evidence & practice / clinical investigations series
DIAGNOSTICS
X-rays: what the nurse needs to know Myatt R (2017) X-rays: what the nurse needs to know. Nursing Standard. 32, 1, 39-43. Date of submission: 16 November 2016; date of acceptance: 15 March 2017. doi: 10.7748/ns.2017.e10749
Rebecca Myatt Respiratory diagnostic clinical nurse specialist, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, England Correspondence Rebecca.Myatt@gstt. nhs.uk Conflict of interest None declared Peer review This article has been subject to external double-blind peer review and checked for plagiarism using automated software Contributing to the clinical investigations series To suggest an article for the series, please email [email protected] with a synopsis of your idea Online For related articles visit the archive and search using the keywords. Guidelines on writing for publication are available at: rcni.com/writeforus
Rationale and key points
X-ray imaging is a form of electromagnetic radiation that is able to pass through the human body producing an image of the internal structures. X-rays are one of the main investigations for confirming a suspected diagnosis. Developing an understanding of the underlying mechanism and the rationale for requesting an X-ray will increase nurses’ understanding of the process and enable improved patient preparation through explanation and reassurance. This article provides an overview of the fundamental principles underlying the process of obtaining an X-ray. »» X-ray imaging is a common diagnostic tool that nurses will encounter on a regular basis. »» Several factors affect the production of a clear X-ray image, including patient movement. »» Radiation safety and avoidance of unnecessary exposure are paramount. »» Co-operation and communication by the multidisciplinary team are vital to ensure that X-ray imaging can be requested, performed, interpreted and acted on, and the findings communicated to the patient.
Keywords
clinical investigations, diagnostics, imaging, plain radiography, radiation, radiology, X-ray
Learning outcomes
After reading the article you should be able to: »» Describe the appearance of body tissues on a plain X-ray. »» List the main patient information required by a radiographer before undertaking X-ray imaging. »» Explain the contraindications and potential complications associated with X-ray imaging.
X-rays
X-rays are a form of electromagnetic radiation that is able to pass through the human body producing an image of the internal structures (Lisle 2012). The image produced is called a radiograph, but is more commonly known as an X-ray or plain film (Figure 1) (Lisle 2012). The term plain film differentiates between an image created using contrast medium
and one created without contrast. Plainfilm radiography is inexpensive, readily accessible and easy to perform, making it commonly the first-line imaging method used by clinicians, especially for investigation of the abdomen, thorax or skeletal system (Darby et al 2012).
Explanation and related physiology
An X-ray is formed when a controlled dose of short wavelength electromagnetic radiation is directed through the body to an image receptor, placed behind or under the area to be viewed (Lisle 2012, Dimech et al 2015). It is a complex process that requires four important components (Ehrlich and Daly 2009): »» An X-ray tube (vacuum). »» A source of electrons. »» A target for these electrons. »» A high potential difference (voltage) between the electron source and the target.
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evidence & practice / clinical investigations series
Disclaimer Please note that information provided by Nursing Standard is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed by a nurse educator or mentor. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence
Using the X-ray tube, electrons are produced from the negatively charged cathode and accelerated to the positively charged anode. An interaction occurs between the fast-moving electrons and the metallic anode, which converts the kinetic energy into X-rays (1%) and thermal energy (99%) (Darby et al 2012). As the beam of X-rays passes through the atmosphere and the body tissue, some of the X-rays are scattered while others are absorbed. This gradual reduction or loss of intensity of the radiation is known as attenuation (Lisle 2012). The darkness of the image depends on the density of the body tissue receiving the radiation. High-density tissue, such as bone, causes more X-ray beam attenuation and is shown on the radiograph as lighter grey or white. Less-dense tissues or structures, such as air or gas, cause less attenuation and therefore appear darker (Lisle 2012). Table 1 shows the appearance of body tissues on an X-ray image.
