Download MEDICAL IMAGING / INTERVENTIONAL RADIOLOGY

CHAPTER 17
MEDICAL IMAGING /
INTERVENTIONAL RADIOLOGY
Theresa Clifford, MSN, RN, CPAN
Kathy Daley, MSN, RN, CNS,
CCRN-CMC-CSC, CPAN
CHAPTER 17
OVERVIEW
Purpose: The perianesthesia registered nurse (RN) will demonstrate knowledge of basic medical
imaging procedures and radiological interventions, identify possible complications associated with these
procedures, and identify appropriate nursing interventions to maximize patient safety and comfort.
Competency Statement: Provide perianesthesia nursing management for the patient undergoing
medical imaging procedures or radiological interventions.
Criteria:
1. Identify principles of radiation safety.
• Radiation exposure can contribute to damage of cellular structures such as chromosomes and
membranes
• Effects of excessive exposure observed in unprotected employees are somatic and/or genetic in nature
o Acute exposure may be evidenced by erythema and dermatitis while whole-body exposures can be
the source of nausea, vomiting, diarrhea, weakness and death
o Excessive chronic exposure increases the risk of skin cancer and bone marrow suppression,
leukemia, genetic anomalies, cataracts, and goiter
• Personnel radiation monitors such as pocket ionization chambers, film badges, and
thermoluminescent dosimetry (TLC chips) must be properly worn and cared for per facility policy
• Controlling and minimizing exposure to radiation can be achieved by the following:
o Minimize or decrease length of time spent in and around radiation field
o Maintain the furthest distance possible (six feet or greater) during radiographic exposure
o Observe proper storage of radioactive sources including specimens and other radioactive materials
o Utilize appropriate absorbent or lead shields to lessen amount of penetrating radiation such as
leaded thyroid collars, glasses, gloves, and aprons
• Additional facility protocols may include, but are not limited, to the following:
o Reinforce proper handling and care of lead shield devices (i.e., hang aprons, do not fold leaded
shields to prevent cracking)
o Maintain body substance protection while handling any body fluids of post- nuclear medicine
patients
o Reinforce facility radiation safety protocols including maintaining radiation exposure records for
all employees
o Initiate patient education and support
2. Identify indications and physiologic implications for the use of contrast media, as well as
interventions for adverse reactions.
• Types of contrast media used for radiography include negative contrast media, positive contrast
media, air, gases, barium sulfate, iodinated media, and noniodinated media
• Routes of administration include ingestions, injections, and enemas
• All contrast medium enhance the diagnostic capabilities of radiologic techniques by altering the x-ray
absorption in various body tissues or organs
Conditions related to adverse reactions to contrast media include:
• Preexisting renal insufficiency, serum creatinine greater than 2.0, dehydration or nephritic syndromes
• Advanced age
• Previous reactions to contrast materials
• Asthma
• Multiple food or medication allergies
• Multiple medical conditions/underlying diseases such as CHF, diabetes mellitus, hypotension,
dehydration, multiple myeloma, cirrhosis, myasthenia gravis and anemia
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• Patients treated with nephrotoxic medications (i.e., aminoglycosides and nonsteroidal antiinflammatory agents) are at greater risk of developing renal failure
Drug Interactions
• Diabetic nephropathy may predispose to renal impairment following intravascular contrast medium
administration. This may precipitate lactic acidosis in patients who are taking biguanides (i.e.,
glucophage). As a precaution, biguanides should be stopped 48 hours prior to the contrast medium
