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Chapter 18 Urinary System and Venipuncture Lesson 1 Anatomy and Procedures of the Urinary System Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Anatomy Review Urinary System Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2 Anatomy: Urinary System Includes Two kidneys Two ureters One urinary bladder One urethra Often called the excretory system Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3 Anatomy: Kidneys Bean-shaped bodies Convex lateral borders Concave medial borders Divided into upper and lower poles Measure about 4.5 (11.5 cm) long, 2 to 3 (5 to 7.6 cm) wide, and 1.25 (3 cm) thick Left kidney slightly longer and narrower Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4 Anatomy: Kidneys Located retroperitoneal in contact with posterior abdominal wall Superior aspect more posterior than inferior Lie in oblique plane about 30 degrees anteriorly toward the aorta Extend from about T12 to L3 Right kidney slightly lower than left Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5 Anatomy: Kidneys Renal capsule = outer covering Renal cortex = outer layer of renal tissue Renal medulla = inner layer of renal tissue Composed of 8 to 15 cone-shaped segments of collecting tubules = renal pyramids Renal columns = extensions of cortex between renal pyramids Nephron = essential microscopic component of kidney Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6 Anatomy: Kidneys Midcoronal section of kidney Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7 Anatomy: Nephron Each contains about one million nephrons Nephron consists of Renal corpuscle Renal tubule Renal corpuscle consists of Glomerular capsule (Bowman’s capsule) Glomerulus Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8 Anatomy: Nephron Glomerulus formed by tiny branch of renal artery entering capsule and dividing into capillaries Capillaries unite to form a single vessel leaving capsule Afferent arteriole = vessel entering capsule Efferent arteriole = vessel exiting capsule Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9 Anatomy: Nephron Glomerulus is a filter for blood, allowing fine particles and water to pass into the capsule Renal tubule is continuous with capsule Proximal convoluted tubule Nephron loop (loop of Henle) Distal convoluted tubule Distal convoluted tubule opens into the collecting ducts Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10 Anatomy: Nephron Diagram of nephron and collecting duct Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11 Anatomy: Kidneys Collecting ducts converge to form a central tubule within the pyramid Calyces = cup-shaped stems that enclose one or more papilla Opens at renal papilla Drains into minor calyx Usually fewer calyces than pyramids Minor calyces unite to form major calyces Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12 Anatomy: Kidneys Major calyces unite to form renal pelvis Renal pelvis lies within hilum Hilum = longitudinal slit in medial border for transmission of blood vessels, nerves, lymphatic vessels, and ureter Renal pelvis is continuous with ureter Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13 Anatomy: Midcoronal section of kidney Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14 Anatomy: Ureter 10to 12 (25 to 30 cm) long Enters posterolateral surface of bladder Conveys urine from renal pelvis to bladder via peristaltic contractions Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15 Anatomy: Urinary Bladder Musculomembranous sac Serves as a reservoir for urine Located immediately posterior and superior to pubic symphysis Anterior to rectum in males Anterior to vaginal canal in females Apex is anterosuperior aspect Neck is lowest part Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16 Anatomy: Urinary Bladder Trigone = triangular area of bladder base between three openings Two for ureters One internal urethral orifice Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 17 Anatomy: Urinary Bladder Anterior view Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 18 Anatomy: Urethra Conveys urine out of the body About 1.5 (3.8 cm) long in females About 7 to 8 (17.8 to 20 cm) long in males Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19 Anatomy: Prostate Small glandular body surrounding the proximal part of the male urethra Considered part of the male reproductive system, but due to location, is often described with the urinary system Measures about 1.5 (3.8 cm) transversely, ¾ (1.9 cm) at its base, and 1 (2.5 cm) vertically Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20 Overview Contrast studies Contrast media Adverse reactions to contrast media Preparation of intestinal tract Patient preparation Equipment Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 21 Contrast Studies To demonstrate the renal parenchyma, contrast media is needed, followed by imaging by either x-ray or CT Two filling techniques Antegrade Retrograde Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 22 Contrast Media Lower concentrations required for bladder studies due to large amount required to fill bladder Higher concentrations used for excretory urography Nonionic media less likely to cause an adverse reaction Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23 Adverse Reactions to Contrast Media Usually mild and of short duration Severe reactions can occur, but are rare Characteristic reactions Feeling of warmth Flushing A few hives, sometimes Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 24 Adverse Reactions to Contrast Media Occasional reactions Nausea Vomiting