CH18 Aseptic Technique.docx

Key Terms Angiography Radiographic procedure used to visualize blood vessels after the introduction of contrast material; used as a diagnostic aid in conditions such as cerebrovascular attacks (strokes) and myocardial infarctions Arrhythmia Any change from the normal sequence of electrical impulses...

Key Terms Angiography Radiographic procedure used to visualize blood vessels after the introduction of contrast material; used as a diagnostic aid in conditions such as cerebrovascular attacks (strokes) and myocardial infarctions Arrhythmia Any change from the normal sequence of electrical impulses of the heart, such as bradycardia (slow), tachycardia (fast), atrial/ventricular fibrillation, or rhythm disorders Arthrography Examination of a joint using x-rays after the injection of opaque contrast material Aseptic Describes a product or method that is free of microbiological organisms Atelectasis Medical condition in which the lungs are not fully inflated Auscultation Technical term for listening to the internal sounds of the body, usually using a stethoscope; based on the Latin verb auscultare (“to listen”); performed for the purposes of examining the circulatory system and respiratory system (heart sounds and breath sounds), as well as the gastrointestinal system (bowel sounds) Benign Prostatic Hypertrophy Benign prostatic hypertrophy is a noncancerous enlargement of the prostate gland, commonly found in men over the age of 50 C-arm X-ray image intensifier, sometimes referred to as a fluoroscope in medical settings; a highly complex piece of equipment that uses x-rays and produces a real-time imaging that is displayed on a monitor Central Venous Pressure (CVP) Pressure of blood in the thoracic vena cava, near the right atrium of the heart; reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system Contaminated Presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface Foley Catheter Indwelling catheter retained in the bladder by a balloon inflated with air or fluid Isolette Used as an incubator for premature infants; provides controlled temperature and humidity and an oxygen supply Lithotomy Position Common position for surgical procedures and medical examinations involving the pelvis and lower abdomen; patient is in the dorsal decubitus position with the hips and knees flexed and the thighs abducted and externally rotated; also called dorsosacral position Manual Resuscitator (Proprietary name Ambu bag) is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately Microorganisms Microscopic organisms; those of medical interest include bacteria, viruses, fungi, and protozoa Myelography X-ray examination of the spinal canal; a contrast agent is injected through a needle into the space around the spinal cord to display the spinal cord, spinal canal, and nerve roots on an x-ray; purpose of a myelogram is to evaluate the spinal cord and/or nerve roots for suspected compression Pneumothorax Accumulation of air or gas in the pleural space, which may occur spontaneously or as a result of trauma or a pathologic process or which may be introduced deliberately Purulent Consisting of or containing pus. The term purulent is often used with regard to drainage Serous Resembling serum, having a thin watery constitution; various bodily fluids that are typically pale yellow and transparent and of a benign nature that fill the inside of body cavities Sterile Aseptic; free of living microorganisms Subungual Beneath a fingernail or toenail Swan-Ganz Catheter The flow-directed balloon-tipped pulmonary artery catheter (also known as the Swan-Ganz or right heart catheter) has been in clinical use for more than 40 years. Initially developed for the management of acute myocardial infarction, the Swan-Ganz catheter provides right heart diagnostic information to rapidly determine hemodynamic pressures, cardiac output, and mixed venous blood sampling. Tracheostomy Surgical creation of an opening into the trachea through the neck; also used to refer to the creation of an opening in the anterior trachea for insertion of a tube to relieve upper airway obstruction and to facilitate ventilation Trendelenburg Position Position in which the patient is supine on the table or bed, the head of which is tilted downward 30 to 40 degrees, with the feet higher than the head; also, supine position with the patient inclined at an angle of 45 degrees so that the pelvis is higher than the head Urinary Meatus External urethral orifice; the opening of the urethra on the body surface through which urine is discharged Voiding Cystourethrogram Radiographic procedure obtained by the use of fluoroscopy and a contrast agent introduced through a catheter in the bladder; radiographic images are obtained before, during, and after voiding of the bladder, urethra, and kidneys Aseptic technique can be applied in any clinical setting. Pathogens may introduce infection to the patient through contact with the environment, personnel, or equipment. All patients and the healthcare worker are potentially vulnerable to infection, although certain situations further increase vulnerability such as extensive burns or immune disorders that disturb the body’s natural defenses. Typical situations that call for aseptic measures include surgery and the insertion of intravenous lines, urinary catheters, and drains. In healthcare settings, hand washing can prevent potentially fatal infections from spreading from patient to patient and from patient to healthcare worker and vice versa. The basic rule in the hospital is to cleanse hands before and after each patient contact by either washing hands with soap and water or using an alcohol-based hand sanitizer. Remember: If soap and water are not available, use an alcohol-based hand sanitizer to clean hands. When using an alcohol-based hand sanitizer, use the following procedure: 1. Apply product to the palm of one hand. 2. Rub hands together. 3. Rub the product over all surfaces of hands and fingers until hands are completely dry. The goals of aseptic technique are to protect the patient from infection and prevent the spread of pathogens and harmful microorganisms. Often, practices that clean (remove dirt and other impurities), sanitize (reduce the number of microorganisms to safe levels), or disinfect (remove most microorganisms but not highly resistant ones) are not sufficient to prevent infection. Surgical asepsis is protection against infection before, during, and after surgery by using sterile technique. Medical asepsis is the removal or destruction of infected material. Practices performed are aimed at destroying pathological organisms after they leave the body in the care of patients. Included in these practices is to avoid reinfection and the spread of infection from one person to another. It is the responsibility of the radiologic and imaging sciences professional to be knowledgeable and practice these techniques daily. Among the numerous imaging procedures that require sterile technique are angiography, arthrography, hysterosalpingography, myelography, and biopsies in the surgical environment. Other procedures described here require aseptic technique on the part of the radiologic and imaging sciences professional or an understanding of how aseptic technique is to be used for the specific procedure to improve care for patients. STERILE DRAPING A sterile field is a specified area (such as within a tray or on a sterile towel) that is considered free of viable microorganisms. In most instances a sterile field is established using a sterile drape. The first step in using a sterile drape is confirming that the package is sterile. If a package is not clean and dry, it is considered unsterile. If it appears to have been previously opened or if the expiration date has passed, it is also considered unsterile. The procedure for opening a sterile package (e.g., one prepared in the hospital) containing a sterile drape on a surface such as a table is as follows (Fig. 18.1): 1. Place the package on the center of the surface with the top flap of the wrapper set to open away from the person opening the package. 