examination and for at least 48 hours following administration of the contrast material
• Hypersensitivity reactions can be aggravated in patients on beta-blockers, and these patients may be
refractory to standard treatment with beta agonists
• The prevalence of delayed reactions (i.e., fever, rash, flulike symptoms, joint pain and pruritus) to
iodinated contrast media is higher in patients who have received interleukin, as long as several
months prior to the administration of iodinated contrast medium
• Renal toxicity has been reported in a few patients with liver dysfunction who were given an oral
cholecystographic agent followed by intravascular contrast agents. Administration of any
intravascular contrast agent should therefore be postponed in patients who have recently received a
cholecystographic contrast agent
Extravasation of contrast material
• Tissue damage is caused by the direct toxic effect of the agent
• Compartment syndrome may also occur
Overdosage
• The adverse effects of overdosage are life-threatening and affect mainly the pulmonary and
cardiovascular systems
• Treatment of an overdosage is directed toward the support of all vital functions, and prompt
institution of symptomatic therapy
Adverse effects by organ systems
System
Adverse Effects
Central Nervous System
Headache, confusion, dizziness, seizure
Gastrointestinal Tract
Nausea, vomiting, diarrhea
Skin
Pain, swelling, heat, erythema, hives, urticaria, rash
Kidney
Decreased urine output, hypertension
Heart
Dysrhythmia, asystole, hyper/hypotension
Respiratory System
Bronchospasm, dyspnea, laryngospasm
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• Treatment of anaphylactoid reactions is dictated by the nature and severity of symptoms
Degree
Signs and Symptoms
Treatment Plan
Mild
Diaphoresis
Nausea
Pruritus
Sneezing
Urticaria (limited)
Vomiting (limited)
Usually self limiting requires close observation,
monitor reactions which may indicate more
serious reactions impending.
Moderate
Bronchospasm (mild)
Chest Pain (mild)
Dyspnea/wheezing
Facial Edema
Faintness
Hypotension
Tachycardia
Urticaria (generalized)
Vomiting (severe)
Seldom life threatening requires only
symptomatic treatment without hospitalization,
usually good response to treatment.
Severe
Cardiac Arrest
Cardiac Dysrhythmias
Chest pain (severe)
Convulsions
Hypotensive shock
Laryngeal edema
Loss of consciousnes
Pulmonary edema
Respiratory arrest
Life threatening requires immediate response
and intensive treatment in most cases, almost
always requires hospitalization, delayed or
inappropriate treatment could result in death.
Preventative measures:
• Use smallest amount of contrast agent possible
• Allow 48 hours to lapse between procedures which require contrast agents
• Provide adequate hydration pre and post procedure
• Hydration can be achieved through ingestion of 500 mL of fluid before the procedure followed by
2,500 mL over the 24 hours after the procedure
• Pretreatment with antihistamines and corticosteroids is indicated for patients with previous reactions
to contrast medium as well as those with multiple risk factors
• Treatment with Sodium Bicarbonate intravenous fluids (150meq NaHCO3 in 1000 mL Normal
Saline) before (200 mL bolus), during and after (set rate 75-100 mL/hour) until liter infused is
indicated for patients with serum creatinine greater than 2.0
Treatment responses include:
• IV fluids
• Nasal oxygen
• Drug therapy:
o Adrenergic agonists
o Bronchodilators
o Anticholinergics
o Antihistamines
o Anticonvulsants
o Steroids
• Sedation
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For extravasation:
• Apply ice packs and/or heating pads and elevation to alleviate the symptoms associated with
extravasation of contrast material
• Tissue damage is more likely to occur with extravasation of ionic contrast material than with nonionic