Edema of respiratory mucous membranes Check clinical history carefully Observe patient closely after contrast administration Emergency equipment and medication must be readily available Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25 Preparation of Intestinal Tract Clear demonstration of urinary system requires intestinal tract to be free of gas and fecal material Bowel prep is not attempted in infants and children Adult prep is dependent on patient condition Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 26 Patient Preparation When time permits, low-residue diet for 1 to 2 days before examination Light evening meal on day before examination Non–gas-forming laxative, when indicated, the day before the examination Nothing by mouth after midnight the day of the examination Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 27 Patient Preparation Patient should be well hydrated Hydration particularly important for patients with Diabetes Multiple myeloma High uric acid levels These conditions put patient at increased risk for contrast medium-induced renal failure if dehydrated Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 28 Patient Preparation For retrograde urography, patient should drink 4 to 5 cups of water several hours before examination No prep usually required for examinations of the lower urinary tract Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 29 Equipment Standard radiographic room sufficient for excretory urography and most retrograde studies of the bladder and urethra Combination cystoscopic-radiographic unit needed for retrograde urographic procedures that require cystography Tomography unit required for infusion nephrourography Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 30 Equipment Time-interval and body position markers should also be used Sufficient number of proper size IRs Emergency cart Check to make sure stocked Know location Venipuncture supplies Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 31 Procedure Image quality Motion control Ureteral compression Respiration Preliminary examination Radiation protection Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 32 Image Quality Contrast and density is the same as for abdominal radiographs Soft tissues that must be defined Kidneys Lower border of liver Lateral margin of psoas muscles Bone detail varies according to thickness of abdomen Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 33 Motion Control Immobilization not recommended due to interference with fluid flow through ureters and distortion of canals Motion control dependent on Exposure time Patient cooperation Important to inform patient of sensations caused by contrast injection Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 34 Ureteral Compression In excretory urography, compression is sometimes applied over the distal ends of the ureters Purpose is to retard the flow of opacified urine into the bladder to ensure filling of renal pelves and calyces Compression centered over level of ASIS Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 35 Ureteral Compression Apply and remove slowly to reduce patient discomfort caused by changes in intraabdominal pressure Contraindicated in patients with Urinary stones Abdominal mass Aortic aneurysm Colostomy Suprapubic catheter Traumatic injury Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 36 Respiration Exposures should be made at the end of expiration, unless otherwise requested Due to kidney excursion during respiration, it is possible to differentiate kidneys from other shadows by making exposure on different phase of respiration Image should be marked if exposed on phase of respiration other than expiration Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37 Preliminary Examination Abdominal images made before specialized urinary tract studies Examination used to reveal extrarenal lesions that could cause symptoms, making urinary studies unnecessary Scout AP radiograph, supine position, demonstrates location of kidneys, their contour, and opaque calculi, if present Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 38 Preliminary Examination Scout image also serves to check GI tract preparation and exposure factors Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 39 Radiation Protection Radiographer is responsible for observing guidelines for radiation protection Gonadal shield used if it does not interfere with examination objective Close collimation should be used Avoid repeat exposures Shield males for all urinary studies, except when urethra is of primary interest Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 40 Radiation Protection Shield females when IR centered over kidneys Rule out chance of pregnancy before examination Emergency cases may not allow time Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 41 Radiographic Procedures Urinary System Procedures Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42 Urinary System Procedures Intravenous urography (IVU) Nephrotomography Nephrourography Retrograde urography Cystography Cystourethrography Male Female Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43 Intravenous Urography Also called excretory urography Demonstrates structure and function of kidneys Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 44 Intravenous Urography Indications for IVU Evaluation of abdominal masses, renal cysts, and tumors Urolithiasis = stones of the urinary tract or kidneys Pyelonephritis = infection of the upper urinary tract Hydronephrosis = abnormal dilation of pelvicaliceal system Evaluation of trauma effects