2. Pinch the first flap on the outside of the wrapper between the thumb and index finger by reaching around (not over) the package. Some packages require that the uppermost flap at each corner be grasped. The flap should be pulled open and laid flat on the far surface. 3. Use the right hand to open the right flap and the left hand to open the left flap. 4. Grasping the turned-down corner, pull the fourth and final flap. If the inner surface of any of the package touches an unsterile object, such as a sleeve, the entire pack and contents are considered unsterile and must be replaced. FIG. 18.1 Opening a sterile package. (A) Opening the first flap. (B and C) Opening the side flaps. (D) Pulling the last flap by grasping the corner. Note: The outer 1-inch edge of the sterile package’s margin is not sterile. A sterile package may also be opened as follows: 1. Hold the package in one hand with the top flap opening away from the person opening the package. 2. Pull the top flap well back and hold it away from both the contents of the package and the sterile field. Using the free hand to hold the flap against the wrist of the hand holding the package is an effective technique. 3. Drop the contents gently onto the sterile field from approximately 6 inches above the field and at a slight angle. These techniques help ensure that the package wrapping does not touch the sterile field at any time. Commercial packages usually have specific directions written on the package for opening. In general, available packages include those with partially sealed corners, in which the container is held in one hand and the flap is pulled back with the other, and those with partially sealed edges, in which both sides of the edge are grasped, one with each hand, and gently pulled apart (Fig. 18.2). FIG. 18.2 Opening commercially prepared sterile packs to drop sponges onto a sterile field. For a sterile field to be established, the drape is plucked with one hand by the corner and opened. This corner is used to fold back the top. Then the drape is lifted out of the cover and allowed to open freely without touching anything. Another corner of the drape then is picked up carefully and laid on a clean, dry surface with the bottom laid farthest from the person first, as they are establishing the field (Fig. 18.3). FIG. 18.3 Establishing a sterile field. (A) Holding the drape with one hand by the corner. (B) Folding back the top to lift the cover and lay the drape on a clean, dry surface with the bottom farthest from the person first, while establishing the field. Adding Sterile Supplies to an Established Sterile Field Necessary sterile supplies can be added to the field using the proper package-opening techniques. Remember the following: 1. Do not reach across a sterile field. 2. Do not flip or toss objects on the sterile field. 3. A 1-inch border around the outermost portion of the sterile field is not considered sterile. 4. Discard the outer wrapper from each sterile item. 5. Repeat this process for adding additional items to the sterile field. 6. Any opened sterile item or sterile area is considered contaminated if left unattended. 7. Sterile items that are located at or below waist level are considered contaminated because they are not within critical view. Pouring a Sterile Solution Sterile solutions are frequently poured into a metal or other container within the sterile field. Bottles containing sterile solutions are usually considered sterile on the inside but contaminated on the outside; thus, special care is needed in pouring these solutions. Begin with verifying the contents and expiration date on the solution. When possible, show the name to another healthcare person for verification. Always try to use the exact amount of solution. Once opened, the solution can be considered sterile only if it is used immediately. Once the container has been set down, it is no longer considered sterile and a new container must be opened. The procedure for pouring sterile solutions is as follows: 1. Remove the lid or cap from the bottle; place it on an unsterile surface with the topside down immediately to ensure the sterility of the inner surface. 2. Hold the bottle with the label uppermost so that poured solution cannot stain and obscure the label. 3. Sterile basins into which sterile liquids will be poured are generally placed at the end of the table to avoid splashing over the entire sterile field. 4. With as little of the bottle as possible over the field, hold it at a height of approximately 1 to 2 inches over the bowl (Fig. 18.4). Gently pour the solution so that no splashing occurs. Splashing of liquids can destroy a sterile field by allowing microorganisms to move from the unsterile tabletop through the wet drape that forms the bottom of the sterile field. 5. Close the bottle with the cap if appropriate. Some institutions require marking on the label of the bottle with the date and time that the bottle was opened along with the initials of the person who opened the bottle. FIG. 18.4 Pouring a sterile solution into a sterile bowl on a sterile field. STERILE PACKS Commonly used sterile packs include mylegraphy, minor procedures, and various special procedure packs used for exams such as venograms and angiograms. Items in the typical myelography pack are shown in Fig. 18.5 and often include the following: Injectable local anesthetic Syringes and needles of various sizes Sterile drape (fenestrated sheet or towel) Collection tubes (for spinal fluid) FIG. 18.5 A typical myelography pack. A minor procedure pack, used for arthrography and biopsies (tissue and/or fluid samples), usually contains all of the preceding items, as well as a sterile gown. Although commercially prepared angiography packs are available, many hospitals prefer to make up their own trays. Typical supplies for angiography procedures and biopsies include the following: Needles, including three 18-gauge, one 20-gauge, one 22-gauge, and one 25-gauge (the larger-gauge needles are used to inject local anesthetic) Sterile containers for biopsy specimens Plastic connector for test injections of contrast material One manifold (three stopcocks) for the contrast test, heparin drip, or saline flush Scalpel handle and no. 10 scalpel blade, used for arterial cut-down techniques and superficial structures Large number of gauze pads or topper sponges Up to five 10-, 20-, or 30-mL Luer-Lok syringes for saline flush Three 10-mL Luer-Lok syringes: Two for contrast tests, one for local anesthetic Forceps for sponges Six sponges for preparation of the puncture site with anesthetic Three stainless steel basins—one for saline solution, one for antiseptic, and one used as a waste basin—and one emesis