Factors affecting radiographic exposure
The following factors are essential to produce a clear X-ray image (Ehrlich and Daly 2009): »» Distance. The distance between the source of the X-ray beam and the image Figure 1. X-ray image of the chest
SPL
receptor affects the intensity of the X-ray beam and the exposure of the final image. »» Exposure. Time is measured in fractions of seconds and, together with milliamperage, determines the total quantity of radiation that will be produced. A longer exposure time results in the production of more X-rays and a darker image. A decrease in exposure time results in lower radiation exposure and a lighter image. Exposure time settings vary from 1 millisecond (0.001 second) to several seconds. The dose of radiation a patient receives is directly proportionate to the exposure time. »» Milliamperage. The milliamperage measures current flow rate in the X-ray tube circuit and dictates the number of electrons available, therefore determining the rate at which X-rays are produced. A high milliamperage setting would be used to shorten the exposure time, for example when movement during a longer exposure would cause the image to blur. The milliamperage settings for various applications commonly range between 1 and 300, but some machines are capable of much higher amounts. »» Kilovoltage. The amount of kilovoltage to produce optimum penetration of the radiation into the patient varies with the examination and is fundamental for image quality. Kilovoltage settings for typical radiographic units range between 40 and 150, increasing in increments of 1 or 2 kilovolts (kV). Low kV settings are used for small body parts, for example 50-60kV are commonly used for radiographic examination of the patient’s hand, wrist or foot, 75-100kV for the spine and up to 100kV for the chest. »» Technique charts. These provide the radiographer with information on the correct milliamperage, kilovoltage and distance for each of the various body parts. X-rays are formed in a very small area known as the focal spot. This is no more than a few millimetres in diameter (Ehrlich and Daly 2009). From the focal spot, the X-rays diverge into space forming a coneshaped primary X-ray beam, controlled
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Interfering factors and potential complications
by the radiographer using a collimator. The cross-section of this beam is called the radiation field; it is indicated by a red light directed at the selected target body. When the primary X-ray beam hits a solid object, some of the radiation is absorbed but some is distributed in all directions. This is known as scatter radiation and it poses a radiation hazard for anyone else in the room because the direction is difficult to control. Scatter radiation is the principle source of occupational exposure to radiation (Ehrlich and Daly 2009).
Contrast media
In some investigations, the radiographic image can be enhanced by the use of contrast media, most commonly barium or iodine. Both of these mediums have a high atomic number and so strongly absorb X-rays, and are shown as bright white on the image (Lisle 2012). For a barium swallow (radiographic examination of the oesophagus, stomach and intestinal tract), the patient needs to drink the contrast and for a barium enema (radiographic examination of the large intestine), the contrast is administered rectally (Dimech et al 2015). A series of images is taken showing the movement of the contrast through the body. Post-procedure patients are encouraged to drink water to remove the contrast from their system (Dimech et al 2015). Before the contrast can be administered, a pre-contrast history is taken, which includes details of the patient’s renal function as well as a history of allergies and reactions to iodinated contrast (Lisle 2012).
Storing and viewing an image
Most medical imaging departments have large computer storage facilities, known as picture archiving and communication systems. These systems allow storage of images from other imaging methods such as computed tomography, magnetic resonance imaging (MRI) and ultrasound. They enable images to be displayed on monitors instantly when required throughout the hospital in wards, meeting rooms and operating theatres (Lisle 2012).
