Unit 7
Ergonomics
Body Mechanics
Base of Support
Center of Gravity
Lifting Principles
Standby - Assist Transfer
Assisted Standing Pivot Transfer
Two-Person Lift
Hydraulic Lift Techniques
Cart Transfers
Aseptic Techniques
Surgical Asepsis
Sterile Field
Sterile Draping
Surgical Hand Scrub
Surgical Hand Rub
Sterile Gowning
Sterile Gloving
Dressing Changes
Mobile (Portable) Radiography
Surgical Radiography
ED
NICU
ICU
CCU
Endotracheal (ET) Tubes
Chest Tubes (Thoracostomy)
Central Venous Pressure (CVP) Lines
NG Tube
NE Tube
Urinary Catheters
Foley Catheter
Straight Catheter
Introduction to Radiologic Sciences and Patient Care 5th Edition (Adler and Carlton)
Chapter 13 - Pages 146-157
Chapter 15 - Pages 185-192
Chapter 17 - Pages 216-233
Here is what you must complete within Unit 7!!!
1. Reading Assignment
2. Read through the Lesson
3. Complete the Unit 7 Test
Ergonomics - The study of the human body in relation to the working environment
Ergonomic awareness and education in the workplace have reduced job injuries in recent years.
Body Mechanics - The principles of proper body alignment, movement and balance.
The purpose of a patient transfer is to safely move a patient from one place to another. Safety involves both the patient and the people doing the transfer. The application of proper lifting and transfer techniques increases job safety. Radiologic imaging professionals who use proper transfer techniques can reduce their injuries and minimize low back pain.
***Fundamental to good patient handling techniques are the concepts of the base of support, center of gravity and mobility and stability muscles.***
Base of Support - The base of support is the foundation on which a body rests. Base of support is the area between the feet, including the plantar surface area, in a standing position.
Here are some guidelines for base of support:
1. A wider stance improves your base of support.
2. Standing with both feet flat on the floor improves the base of support.
3. Standing with feet apart to increase the base of support improves stability.
4. Standing on "tiptoes" decreases surface in contact with the floor and narrows the base of support.
Center of Gravity - A hypothetical area of the body where the mass of the body is concentrated; gravity works from this area.
The center of gravity is typically at the level of the second sacral segment. Holding heavy objects close to your center of gravity permits easier and safer transfer. Stability can be achieved when a body's center of gravity is over its base of support.
Muscles and Transfers
Extremity muscles are classified as mobility muscles. Muscles of the torso are stability muscles. For effective patient transfers and handling, technologists should use mobility muscles for lifting and stability postural muscles for support.
Good Body Mechanics
Here are some principles of good body mechanics:
1. Use good posture and provide a broad base of support.
2. Always keep your body's line of balance close to your center of gravity (below waistline).
3. Hold object well balanced and close to your body.
4. When lifting, bend your knees and keep your back straight.
5. Don't twist your trunk.The most common cause of back strain is bending and twisting while lifting.
6. Roll or push a heavy object. Avoid pulling or lifting.
7. Work at a comfortable height.
Transfer Techniques Mean Teamwork!
Someone needs to take charge of the transfer by:
1. Reviewing all procedures with team members.
2. Calling the play
3. Establishing timing of the play
4. Synchronizing play events
Patient-Transfer Considerations - You need to know the age and condition of the patient you will be moving.
1. Moving patients from one place to another in a hospital requires wheeled transport which is the only method to assure patient safety.
2. Wheelchairs can be used for those who can sit upright.
3. Stretchers can be used for those too weak to sit.
4. Small children may be transported in cribs.
5. Infants may be transported in incubators.
Preparation for Transfer - You must make sure to follow these steps in preparing to transfer a patient.
1. Check with nursing service and obtain chart.
2. Check patient identification.
3. Plan what you are going to do and prepare your work area.
4. Obtain equipment and check it for safety and function.
5. Enlist the patient's help and cooperation. In order to enlist the patient's help, you must communicate with the patient what you are doing.
6. Obtain additional help when necessary to avoid injury. Communicate role of assistants in the transfer plan.
•Lifting should be done by bending and straightening the knees.