basin Straight and curved clamps for arterial cut-down techniques Clamp to keep guidewire wrapped Several biopsies are performed under ultrasound guidance (thyroid, breast, kidney, and liver). These are done in real-time and utilize many of the same items in the sterile tray. An additional consideration for sterile technique during ultrasound guided biopsies includes the use of a commercially available sterile disposable sleeve to cover the transducer. If a commercially available sterile disposable sleeve is not available, the surgical drape, surgical gloves or condoms are used. There are various items that may be different, depending on the procedure and/or the provider preference. SURGICAL SCRUBBING Although persons performing aseptic procedures wear gloves, the skin of their hands, wrists and forearms should be cleaned routinely to reduce the number of microorganisms in case of a glove tear. A surgical scrub is required before participation in many interventional studies. The purpose of the surgical hand scrub is (1) to remove debris and transient microorganisms from the hands, nails, wrists and forearms, (2) to reduce the resident microbial count to a minimum, and (3) to inhibit rapid rebound growth of microorganisms. The sterile scrub consists of scrubbing with an antimicrobial agent. Surgical scrubbing involves two basic methods: (1) the numbered stroke method, in which a certain number of brush strokes are used for each finger, the palms, the backs of the hands, the wrists and the forearms, and (2) the timed scrub. Although exact procedures and times for the scrub vary among different settings and institutions, the following can serve as guidelines for the timed scrub (currently a surgical scrub with chlorhexidine gluconate (CHG), idophor, or parachlorometaxylenol (PCMX)) is performed before each procedure): 1. Be sure that scrub brushes, antiseptic soap, and nail cleaners are available. 2. Remove all jewelry, including watches. 3. Wash hands, wrists and forearms with antiseptic soap. 4. Clean subungual areas with nail file. 5. Scrub the sides of each finger, between the fingers, and the back and front of the hand for 3 minutes. 6. Scrub the wrist and forearm with the hands higher than the elbows. Each side of the arm is washed to 3 inches above the elbow for 1 minute. 7. Repeat the process for the other hand, wrist and forearm. The hands remain above the elbows at all times. 8. Dry the hands as shown in Fig. 18.6. FIG. 18.6 Drying the hands and arms after a surgical scrub. (A) Pick up a sterile towel from the table, being careful not to drip water on the gown beneath it. (B) Fold the towel lengthwise. (C) Use one end of the towel only to dry one hand. (D) Rotate the arm as you proceed to dry it, working from the wrist to the elbow. Do not allow the towel to contact the scrub suit. (E and F) After the arm is dried, bring the dry hand to the opposite end of the towel and begin drying the other hand. (G) Dry the arm using the blotting rotating motion. (H) Proceed to the elbow. The towel must be discarded in the linen hamper or kick bucket. STERILE GOWNING AND GLOVING Gowns and gloves are put on after the surgical scrub. Gowning can be done in two ways: (1) self-gowning and (2) gowning by another person. Sterile gowning differs from gowning for isolation in that the focus is on surgical rather than medical asepsis. Gloving can also be done in two ways: (1) self-gloving and (2) gloving by another person. A sterile surface is always required for sterile gloving. Gloves have two surfaces: an inside and an outside. Before the gloves are touched, the entire glove is sterile; however, once gloving has started, the inside surface of the cuff is considered nonsterile. Gloves are packaged in a paper wrapper with the palms of the gloves facing upward and the top of the glove folded over to form a 2- to 3-inch cuff. The exposed cuff is part of the inside of the glove and is therefore part of the nonsterile side. Self-Gowning (Fig. 18.7) 1. Standing approximately 12 inches from the sterile area, pick up the gown by the folded edges and lift it directly up from the package. The gown is folded so that the outside faces away. 2. Stepping back from the table, make sure no objects are near the gown. Holding the gown at the shoulders, allow it to unfold gently. Do not shake the gown. 3. Place the hands inside the armholes and guide each arm through the sleeves by raising and spreading the arms. 4. An unsterile assistant can adjust the gown by standing behind and reaching inside the sleeves, grasping them, and pulling gently. 5. For the open gloving technique, pull the sleeves over the hands. For the closed gloving technique, keep the hands and fingers covered by the sterile gown. 6. An assistant fastens the back and waistband of the gown. FIG. 18.7 Self-gowning. (A) Grasp the gown firmly and bring it away from the table. It has been folded so that the outside faces away. (B) Holding the gown at the shoulders, allow it to unfold gently. Do not shake the gown. (C) Place hands inside the armholes and guide each arm through the sleeves by raising and spreading the arms. Do not allow hands to slide outside cuff of gown. (D) The circulator assists by pulling the gown over the shoulders and tying it. After the gown is on, only the sleeves and front of the gown down to the waist are considered sterile. To maintain sterile technique once in sterile gown and gloves, persons must pass each other back-to-back. Self-Gloving Self-gloving can be done using a closed or an open gloving technique. It is performed after gowning or, in the case of the open gloving technique, may be used during sterile procedures that do not require donning a sterile gown. All jewelry, including watches, should have been removed. Select the appropriate size and type then check to make sure that the package is intact and dry and no tears or water stains are seen. Hands must be washed and dried before opening and putting on the gloves. The glove package should be opened facing the person who is going to wear the gloves with the right glove on the right side. Closed Technique (Fig. 18.8). 1. After donning a sterile gown with the fingers still inside the cuff of the gown, pick up the glove and lay it palm-down over the cuff of the gown. The fingers of the glove should face toward you. 2. Working through the gown sleeve, grasp the cuff of the glove and bring it over the open cuff of the sleeve. 3. Unroll the glove cuff so that it covers the sleeve cuff. 4. Pull the glove on by grasping the glove cuff and advancing the hand into the glove. 5. Proceed with the opposite hand, using the same technique. Never allow the bare hand to contact the gown cuff edge or outside of glove. 6. The fingers are adjusted until comfortable. FIG. 18.8 Self-gloving, closed technique. (A) Lay the glove palm-down over the cuff of the gown. The fingers of the glove face toward you. (B and C) Working through the gown sleeve, grasp the cuff of the glove and bring it over the open cuff of the sleeve. (D and E) Unroll the glove cuff so that it covers the sleeve cuff. (F–I) Proceed with the opposite hand, using the same technique. Never allow the bare hand to contact the gown cuff edge or outside of glove. Open Technique (Fig. 18.9). 1. Pick up the glove by its inside cuff with one hand. Do not touch the outside surface of the glove or the glove wrapper. 