Effective communication between staff and patients is vital in facilitating patient understanding and co-operation, ultimately fostering an environment where clear X-ray images can be obtained and used effectively for diagnosis. It is paramount to provide the patient with a clear explanation of the procedure, body position and any breathing technique required in a language the patient can understand. Factors that might impede this include non-English speaking patients, hearing impairment, visual impairment, aphasia, impaired cognitive function and altered states of consciousness (Ehrlich and Daly 2009). Emotional preparation of the patient is also important; a patient may have concerns about the safety of radiation, which should be addressed. Anxiety about the investigation or results may also impair the patient’s ability to process and assimilate information that is being provided. For some patients, such as children, a demonstration of what is required may be more effective than verbal instructions. Patient movement during the procedure affects the appearance of the final image. The patient will be required to remain still to prevent any blurring of the X-ray (Dimech et al 2015). The nurse can TABLE 1. Appearance of body tissues on an X-ray image Substance
Colour
Appearance
Air/gas
Black
Lungs, bowel and stomach
Fat
Dark grey
Subcutaneous tissue layer and retroperitoneal fat
Soft tissues/water
Light grey
Solid organs, heart and blood vessels, muscle and fluid-filled organs such as the bladder
Bone
Off-white
Skeletal system
Contrast media/ metal
Bright white
Contrast material defines the shape of internal structures such as the lower gastrointestinal tract (barium enema) or upper gastrointestinal tract (barium swallow)
(Adapted from Lisle 2012)
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evidence & practice / clinical investigations series
alleviate any issues related to this through clear communication with the radiology department before the investigation takes place. A major disadvantage of radiography is the suboptimal soft tissue contrast resolution, so an alternative imaging method such as MRI may be required to provide further diagnostic information (Darby et al 2012).
Contraindications
Exposure to X-rays generates risk for patients and radiographers, therefore radiation safety and avoidance of unnecessary exposure is paramount (Ehrlich and Daly 2009). In practice, staff are protected by limiting the time they spend in the radiation field, increasing the distance between themselves and the radiation source and using protective equipment such as lead aprons, gloves, thyroid shields and personal radiation exposure monitors, known as dosimeters (Ehrlich and Daly 2009). Dosimeters are worn at waist level, below protective equipment, and are regularly reviewed by a radiation protection supervisor who can identify and investigate excessive dosage, as well as recommend additional monitors (Royal College of Nursing (RCN) 2014). The amount of radiation staff can safely be exposed to each year is regulated by UK legislation and documented in the Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000 (Department of Health 2012). Radiation exposure during pregnancy can put the developing embryo or fetus at risk. It may result in spontaneous abortion, congenital defects in the child, increased risk of malignant disease in childhood and an increased risk of significant genetic abnormalities in the child (Ehrlich and Daly 2009). The embryo is most vulnerable to radiation in the first trimester, when whole tissues are in the process of differentiation; however, this is the time when a woman may not know she is pregnant. To avoid undue harm, radiation control regulations require that female patients of childbearing age be advised of potential radiation hazards before
a radiographic examination (Ehrlich and Daly 2009). Male and female lead gonad shields prevent unnecessary radiation to the reproductive organs and are required if patients are of reproductive age or younger and the gonads are in the primary radiation field. The IRMER 2000 (Department of Health 2012) prohibit any X-ray from being carried out that has not been justified and authorised, and set out the legal responsibility related to medical exposure to radiation. Before an X-ray can be performed, the following information is required: »» Patient identification. Three identifiers are required: hospital number, name, date of birth or NHS number. »» Details of the clinical issue that allows the IRMER practitioner to justify the exposure. »» Details of pregnancy status of female patients. »» Identification of the person requesting the investigation to ensure they are qualified to order an X-ray.
Requesting an X-ray
The Society and College of Radiographers and the Royal College of Radiologists (RCR) permit non-medically qualified referrers to request an X-ray (RCN 2008). These individuals must be registered healthcare practitioners who have been adequately trained and are competent to provide the radiographer with sufficient appropriate clinical information. They must comply with the IRMER 2000 (Department of Health 2012) and ensure local agreements and protocols are in place (RCN 2008).
Undertaking X-ray imaging
It is important to note that specific requirements relating to X-ray imaging will be communicated to the patient by the radiology department (Dimech et al 2015). Procedure 1. Check the identity of the patient using three identifiers, such as their name, date of birth, hospital number or NHS number.
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2. Explain the investigation to the patient and reassure them that it is safe, noninvasive and not painful. 3. Show the patient to the changing room so they can remove clothes or jewellery that may interfere with the X-ray image and dress in a hospital gown, maintaining privacy and dignity at all times. 4. Discreetly check if a female patient is pregnant to avoid undue harm to the developing fetus. 5. Describe or demonstrate the correct position to the patient and emphasise the importance of remaining still to prevent blurring of the X-ray image and to ensure a clear picture of the underlying structures. 6. Check the X-ray image to ensure clarity and that blurring has not occurred. 7. Inform the patient if the procedure has finished and reassure them that the results will be available to the requesting practitioner. 8. Allow the patient to dress, maintaining privacy and dignity at all times, and discharge them from the department. 9. Report findings if urgent to the practitioner who requested the X-ray.