•The back should be kept straight or in a position of slightly increased lumbar lordosis. Twisting should be avoided.
•Allow ample time and handle patients gently. Execute the transfer slowly enough for the patient to feel secure.
•Always inform the patient of what you are going to do and how you intend to proceed.
•Before executing the transfer, check the patient's chart and verify whether he or she has a restricted weight-bearing status.
•Patients with cognitive impairments, such as dementia, may overestimate their transfer abilities and require assistance.
•When performing a transfer, let patients do as much of the work as possible. By asking a patient what his or her moving capabilities are, the radiographer provides only the assistance needed to move the patient comfortably.
•The patient's center of gravity should be held close to the transferer's center of gravity.
•Taking a transfer belt is a good practice when planning to perform transfers.
•Avoid loose clothing on the patient.
•When lifting patients, keep the back stationary and let the legs do all of the lifting.
•After the patient is standing, help him or her to pivot around to a bed or x-ray table and to sit down.
First, you must determine the patient's strong and weak sides. Always position the patient so that he or she transfers toward the strong side. Lock wheelchair locks and move footrests out of the way.
Take special considerations for wheelchair transfers on patients who:
1. Are stroke victims
2. Have fractures of the lower extremity
3. Have spinal trauma or surgery
4. Cannot stand safely
Four Types of Wheelchair Transfers
Standby - Assist Transfer
This is used for patients who have the ability to transfer from a wheelchair to a table on their own. But, you must provide movement instructions to the patient continually during transfer.
Assisted Standing Pivot Transfer
An assisted standing pivot transfer is used when transferring a patient from a wheelchair to a table. Use a transfer belt to hold the patient securely. Have the patient sit on the edge of the wheelchair seat. Provide assistance as needed. Have the patient push down on the arms of the wheelchair to assist in rising. Bend at the knees, keeping your back straight, and grasp the transfer belt with both hands. As the patient rises to a standing position, rise also by straightening your knees. When the patient is ready, pivot toward the table until the patient can feel the table against the back of the thighs. Ask the patient to hold onto the table with both hands and to slowly sit down.
Two-Person Lift
The two-person lift is used for non-weight bearing patients. The first person asks the patient to cross his or her arms over the chest. The person making the transfer stands behind the patient, reaches under the patient's axillae and grasps the patient's crossed forearms. The stronger person should lift the torso. The assistant squats in front of the patient and cradles the patient's thighs in one hand and the patient's calves in the other. At the command of the person supporting the patient's upper body, the patient is lifted to clear the wheelchair and moved as a unit to the desired place.
Hydraulic Lift Techniques
The hydraulic lift is used for heavy patients. Familiarize yourself thoroughly with lift operations before using this type of lift. Patients need to be seated on a lift sling before using this type of lift. Sending a patient back to the ward to return sitting on a sling is better than risking injury to the patient, the transferer, or both by attempting transfer without using a sling. Communication is critical to lift success.
Bed-to-Wheelchair Transfer
1. Lower the bed to wheelchair level, and elevate the head of the bed.
2. Position the wheelchair parallel to the bed with wheels locked and footrests out of the way.
3. With the patient in the supine position, place one arm under the patient's shoulders, one under the knees, and in a single, smooth motion, raise and turn the patient to a sitting position with his or her feet dangling over the side. Patients with back pain may find it easier to sit up from a lateral recumbent position.
4. Take a moment to assist the patient with slippers and a robe, and allow time for the patient to regain a sense of balance, as this may help to alleviate orthostatic hypotension. At this point, competent patients are able to stand and move to the wheelchair with little assistance, although a steadying hand at the patient's elbow is a good practice.
5. A gait belt, or transfer belt, should be used with weak, unsteady patients, which provides a secure hold. Grasp the gait belt or reach around the patient and place your hands firmly over the scapulae; the patient's hands may rest on your shoulders. On your signal, lift upward to help the patient stand. Use a broad base of support and keep your back straight. Now instruct and assist the patient to pivot a quarter turn so that the edge of the wheelchair is touching the back of the patient's knees, then ease the patient into a sitting position in the chair. Position the footrests and leg rests, and cover the patient's lap and legs with a sheet or bath blanket to provide warmth and comfort and to protect the patient's modesty.
