Radiography

Chapter 24 Radiography



Joanne Moore



CHAPTER CONTENTS


Introduction 240
Learning outcomes 240

Rationale 241

Factors to note 241

General principles 242
General environment 242

Preparation of the child and parent/carer 242

General care 243

Sedation and general anaesthetics 244

Investigations 245
Some common investigations 245

Computed tomography (CT) imaging 246

Ultrasound 246

Magnetic resonance imaging (MRI) 246

Nuclear medicine 247

Interventional radiology 248

Dos and don’ts 249


INTRODUCTION


This section is written to help nurses understand their role in preparing children for radiological investigation and assisting the radiologist/radiographer to perform radiological investigations on children. Some radiology departments may have a designated radiology nurse who is experienced in all aspects of the department and the procedures that are performed. When this facility is not available, the role will often fall on the ward nurse who accompanies the child to the radiology department. In some instances, even if there is a radiology department nurse available, it may be necessary for the nurse caring for the child to stay during the procedure to assist with holding, provide advice on the child’s condition and utilise previously developed nurse–patient and parental rapport to gain optimal imaging. The role of the escort nurse will be primarily that of patient advocate but equally important will be the preparation of the child and carer, based on a thorough assessment of the child and knowledge of the examination required. The nurse may be involved in the preparation of equipment prior to the examination and will also be required to support the child and family. The nurse may also assist the radiographer in ensuring that the child remains in the correct position.



LEARNING OUTCOMES


By the end of this section you should be able to:


• Prepare a child and their family for X-ray examination

• Identify ways to minimise radiation

• Provide detailed explanation to child and family of what they will see, hear and feel throughout the radiological examination

• Observe and adhere to IRMER (TSO 2000) guidelines

• Explain the difference between ionising radiation and non-ionising radiation

• Assist in performing a radiological examination safely with or without sedation

• Describe the common types of radiological investigations.


RATIONALE


The need for an X-ray examination is usually for diagnostic purposes. The most common types of radiology modalities include plain film, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), interventional radiology/angiography and nuclear medicine. Interventional radiology is a rapidly growing subspecialty within radiology that is becoming increasingly popular and useful as both a diagnostic and treatment tool (Kaye 2000, Roebuck 2001). A child may also need to be supported during radiotherapy. If children are being treated in district general hospitals and require X-rays, in a department that mainly treats adults, the child’s nurse will need to ensure that they are adequately prepared, taking into account the size and unfamiliarity of the equipment.



FACTORS TO NOTE



• All X-ray examinations must be requested either by a medical practitioner or by a nurse or other healthcare professional that has undergone the appropriate training and has been allowed by their trust/hospital to request certain radiology examinations. The benefits of radiological information that may aid in clinical diagnosis or treatment must be balanced against the potential hazards of the exposure to radiation (TSO 2000).

• The X-ray examination is clinically directed by the radiologist or trained physicist.

• The radiographer normally directs and is responsible for the examination.

• All X-rays hold a potential risk.

• It is important to remember that although the risk to the individual child is insignificant, it is general philosophy that the dose to the general public from medical use of ionising radiation should be reduced.

• The dose to the child in diagnostic radiology is generally a very low or low dose. We are all exposed to background radiation on a daily basis and a child’s chest X-ray is equivalent to 1 day of background radiation, therefore one could assume that a child undergoing a plain chest X-ray is 1 day older in radiation terms (Crawley 2002).

• The net gain should outweigh the risk; this is especially pertinent to children undergoing frequent X-ray examinations.

• Before any investigations are performed on any child, the principles laid down in the Ionising Radiation (Medical Exposure) Regulations 2000 must be adhered to (TSO 2000).

• Nurses should take responsibility and act as an advocate for the child, i.e. ensure there is no possibility of pregnancy in girls of child-bearing age.

• Nurses or mothers who are pregnant should not assist with X-ray examinations in order to protect the unborn child. It is the responsibility of the operator to determine whether or not the patient and/or their carers may be pregnant. It is sufficient to ask the accompanying adult if there is any chance they may be pregnant. Determining possible pregnancy in children undergoing tests requires diplomacy and sensitivity. If the child is competent to answer the question independently, you must determine whether they have started having regular periods. For patients with regular periods undergoing low-dose tests, e.g. plain chest film, who are sure their period is not overdue, you should proceed with the examination. Patients requiring high-dose procedures, e.g. barium enemas, CT of abdomen and pelvis, interventional procedures involving direct exposure of the abdomen and pelvis, and nuclear medicine tests with high fetal dose investigations, should be asked when their last period started. If it was within 10 days of the start of their last period, the test may proceed. If the test is requested more than 10 days since the start of their last period, it must be determined if there is any chance they may be pregnant. The answer to the pregnancy question should be documented on the radiology request form (TSO 2000). Staff that think they may be pregnant are asked not to accompany the child into the examination room, and all young females are asked if they have started their menstrual cycle; if so, the steps outlined above are actioned, otherwise no further action is taken.


GENERAL PRINCIPLES



GENERAL ENVIRONMENT


Many radiology departments are largely adult focused, particularly in district general hospitals. It is important that consideration is given to the child in the environment of the X-ray department. The area should be child friendly with toys and games appropriate for different ages. Posters of current television favourites may be displayed. This helps to distract the child and may help in developing a relationship that will assist the radiographer. The National Service Framework for Children (DoH 2003) clearly states that children should be cared for in child-friendly hospitals and that hospitals should be safe and healthy places for children. Children should receive care based on their needs and the needs of their family. They should also be encouraged to participate in their care. Children should be encouraged to bring one of their favourite toys into the department with them so that they can be X-rayed together. Depending on the type of test being carried out, it may be possible for children to listen to their favourite CD or watch a video. These options should be discussed with the child prior to arriving at the radiology department and, if appropriate, the child can choose their entertainment or bring their own with them.