Critical, urgent and unexpected significant findings
A written report on the X-ray image is produced by a radiologist; this will comment on normal findings as well as any abnormalities that have been detected. The reporting of all imaging procedures is guided by standards, which state that to prevent any detrimental effect on the patient, all critical,
urgent or unexpected significant findings should be communicated immediately to the relevant individual. The radiologist is responsible for producing a report as quickly and efficiently as possible, the requesting practitioner or clinical team is responsible for acting on the findings, and the trust is responsible for providing systems that enable this to happen (RCR 2012). In some UK NHS hospitals, radiographers can alert the referring practitioner to an abnormality before the formal report of the X-ray image is issued. This is done through the radiographer abnormality detection scheme and the use of a ‘red dot’ system (Berman et al 1985). This takes the form of a red dot sticker on the X-ray image, a comment or the phrase ‘red dot’, or direct communication with the referrer (Price and Le Masurier 2007). The system was introduced to reduce misdiagnosis in emergency departments and is vital to alert the relevant clinical team of untoward findings, in the absence of 24-hour radiological reporting.
USEFUL RESOURCES »» British Institute of Radiology (2009) Pregnancy and Work in Diagnostic Imaging Departments. Second Edition. www.rcr.ac.uk/ system/files/ publication/field_ publication_files/ Pregnancy_Work_ Diagnostic_ Imaging_2nd.pdf
»» Care Quality
Commission (2017) Ionising Radiation. www.cqc.org. uk/guidanceproviders/ionisingradiation/ionisingradiation
Conclusion
The development of plain-film radiography has heralded a significant advance in the diagnostic field and enhanced patient care. Contemporary systems are safe and effective, if used appropriately. To be effective, X-ray imaging involves co-operation and communication from the multidisciplinary team to ensure the investigation can be requested, performed, interpreted and acted on, and the findings communicated to the patient.
References Berman L, de Lacey G, Twomey E et al (1985) Reducing errors in the accident department: a simple method using radiographers. BMJ. 290, 6466, 421-422. Darby MJ, Barron DA, Hyland RE (Eds) (2012) Oxford Handbook of Medical Imaging. Oxford University Press, Oxford. Department of Health (2012) Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER). www.gov.uk/government/ publications/the-ionising-radiation-medicalexposure-regulations-2000 (Last accessed: 16 August 2017.)
Dimech A, Fernandes A, Forsythe C et al (2015) Interpreting diagnostic tests. In Dougherty L, Lister S (Eds) The Royal Marsden Manual of Clinical Nursing Procedures. Ninth edition. Wiley-Blackwell, Chichester, 509-594. Ehrlich RA, Daly JA (2009) Patient Care in Radiography. Seventh edition. Mosby Elsevier, Missouri MO. Lisle DA (2012) Imaging for Students. Fourth edition. CRC Press, Boca Raton FL.
Price RC, Le Masurier SB (2007) Longitudinal changes in extended roles in radiography: a new perspective. Radiography. 13, 1, 18-29. Royal College of Nursing (2008) Clinical Imaging Requests from Non-Medically Qualified Professionals. www.rcn.org.uk/ professional-development/publications/ pub-003101 (Last accessed: 16 August 2017.) Royal College of Nursing (2014) Ionising Radiation Protection and the Use of Radiation Protective Equipment: Guidance for Nursing Staff. www.rcn.org.uk/-/media/ royal-college-of-nursing/documents/
publications/2014/july/pub-004607.pdf (Last accessed: 16 August 2017.) Royal College of Radiologists (2012) Standards for the Communication of Critical, Urgent and Unexpected Significant Radiological Findings. Second Edition. www. rcr.ac.uk/sites/default/files/docs/radiology/ pdf/BFCR(12)11_urgent.pdf (Last accessed: 16 August 2017.)