6. Falls most commonly occur when the patient sits in the wheelchair. The patient may miss the edge of the seat or tip the chair by sitting too near the edge. To avoid such an accident, be sure to lock the wheels of the chair and assist the patient until seated securely.
Wheelchair-to-X-Ray Table Transfers
1. Place the wheelchair parallel to the table, lock the brakes and move footrests out of the way.
2. Adjust the height of the table lower to the chair height.
3. Help the patient to stand and pivot with the patient's back to the table.
4. Then ease the patient into a sitting position on the edge of the table.
5. If the table is a stationary table, place a step stool with a tall handle nearby.
6. Have the patient place one hand on the stool handle, put the other arm on your shoulder and step up onto the stool, pivoting with the back to the table.
7. Now ease the patient to a sitting position.
8. After the patient is seated on the table, raise the table if its height is adjustable.
9. Place one arm around the patient's shoulders and one under the knees. With a single, smooth motion, place the patient's legs on the table while lowering the head and shoulders into the supine position. Patients with back pain may want to lie on one side before moving into the supine position.
Patient Positioning Considerations
Talk with the patient and explain what you are going to do. Let the patient assist as much as possible. Check with patient before any move is attempted. Provide positioning sponges to help the patient maintain correct positioning. Work as a transfer team!
Cart Transfers
Make sure cart wheels are locked and immovable. Allow patient to assist with move based on the patient's ability and condition. Cart transfers usually require three people. Use transfer aids. For the actual lateral transfer, both transfer surfaces must be side to side, as close as possible and at the same height.
Three methods with transfer aids:
1. Draw sheet
2. Slider board
3. Sliding mat
Patient Transfer with Draw Sheet
Begin by rolling up the draw sheet on both sides of the patient. The person directing the transfer supports the patient's head and upper body from the far side of the radiographic table. An assistant supports the patient's pelvic girdle from the cart side. A second assistant supports the patient's legs from the tableside. The patient's arms can be crossed over the chest to avoid injury or getting in the way.
Safety Side Rails
Safety side rails are required to be in up and locked position:
1. For patients who are impaired or unconscious.
2. When patients are left unattended on a stretcher.
Aseptic Techniques
Aseptic technique can be applied in any clinical setting. Typical situations that call for aseptic measures include surgery and the insertion of intravenous lines, urinary catheters and drains. The goals of aseptic technique are to protect the patient from infection and to prevent the spread of pathogens and/or harmful microorganisms.
Surgical Asepsis - Protection against infection before, during and after surgery by using sterile techniques.
1. Any sterile object or field touched by an unsterile object or person becomes contaminated.
2. Never reach across a sterile field. Organisms may fall from your arm into the field. Reaching across increases the risk of brushing the area with your uniform.
3. If you suspect an item is contaminated, discard it. When in doubt, consider it contaminated. This includes damp items, items with broken seal or on which the indicator tape has not assumed the correct color.
4. Do not pass between the physician and the sterile field.
5. Never leave a sterile area unattended, no one would know if field were contaminated.
6. A one-inch border at the perimeter of the sterile field is considered a "buffer zone" and is treated as if it were contaminated.
Sterile Field - A microorganism-free area that can receive sterile supplies. Do not put anything on a sterile field that is not clean, dry or that is expired. Only sterile items are used in sterile fields.
Sterile Corridor - The area between patient drape and instrument table.
Establishing a Sterile Field and Sterile Draping
A sterile field is established using a sterile drape. A first step in using a sterile drape is confirming that the package is sterile. If it appears to have been previously opened or the expiration date has passed, it is considered unsterile. Hold the drape with one hand by the corner. Fold back the top to lift the cover and laying the drape on a clean, dry surface with the bottom farthest from the person establishing the field.
When opening sterile contents for a procedure, drop the contents gently onto the sterile field from approximately 6 inches above the field and at a slight angle. This technique helps ensure that the package wrapping does not touch the sterile field at any time.
When opening a sterile pack (tray), such as a myelogram pack, place the pack on a clean surface within reach of the physician. Just before the procedure begins, break the seal and open the pack. Unfold the first corner away from you; then unfold the two sides. Pull the front fold down toward you and drop it. Do not touch the inner surface. The inner wrap, if there is one, is opened in the same manner. You have now established a sterile field.
