rendered invalid if the patient is intoxicated, under the influence of narcotics, delirious, or irrational.
    • If a patient is mentally incompetent, consent is obtained from a legally authorized person.

Spousal and Minor Consent and Implied Consent

  • Spousal Consent: A spouse is permitted to provide consent ONLY in the case of an emergency.
  • Jurisdiction Over Minors: A minor is generally under the jurisdiction of their parents until the age of majority, which is 1818 in most states.
    • Exceptions for Minor Consent: A minor may consent to their own care if they are married, emancipated, pregnant, suffering from a venereal disease, or in need of psychiatric/psychological care.
  • Implied Consent: This is consent not expressly granted but implicitly given through a person's actions.
    • Examples: If a technologist asks a patient to lie on an MRI table and the patient complies, it is implied consent.
    • Factors: Consent can be implied through silence or inaction in specific circumstances.

Patient Confidentiality and HIPAA Regulations

  • HIPAA Legislation: Passed by the U.S. Congress and enacted under the Department of Health and Human Services (HHS), this legislation mandates that patient healthcare information and records remain confidential.
  • Policies and Release: Hospitals must establish procedures for releasing information. Patients must provide clear, written permission before any data is shared with outside parties (medical, financial, or employment).
  • Patient Rights under HIPAA:
    • The right to be informed in writing about how released information will be used.
    • The right to view, copy, and amend their medical records.
    • The right to a disclosure history regarding how their information has been shared.
    • The right to restrict the sharing of information.
    • The right to file a complaint regarding HIPAA violations.

American Hospital Association (AHA) Patient Care Partnership

  • Fundamental Patient Rights:
    • Receiving respectful care.
    • Obtaining up-to-date, understandable medical information regarding diagnosis, treatment, and outcomes.
    • Being involved in decision-making throughout the diagnosis and treatment process.
    • Maintaining an advance directive on file.
    • Privacy during all aspects of diagnosis and treatment.
    • Complete confidentiality of records.
    • The right to view medical records pertaining to their case.
    • The right to expect the hospital to respond to requests for care and services.
    • Knowledge of business or educational relationships that could affect care.
    • The right to consent to or decline participation in research studies.
    • Continuity of care and options for care beyond the hospital stay.
    • Information regarding hospital policies, procedures, and resources for resolving disputes.
    • Information regarding service charges and payment options.
    • The right to refuse a procedure and to know the potential risks.

Advance Directives and End-of-Life Wishes

  • Advance Directive: A document where a person states choices for medical treatment or designates a surrogate to make choices if they lose decision-making capacity.
  • Living Will: A written, voluntary document directing that life-sustaining measures be withheld or withdrawn if the patient has a terminal condition.
  • Durable Power of Attorney for Healthcare (DPOA): A document naming another individual to make health care decisions if the patient becomes unable. It can include specific instructions for various choices.
  • Health Care Proxy: A trusted individual designated to make decisions when the patient cannot speak. This person can sign informed consent forms. Clear communication between the patient and proxy regarding extraordinary treatment and end-of-life wishes is essential.
  • Extent of Care (DNR/DNI):
    • DNR (Do Not Resuscitate): An agreement between the physician and patient (or DPOA) often used when quality of life has declined or a condition is terminal. This must be noted on the patient's chart.
    • DNI (Do Not Intubate): A specific directive regarding the avoidance of intubation.

Legal Terms and Professional Liability

  • Civil Trial Participants:
    • Plaintiff: The party bringing the suit.
    • Defendant: The party being sued.
  • Torts: A type of law for suits against healthcare workers for unintentional acts below the standard of care. This covers private/civil wrongs or injuries. Examples include assault, false imprisonment, defamation, negligence, lack of informed consent, and breach of confidentiality.
  • Liability: An obligation incurred through an act or a failure to act.
  • Assault: The threat of touching in an injurious way that causes the patient to be apprehensive. Imprudent conduct causing fear is grounds for civil assault allegations.
  • Battery: The intentional touching or use of force without permission. This includes imaging the wrong patient, imaging the wrong body part, performing procedures against a patient's will, or restraining a patient without an order.