2. Slide the glove onto the opposite bare hand, leaving the cuff down. 3. With the gloved (and now sterile) hand, pick up the other glove by reaching under the cuff. Touch only the outside surface of the glove with the sterile gloved hand. 4. The glove is then pulled onto the hand without touching the inside surface of the glove, which is actually the outside surface of the folded cuff. 5. Interlock your hands and remember to keep them at or above waist level. FIG. 18.9 Self-gloving, open technique. (A) Pick up the glove by its inside cuff with one hand. Do not touch the glove wrapper with the bare hand. (B) Slide the glove onto the opposite hand. Leave the cuff down. (C) Using the partially gloved hand, slide the fingers into the outer side of the opposite glove cuff. (D) Slide the hand into the glove and unroll the cuff. (E) With the gloved hand, slide the fingers under the outer edge of the opposite cuff and unroll it gently, using the same technique. Removal of Your Gloves. 1. At the completion of the procedure, grasp the cuff of one glove and pull it off inside out and place it in the gloved hand. 2. Now reach inside the cuff of the gloved hand and pull the glove inside out and over the glove that you are holding and discard. 3. Wash and dry hands. Gowning Another Person (Fig. 18.10) 1. The sterile person picks up the gown by the neckband, holds it at arm’s length, and allows it to unfold. 2. The gown is held by the shoulder seams with the outside facing the sterile person. 3. The sterile gloves are protected by placing both hands under the back panel of the gown’s shoulder. 4. The arms are slipped into the sleeves in a downward motion, sliding the gown up to the mid-upper arms. 5. A nonsterile circulator pulls the gown up and fastens the back and waistband of the gown. 6. Gently pull the cuff back over the person’s hands, being careful that your gloved hands do not touch the bare hands. FIG. 18.10 Gowning another person. (A) Grasp the gown so that the outside faces toward you. Holding the gown at the shoulders, cuff your hands under the gown's shoulders. (B) The person steps forward and places their arms in the sleeves. Slide the gown up to the mid-upper arms. (C) The circulator assists in pulling the gown up and tying it. (D) Gently pull the cuffs back over the person's hands. Be careful that your gloved hands do not touch their bare hands. Gloving Another Person (Fig. 18.11) 1. The sterile person opens the package, picks up the right glove, and places the palm away from themself. Slide the fingers under the glove cuff and spread them so that a wide opening is created. Keep the thumbs under the cuff. 2. The person thrusts their hand into the glove. Having an extremely good grasp on the cuff is important because considerable force is exerted when the hand is pushed down into the tight glove. 3. Gently release the cuff while rolling it over the wrist. 4. Proceed with the left glove using the same technique. FIG. 18.11 Gloving another person. (A) Pick up the right glove and place the palm away from you. Slide the fingers under the glove cuff and spread them so a wide opening is created. Keep thumbs under the cuff. (B) The person thrusts their hands into the glove. Do not release the glove yet. (C) Gently release the cuff (do not let the cuff snap sharply) while unrolling it over the wrist. Proceed with the left glove, using the same technique. The procedure for removing gloves aseptically is also important to avoid contamination. The procedure to avoid touching the outside portion of the glove is shown in Fig. 18.12. FIG. 18.12 Removing contaminated gloves aseptically. (A) Grasp the edge of the glove. (B) Unroll the glove over the hand. Discard the glove (not shown). (C) With the bare hand, grasp the opposite glove cuff on its inside surface. (D) Remove the glove by inverting it over the hand. Discard the glove (not shown). STERILE PROCEDURES Box 18.1 lists the basic principles of sterile technique. The field includes the patient, the table, and other furniture covered with sterile drapes, and the personnel wearing sterile attire. Box 18.1 Basic Principles of Sterile Technique Only sterile items are used in sterile fields. If in doubt about the sterility of an object, consider it unsterile. An unsterile object should be removed, covered, or replaced. A sterile field must be continually monitored to be considered sterile. Create sterile fields as close to the time of use as possible. Sterile persons should avoid unsterile areas. Anything below the level of the table or the level of the waist, as well as the undersurface of the drape, is considered unsterile. Any item that falls below this level is considered contaminated. Gowns are considered sterile on the sleeves and the front from the waist up. The back of the gown and the area below the waist are considered unsterile. Persons in sterile gown and gloves must pass each other back-to-back. A sterile person may touch only what is sterile. Unsterile persons cannot reach above or over a sterile field. Sterile materials must be kept dry. Moisture permits contamination. Packages that become wet must be re-sterilized or discarded. If a solution soaks through a sterile field to a nonsterile field, the wet area may be re-draped. Sterile gloves must be kept in sight and above waist level. Dressing Changes Dressings are best changed in a team setting with another radiologic and imaging sciences professional or healthcare worker. The physician is responsible for ordering dressing changes and reapplication. Be sure to secure privacy for the patient, explain the procedure to the patient, and secure consent before beginning the procedure. The equipment needed is as follows: STERILE Disposable gloves Pack containing scissors, forceps, sterile towel, dressings, cotton-tipped swabs, and solution cup Antiseptic solution and sterile saline UNSTERILE Plastic bag for discarded dressings Properly sized adhesive Pads to protect surrounding area from secretions If the wound is draining (purulent or serous) material, to maintain a standard precautions environment, gowns are required at all times. All dressings are treated as though they are infected. Do not touch a dressing with bare hands. The procedure for changing a dressing is as follows: 1. The hands are washed, and patient privacy and consent are obtained. The adhesive tape surrounding the dressing must be removed. This procedure is often painful, and a solvent such as baby oil might be needed to loosen the tape. The amount of solvent should be limited to avoid contaminating the wound. 2. The dressing is removed with forceps or gloved hands, wrapped, and placed in the plastic bag. If the dressing does not come off easily, an appropriate person (e.g., department nurse, department supervisor, physician) should be contacted for additional instructions or to remove the dressing. 3. For reapplication, sterile technique is followed. The hands are washed, and the sterile towel is opened to use as a sterile field on which to place sterile dressings. The dressings are opened and placed on the sterile towel. 4. The tape is cut into the lengths that will be needed. Because the tape is not sterile, it is placed near but not on the sterile field. 