Preoperative evaluation of function, location, size, and shape of kidneys and ureters Renal hypertension Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 45 Intravenous Urography Contraindications relate to Ability of kidneys to filter contrast medium from the blood Patient’s allergic history Some contraindications can be overcome by use of nonionic contrast High-risk patients may be evaluated with other modalities Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 46 Intravenous Urography Some contraindications can be overcome by use of nonionic contrast Risk factors include Asthma Previous contrast reaction Circulatory or cardiovascular disease Elevated creatinine level Sickle cell disease Diabetes mellitus Multiple myeloma Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 47 Intravenous Urography Before procedure, patient must empty bladder, remove clothing, and put on a gown Review blood chemistry Normal creatinine = 0.6 to 1.5 mg/100 mL Normal BUN = 8 to 25 mg/100 mL Elevated levels indicative of renal dysfunction Make scout radiograph Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 48 Intravenous Urography Perform venipuncture Administer 30 to 100 mL of contrast for adult patient of average size Dosage for infants and children is adjusted according to age and weight Produce radiographs at specified time intervals Procedure varies according to department protocol Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 49 Intravenous Urography Most common radiographs for IVU examinations are AP projections at time intervals ranging from 3 to 20 minutes AP oblique projections in 30-degree posterior oblique positions often taken at 5- to 10minute intervals Unless bladder or voiding urethrograms are to be made, the patient is sent to lavatory to void Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 50 Intravenous Urography Postvoid radiograph of bladder may be taken Used to check for small tumor masses or enlarged prostate in male patients After the procedure, patient is instructed to drink extra fluids to aid in flushing contrast Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 51 AP Urinary System Patient position Supine Support at knees to reduce back strain Upright position used to demonstrate opacified bladder and kidney mobility Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 52 AP Urinary System Part position MSP aligned to midline of grid device Move arms out of field Center IR to level of iliac crests Two IRs may be required to demonstrate all anatomy on tall patients CR Perpendicular to center of IR at level of iliac crests Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 53 AP Oblique Urinary System Patient position Supine Support elevated side Kidney closer to IR will be perpendicular to plane of IR Kidney farther from IR will be parallel with IR Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 54 AP Oblique Urinary System Part position Rotated so that MCP forms 30-degree angle from IR Shoulders and hips in same plane MSP aligned to midline of grid device Move arms out of field Center IR to level of iliac crests Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 55 AP Oblique Urinary System CR Perpendicular to center of IR Enters about 2 (5 cm) lateral to midline on elevated side at level of iliac crests Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 56 Lateral Urinary System Patient position Lateral recumbent on right or left side Part position Knees flexed for patient comfort MCP centered to midline Flex elbows and place hands under head Center IR to level of iliac crests Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 57 Lateral Urinary System CR Perpendicular to IR Enters MCP at level of iliac crests Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 58 Lateral Urinary System Dorsal Decubitus Position Patient position Supine, without rotation Right or left side in contact with grid device Arms above head or across upper chest Part position Adjust height of vertical grid device so that long axis of IR is centered to MCP Place level of iliac crests in center of IR Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 59 Lateral Urinary System Dorsal Decubitus Position CR Horizontal and perpendicular to center of IR Enters patient at MCP at level of iliac crests Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 60 Nephrotomography and Nephrourography Tomography performed immediately after contrast administration Demonstrates renal parenchyma (nephrons and collecting tubes) Indications Renal hypertension Renal cysts and tumors Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 61 Nephrotomography and Nephrourography Contraindications Renal failure Contrast media allergy Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 62 Retrograde Urography Requires catheterization of ureters Contrast injected directly into pelvicaliceal system Provides improved opacification of renal collecting system Little physiologic information provided Indicated for evaluation of collecting system in patients with renal insufficiency or contrast sensitivity Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 63 Retrograde Urography Classified as an operative procedure Carried out under aseptic conditions Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 64 Cystography Radiologic examination of the urinary bladder Usually performed via retrograde contrast administration Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 65 Cystography Indicated for Vesicoureteral reflux Recurrent lower urinary tract infection Neurogenic bladder Bladder trauma Lower urinary tract fistulae