nursingstandard.com volume number 1 / uses 30 August / 43 Downloaded from RCNi.com by ${individualUser.displayName} on Sep 03, 2017. For personal use32 only. No other without2017 permission. Copyright © 2017 RCN Publishing Company Ltd
DIAGNOSTICS
X-rays: what the nurse needs to know Myatt R (2017) X-rays: what the nurse needs to know. Nursing Standard. 32, 1, 39-43. Date of submission: 16 November 2016; date of acceptance: 15 March 2017. doi: 10.7748/ns.2017.e10749
Rebecca Myatt Respiratory diagnostic clinical nurse specialist, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, England Correspondence Rebecca.Myatt@gstt. nhs.uk Conflict of interest None declared Peer review This article has been subject to external double-blind peer review and checked for plagiarism using automated software Contributing to the clinical investigations series To suggest an article for the series, please email [email protected] with a synopsis of your idea Online For related articles visit the archive and search using the keywords. Guidelines on writing for publication are available at: rcni.com/writeforus
Rationale and key points
X-ray imaging is a form of electromagnetic radiation that is able to pass through the human body producing an image of the internal structures. X-rays are one of the main investigations for confirming a suspected diagnosis. Developing an understanding of the underlying mechanism and the rationale for requesting an X-ray will increase nurses’ understanding of the process and enable improved patient preparation through explanation and reassurance. This article provides an overview of the fundamental principles underlying the process of obtaining an X-ray. »» X-ray imaging is a common diagnostic tool that nurses will encounter on a regular basis. »» Several factors affect the production of a clear X-ray image, including patient movement. »» Radiation safety and avoidance of unnecessary exposure are paramount. »» Co-operation and communication by the multidisciplinary team are vital to ensure that X-ray imaging can be requested, performed, interpreted and acted on, and the findings communicated to the patient.
Keywords
clinical investigations, diagnostics, imaging, plain radiography, radiation, radiology, X-ray
Learning outcomes
After reading the article you should be able to: »» Describe the appearance of body tissues on a plain X-ray. »» List the main patient information required by a radiographer before undertaking X-ray imaging. »» Explain the contraindications and potential complications associated with X-ray imaging.
X-rays
X-rays are a form of electromagnetic radiation that is able to pass through the human body producing an image of the internal structures (Lisle 2012). The image produced is called a radiograph, but is more commonly known as an X-ray or plain film (Figure 1) (Lisle 2012). The term plain film differentiates between an image created using contrast medium
and one created without contrast. Plainfilm radiography is inexpensive, readily accessible and easy to perform, making it commonly the first-line imaging method used by clinicians, especially for investigation of the abdomen, thorax or skeletal system (Darby et al 2012).
Explanation and related physiology
An X-ray is formed when a controlled dose of short wavelength electromagnetic radiation is directed through the body to an image receptor, placed behind or under the area to be viewed (Lisle 2012, Dimech et al 2015). It is a complex process that requires four important components (Ehrlich and Daly 2009): »» An X-ray tube (vacuum). »» A source of electrons. »» A target for these electrons. »» A high potential difference (voltage) between the electron source and the target.
nursingstandard.com volume number 1 / uses 30 August / 39 Downloaded from RCNi.com by ${individualUser.displayName} on Sep 03, 2017. For personal use32 only. No other without2017 permission. Copyright © 2017 RCN Publishing Company Ltd
evidence & practice / clinical investigations series
Disclaimer Please note that information provided by Nursing Standard is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed by a nurse educator or mentor. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence
Using the X-ray tube, electrons are produced from the negatively charged cathode and accelerated to the positively charged anode. An interaction occurs between the fast-moving electrons and the metallic anode, which converts the kinetic energy into X-rays (1%) and thermal energy (99%) (Darby et al 2012). As the beam of X-rays passes through the atmosphere and the body tissue, some of the X-rays are scattered while others are absorbed. This gradual reduction or loss of intensity of the radiation is known as attenuation (Lisle 2012). The darkness of the image depends on the density of the body tissue receiving the radiation. High-density tissue, such as bone, causes more X-ray beam attenuation and is shown on the radiograph as lighter grey or white. Less-dense tissues or structures, such as air or gas, cause less attenuation and therefore appear darker (Lisle 2012). Table 1 shows the appearance of body tissues on an X-ray image.