5. Gloves are put on, and the dressing is applied. The gloves are removed, and the dressing is secured with the adhesive tape. The hands are washed again, the patient is covered again, and the waste is discarded according to the institutional policy. Tracheostomies A tracheostomy is an operation performed under sterile technique that involves incising the skin over the trachea and then making a surgical incision in the trachea. This procedure provides for an airway during upper airway obstruction. It is used in emergency situations and to replace the airway provided by an endotracheal tube that has been in place for several weeks. To prevent skin breakdown, tracheostomies are always covered with a dressing. If at all possible, the first task in providing care to a patient with a tracheostomy is to establish communication. This provision usually consists of yes-or-no questions, hand signals, and simple sign language. Written communication methods are used less often than verbal methods. Because these patients are often extremely ill, they have difficulty in using written communication and little need for complicated messages. In some cases, after a few days, the tracheostomy may be changed to the talking type, which will allow for speech. The technologist caring for the tracheostomy patient must also be sensitive to unmet and inexpressible needs and the need to keep the patient’s anxiety level low. Thus, these patients often have a great need to have procedures explained and the explanations repeated. To minimize the possibility of infection, the technologist should not touch a tracheostomy except under conditions of sterile technique. A tracheostomy must be suctioned often to remove secretions. This task is usually the responsibility of the respiratory therapist or nurse taking care of the patient, although in certain situations (i.e., emergencies), this responsibility may become the technologist’s. It is recommended that only properly trained personnel suction the tracheostomy patient. The patient must be well aerated with 5 to 10 breaths of oxygen before suctioning, which can be accomplished using a manual resuscitator (Ambu bag) hooked to an oxygen source. In addition, before suctioning, the patency of the suction catheter must be tested by aspirating normal saline through the catheter. The procedure for suctioning is as follows: 1. Insert the catheter in the stoma without suction until the patient coughs or until resistance is met. Then withdraw the catheter approximately 1 cm before beginning suctioning. 2. Apply suction intermittently and withdraw the catheter in a rotating motion. Activate suctioning by placing the thumb over the hole in the suction line to cause the suction to pull from the end of the tube where it is placed in the patient’s body. 3. Assess the airway by auscultation of the lungs. Use a stethoscope to listen to the sounds of inspiration and expiration over the chest wall. Breath sounds are the result of free movement of air into and out of the bronchial tree. The duration, pitch, and intensity of sounds indicate whether breathing is normal or abnormal. 4. Repeat the procedure until the airway is clear. Never suction for longer than 15 seconds, and allow the patient to rest in between. In some patients the distance between the skin and trachea is too great to be safely bridged by the standard tracheostomy tube (e.g., obese patients). In such instances, an extra-long tube may be used. It is a single-lumen tube and does not have an inner cannula to remove for cleaning. Given that the tube is of a variable length, its position may be checked radiographically to avoid main-stem ventilation. Chest Tubes Chest tubes are used to remove fluid, blood, and air from the pleural cavity. They assist in reinflating collapsed lungs (atelectasis), alleviating pneumothorax (i.e., air in the thoracic cavity), and bleeding into the chest (hemothorax). They are also used in cases of thoracotomy and open-heart surgery. Normally the pleural cavity contains no air or blood, containing instead a thin layer of lubricant that allows the pleurae to slide and move over one another without friction. Chest drainage systems have three compartments to which chest tubes are attached (Fig. 18.13). The first compartment is the collection chamber, which collects any fluid leaving the lung. The second compartment is the water seal chamber, which contains water and prevents air from the atmosphere entering the cavity through the chest tube. The concept is similar to that of a drinking straw, through which air can be blown (e.g., into a glass of water) but none can return. The third compartment is the suction control chamber, which also contains water, the amount of which regulates the amount of suction. This suction removes unwanted air or fluid from the pleural cavity. Some units have an additional fourth chamber, a water seal vented to the atmosphere to prevent potential pressure buildup. FIG. 18.13 Chest drainage system. Radiographers often perform chest radiography, especially portable procedures, before and after the insertion of chest tubes to ensure proper placement. Fig. 18.14 shows proper placement of chest tubes on a portable chest radiograph. Radiographers also produce chest images to confirm that the tubes can be removed; these are sometimes taken in the radiology department. An initial radiograph confirms full lung expansion; a second is performed approximately 2 hours after clamping to verify continued expansion. A third image is often obtained after removal of chest tubes, again to confirm full lung expansion. FIG. 18.14 Radiograph verifying proper placement of chest tube in the left lung. All radiologic and imaging sciences professionals must be careful when entering and leaving a patient’s room after chest tubes have been inserted; the tubes can be pulled from the body if caught by a mobile x-ray unit or tugged roughly during handling of the patient or image receptor. Patients may also come to the radiology department by stretcher or wheelchair if they have had the chest tubes in place for a long time. The exterior assembly of the chest tubes must always remain lower than the patient’s chest. Caution is necessary when moving and positioning the patient to prevent compromising the integrity of the tubes. In addition, if the patient is in the department for a longer period (longer than 1 hour), drainage in excess in 100 mL/h should be reported, as well as any change from a serous fluid to a darker red color. Urinary Catheters Urinary catheterization is the insertion of a tube into the bladder using aseptic technique. The two main types of urinary catheters are the Foley catheter (a retention balloon type) and the straight-type catheter (Fig. 18.15). On insertion of the Foley catheter, the balloon is filled with sterile water to hold the catheter in place. Any catheter that remains in place is also called an indwelling catheter. Urinary catheters can be used to do the following: Empty the bladder (e.g., before surgery, radiologic or other examinations, or childbirth) Relieve retention of urine or bypass obstruction Irrigate the bladder or introduce drugs Permit accurate measuring of urine output Relieve incontinence Fill bladder with a contrast agent to assess the urinary system for structure and function, known as a voiding cystourethrogram. When the flow of the contrast is identified as traveling in reverse (bladder to kidney), vesicoureteral reflux is diagnosed. In addition, urinary catheters can be used in sonography to do the following: Fill the bladder to assess the wall thickness and/or pathology Fill bladder to assess the pelvic