Skin Preparation for Sterile Procedures
1. Obtain a "skin-prep set" and a bottle of antiseptic for painting the skin. The preparation set includes a basin, liquid soap such as pHisoderm, gauze sponges, razor, towel, forceps and medicine cup.
2. Perform hand hygiene.
3. Place the patient in a comfortable position and ensure privacy.
4. Explain what is to be done.
5. Expose an area slightly larger than the preparation site, keeping the patient as completely covered as possible to provide comfort and modesty.
6. Fill the basin with warm water.
Note: If hair removal is not ordered, omit steps 7 to 10.
7. Using a gauze sponge, thoroughly wet the area to be shaved and apply soap, forming a lather.
8. Shave a small area at a time. Hold the skin taut with one hand and shave with short, firm strokes in the direction of hair growth. Rinse the razor frequently.
9. Rinse the area, removing all the hair.
10. Rinse and refill the basin with warm water.
11. Using soap and a fresh gauze sponge, cleanse the area completely. Starting at the puncture site, use a circular motion and scrub in ever-widening circles. Do not scrub harshly, but remember that friction is more effective than soap in cleansing the skin.
12. Use a sterile gauze sponge to remove the soap and water, again using a circular pattern and starting at the center. This pattern avoids recontamination of the area that has been cleansed.
13. Pour a little of the antiseptic into a waste container to cleanse the lip of the bottle.
14. Fill the medicine cup with antiseptic.
15. Grasp several gauze sponges with the forceps and dip them into the antiseptic.
16. Paint the skin with the antiseptic, starting in the center of the area and working outward in a circular pattern. Discard the sponge.
17. Allow the skin to dry.
18. Repeat steps 16 and 17.
19. Open the pack containing the sterile drape or sterile towels. The physician, wearing sterile gloves, will drape the area surrounding the prepared site.
Surgical Hand Scrub
1. Don cap or hood, mask; don protective goggles, if appropriate.
2. Using foot or knee lever, adjust water flow and temperature.
3. Wet your hands. Add a few drops of antimicrobial soap and more water as needed to make lather.
4. Wash your hands and forearms thoroughly. Use one brush and soap to clean your nails and clean under your nails with the nail cleaner.
5. Rinse your hands and arms thoroughly, keeping your hands higher than your elbows. Take care to avoid splashing your scrub clothes - dampness may later moisten your sterile gown, causing contamination.
6. Using the second brush and more soap, the actual scrub begins. Number of strokes used:
A. Nails - 30 strokes.
B. 20 strokes to each area of the skin, which usually takes about five minutes.
7. The fingers, hands and arms should be visualized as having four sides and each side must be effectively scrubbed.
A. Starting with the fingernails, scrub them vigorously, holding the brush perpendicular to them.
B. Then scrub all sides of each finger and the palms and backs of the hands.
C. Use a circular motion to scrub each side of the forearms and elbows, up to two inches above the elbows.
8. Keep your hands above your elbows while scrubbing and add small amounts of water as needed to maintain a good lather. When scrubbing is completed, discard the brush.
9. Rinse your hands and arms thoroughly.
10. To dry, grasp the corner of a sterile towel and step back from the field, allowing the towel to fall open. Bend forward at the waist and hold your arms away from your body and above your waist. Dry your hands, then your arms, thoroughly, rotating the towel as required.
11. Take care not to contaminate the sterile field, the towel or your hands.
12. You are now ready to don your sterile gown and gloves.
Surgical Hand Rub
1. Don cap or hood, mask; don protective goggles, if appropriate.
2. Using foot or knee lever, adjust water flow and temperature.
3. Wash hands and arms with approved nonantimicrobial soap and water.
4. Clean fingernails under running water using disposable nail cleaner; discard nail cleaner.
5. Rinse hands and arms under running water.
6. Dry hands and arms.
7. Dispense 2 mL (one foot pump) of antiseptic hand prep into the palm of one hand. Do not use water with the hand prep.
8. Dip the fingertips of the opposite hand into the hand prep and work it under the nails.
9. Spread the remaining hand prep evenly over the hand, forearm and elbow, covering all surfaces.
10. Using an additional 2 mL of hand prep, repeat steps 7 to 9 with the other arm.
11. Dispense an additional 2 mL of antiseptic hand prep into either palm and reapply to all aspects of both hands up to the wrists.