contrast agents
3. Identify basic medical imaging procedures and radiological interventions.
a) Breast imaging
• Breast imaging procedures include mammography, breast ultrasound, MRI, needle localization,
stereotactic breast biopsies, duct injections (galactography), to detect, map, or otherwise diagnose
breast pathologies
b) Cardiac catheterization
i. Diagnostic tool
• Right heart, left heart or vessel catheterization used to visualize coronary arteries and provide
images of the heart in order to identify cardiovascular disease
ii. Minimally invasive interventional procedures
• Interventional techniques used to treat existing cardiovascular disease, which include
percutaneous transluminal coronary angioplasty (PTCA), placement of pacemakers,
intracoronary atherectomy, intracoronary stent insertions, positioning of intraaortic balloon
catheters and intravascular ultrasound (IVUS)
c) Computed tomography
• CT or CAT scans offer detailed images of body structures including tissue density differentiation
and three-dimensional reconstructions which help identify the presence of infections,
inflammations, cysts, tumors, blood clots/bleeding, fractures and vascular structures
• CT-guided procedures include percutaneous biopsies (including but not limited to pulmonary,
liver, renal, pancreatic, bone and pelvic mass biopsies), abscess aspiration and drainage, catheter
placement for continuous drainage system, fiducial (markers) placement, and percutaneous
radiofrequency ablation (RFA)
d) Diagnostic radiology
• Diagnostic radiology involves the use of radiography, fluoroscopy, and/or tomography to diagnose
and treat disease. Common studies include endoscopic retrograde cholangiopancreatography
(ERCP), intravenous pyelography (IVP), voiding cystourethrography, myelography, barium
studies, and hysterosalpingography
e) Lithotripsy
• Shock wave lithotripsy allows for the minimally invasive treatment of a variety of organ stones
found throughout the body. These include kidney, gallbladder, common duct or salivary duct
stones
• Extra-corporeal shockwave lithotripsy (ESWL) provides externally focused sound waves directed
at the stone in the body
• Intracorporeal shock wave lithotripsy (ISWL) requires that the sound waves be directed by a
catheter or cannula placed internally in the body in the location of the stone
f) Magnetic resonance imaging
• Magnetic resonance imaging (MRI) studies provide superior anatomic image data using an
external magnetic field which exposes body tissue to radiofrequency
g) Nonvascular interventional procedures
• Interventional radiographic procedures rely on percutaneous punctures to gain access to a variety
of organ systems for a variety of reasons. Among these are placements of drainage tubes and/or
stents for renal, hepatic, gallbladder, pulmonary or other organ pathologies, as well as the
placement of tubes for abscess drainage or to provide access for injection of diagnostic mediums
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h) Nuclear medicine
• Nuclear medicine involves the administration of organ specific radioactive compounds given
intravenously, orally or via intracavity access. Scanning procedures then assess organ function
and structure
• Interventional radionuclide therapy causes the destruction of selected tissues in the treatment of
disease such as the treatment of certain hyperthyroid conditions
• Common nuclear medicine applications include diagnosis of hyperthyroidism, cardiac stress tests,
bone scans for orthopedic injuries, lung scans for blood clots, staging of certain lymphatic related
cancers, and liver and gall bladder procedures to diagnose abnormal function or blockage
• Children commonly undergo nuclear medicine procedures to evaluate bone pain, injuries,
infection, or kidney and bladder function
i) Ultrasonography
• Ultrasound technology allows for visualization of deep body structures by recording the
reflections of pulses of ultrasonic waves of sound directed into the tissues
• Ultrasound guided biopsies of thyroid, liver, paracentesis, and thorocentesis
j) Vascular procedures
• Vascular interventional radiology involves percutaneous access of the vascular system to diagnose
and treat a variety of conditions. These include, but are not limited to, the assessment and
treatment of peripheral vascular disease, selective arteriography to study hepatic or mesenteric
disease, angioplasty or stent placement for known arterial occlusions or stenoses, as a means to
provide directed thrombolytic therapy, to maintain dialysis access, to implant central venous
access devices or to place vena cava filters
k) Neurointerventional procedures
• Neurointerventional radiology procedures involve percutaneous access of the vascular system to
assess and treat the neurological conditions. These include, but are not limited to: cerebral
angiograms, endovascular intracranial interventions; head, neck and intracranial tumor
embolization; extracranial and intracranial angioplasty and stenting; intracranial thrombolysis; and
spinal column and spinal cord embolization. Neurointerventional radiology procedures also
include spinal procedures such as vertebroplasties, which do not require vascular access