structures in the female patient (uterus, ovaries) Fill bladder and assess the volume of the prostate gland FIG. 18.15 The two main types of urinary catheters: straight (A) and Foley (B). The relative size of a Foley catheter is described using French units (F). The most common sizes are 8/F to 20/F. 1/F is equivalent to 0.33/mm = 0.013 inch = 1/77 inch of diameter. This system indicates the outer diameter of the catheter. Thus, catheters range in diameter from approximately 2.6 to 5.9 mm. Choose a larger size when possible. Because a urinary catheter can interrupt the body’s defense mechanism against disease, a variety of catheters are available. Plastic catheters, for example, are suitable for short-term use only. Latex catheters can be used for 2 to 3 weeks and polyvinyl chloride catheters for 4 to 6 weeks, whereas the expensive pure silicone catheters are used only for long-term catheterization of 2 to 3 months. There are also intraurethral catheters. These self-retaining devices are totally contained within the urethra and placed into position via a cystoscope. This type of catheter can provide continued relief of urinary retention in high-risk patients with benign prostatic hypertrophy. Early reports suggest low incidences of bacteriuria and symptomatic infection over weeks and months of use. An extension of this concept is the more recent use of temporary biodegradable and permanent intraurethral stents in men with benign prostatic hypertrophy, and in women with acontractile bladders and chronic urinary retention. Studies suggest that these stents are an attractive and simple alternative to conventional catheterization. These types of catheters will typically have a bag for drainage that will attach to the individual’s leg and may not be readily identified as an indwelling catheter that continues into the bladder. The urine collection bag should be kept low (below the level of the bladder) to prevent reflux of urine back into the bladder. Failure to do so can lead to infection. Keeping the collection bag low also facilitates drainage from the bladder by gravity. Bags should never drag on the floor. During the transfer of patients by wheelchair or stretcher, ensure that the drainage bag and tubing do not become entangled in wheels or caught on passing objects. If the radiologic and imaging sciences professional empties the urine collection bag, then output must be measured and recorded, unless otherwise noted. Do not forget to reclamp the stopcock after the bag has been emptied. In many cases, the patient’s intake of fluids is also being recorded; if the patient is given a drink of water or any other fluid, it should be recorded in the patient chart along with the recorded output. Always check with the nursing unit whenever a question of recording intake and output exists. In most instances, radiologic and imaging sciences professionals do not catheterize patients, although this practice varies depending on the setting. In some institutions, they may be responsible for catheterizing a patient undergoing a voiding cystogram as an outpatient. The equipment needed to perform urinary catheterization consists of a sterile catheter, a sterile collecting bag, a syringe with sterile water or saline, and a catheterization kit or the following supplies: Sterile gloves Antiseptic solution Sterile cotton balls and sterile forceps Lubricant (water-soluble jelly) Container to receive urine Sterile drape for sterile field The procedure for performing urinary catheterization is as follows: 1. Wash hands, provide for patient privacy, explain the procedure, and secure consent. 2. Place female patients in the lithotomy position; position male patients supine and expose the genitalia. 3. Open the kit and put on the gloves, which will remain sterile during the entire procedure. 4. Place the sterile drape around the penis for a male patient or under the buttocks for a female patient. 5. If a Foley catheter is being used, test-inflate the balloon by injecting a small amount (approximately 1 mL) of sterile water into the balloon port of the catheter. If the balloon holds, deflate it. If it fails to hold, obtain a new Foley catheter. 6. Pour antiseptic over the cotton balls. 7. Coat the catheter tip with sterile lubricant. 8. Expose the urinary meatus using the non-dominant hand. This hand is no longer considered sterile. 9. With female patients, separate the labia majora and minora. For male patients, hold the penis with the foreskin retracted. 10. Clean the urinary meatus with a cotton ball held by forceps. For men, circle the urinary meatus once and repeat. For women, wipe the labia minora from top to bottom, discard the cotton, and then clean the urinary meatus from top to bottom. The labia or foreskin must not contaminate the meatus before or after cleansing. 11. Insert the catheter slowly with the dominant hand until urine flows. For women, this distance is approximately 0.5 inch (Fig. 18.16); for men, it is approximately 8 inches (Fig. 18.17). Always apply gentle pressure, and never force a catheter. 12. Reattach the syringe to the balloon port and fill the balloon. A light tug on the catheter ensures that the balloon is holding the catheter in place. FIG. 18.16 Proper placement of a urinary catheter in a female patient. FIG. 18.17 Proper placement of a urinary catheter in a male patient. Radiologic and imaging sciences professionals are often responsible for removing a urinary catheter after procedures such as a voiding cystourethrogram and sonographic procedures. The materials needed to remove an indwelling catheter are a basin, such as an emesis basin, scissors, and several paper towels. The procedure is as follows: 1. Wash hands, provide for privacy, explain the procedure to the patient, and secure consent. 2. Uncover the patient and place the basin under the catheter valve. Cut the tip of the balloon valve with the scissors and allow the water from the balloon to drain into the basin. 3. Once the flow of water has ceased, place the towels under the catheter and pull gently. Stop and notify a physician or nurse if any resistance is noted. 4. When the catheter has been completely removed, wrap it in the towels, cover the patient, and discard the catheter. Another type of urinary catheter is the suprapubic catheter, a closed drainage system inserted approximately 1 inch above the symphysis pubis into the distended bladder. The procedure is performed with the patient under general anesthesia. If the catheter is to be retained in place, it is sutured to the skin of the abdomen. Reasons for inserting a suprapubic catheter include the need for long-term catheterization, urethral injury or obstruction, and the period after some gynecologic surgeries. Male patients may also have a condom catheter, a specially designed condom with a catheter at the end attached to a collecting bag. This device allows an incontinent male patient the use of a catheter without the permanence or inconvenience of a Foley or straight catheter. This type of catheter is associated with an increased susceptibility to infection at the tip of the penis and requires regular cleaning, care, and changing of the condom sleeve. Intravenous and Intraarterial Lines Sterile technique is required for the insertion of lines (catheters) into veins and arteries. These lines are also called central venous and arterial lines. Intravenous lines are inserted for a variety