Factors affecting radiographic exposure
The following factors are essential to produce a clear X-ray image (Ehrlich and Daly 2009): »» Distance. The distance between the source of the X-ray beam and the image Figure 1. X-ray image of the chest
SPL
receptor affects the intensity of the X-ray beam and the exposure of the final image. »» Exposure. Time is measured in fractions of seconds and, together with milliamperage, determines the total quantity of radiation that will be produced. A longer exposure time results in the production of more X-rays and a darker image. A decrease in exposure time results in lower radiation exposure and a lighter image. Exposure time settings vary from 1 millisecond (0.001 second) to several seconds. The dose of radiation a patient receives is directly proportionate to the exposure time. »» Milliamperage. The milliamperage measures current flow rate in the X-ray tube circuit and dictates the number of electrons available, therefore determining the rate at which X-rays are produced. A high milliamperage setting would be used to shorten the exposure time, for example when movement during a longer exposure would cause the image to blur. The milliamperage settings for various applications commonly range between 1 and 300, but some machines are capable of much higher amounts. »» Kilovoltage. The amount of kilovoltage to produce optimum penetration of the radiation into the patient varies with the examination and is fundamental for image quality. Kilovoltage settings for typical radiographic units range between 40 and 150, increasing in increments of 1 or 2 kilovolts (kV). Low kV settings are used for small body parts, for example 50-60kV are commonly used for radiographic examination of the patient’s hand, wrist or foot, 75-100kV for the spine and up to 100kV for the chest. »» Technique charts. These provide the radiographer with information on the correct milliamperage, kilovoltage and distance for each of the various body parts. X-rays are formed in a very small area known as the focal spot. This is no more than a few millimetres in diameter (Ehrlich and Daly 2009). From the focal spot, the X-rays diverge into space forming a coneshaped primary X-ray beam, controlled
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Interfering factors and potential complications
by the radiographer using a collimator. The cross-section of this beam is called the radiation field; it is indicated by a red light directed at the selected target body. When the primary X-ray beam hits a solid object, some of the radiation is absorbed but some is distributed in all directions. This is known as scatter radiation and it poses a radiation hazard for anyone else in the room because the direction is difficult to control. Scatter radiation is the principle source of occupational exposure to radiation (Ehrlich and Daly 2009).
Contrast media
In some investigations, the radiographic image can be enhanced by the use of contrast media, most commonly barium or iodine. Both of these mediums have a high atomic number and so strongly absorb X-rays, and are shown as bright white on the image (Lisle 2012). For a barium swallow (radiographic examination of the oesophagus, stomach and intestinal tract), the patient needs to drink the contrast and for a barium enema (radiographic examination of the large intestine), the contrast is administered rectally (Dimech et al 2015). A series of images is taken showing the movement of the contrast through the body. Post-procedure patients are encouraged to drink water to remove the contrast from their system (Dimech et al 2015). Before the contrast can be administered, a pre-contrast history is taken, which includes details of the patient’s renal function as well as a history of allergies and reactions to iodinated contrast (Lisle 2012).
Storing and viewing an image
Most medical imaging departments have large computer storage facilities, known as picture archiving and communication systems. These systems allow storage of images from other imaging methods such as computed tomography, magnetic resonance imaging (MRI) and ultrasound. They enable images to be displayed on monitors instantly when required throughout the hospital in wards, meeting rooms and operating theatres (Lisle 2012).