The X-ray room should be warm to avoid cooling of the child. Some clothing can be left in place, depending on the type of X-ray examination; if there is any doubt the nurse should check with the radiographer. It is advisable to remove any clothes with metal buttons or zippers beforehand. If it is anticipated that the procedure will be lengthy or if the patient is a neonate, a warming blanket should be placed on the bed. Children undergoing a MRI scan need to be checked more thoroughly by a trained person to ensure they have nothing on them that is incompatible with the MRI scanner. This includes any jewellery, body piercings, hair grips/slides, coins and medical implants. Anything metallic that can be removed should be, and any surgical implants should be thoroughly investigated prior to the scan to ensure they are MRI compatible. Many MRI departments have a folder which lists devices and their compatibility.


The stability of the child’s condition must be assessed before considering a move to the radiology department. The use of portable X-ray machines within intensive care units and isolation cubicles is common practice. Children whose access to the department is difficult or whose condition might be compromised, e.g. children in balanced traction or immune-suppressed children being reverse barrier nursed (nursed in protective isolation), should also be considered for a portable X-ray machine. Wall-mounted oxygen, suction and monitoring equipment should be available in every radiology room. Full resuscitation equipment for all ages of children must be present within the department.



PREPARATION OF THE CHILD AND PARENT/CARER


Preparation is one of the most important parts of any investigation in paediatric radiology. Parent participation is actively encouraged.


A full explanation of the procedure, equipment and process of events will help alleviate both the child’s and the parent’s anxiety. The provision of age-appropriate leaflets should be made available for the parent and child to take away with them to read at their leisure; this allows them the opportunity to think of any questions they may want answering prior to the planned procedure. A play specialist may also provide useful demonstrations using a favourite toy to show the child where they will be placed within the room and how close the X-ray equipment will come to them, but will not touch them. The explanation to the parents and the child should be provided before the child enters the investigation room. The language and depth of the explanation should be appropriate to the patient’s age and understanding and will include any activity expected of the child, e.g. drinking the medication, holding their breath or micturating during the procedure. If the investigation requires the insertion of a cannula or catheterisation, the child and family will need to be given an indication of how and when this is likely to occur.


The child and parents need to know and understand that it is important for the child to remain still during the X-ray examination. If analgesia or sedation is to be used, this needs to be discussed with the parents as part of the preparation. There should also be a discussion on the most appropriate person to accompany the child to the department. This should be the person who is most able to comfort, calm, help restrain and offer reassurance to the child during the investigation.


An assessment of the child will be required as part of the admission process. If the child is an outpatient, an explanation of what will happen and reinforcement of the events during the procedure are necessary. The child should be weighed to enable the correct doses of drugs and radiopaque dye to be administered.


There needs to be communication between the nurse and radiologist to arrange the most suitable time for the procedure and to enable analgesia and sedation to be administered at the most appropriate time for it to be effective. Always check the name and date of birth of the child against the radiology request form prior to undertaking any investigation.



Preparation books


Books and leaflets written for children can help in explaining the type of equipment that will be used and the procedures involved. These will give a simple explanation of the process during the procedures and explain that the X-ray machines are large, can be mobile, i.e. move around the child, and that sometimes a tube above them may move towards them but it will never actually touch them during the procedure. The examination table on which the child is lying may also move at various times throughout the procedure. If a detailed explanation, including pictures, is given to the child and their parent/carer beforehand, it may help to alleviate unnecessary anxiety and make the equipment appear less frightening. Some departments may have an album with photographs of the various members of staff that the child and parents will meet and the various pieces of equipment they may encounter.



Play therapy


Some hospitals are fortunate in having a play therapy department. Play therapists are trained to help prepare the child for a variety of procedures, through play (see Ch. 10).



GENERAL CARE



Privacy


This is an important aspect of any procedure. All children should have their investigation in private and only people who are necessary for the investigation should remain in the X-ray room.



Protection


The nurse and/or parent must wear a lead apron and thyroid collar if assisting with the X-ray examination. Local protection for the child may be required, for example ovary/gonad pads. When X-rays are being taken on the ward using portable equipment, a safe zone should be established, ensuring that no unnecessary personnel are present in the area and that those who are required are wearing protective clothing. The nurse may be asked to help if the mother is pregnant and is unable to hold the child herself.



Positioning


The correct positioning of the child and the maintenance of the position during the X-ray examination is one of the most important aspects of the care. The radiographer will assist the nurse and/or parent in achieving the position that is required. The difficulty in positioning is greater with a child up to the age of 5 years (Gyll 1982) but does become easier as the child gets older. The radiographer may provide various adapted boxes or stools for the child to sit or lie on, to get the best picture/results first time.


It is the nurse’s role to ensure that the child is not restrained against their will or for any great length of time and that appropriate explanation and reassurance are given. Where possible the nurse should anticipate and prevent the need for holding through giving the child information encouragement and distraction (RCN 2003).


In the case of a wheelchair-bound or physically handicapped child it is always advisable to ask the child’s usual carer how to lift the child without harming yourself or the child. It may not be possible to obtain particular X-rays on some physically handicapped children because of their inability to move or maintain a particular position. The nurse should remember that they are the child’s advocate on these occasions. Local lifting and handling policies must be adhered to.

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Mar 7, 2017 | Posted by in NURSING | Comments Off on Radiography

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