12. To facilitate drying, continue running antiseptic hand prep into hands until dry.
13. Keep scrubbed hands and arms in view and avoid contamination; allow to dry completely before donning gloves.
Sterile Gowning with Closed Gloving Technique
1. Assistant opens gloves and sterile gown pack.
2. Lift folded sterile gown and step back from table. Allow gown to unfold with inside of gown toward you. Do not shake the gown.
3. Insert arms into sleeves.
4. Do not allow hands to protrude through cuffs.
5. Assistant fastens gown at neckline.
6. With dominant hand remaining inside sleeve, pick up glove for nondominant hand.
7. Insert nondominant hand into glove. Stretch cuff of glove over cuff of gown.
8. With nondominant hand, pick up second glove. Stretch cuff of glove over cuff of gown.
9. Closed gloving is complete.
10. Separate waist tie from gown and pass tie with tab to assistant.
11. Turn in a circle to wrap tie around your waist.
12. A sharp tug on tie will separate it from the contaminated tab, allowing you to fasten the tie without contaminating gown.
Open Gloving Technique
1. Perform hand hygiene. Obtain gloves, and check for correct size.
2. Open outer wrap to remove folded inner wrap.
3. Expose gloves with open ends facing you.
4. Open inner wrap completely, taking care not to contaminate gloves or wrap immediately surrounding gloves.
5. With one hand, grip cuff fold of glove for opposite hand.
6. Put on first glove, touching only inner surface of folded cuff.
7. Using gloved hand, grasp second glove under cuff.
8. Insert hand into second glove.
9. Put on second glove, and unfold cuff.
10. Insert fingers under cuff of first glove, and unfold cuff.
11. Gloving complete. Keep hands in front of body and at safe distance from uniform to avoid contamination.
Gowning Another Person
Grasp the gown so that the outside faces toward you. Holding the gown at the shoulders, cuff your hands under the gown's shoulders. The person steps forward and places his or her arms in the sleeves. Slide the gown up to the mid-upper arms. The circulator assists in pulling the gown up and tying it. Gently pull the cuffs back over the person's hands. Be careful that your gloved hands do not touch his or her bare hands.
Two-Person Gloving
Pick up the right glove and place the palm away from you. Slide the fingers under the glove cuff and spread them so a wide opening is created. Keep thumbs under the cuff. The person thrusts his or her hands into the glove. Do not release the glove yet. Gently release the cuff (do not let the cuff snap sharply) while unrolling it over the wrist. Proceed with the left glove, using the same technique.
Removing Sterile Gloves
Grasp the edge of the glove. Unroll the glove over the hand. Discard the glove. With the bare hand, grasp the opposite glove cuff on its inside surface. Remove the glove by inverting it over the hand. Discard the glove.
Dressings are best changed in a team setting with another radiologic and imaging sciences professional. The physician is responsible for ordering dressing changes and reapplication. Be sure to secure privacy for the patient. Explain the procedure to the patient. Secure consent before beginning the procedure. All dressings are treated as though they are infected.
Dressing Removal
1. Do not touch a dressing with bare hands.
2. The hands are washed and patient privacy and consent are obtained.
3. Inform the patient of what you are about to do.
4. The adhesive tape surrounding the dressing is removed.
5. Use care in removing the dressing to prevent cross contaminating the wound and yourself. Remove the dressing gently to avoid hurting the patient.
6. The dressing is removed with forceps or gloved hands, wrapped and placed in the plastic bag. Place the soiled dressing in a plastic bag and seal it before adding it to the biohazard container.
7. Remove your gloves following the same procedure used with isolation techniques. Perform hand hygiene.
Applying a Sterile Dressing
Prepare supplies:
1. Sterile gloves
2. Sterile drape
3. Sterile gauze
4. Tape
5. Normal saline
For reapplication, sterile technique is followed.