Legal Doctrines and Professional Ethics

  • Negligence Terms:
    • Negligence: The omission of reasonable care or caution.
    • Unintentional Misconduct: Based on the Doctrine of the Reasonable Prudent Person, comparing actions to what a person with similar education and experience would do.
    • Gross Negligence: Acts showing reckless disregard for life or limb.
    • Contributory Negligence: When the injured person contributed to their own injury.
    • Malpractice: A breach of applicable standards of care resulting in harm. The burden of proof lies with the patient.
  • Respondeat Superior: "Let the master answer." The employer is responsible for the legal consequences of employee acts within the scope of employment.
  • Invasion of Privacy: Includes improperly exposing or touching a patient's body, photographing without permission, or discussing confidential info with unauthorized personnel.
  • Res Ipsa Loquitor: "The thing speaks for itself." Applied when the defendant had exclusive control and the harm could not have occurred without negligence.
  • Doctrine of Foreseeability: Liability for actions or inactions known to potentially cause injury.
  • Doctrine of Personal Liability: Individuals are liable for their own negligent behavior.
  • Spoliation: The intentional destruction or alteration of medical records/evidence without authorization.
  • Beneficence and Non-maleficence: Beneficence refers to acts of mercy and charity. Non-maleficence means "First do no harm."
  • Stare Decisis: "To stand by things decided."
  • Doctrine of Double Effect: An action causing harm as an unintended side effect of a beneficial action is permissible (e.g., the intended good effect versus the indirect bad consequence).

Patient Restraints vs. Immobilization

  • False Imprisonment: Unjustified restraint of a person, such as refusing to let a patient leave or using restraint straps inappropriately.
  • Safety Protocols:
    • Never leave patients unattended.
    • Use safety straps on tables.
    • Use immobilization devices for pediatric patients when necessary.
  • Legal Requirements for Restraints: A written physician order is required for restraints unless they are used solely for radiographic positioning.
  • Restraint Types:
    • 44-Point Restraint: Used for patients on stretchers.
    • Vest Restraint: Used for patients in wheelchairs.
    • Supervision: Disoriented, unstable, sedated, senile, or intoxicated patients must not be left alone.

Interpersonal and Professional Communication

  • ARRT Standards of Ethics:
    • Ethics: The science of human behavior to systemize morally correct conduct.
    • Code of Ethics: Specific guidelines for professional conduct.
    • Rules of Ethics: Mandatory and enforceable rules. Honor code violations (cheating, suspension) can prevent ARRT certification.
  • Components of Effective Communication: Skills include active listening, verbal and written communication, nonverbal communication, trust, cultural awareness, compassion, and patient education.
  • Importance of Clear Communication: Builds professional relationships, ensures accurate exam explanations, makes patients comfortable, and demonstrates respect.
  • Modes of Communication:
    • Verbal: Clear, distinct language in terms the patient understands; tone of voice must remain professional regardless of personal stress.
    • Nonverbal: Facial expressions, eye contact, and body motions. Touch must be appropriate and purposeful.
    • Written: Utilizing the written word to convey information.

Challenges and Diversity in Communication

  • Barriers to Communication:
    • Language: Use certified interpreters and post signs about availability.
    • Hearing Impairment: Get attention before speaking, face the patient, and speak at a moderate pace without background noise.
    • Deafness: Use ASL interpreters, gestures, or written instructions.
    • Vision Impairment: Good communication helps determine the specific help needed.
    • Aphasia: A defect in language function due to brain injury. Use artificial speech aids and simple instructions.
    • Emotional Status: Use supportive listening and rephrase patient remarks to convey acceptance.
  • Diversity Factors: Technologists must respect diversity across age, gender, race, ethnicity, sexual preference, family structure (nuclear vs. extended), marital status, socioeconomic background, political/religious beliefs, geographic origin, and mental or physical disability.
  • Special Patient States:
    • Children: Get on their level and be truthful about choices.
    • Altered Consciousness: Communicate as if they can hear; recognize they may not remember instructions or may give incorrect answers (e.g., stroke patients).