Effective communication between staff and patients is vital in facilitating patient understanding and co-operation, ultimately fostering an environment where clear X-ray images can be obtained and used effectively for diagnosis. It is paramount to provide the patient with a clear explanation of the procedure, body position and any breathing technique required in a language the patient can understand. Factors that might impede this include non-English speaking patients, hearing impairment, visual impairment, aphasia, impaired cognitive function and altered states of consciousness (Ehrlich and Daly 2009). Emotional preparation of the patient is also important; a patient may have concerns about the safety of radiation, which should be addressed. Anxiety about the investigation or results may also impair the patient’s ability to process and assimilate information that is being provided. For some patients, such as children, a demonstration of what is required may be more effective than verbal instructions. Patient movement during the procedure affects the appearance of the final image. The patient will be required to remain still to prevent any blurring of the X-ray (Dimech et al 2015). The nurse can TABLE 1. Appearance of body tissues on an X-ray image Substance
Colour
Appearance
Air/gas
Black
Lungs, bowel and stomach
Fat
Dark grey
Subcutaneous tissue layer and retroperitoneal fat
Soft tissues/water
Light grey
Solid organs, heart and blood vessels, muscle and fluid-filled organs such as the bladder
Bone
Off-white
Skeletal system
Contrast media/ metal
Bright white
Contrast material defines the shape of internal structures such as the lower gastrointestinal tract (barium enema) or upper gastrointestinal tract (barium swallow)
(Adapted from Lisle 2012)
nursingstandard.com volume number 1 / uses 30 August / 41 Downloaded from RCNi.com by ${individualUser.displayName} on Sep 03, 2017. For personal use 32 only. No other without2017 permission. Copyright © 2017 RCN Publishing Company Ltd
evidence & practice / clinical investigations series
alleviate any issues related to this through clear communication with the radiology department before the investigation takes place. A major disadvantage of radiography is the suboptimal soft tissue contrast resolution, so an alternative imaging method such as MRI may be required to provide further diagnostic information (Darby et al 2012).
Contraindications
Exposure to X-rays generates risk for patients and radiographers, therefore radiation safety and avoidance of unnecessary exposure is paramount (Ehrlich and Daly 2009). In practice, staff are protected by limiting the time they spend in the radiation field, increasing the distance between themselves and the radiation source and using protective equipment such as lead aprons, gloves, thyroid shields and personal radiation exposure monitors, known as dosimeters (Ehrlich and Daly 2009). Dosimeters are worn at waist level, below protective equipment, and are regularly reviewed by a radiation protection supervisor who can identify and investigate excessive dosage, as well as recommend additional monitors (Royal College of Nursing (RCN) 2014). The amount of radiation staff can safely be exposed to each year is regulated by UK legislation and documented in the Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000 (Department of Health 2012). Radiation exposure during pregnancy can put the developing embryo or fetus at risk. It may result in spontaneous abortion, congenital defects in the child, increased risk of malignant disease in childhood and an increased risk of significant genetic abnormalities in the child (Ehrlich and Daly 2009). The embryo is most vulnerable to radiation in the first trimester, when whole tissues are in the process of differentiation; however, this is the time when a woman may not know she is pregnant. To avoid undue harm, radiation control regulations require that female patients of childbearing age be advised of potential radiation hazards before
a radiographic examination (Ehrlich and Daly 2009). Male and female lead gonad shields prevent unnecessary radiation to the reproductive organs and are required if patients are of reproductive age or younger and the gonads are in the primary radiation field. The IRMER 2000 (Department of Health 2012) prohibit any X-ray from being carried out that has not been justified and authorised, and set out the legal responsibility related to medical exposure to radiation. Before an X-ray can be performed, the following information is required: »» Patient identification. Three identifiers are required: hospital number, name, date of birth or NHS number. »» Details of the clinical issue that allows the IRMER practitioner to justify the exposure. »» Details of pregnancy status of female patients. »» Identification of the person requesting the investigation to ensure they are qualified to order an X-ray.
Requesting an X-ray
The Society and College of Radiographers and the Royal College of Radiologists (RCR) permit non-medically qualified referrers to request an X-ray (RCN 2008). These individuals must be registered healthcare practitioners who have been adequately trained and are competent to provide the radiographer with sufficient appropriate clinical information. They must comply with the IRMER 2000 (Department of Health 2012) and ensure local agreements and protocols are in place (RCN 2008).