of reasons, including the introduction of medications and intravenous fluids and the measurement of central venous pressure. The Swan-Ganz catheter, a specific type of intravenous catheter, is used to measure the pumping ability of the heart and other heart parameters. Other types of venous lines include the Intracath, Hickman, Broviac, and Arrow-Howes triple lumen. Arterial lines include the radial arterial and femoral arterial lines. These lines are typically used for drawing blood and measuring blood pressure. When performing special radiologic procedures, the radiologic technologist may encounter patients with arterial and venous lines in place. In addition, fluoroscopy and portable chest radiography are often used to verify placement of the lines. The portable chest radiograph is also used to assess for pneumothorax. Gloves, masks, and gowns are typically worn. The patient is usually in the Trendelenburg position when the line is placed. Fig. 18.18 demonstrates correct placement of a Swan-Ganz catheter. FIG. 18.18 Radiograph verifying proper placement of a Swan-Ganz line. Pacemakers Permanent pacemakers are electromechanical devices inserted under the patient’s skin and leads (wires) that are placed in the right atrium and/or the right ventricle to regulate the heart rhythm and normal speed. Single- or dual-chamber pacemakers may be utilized, depending on the correction needed. Patients with an arrhythmia, such as symptomatic bradycardia (a slow heart rate), are the most likely candidates for permanent pacemakers. A pacemaker can prevent bradycardia by sensing the heartbeats of a patient and pacing the heart when it does not initiate a heartbeat on its own. Pacemaker units are approximately 1 inch wide in diameter and thickness, weighing just a little over 1 ounce. The unit consists of a pulse generator and accompanying circuitry and is connected to a lead. The tip of the lead contains a metal electrode that is put into contact with the heart. The electrode senses heartbeats and can also produce an electrical impulse to make the heart contract. Using aseptic technique, the surgeon makes an incision at the level of the pectoral fascia, secures percutaneous access to a vein, and forms a pocket for the pulse generator. Before insertion of the pacing lead, a needle and syringe are inserted into the subclavian vein for verification. Then a guidewire is inserted through the needle to establish a pathway through the vein. The role of the radiographer is to operate the fluoroscopy unit, which will allow the physician to place the guidewire correctly. After the guidewire is determined to be in the correct position, an introducer sheath is used to place the pacing lead into the subclavian vein. Under fluoroscopy, the lead is advanced into the right atrium, the introducer sheath is withdrawn, and the lead is positioned in the apex of the right ventricle. Temporary pacemakers are also usually connected to a transvenous pacing electrode, but the pacemaker is external to the patient’s body. The fluoroscopic technique is similar to that for permanent pacemaker insertion. A new magnetic resonance–conditional pacemaker system has been designed, tested, and approved for safe use in magnetic resonance imaging (MRI). This represents a major milestone in the evolution of implantable cardioverter-defibrillators. For the first time, patients with this new pacing system will be able to undergo MRI scans under certain conditions. Currently, most patients with implanted pacemakers are restricted from receiving MRI examinations. Special care is also needed for the patient with a pacemaker undergoing radiation therapy; the pacemaker must be shielded from the radiation field, or damage to the circuit may occur. Surgical and Portable Radiography Radiography in the surgical environment requires strict attention to sterile technique. Specific guidelines are difficult to give because procedures vary greatly among surgeons and facilities. The one constant is the existence of a sterile corridor, the area between the patient drape and the instrument table. Radiographic image receptors are sometimes positioned under the table through a tunnel device; in other cases, they are enclosed in sterile covers and positioned by the physician. In most cases, especially at first, the radiography student observes procedures performed in surgery. In some cases, the machinery is left outside the room until right before the procedure; in other cases, the surgeon or procedure demands that setup occur before the operation begins. Use of the C-Arm in Surgery. A C-arm is an x-ray image intensifier. The name derives from the C-shaped arm used to connect the x-ray source and x-ray detector to one another. They are used primarily for fluoroscopic intraoperative imaging during surgical, orthopedic, and emergency procedures. The use of the C-arm fluoroscopy in surgery requires increased attention to maintaining a sterile field. The surgical draping of the C-arm and the patient is performed by the surgical team. Basically, three approaches can be used to maintain a sterile field. The most common approach is draping the image intensifier and C-arm with what is known as a snap cover. A tension band is snapped in place when the image intensifier and C-arm are covered with a sterile cloth or bags. This approach allows the physician to manipulate the C-arm while maintaining a sterile field. Hip pinning or femur rodding may use an approach known as the shower curtain approach. On the patient’s affected side, a sterile clear plastic sheet is suspended from a long horizontal metal bar attached to two vertical suspending rods. An opening is located in the middle of the sheet, which is attached using a special adhesive to the patient, allowing access to the surgical site. A third but less common approach is to drape the site with an additional sterile cloth. The C-arm then is brought over the anatomic area of interest. When the C-arm is no longer needed, it is removed, as is the cloth. This approach is a stop-gap measure in many cases and is useful only when the physician does not need to manipulate the C-arm. Care is needed when removing the cover. Gloves should be worn to protect the individual from any debris that may have been collected from the procedure. Surgical and Portable Sonography The same holds true for sterile technique in the surgical environment while utilizing sonography. The probe (transducer) may be used directly on a kidney in surgery to check the blood flow or on the brain that is open. All sterile draping of the probe must be performed and the machine must be cleaned prior to entering and exiting the surgical suite. The same techniques are applied when working in the intensive care, neonatal units, and in neurointensive care units. Ultrasound-guided procedures should be performed in accordance with the facility’s infection control guidelines. The patient’s skin should be cleansed with an antiseptic cleanser. The ultrasound probes represent a potential source of contamination. Probes should be disinfected between each procedure according to manufacturer recommendations and practice-specific infection control guidelines. The use of sterile drapes, sterile probe covers, and sterile ultrasound gel may provide the best method to reduce the risk of contamination and infection. Neonatal Portable Radiography. Neonatal infant patients require many therapeutic