Psychological Frameworks and The Grieving Process

  • Maslow’s Theory (Physiologic Needs): Basic needs include food, shelter, air, water, sleep, and sexual fulfillment. If these are unmet, a person cannot pursue higher needs.
  • The Grieving Process (Kübler-Ross): Patients facing terminal diagnoses, disfigurement, or loss may move through these stages:
    • 11. Denial
    • 22. Anger
    • 33. Bargaining
    • 44. Depression
    • 55. Acceptance

Patient Education and CT Procedure Preparations

  • Technologist Scope: Patient education is part of the scope of practice. This includes explaining the procedure purpose, length, and answering questions.
  • CT Preparation and Medications:
    • Movement: Patients must remain still. Use sponges/sheets for comfort and head security.
    • Diet: Abdominal contrast studies require the patient to be NPO (nothing by mouth) or avoid solid food for 44 hours prior.
    • Metformin: Patients must stop taking Metformin at the time of or prior to CT studies with IV contrast and withhold it for 4848 hours after the procedure.
    • Post-Procedure: Discharge instructions should include drinking plenty of water to filter contrast material.

Physical Assistance, Body Mechanics, and Patient Transfer

  • Body Mechanics:
    • Balance: Establish a broad base of support (feet apart, one slightly forward) and keep loads balanced.
    • Alignment: Center of gravity should be in the pelvis. Bend from the knees, not just the waist.
    • Movement: Lift with leg muscles; roll or push heavy objects rather than lifting when possible.
  • Transfer Methods:
    • Wheelchair: Angle at 45∘45^∘ to the table. Lock brakes and move footrests. If a 22-person lift is needed, place the chair parallel to the table.
    • Gurney (Stretcher): Keep rails up except during transfer. Require a minimum of 33 people for transfer.
    • Log Roll: Requires 44 to 55 people. Specifically used for patients with known or suspected spinal injuries.

Assisting Patients with Medical Equipment

  • Oxygen Delivery Systems:
    • Low Flow: Mixed with room air.
    • High Flow: Controlled mix of room air and oxygen.
    • Nasal Cannula: 21%21\% to 60%60\% oxygen for patients with normal breathing rates.
    • Nasal Catheter: Inserted to the trachea; not common.
    • Face Mask: Variable oxygen levels; not precise.
    • Nonrebreathing Mask: 11-way valve; can supply 100%100\% oxygen; most precise.
    • Partial Rebreathing Mask: Reservoir bag; 60%60\% to 90%90\% oxygen.
    • Venturi Mask: Precise delivery; used for specific room air/oxygen percentages.
    • Oxygen Tent: Used for children for cool/humid oxygen.
  • Other Respiratory Aids:
    • Ambu Bag: Used for emergency respiratory assistance or temporary support for ventilator-dependent patients.
    • Tracheostomy Collar: Provides mist to tracheostomy tubes.
    • Mechanical Ventilator (Respirator): For patients unable to breathe independently.
  • Tubes and Catheters:
    • Nasogastric (NG) Tubes: Levin and Sump tubes.
    • Urinary Catheters: Sterile procedure. Keep the drainage bag below the level of the bladder. Clamp tubing only if required by a specific procedure or if the bag must be raised briefly.
    • Tracheostomy Tubes: Incision in neck for long-term airway maintenance.

Routine Monitoring: Vital Signs — Temperature

  • Body Temperature: The balance between heat produced and heat lost.
  • Measurement Sites and Norms:
    • Oral (under tongue): Normal is 37∘C37^∘\text{C} (98.6∘F98.6^∘\text{F}). Do not use if the patient is on oxygen.
    • Infrared (forehead): Normal is 36.7∘C36.7^∘\text{C} (97.6∘F97.6^∘\text{F}).
  • Terms:
    • Pyrexia (Fever/Febrile): Elevation above normal, specifically 100.6∘F100.6^∘\text{F} and above.
    • Hyperpyrexia: Extreme high temperature, 105.8∘F105.8^∘\text{F} and above.
    • Hypothermia: Below normal, specifically below 95∘F95^∘\text{F} (oral).