1. Tell the patient what you plan to do.
2. The hands are washed and the sterile towel is opened to use as a sterile field on which to place sterile dressings.
3. Open the dressing package and add the sterile dressing to your sterile field.
4. Tear several strips of tape to a convenient length. Because the tape is not sterile, it is placed near but not on the sterile field.
6. If you will need to cleanse around the wound, drop sterile gauze sponges into your field for this purpose.
7. To moisten the gauze sponges, open a small vial of sterile normal saline solution. Recheck the label and pour a small amount of the saline over the sponges. Do not allow liquid to soak through to the sterile towel. Check the label for the third time before discarding the vial.
8. Don sterile gloves using the open method described for sterile gloving.
9. Use the moist sponges to clean gently around the wound.
10. Allow the area to dry completely.
11. Apply the dressing over the wound, and secure it in place with tape.
12. Cover the patient.
13. Dispose of any waste according to the institutional policy.
14. Remove your gloves.
15. Perform hand hygiene.
Mobile Radiography (Portable Radiography) - Radiographic procedures performed at the patient's bedside.
Mobile radiography requires a special mobile radiographic unit. Mobile radiographic units are used extensively in the hospital in many settings. The x-ray capabilities are similar to those of a fixed radiographic unit. Designs are compact and user-friendly. There is limited power for x-ray studies. The exposure switch is on a coiled cord to maximize distance from the patient during exposure. The portable unit must be plugged into wall outlet for charging when it is not in use. Newer systems use a portable DR detector to replace cassette.
Bedside radiography is often preferable to radiography in the diagnostic imaging department when patients are in the PACU, isolation or orthopedic traction to name a few.
Mobile Radiography: General Guidelines
1. Call the nursing station before leaving the imaging department unless responding to a STAT request.
2. Ask nurse about the patient's condition.
3. Confirm the order in the patient's chart.
4. Greet the patient and explain procedure.
5. Check patient ID and birth date on the wrist band.
6. Inspect and prepare the room before bringing in the x-ray equipment.
Postanesthesia Care Unit - Abbreviated as PACU or referred to as the "recovery room". Located outside surgery for ease of transfer and access by surgeons and anesthesia personnel.
Mobile radiographic exams are ordered to:
1. Check line placement.
2. Rule out pneumothorax or atelectasis.
3. Check orthopedic hardware placement.
Emergency Trauma Unit or Emergency Department (ED)
Mobile radiography is used in the ED to:
1. To avoid interruption of care for very critical patients.
2. Assess injuries of spine, pelvis and chest without removing immobilization or risking confounding injuries to the patient.
You must provide aprons for all essential ED personnel in the room. Use proper protection from blood and other bodily fluids for yourself and the equipment.
Neonatal Intensive Care and Newborn Nursery (NICU) – A special unit for care of babies who are premature, low birth weight or have a health issue. Many are very–high-risk infants.
Mobile exams often must be performed while the infant is in an incubator that is necessary to keep baby warm. Use proper shielding guidelines. Extra care is required when using aseptic techniques, gowns and gloves are often required when handling the infants. Often performed for transient tachypnea of the newborn (TTN) or respiratory distress syndrome (RDS). The task of obtaining images of the infant and maintaining a safe environment without cross-infection is very important.
Intensive Care and Coronary Care Units (ICU and CCU) - Are used to care for very ill patients who require frequent, if not constant, monitoring.
Chest radiograph is the most common mobile exam requested.
You must be able to maneuver and work around a lot of equipment such as:
1. Cables
2. Pumps
3. Tubing
4. Lines
Shield the patient and provide aprons for personnel who cannot exit area to protect them from exposure.
Special Beds and Mattresses
Certain beds and equipment provides continual position and pressure changes to decrease the frequency requirements for turning patients.
Examples:
1. Alternating pressure mattresses
2. Air mattresses
3. Rocking beds
4. Various types of wave, flotation and bead mattresses
Moving beds have to be turned off for mobile exams. Air beds should be inflated to maximum pressure fro mobile exams. You should inflate the mattress to firm up and level the bed before placing the image receptor.
Warming/Cooling Devices
IR must be placed in front of warming and cooling devices that use water or alcohol and must be on top of reflective blankets.
Orthopedic Traction
Be careful! Do not change or alter traction. Ask patient to move as much as is tolerable, but first ask the nurse if unsure of allowed movements by patient.