Urethral stricture Posterior urethral valves Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 66 Cystography Contraindications related to catheterization of urethra Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 67 AP Axial Bladder Patient position Supine Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 68 AP Axial Bladder Part position MSP centered to midline Shoulders and hips in same plane and equidistant to IR Arms moved out of anatomy of interest Legs extended Center IR 2 (5 cm) above upper border of pubic symphysis • At level of symphysis for voiding studies Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 69 AP Axial Bladder CR Angled 10 to 15 degrees caudad to center of IR Enters 2 (5 cm) above upper border of pubic symphysis CR angle depends on lumbar lordosis (greater = less angle) Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 70 PA Axial Bladder Patient position Prone Patient position MSP centered to midline Shoulders and hips in same plane and equidistant to IR Arms out of anatomy of interest IR centered to CR Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 71 PA Axial Bladder CR Angled 10 to 15 degrees cephalad Enters about 1 (2.5 cm) distal to coccyx Exits just above superior border of pubic symphysis Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 72 AP Oblique Bladder Patient position 40- to 60-degree posterior oblique position RPO or LPO depends on physician preference Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 73 AP Oblique Bladder Part position Align pubic arch closer to IR to midline Extend and abduct thigh of elevated side to prevent superimposition on bladder Center IR 2 (5 cm) above upper border of pubic symphysis and about 2 (5 cm) medial to upper ASIS • Level of pubic symphysis for voiding studies Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 74 AP Oblique Bladder CR Perpendicular to center of IR CR will fall 2 (5 cm) above the upper border of pubic symphysis and 2 (5 cm) medial to upper ASIS If bladder neck and proximal urethra is of interest, 10-degree caudal angle of CR will project pubic bones below them Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 75 Lateral Bladder Patient position Lateral recumbent, right or left side Part position Knees flexed for comfort MCP aligned to midline Flex elbows and place hands under head Center IR 2 (5 cm) above upper border of pubic symphysis at MCP Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 76 Lateral Bladder CR Perpendicular to IR Enters patient on MCP at level 2 (5 cm) above upper border of pubic symphysis Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 77 Male Cystourethrography May be performed via endoscopic examination Essential projection = AP oblique Demonstrates bladder neck and urethra with as little bony superimposition as possible Patient position = recumbent 35- to 40degree posterior oblique IR centered to superior border of pubic symphysis Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 78 Male Cystourethrography Elevated pubis centered to midline Image should demonstrate superimposed pubic and ischial rami of down side and body of elevated pubis anterior to bladder neck, proximal urethra, and prostate Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 79 Lesson 2 Image Critique Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 80 Image Evaluation Essential Projections Urinary System Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 81 AP and PA Projections Entire renal outlines Bladder and pubic symphysis Separate radiograph may be needed No motion Short scale radiographic contrast to demonstrate contrast medium in renal area, ureters, and bladder Compression devices, if used, centered over upper sacrum Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 82 AP and PA Projections Vertebral column centered No artifacts from elastic in clothing Prostatic region inferior to the pubic symphysis on older male patients Time marker PA projection demonstrating lower kidneys and entire ureters (bladder included if patient size permits) Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 83 AP and PA Projections Superimposing intestinal gas in the AP projection moved for the PA projection Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 84 Projection? Anatomy? Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 85 AP Bladder Bladder No rotation of pelvis Prostate area in male patients Postvoid radiographs clearly labeled and demonstrating only residual contrast medium Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 86 Projection? Anatomy? Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 87 AP Oblique Projections Patient rotated about 30 degrees No superimposition of kidney remote from IR on vertebrae Entire down-side kidney Bladder and lower ureters on 35- × 43-cm IRs if patient’s size permits Time marker Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 88 Projection? Anatomy? Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 89 Lateral Urinary System Entire urinary system Bladder and pubic symphysis Short scale contrast clearly demonstrates contrast medium in renal area, ureters, and bladder No rotation Check pelvis and lumbar vertebrae Time marker Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 90 Projection? Anatomy? Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 91 Lateral: Dorsal Decubitus Position Entire urinary system Bladder and pubic symphysis Short scale contrast clearly demonstrates contrast medium in renal area, ureters, and bladder Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 92 Lateral: Dorsal Decubitus Position No rotation Check pelvis and lumbar vertebrae Time marker Patient elevated so that entire abdomen is visible Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 93 Projection? Anatomy? Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 94 AP Axial Bladder Region of distal end of ureters, bladder, and proximal portion of the urethra Pubic bones projected below the bladder neck and proximal urethra Short scale of contrast clearly demonstrating contrast medium in bladder, distal ureters, and proximal urethra Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 95 Projection? Anatomy? Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 96 AP Oblique Bladder Region of distal end of ureters, bladder, and proximal portion of the urethra Pubic bones projected below the bladder neck and proximal urethra Short scale of contrast clearly demonstrating contrast medium in bladder, distal ureters, and proximal urethra No superimposition of bladder by uppermost thigh Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 97 AP Oblique Bladder For voiding studies Entire contrast-filled urethra visible Urethra overlapping thigh on oblique projections for improved visibility Urethra lying posterior to superimposed pubic and ischial rami on the side down in oblique projections Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 98 Projection? Anatomy? Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 99 Lateral Bladder • Region of distal end of ureters, bladder, and proximal portion of the urethra • Pubic bones projected below the bladder neck and proximal urethra • Short scale of contrast clearly demonstrating contrast medium in bladder, distal ureters, and proximal urethra • Bladder and distal ureters visible through pelvis • Superimposed hips and femur Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 100 Projection? Anatomy? Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 101 Lesson 3 Venipuncture and Contrast Administration Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 102 Professional and Legal Considerations Radiographers must know the professional recommendations, state regulations, and facility policies for administration of medications ASRT Standards of Practice for Radiography support administration of medication by technologists State laws and facility policy determine legality Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 103 Medications Imperative for radiographer to be knowledgeable of all medications administered in the department, including Name Dosages Indications Contraindications Adverse reactions See Table 18-1 in Merrill’s Atlas Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 104 Patient Education Important to explain Procedural steps Expected duration Limitations and restrictions associated with procedure performance Anxiety can cause vasoconstriction making venipuncture more painful Information can ease patient’s fear and reduce discomfort of procedure Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 105 Patient Education Provide honest, factual, and appropriate information Be honest about pain that might be felt and note that pain experience is different for each patient Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 106 Patient Assessment Must occur before the contrast is administered Assess and document History of allergies Current medications Surgical procedures Past and current disease processes Lab values for BUN and creatinine Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 107 Patient Assessment History of allergies Include food and medication allergies Used to determine potential for adverse reaction to contrast Current medications Some medications for diabetes interact adversely with contrast Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 108 Patient Assessment Surgical procedures Past and current disease processes Used to determine site for venipuncture Used to determine appropriate amount of contrast Lab values for BUN and creatinine Indicators of normal kidney function Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 109 Infection Control Venipuncture may cause infection if performed incorrectly Strict aseptic techniques and universal precautions must be used IV filters can reduce the risk of infection Reduces rate of injection, too Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 110 Venipuncture Supplies and Equipment Supplies Needles Syringes Medication preparation Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 111 Supplies Tourniquet Tape Gauze pads Skin prep Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 112 Needles All are single-use only, disposed of properly after one use Parts Hub = attaches to syringe Cannula or shaft = length of needle Bevel = slanted portion at tip Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 113 Needles Gauge = diameter of needle bore Types Hypodermic Butterfly sets Angiocatheters Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 114 Needles Butterfly sets and angiocatheters usually used by radiographers for IV administration Needle type depends on Patient assessment Institutional policy Technologist’s preference Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 115 Syringes Types Plastic = disposable, single-use Glass = must be sterilized between uses Parts Tip = where needle attaches Barrel = has calibration markings and holds medication Plunger = fits snugly inside barrel and allows user to instill medication Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 116 Syringes Syringe size should be one size larger than volume to be injected Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 