Routine Monitoring: Vital Signs — Pulse and Respiration

  • Pulse Dynamics: Wave in the artery from left ventricle contraction.
    • Monitoring: Use a watch with a second hand at the carotid artery or a stethoscope for apical pulse.
    • Adult Average: 6060-9090 beats/min.
    • Infant Average: 120120 beats/min.
    • Child Average: 9090-100100 beats/min.
    • Pulse Terms: Tachycardia (>100> 100 bpm), Bradycardia (<60< 60 bpm), Palpitation (patient awareness of heartbeat), and Arrhythmia (irregular rhythm).
  • Respiration Dynamics: Exchange of oxygen and carbon dioxide.
    • Adult Average: 1212-2020 respirations/min.
    • Child Average: 2020-3030 respirations/min.
    • Infant Average: 3030-5050 respirations/min.
    • Ratio: Approximately 11 respiration per 44 heartbeats.
  • Respiratory Distress Symptoms: Cyanosis, apprehension, restlessness, diaphoresis, and needing to sit up or lean forward to breathe.
  • Respiratory Terms:
    • Apnea: Not breathing.
    • Dyspnea: Labored breathing.
    • Orthopnea: Ease of breathing only when upright (erect), common in COPD.
    • Tachypnea: Rapid breathing.
    • Oligopnea: Shallow, slow breathing.
    • Hypoxia: Low blood oxygen; pulse oximetry reading of 85%85\% or lower.
    • Cheyne-Stokes: Dyspnea followed by apnea.
    • Hyperventilation: Low carbon dioxide with increased rate and depth.

Routine Monitoring: Vital Signs — Blood Pressure

  • Blood Pressure Dynamics: Flow from the left ventricle during systole versus systemic vascular resistance.
    • Systolic: Ventricular contraction.
    • Diastolic: Heart at rest.
    • Pulse Pressure: The difference between systolic and diastolic values.
  • Measurement:
    • Instrument: Sphygmomanometer and stethoscope.
    • Unit: Millimeters of mercury (mm Hg\text{mm Hg}).
    • Adult Normal: Systolic 110110-140 mm Hg140\,\text{mm Hg}; Diastolic 6060-80 mm Hg80\,\text{mm Hg}.
  • Pathological Values:
    • Hypertension: Systolic >140> 140 or Diastolic >90> 90.
    • Hypotension: Systolic <90< 90.
    • Shock: Diastolic pressure at 40 mm Hg40\,\text{mm Hg} or lower.
    • Orthostatic Hypotension: Drop in pressure when rising quickly; place patient in Fowler's position.
  • Auscultation: Listening for Korotkoff sounds over the artery as cuff pressure is released.

Pulse Oximetry and Invasive Procedure Monitoring

  • Pulse Oximeter (Capnometer): Monitors hemoglobin oxygen saturation (SaO2SaO_2) via sensors on the fingertip or earlobe.
    • Normal range: 95%95\% to 100%100\%.
    • Oxygen Deficiency: Values less than 85%85\%.
    • Indications for Use: Sedated, unresponsive, uncommunicative, psychiatric, or pediatric patients, and those with weak voices or hearing impairment.
  • Invasive Procedure Risk (e.g., Biopsy): Monitor hemorrhage risk using:
    • Prothrombin time (PT)
    • International normalized ratio (INR)
    • Platelet count
    • Hematocrit (to assess hydration)

Physical Assessment, Documentation, and Special Populations

  • Monitoring Signs: Assess motor control, injury severity, skin color (diaphoretic), and levels of consciousness (Alert, Drowsy, Unconscious but reactive, or Comatose).
  • Fall Prevention: Use gait belts for weak patients. Keep equipment away from corners/hallway intersections.
  • Charting: Records should include clear statements on condition, reactions to contrast, amount of contrast injected, date, and time. Errors must be corrected electronically according to protocol.
  • Special Population Considerations:
    • Geriatric: Fragile skin, balance issues, and kyphosis.
    • Head Injury: Maintain the airway.
    • Sedated Patients: Use safety straps and side rails. Do not leave unattended. No driving or alcohol for 2424-2828 hours post-procedure. Monitor with pulse oximetry.
    • Pediatric Sedation: Requires NPO for 44 hours prior.
    • CT Communication: Tell patients about table movement into the gantry and intercom availability. Friends/family may only stay for pediatric scans and must wear lead aprons.