4. Identify possible complications for medical imaging or radiological interventions.
a) Breast imaging
• Vasovagal reactions to diagnostic breast procedures have been reported secondary to positioning
during procedures, length of certain procedures, pain, bleeding and/or hematomas and stress
b) Cardiac catheterization
• Major complications include retroperitoneal bleeding particularly with femoral cannulations, MI,
stroke, dissection of coronary artery walls, cardiac perforation, and death (in less than 0.2% cases)
• Minor complications include but are not limited to dysrhythmias, vascular injuries such as
hematomas and vasovagal reactions, CHF, and contrast material reactions
c) Computed tomography
• The requirement of contrast material for certain studies may result in side effects including nausea
and vomiting, diarrhea, and vasovagal responses
• Patients undergoing percutaneous CT-guided biopsies may have site specific complications
including hemoptysis, pneumothorax, bleeding or hematoma, pain, nausea, infection or sepsis
d) Diagnostic radiology
• Consequences of diagnostic radiology are procedure specific but may include vasovagal reactions,
electrolyte imbalances related to bowel preps, nausea, local discomfort, and adverse reactions to
contrast materials
e) Lithotripsy
• Complications of lithotripsy include, but are not limited to, biliary or urologic obstructions with
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fragments, perforations, hemorrhage, infection, extrarenal soft tissue injuries, and hypertension
• Contraindications include pregnancy, presence of cardiac pacemakers, calcified arterial aneurysms
(particularly renal), body size limiting appropriate positioning, and coexisting risks for anesthesia
f) Magnetic resonance imaging
• Absolute contraindications for the use of MRI technology include pacemakers, implanted
defibrillators, neuro- or bone growth stimulators, aneurysm or hemostatic clips, cochlear implants,
metallic foreign bodies in the eye, past CABG surgery if clip type unknown, and implantable drug
infusers
• An MRI should be considered carefully if the patient is pregnant, has a Greenfield filter, is less
than 6 weeks postoperative with metal implants, shrapnel, and prosthetic heart valves, or has a
pulmonary artery catheter
• For patients undergoing a MRI procedure, ear protection should be provided. All medical
equipment accompanying the patient should be safety tested (i.e., some IV pumps actually speed
up delivery near the magnetic field) and any monitors should be carefully shielded. Remove all
ferromagnetic objects from the field such as pens, coins, scissors, stethoscopes, jewelry, name
badges, pulse oximetry devices, etc., that are incompatible
g) Nonvascular interventional procedures
• All complications are procedure specific but generally may include pain, bleeding, sepsis,
perforation, and failure of procedure to provide relief of symptoms or improved outcomes
h) Nuclear medicine
• Nuclear medicine tests and radionuclide therapy are not recommended for pregnant women,
people allergic to iodine or other materials, and individuals undergoing radiation therapy
• Reactions in nuclear medicine procedures are generally contrast induced and are quite rare. They
may include hypotension, development of a rash, itching, and flushing
i) Ultrasonography
• Rare side effects have been reported but are related to molecular agitation in the tissues being
examined. This may cause a rise in temperature, cavitations (a collection of gas bubbles in
aqueous suspensions), and viscous stresses
j) Vascular procedures
• All complications are procedure specific but generally may include pain, bleeding or hematoma
formation, local arterial thrombosis and embolus, neurological complications, sepsis, perforation,
and failure of procedure to provide relief of symptoms or improved outcomes
k) Neurointerventional procedure
• As with vascular procedures, all complications are procedure specific, and include complications
from the puncture site
• With vertebroplasties, the biggest concern is foraminal or epidural cement leakage, which can lead