C-arm - Mobile fluoroscopy unit that is used in surgery and interventional exams.
Utilizes a C-arm design. The image receptor is at a fixed SID and centered to x-ray tube. Receptors vary from 6- to 12-inch input diameter. C-arms have limited power. There are video monitors and a computer for digital enhancement of images included in a monitor cart.
Surgical Medical Imaging and Surgical Team
The surgical team may consist of:
Chief Surgeon
Assisting Surgeon
Anesthesiologist or CRNA
OR Nurse—Circulating
Support OR staff
Members classified as:
1. Sterile
2. Nonsterile
Sterile members include:
Surgeon
Assistant to the surgeon (physician)
Nonphysician assistant
Scrub person (registered nurse, licensed vocational nurse or surgical technologist)
Nonsterile team members include:
Anesthesiologist or anesthetist
Circulating nurse or surgical technologist
Various other technologists:
1. Biomedical
2. Orthopedic
3. Radiologic
Surgical Suite
Access to the surgical suite is limited to personnel and items with a legitimate reason to be there. Special surgical attire must be worn in a surgical suite. Radiographic equipment must be wiped down with appropriate aseptic solution and a sterile cover is placed over portion going over the patient. Some hospitals have imaging equipment reserved only for use in surgery and some surgery suites have permanent imaging equipment installed which reduces contamination.
Surgical Clothing
Surgical Clothing Includes:
1. Nonsterile shirt and pants
2. Mask - covers nose and mouth
3. Hat or hood - covers all hair (including a beard, if applicable)
4. Shoe covers - may be optional
5. Gloves - donned to handle anything contaminated with blood
Sterile Corridor - The area between the patient drape and the instrument table. Only those wearing sterile attire are allowed in this area.
Guidelines:
1. Be aware of the sterile field.
2. Do not wear anything that dangles.
3. Avoid putting any objects in your pockets that can fall out.
4. Pass behind the back of a sterile team member to avoid contamination.
Surgical C-Arm Radiography
1. Requires strict attention to sterile technique.
2. Be aware of sterile corridor.
3. Portable fluoroscopy requires the image receptor and patient be draped.
4. The surgical draping of the C-arm and the patient is performed by the surgical team.
5. C-arm draping may use any of 3 designs.
Taking Portable Radiographs in the Operating Room
1. Dress appropriately.
2. Be aware of sterile areas.
3. Identify surgical team and float nurse.
4. Take charge of your area of responsibility.
5. Position the image receptor and the x-ray unit appropriately.
6. Communicate clearly with the operating room staff.
Endotracheal Tubes
Indications:
–Need mechanical ventilation or O2 delivery
–Inadequate arterial oxygenation
–Parenchymal diseases that impair gas exchange
–Upper-airway obstruction
–Impending gastric acid reflux or aspiration
–Tracheobronchial toilet (lavage)
A radiograph is needed to check tube placement and thereafter.
Tracheostomy - An operation performed under sterile technique that involves incising the skin over the trachea and then making a surgical wound in the trachea. A tube is placed in the opening in the trachea to provide an open airway and may sometimes be hooked to a ventilator. The tube is inserted directly into the trachea through the anterior surface of the neck.
A tracheostomy provides for an airway during upper-airway obstruction and is an emergency procedure only. Communication with tracheostomy patients is critical as their anxiety level is typically high. The technologist caring for the tracheostomy patient must also be sensitive to unmet and inexpressible needs and the need to keep the patient's anxiety level low. To minimize the possibility of infection, the technologist should not touch the tracheostomy area except under conditions of sterile technique. It is recommended that only properly trained personnel suction the tracheostomy patient.
Mechanical Ventilation - A machine that provides breathing through a tube passed through the mouth into the trachea and also may be attached to a tracheostomy.
Thoracostomy Tubes (Chest Tubes)
A chest tube can be used to re-inflate the lung.
Indications:
–Drain the intrapleural space and mediastinum
–To drain Fluid or air
–Creates negative pressure
–For Atelectasis
–For Pneumothorax
–For Hemothorax
–For Pleural effusion
–For Empyema
Common Insertion Sites - Insertion sites for thoracostomy vary with the intrapleural substances to be removed.