Undertaking X-ray imaging
It is important to note that specific requirements relating to X-ray imaging will be communicated to the patient by the radiology department (Dimech et al 2015). Procedure 1. Check the identity of the patient using three identifiers, such as their name, date of birth, hospital number or NHS number.
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2. Explain the investigation to the patient and reassure them that it is safe, noninvasive and not painful. 3. Show the patient to the changing room so they can remove clothes or jewellery that may interfere with the X-ray image and dress in a hospital gown, maintaining privacy and dignity at all times. 4. Discreetly check if a female patient is pregnant to avoid undue harm to the developing fetus. 5. Describe or demonstrate the correct position to the patient and emphasise the importance of remaining still to prevent blurring of the X-ray image and to ensure a clear picture of the underlying structures. 6. Check the X-ray image to ensure clarity and that blurring has not occurred. 7. Inform the patient if the procedure has finished and reassure them that the results will be available to the requesting practitioner. 8. Allow the patient to dress, maintaining privacy and dignity at all times, and discharge them from the department. 9. Report findings if urgent to the practitioner who requested the X-ray.
Critical, urgent and unexpected significant findings
A written report on the X-ray image is produced by a radiologist; this will comment on normal findings as well as any abnormalities that have been detected. The reporting of all imaging procedures is guided by standards, which state that to prevent any detrimental effect on the patient, all critical,
urgent or unexpected significant findings should be communicated immediately to the relevant individual. The radiologist is responsible for producing a report as quickly and efficiently as possible, the requesting practitioner or clinical team is responsible for acting on the findings, and the trust is responsible for providing systems that enable this to happen (RCR 2012). In some UK NHS hospitals, radiographers can alert the referring practitioner to an abnormality before the formal report of the X-ray image is issued. This is done through the radiographer abnormality detection scheme and the use of a ‘red dot’ system (Berman et al 1985). This takes the form of a red dot sticker on the X-ray image, a comment or the phrase ‘red dot’, or direct communication with the referrer (Price and Le Masurier 2007). The system was introduced to reduce misdiagnosis in emergency departments and is vital to alert the relevant clinical team of untoward findings, in the absence of 24-hour radiological reporting.
USEFUL RESOURCES »» British Institute of Radiology (2009) Pregnancy and Work in Diagnostic Imaging Departments. Second Edition. www.rcr.ac.uk/ system/files/ publication/field_ publication_files/ Pregnancy_Work_ Diagnostic_ Imaging_2nd.pdf
»» Care Quality
Commission (2017) Ionising Radiation. www.cqc.org. uk/guidanceproviders/ionisingradiation/ionisingradiation
Conclusion
The development of plain-film radiography has heralded a significant advance in the diagnostic field and enhanced patient care. Contemporary systems are safe and effective, if used appropriately. To be effective, X-ray imaging involves co-operation and communication from the multidisciplinary team to ensure the investigation can be requested, performed, interpreted and acted on, and the findings communicated to the patient.
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Price RC, Le Masurier SB (2007) Longitudinal changes in extended roles in radiography: a new perspective. Radiography. 13, 1, 18-29. Royal College of Nursing (2008) Clinical Imaging Requests from Non-Medically Qualified Professionals. www.rcn.org.uk/ professional-development/publications/ pub-003101 (Last accessed: 16 August 2017.) Royal College of Nursing (2014) Ionising Radiation Protection and the Use of Radiation Protective Equipment: Guidance for Nursing Staff. www.rcn.org.uk/-/media/ royal-college-of-nursing/documents/
publications/2014/july/pub-004607.pdf (Last accessed: 16 August 2017.) Royal College of Radiologists (2012) Standards for the Communication of Critical, Urgent and Unexpected Significant Radiological Findings. Second Edition. www. rcr.ac.uk/sites/default/files/docs/radiology/ pdf/BFCR(12)11_urgent.pdf (Last accessed: 16 August 2017.)
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