interventions to support them, which may lead to frequent invasive procedures and long exposure to the hospital environment. Sepsis and nosocomial infections are recognized as major threats that result in significant morbidity and mortality each year in the neonatal unit. Thus, in neonatal radiography, maintaining asepsis as much as possible is important. The task of obtaining images of the infant and maintaining a safe environment without cross-infection are very important, and the radiographer must pay close attention to all that they are in contact with, including the x-ray machine, image receptor, patient, bed and bedding, and protective lead shielding. Protocol for neonatal units should be outlined by the institution and implemented by the healthcare worker. Although some institutions may not be specific regarding protocol, the following are suggestions that may be helpful in reducing contaminants and possible infection in an already compromised patient: Hand washing (before and after each patient) Wiping down the machine (before and after use) Keeping multiple pieces of lead in the units and sterilizing after use Covering the lead with a pillowcase or other protective covering Assigning a piece of lead to each crib and cleaning after each use For radiography of the neonate, two methods of gonadal shielding are accepted when imaging any part, other than the abdomen or pelvis: (1) contact, which places lead directly on the infant’s gonads, and (2) shadow, which hangs a piece of lead in the beam (or places a piece of lead on the isolette), casting a shadow in the collimator light. Each method has advantages and disadvantages. Shadow shielding, for example, requires low levels of ambient lighting for proper use. Contact shielding has the greatest potential for cross-infection. Emergency Department, Patient Room, and Intensive Care Unit Portables. Some patients located in the emergency department, patient rooms, or intensive care unit may be unable to travel to the radiology department owing to the severity of their condition. This requires the radiologic and imaging sciences professional to go to their rooms to obtain images, if possible. All precautions for the safety of the patient and healthcare worker must be considered. The emergency department provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. The patient undergoes a brief triage (sorting) interview to help determine the nature and severity of the illness or injury. After assessment, imaging studies may be ordered. These patients may require portable imaging to assist in appropriate treatment. Unfortunately, movement is necessary to obtain images, and this can cause additional injury to the patient if they are not moved correctly. In addition, with this movement comes increased exposure to possible infectious agents owing to contact with blood and other body fluids from a severely injured patient. It is very important to implement proper protection protocols. Care must be taken with the patient and all devices that are being used (e.g., respirators, central lines). Recommended Good Practices for Removal of Hazardous Waste Thick, leak-proof plastic bags, colored differently from other hospital trash bags, should be used for routine collection of discarded gloves, gowns, tubing, and other disposable material and labeled as Hazardous Drug-Related Wastes. Hazardous Waste Disposal and Containers The Occupational Safety and Health Administration (OSHA) Technical Manual Part IV (section c) requires the labeling of needle containers and breakable items of hazardous waste as hazardous drug waste only. It also mandates the use of properly labeled, sealed, and covered disposal containers, handled by trained and protected personnel, as required under the Bloodborne Pathogens Standard if such items are contaminated with blood or other potentially infectious materials. SUMMARY The purpose of aseptic technique is to reduce the number of harmful microorganisms. Surgical asepsis is protection against infection before, during, and after surgery by using sterile technique. Medical asepsis is the removal or destruction of infected material. A variety of radiologic and other imaging procedures require sterile technique. A sterile field is a microorganism-free area that can receive sterile supplies. The patient is the center of the sterile field. The field includes the patient, the table and other furniture covered with sterile drapes, and the personnel wearing sterile attire. Commonly used sterile packs include myelography, minor procedure, and special procedure packs. Minor procedure packs are used for arthrography and biopsies. The purpose of the surgical hand scrub is to remove debris and transient microorganisms from the hands, nails, wrists, and forearms; to reduce the resident microbial count to a minimum; and to inhibit rapid rebound growth of microorganisms. Gowns and gloves are put on after the surgical scrub. Gowning can be done in two ways: self-gowning and gowning performed by another person. Sterile gowning differs from gowning for isolation in that the focus is on surgical rather than medical asepsis. Gloving can also be done in two ways: self-gloving and gloving performed by another person. All dressings are treated as though they are infected and are not touched with bare hands. Dressings are best changed with an assistant. A tracheostomy involves incising the skin over the trachea and then making a surgical wound in the trachea. This procedure provides for an airway during tracheal obstruction. If at all possible, the first task in providing care to a patient with a tracheostomy is to establish communication. Chest tubes are used to remove fluid, blood, and air from the pleural cavity. Special caution is needed when dealing with a patient with chest tubes to keep the drainage system below the chest and to maintain the integrity of the tube. Urinary catheterization is the insertion of a tube into the bladder using aseptic technique. The two main types of catheters are the Foley catheter (a retention balloon type) and the straight-type catheter. Intravenous and intraarterial lines are inserted for a variety of reasons, including the introduction of medications and pressure measurements. The radiographer may assist the physician in determining the placement of the line with fluoroscopy or a portable chest radiograph. Pacemakers are electromechanical devices inserted under the patient’s skin to regulate the heart rate. They are further subdivided into permanent pacemakers, which are inserted in a pocket of skin, and temporary pacemakers, which are placed outside the patient’s body. Both types use a transvenous pacing electrode that is monitored with fluoroscopy for proper placement. Surgical radiography procedures vary greatly among surgeons and institutions. The one consistency is the existence of a sterile corridor, the area between the patient drape and the instrument table. Portable radiography and other imaging equipment is a very important service for the critically ill patient who cannot be transported, and special care must be taken with all the equipment that may be associated with the patient. Special precautions must be taken for personal safety regarding patient body fluids and secretions, which includes the proper disposal of all potential hazardous waste. It is your professional responsibility to take care of yourself and your patients.