117 Medication Preparation IV administration cannot be retrieved and medication effects are almost instant For this reason, safety precautions must be followed Verify patient identity Verify correct medication three times Before preparation During preparation Before administration Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 118 Medication Preparation Containers Single-dose vials do not require prep before withdrawal Multiple-dose vials must be cleaned before drawing into syringe Needle inserted into rubber stopper to hub Air equal to amount of contrast needed injected into vial above fluid level Reduces air bubbles in contrast Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 119 Medication Preparation After air is injected, pull needle back to below fluid level Pull back on plunger until needed amount of fluid is aspirated into barrel Lightly tap on syringe barrel to remove air bubbles Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 120 Medication Preparation Infusions may be prepped from Glass bottle Plastic bag Glass requires vented tubing Plastic requires nonvented tubing Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 121 Procedure Site selection Site preparation Venipuncture Administration Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 122 Site Selection Prime factors to consider Suitability of location Condition of vein Purpose of infusion Duration of therapy Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 123 Site Selection Veins most often most often used for IV injection in radiography located Anterior forearm Posterior hand Radial aspect of wrist Antecubital space of elbow General rule: Select most distal site that can accept the needle size and can tolerate injection rate and solution Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 124 Site Selection Veins easily accessed for venipuncture Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 125 Site Preparation Skin must be prepared and cleaned If hair is present, shaving is not recommended Clip hair for better visualization of vein Antiseptic used for cleaning should be in contact with skin for at least 30 seconds Iodine tincture 1% to 2% Isopropyl alcohol 70% Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 126 Site Preparation Skin cleaned in circular motion from center of injection site to about a 2 circle Once cleaning swab is placed on skin it should not be lifted off until cleaning is complete Local anesthetic may be used before IV access Administered topical or by injection Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 127 Venipuncture Two methods Direct or one-step entry Indirect method Steps 1) 2) 3) Radiographer puts on gloves and cleans skin Local administered (optional) Tourniquet applied 6 to 8 above puncture site Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 128 Venipuncture Steps – cont’d 4) 5) 6) 7) Hold limb with nondominant hand and anchor vein with thumb Using dominant hand, position needle bevel side up at 45-degree angle to skin surface Enter skin with quick, sharp, darting motion and decrease angle to 15 degrees after entering vein Release tourniquet Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 129 Venipuncture Steps – cont’d 8) 9) 10) 11) Look for blood return If no blood return, pull back on plunger slowly to aspirate blood and verify placement in vein Anchor needle with tape Administer medication Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 130 Administration Must occur at established rate During injection, site should be observed and palpated proximal to puncture site for signs of infiltration Infiltration or extravasation means fluid has entered tissues instead of vein After contrast administration, remove tape or dressing Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 131 Administration Hold gauze pad over injection site and remove needle by pulling straight from vein Apply pressure to site with gauze Discard gloves, needles, and gauze in appropriate manner Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 132 Administration If patient has established IV site, check compatibility before using for contrast administration To administer contrast in existing IV line, stop infusion of medication Flush IV line with saline before and after contrast administration Restart infusion Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 133 Reactions and Complications Categorized as Mild Moderate Severe Mild reactions include Sensation of warmth Metallic taste Sneezing Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 134 Reactions and Complications Moderate reactions include Nausea Vomiting Itching Severe reactions, or anaphylactic reactions, can cause cardiac or respiratory crisis Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 135 Reactions and Complications Infiltration is a complication and its symptoms include Swelling Redness Burning Pain Treatment Application of ice within 30 minutes of occurrence Application of warmth if more than 30 minutes since occurrence Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 136 Documentation Adhere to and document the five “rights” of medication administration Right patient Right medication Right route Right amount Right time Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 137 Conclusions Medications are intended to benefit patient with minimum harm Because medications carry inherent risk, proper administration is critical Radiographers must be knowledgeable and competent, and practice within their local scope of practice Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 138