to damage to the spinal cord and nerve roots and subsequent pain
5. Identify appropriate nursing interventions for medical imaging or radiological interventions.
• Each radiologic procedure, whether for imaging or for intervention, requires procedure specific
nursing interventions. There are, however, general principles to follow for most clinical situations:
o Preprocedure care includes teaching, emotional support if indicated, review of medical history
including labs, medications and allergies. Procedural consents are obtained at this time if
necessary. Patient education should include information regarding the actual procedure,
required patient preparations such as remaining NPO or forcing fluids, as well as expected
post-procedure outcomes
o Intraprocedure care includes reinforcement of teaching, documentation as per facility policies,
administration of sedatives and/or analgesics as per facility moderate sedation protocols, and
communication and collaboration with other healthcare providers. Careful monitoring if
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sedation/analgesia is required and frequent observation of any intravenous/vascular access site
through which contrast is given. Proper patient positioning will be necessary to provide
optimal imaging as well as patient safety and comfort. Prompt initiation of
treatment/prophylaxis for moderate to severe reactions must occur
o Postprocedure care includes vital sign assessments, assessment of puncture sites and distal
pulses, labs if indicated, maintenance of compression to arterial puncture sites, and ongoing
teaching and reassurance. Careful observation of radiation safety guidelines as well as proper
handling of radionuclide wastes is maintained
6. Identify principles of sedation/analgesia.
a) See Moderate Sedation/Analgesia Chapter
7. Communicate and document all pertinent information per facility/unit specific policy/protocol.
• Facilitation of a collaborative effort to maintain quality patient care through communication of
pertinent data
• Documentation will include assessment, interventions and outcomes of nursing management during
diagnostic and interventional radiology
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Bibliography
Armstrong P, Wastie ML. Diagnostic and Interventional Radiology in Surgical Practice. 1st ed. Chapman
& Hall; 1997.
Hospital eTool: Radiology Module. Available at:
http://www.osha.gov/SLTC/etools/hospital/clinical/radiology/radiology.html [Radiation Exposure] Last
accessed 2/07.
RadiologyInfo: the radiology information resource for patients. Available at: http://www.radiologyinfo.org/
Last accessed 3/07.
NeuroInterventional Radiology. Available at:http://www.radiology.ucsf.edu/neuroir/clinical Last accessed 3/07.
Maddox TG. Adverse Reactions to Contrast Material: Recognition, Prevention and Treatment. Am Fam
Physician. October 1, 2002; 66(7): 1229-34.
Morgan L, Nunnelee J. American Radiological Nurses Association Core Curriculum for Radiological
Nursing. Oak Brook, IL: 1999.
Quinn D, Schick L, eds. Perianesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II
PACU Nursing. St.Louis, MO: Saunders; 2004.
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QUESTIONS:
MEDICAL IMAGING / INTERVENTIONAL RADIOLOGY COMPETENCY
1. Identify three ways to limit exposure to radiation.
a. Increase the duration of exposure; decrease the distance from the radiation source; place an
absorbent shield over the patient
b. Decrease the time of exposure; increase the distance from the radiation source; place an
absorbent shield between staff and the radiation source
c. Decrease the duration of exposure; decrease the distance from the radiation source; place an
absorbent shield over the physician
2. Treatment of severe anaphylactoid reactions to radiologic contrast material include the
following:
a. Intravenous fluids
b. Oxygen administration
c. Antihistamines
d. Bronchodilators
e. a and c
f. All of the above
3. Name three major complications of cardiac catheterization.
a. Death, stroke, and cardiac perforation
b. Death, hematoma, and contrast reaction
c. Death, hematoma, and vasovagal reaction
4. Extra-corporeal shockwave lithotripsy (ESWL) is the ideal procedure for pregnant women
with gallstone disease.
a. True
b. False
5. Absolute contraindications for the use of MRI technology include:
a. Pacemakers, plaster casts, contact lenses
b. Pacemakers, implanted defibrillators, implantable drug infusers.