Usually inserted in 5th to 6th intercostal space, but can be as high as 4th intercostal space and as low as 8th.
Technologist Responsibilities
Images are performed to confirm chest tube position and chest status. Be careful to not catch tubing on x-ray equipment. The exterior assembly of the chest tubes must always remain lower than the patient's chest. You must use caution when moving and positioning the patient. You should report drainage in excess of 100 mL/hr and any change from a serous fluid to a darker red color.
Nasogastric and Nasoenteric Tubes
NG Tubes – Passed from nose to stomach.
NE Tubes – Passed from nose to duodenum.
Uses:
1. Feeding the patient
2. Decompression (aspirate gas and fluid from the stomach)
3. Radiographic examination of the stomach
Central Venous Pressure Line (CVP) - Catheter that is inserted into a large vein.
Types:
1. Central venous catheters
2. Venous access devices
Wide variety of clinical applications:
1. Mainly used for chemotherapy and parenteral nutrition
2. Administer a variety of drugs
3. Manage fluid volume
4. Serve as a conduit for blood analysis and transfusions
5. Monitor cardiac pressures
First developed by Broviac, then later by Hickman, hence the names of the CVP lines.
CVP Lines:
1. Port-A-Cath (chemotherapy)
2. PICC (peripherally inserted central catheter)
3. Swan-Ganz catheter
They may be single-, double- or multi-lumen. Most common insertion site is subclavian vein; also can be internal jugular and femoral veins. Position should be superior vena cava, approximately 2 to 3 cm above the opening of the right atrium.
PICC Line Placement - Placed to help monitor and manage critical patients and patients requiring long-term care.
Placed in the pulmonary artery, central vein (CVC) or peripherally (PICC). Care must used to avoid disruption of catheter. Often requires the use of the C-arm during insertion. Mobile images are often used to verify placement.
Pulmonary Arterial (PA) Catheter - 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 one of the two pulmonary arteries. Has balloon on distal end; during pressure monitoring inflates balloon and allows tip to float and wedge in pulmonary artery. It measures pressure and then the balloon deflates.
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 pathologic diagnostic standpoint, when malpositioning is thought to occur, alerting the appropriate authority (e.g., radiologist, attending physician) is both appropriate and beneficial to the patient.
Intravenous and Intraarterial Lines
Sterile technique is required for the insertion of lines (catheters) into veins and arteries. They are used for a variety of purposes. They are classified as venous and arterial lines. Requires imaging to confirm placement and functionality. Technologists must be ever-aware of lines and their equipment and positioning.
Pacemakers - Permanent pacemakers are electromechanical devices inserted under the patient's skin that regulates the heart rate by providing low levels of electrical stimulation to the heart muscle.
Pacemaker units are approximately 1 inch in width, in diameter and in thickness, weighing just a little over 1 ounce. The role of the radiographer is to operate the fluoroscopy unit, which will allow the physician to place the guidewire and pacemaker assembly correctly. Newer pacemaker designs are MRI compatible.
Urinary Catheters (Indwelling Catheters)
Two main types:
1. Retention balloon (Foley) Uses saline in the balloon
2. Straight Catheter
Uses French system for sizing.
2.6 to 5.99 mm
8 F to 18 F
Urinary or Indwelling Catheter Placement
Urinary catheterization is performed under aseptic technique.
1. Tip of catheter goes into the urinary bladder cavity.
2. Catheter tubing is taped to the inside of the leg.
3. The end of tube is attached to a calibrated drainage bag.
4. The drainage bag must be kept lower than patient's bladder at all times to prevent retrograde flow into bladder.
Foley Catheter
Various purposes:
–Bladder emptying
–Relieve bladder retention
–Irrigate bladder
–Introduce drugs into bladder
–Permit accurate measurement of urine output
–Relieve incontinence
Removing a Urinary Catheter
Is performed for voiding cystourethrograms. Put on gloves. Uncover the patient and place a basin under the catheter valve, cut the tip of the balloon valve with scissors and allow water to drain into basin. Once flow has ceased, place towels under catheter and pull gently. Once removed, wrap in towels, cover patient and discard the catheter.