c. Implanted defibrillators, plaster casts, chewing gum
6. Angioplasty or stent placement for known arterial occlusions or stenoses is best performed by
a. Ultrasound
b. MRI
c. Nuclear Medicine
d. Interventional Vascular Radiology
7. Which of the following statements is true:
a. Patients prone to contrast medium reactions ought to be premedicated with beta-blockers and H-2
blockers
b. Patients prone to contrast medium reactions ought to be premedicated with analgesics and steroids
c. Patients prone to contrast medium reactions ought to be premedicated with steroids and antihistamines
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KEY:
MEDICAL IMAGING / INTERVENTIONAL RADIOLOGY COMPETENCY
QUESTIONS
1. Identify three ways to limit exposure to radiation.
a. Increase the duration of exposure; decrease the distance from the radiation source; place an
absorbent shield over the patient
b. Decrease the time of exposure; increase the distance from the radiation source; place an
absorbent shield between staff and the radiation source
c. Decrease the duration of exposure; decrease the distance from the radiation source; place an
absorbent shield over the physician
2. Treatment of severe anaphylactoid reactions to radiologic contrast material include the
following:
a. Intravenous fluids
b. Oxygen administration
c. Antihistamines
d. Bronchodilators
e. a and c
f. All of the above
3. Name three major complications of cardiac catheterization.
a. Death, stroke, and cardiac perforation
b. Death, hematoma, and contrast reaction
c. Death, hematoma, and vasovagal reaction
4. Extra-corporeal shockwave lithotripsy (ESWL) is the ideal procedure for pregnant women
with gallstone disease.
a. True
b. False
5. Absolute contraindications for the use of MRI technology include:
a. Pacemakers, plaster casts, contact lenses
b. Pacemakers, implanted defibrillators, implantable drug infusers.
c. Implanted defibrillators, plaster casts, chewing gum
6. Angioplasty or stent placement for known arterial occlusions or stenoses is best performed by
a. Ultrasound
b. MRI
c. Nuclear Medicine
d. Interventional Vascular Radiology
7. Which of the following statements is true:
a. Patients prone to contrast medium reactions ought to be premedicated with beta-blockers and H-2
blockers
b. Patients prone to contrast medium reactions ought to be premedicated with analgesics and steroids
c. Patients prone to contrast medium reactions ought to be premedicated with steroids and
antihistamines
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Provide perianesthesia nursing management for the patient
undergoing medical imaging procedures or radiological
interventions.
CRITERIA:
1. Identify principles of radiation safety.
2. Identify indications and physiologic implications for the use of
contrast media, as well as interventions for adverse reactions.
3. Identify basic medical imaging procedures and radiological
interventions.
a. Breast imaging
b. Cardiac catheterization
c. Computed tomography
d. Diagnostic radiology
e. Lithotripsy
f. Magnetic resonance imaging
g. Nonvascular interventional procedures
h. Nuclear medicine
i. Ultrasonography
MEDICAL IMAGING / INTERVENTIONAL RADIOLOGY
Competency Criteria can be validated by discussion, or by
performance, or both. If an item is not appropriate for each
column, please indicate with “N/A.”
Competency Statement
Written Competency Test
Discusses
with
Preceptor
Pass & Date
(90%)
Observed
Retake &
Date
Competency Based Orientation for the Perianesthesia Nurse
Name_______________________________________________________
Performs
with
Assistance
Independent
Date____________________
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Date__________________________
Date__________________________
Preceptor Signature____________________________________________________
Re-Validate – Meets Criteria
Employee Signature____________________________________________________
Meets Criteria
Does Not Meet Criteria
j. Vascular procedures
k. Neurointerventional procedures
4. Identify possible complications for medical imaging or radiological
interventions.
a. Breast imaging
b. Cardiac catheterization
c. Computed tomography
d. Diagnostic radiology
e. Lithotripsy
f. Magnetic resonance imaging
g. Nonvascular interventional procedures
h. Nuclear medicine
i. Ultrasonography
j. Vascular procedures
k. Neurointerventional procedures
5. Identify appropriate nursing interventions for medical imaging or
radiological interventions.
6. Identify principles of sedation/analgesia (See Moderate
Sedation/Analgesia Chapter).
7. Communicate and document all pertinent information per facility/unit
specific policy/protocol.
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A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting