Rad Notes Patient Care PDF (ARRT Exam Guide)

Patient Care A simple and complete guide to the ARRT exam derived from real school notes from a broad range of sources, based on the ARRT content specifications. Written by Amanda White, RT (R) 2023 Table of Contents Patient Care Chapter 1 - Ethical & Legal Consideratio...

Patient Care A simple and complete guide to the ARRT exam derived from real school notes from a broad range of sources, based on the ARRT content specifications. Written by Amanda White, RT (R) 2023 Table of Contents Patient Care Chapter 1 - Ethical & Legal Considerations…………………….Page 2 Chapter 2 - Direct Patient Care…………………………………..Page 7 Chapter 3 - Medical Equipment…………………………………..Page 19 Chapter 4 - Infection Control……………………………………...Page 23 Chapter 5 - Pharmacology & Contrast…………………………..Page 29 Chapter 6 - Common Pathology & Fractures…………………...Page 33 Chapter 7 - Patient & Personnel Safety…………………………Page 43 1  Patient Care Chapter 1 Ethical & Legal Considerations ARRT Code of Ethics Patient Bill of Rights Advance Directives Legal Doctrines Documentation 2 ARRT Rules of Ethics vs Code of Ethics The Standards of Ethics includes both the Rules of Ethics and the Code of Ethics. The Code of Ethics serves as a guide for what radiologic technologists should strive to be as medical professionals. The Rules of Ethics are mandatory, enforced, and have sanctions for violations. ARRT Standard of Ethics Scope of Practice for Radiographers It is within the radiographer’s scope of practice to verify within ordering physicians about the clinical indications and necessity for specific exams; however they may not tell patients that an exam is or is not necessary. The radiographer may inform patients of their right to refuse an exam. It is within the technologist’s scope of practice to alert the attending physician or reading radiologist of suspected urgent or emergent pathology. It is not within the scope of practice to give patients any diagnosis or clinical information about their images. Patients wishing to discuss their medical records and results, including imaging, should review the results with physicians only. Consent Patient consent for treatment is typically given upon admission, or as part of their patient care agreement with a facility. Invasive procedures or procedures involving potential risks require additional consent. Informed consent (valid consent) requires the following: ○ Full explanation of the procedures in plain terms that the patient can understand, including risks and benefits. ○ Must be offered voluntarily. ○ Consent forms must be signed prior to any sedation or anesthesia administration. ○ Consent forms must be filled out entirely prior to being signed; there should be no blank spaces. ○ The patient must be of legal age and mentally competent to sign. If the patient is unable to sign for themselves, only a legal guardian may sign for them. ○ Only the physician named on the consent form may perform the procedure. ○ If there are any conditions stated on the form, the consent is only valid if those conditions are met. ○ The patient may revoke their consent at any time during the procedure. Implied consent allows for care when a patient is unconscious or incapacitated and cannot provide consent. Based on the assumption the patient would approve of care if they were able to do so. 3 Health Insurance Portability and Accountability Act (HIPAA) HIPAA protects the patients rights to privacy of their information. Patients must receive a clear, written explanation of how their information may be used. Patients must be able to see their records, make copies, and request amendments. A historical account of routine disclosures (record sharing) must be available to the patient. Patients must give consent for their information to be shared. Patients have the right to request restrictions on the sharing of their information. Patients have the right to file complaints if HIPAA is violated. Patient Bill of Rights Patients may consent or refuse any procedure; the patient also has the right to: ○ Respectful care. ○ Updated information that is understandable regarding diagnosis, treatment, and outcomes. ○ Involvement in decision making through diagnosis, treatment, and recovery. ○ Have an advance directive. ○ Privacy in all aspects of medical care. ○ Total confidentiality. ○ View their medical records. ○ Expect a hospital to respond to their needs for medical care. ○ Be informed of any business relationships that may affect their care. ○ Consent to or decline to participate in research and experimental studies. ○ Continuity of care, and options outside of the hospital. ○ Be informed of any policies or procedures within the hospital that may affect their care. ○ Be informed of all resources available to them. ○ Be informed of charges for services and options for payment. Advance Directives Advance directives (living will)(health care proxy)(durable power of attorney) allow the patient to direct their medical care according to their wishes should they become incapacitated. Copies of advance directives can and should be included in the medical record, as well as given to physicians, family members, and attorneys. Durable power of attorney allows another person named by the patient to represent them and make decisions if they are unable to communicate. This individual may sign consents and forms. Do not resuscitate (DNR) orders, or no code, may be placed on file if the patient wishes that no life saving measures be taken should they become unresponsive. Do not intubate (DNI) orders may be placed if the patient wishes to not be placed on a ventilator in order to be kept alive. This can stand with or without a DNR also in place. DNR and DNI orders should be very clearly noted on the patient's chart. 4 Legal Doctrines Respondeat superior; “Let the master answer.” An employer is liable for their employees actions. Res ipsa loquitur; “The thing speaks for itself.” The cause of the negligence is obvious. Common Legal Terminology Assault - Threat of touching a patient in a way that may cause them harm; can occur even if the patient feels apprehension or fear that they may be harmed. Battery - Unlawful touching without consent; harm resulting from physical contact, in this case, with a medical professional. Includes x-raying the wrong patient or performing the wrong exam on a patient. False imprisonment - Restraint of a patient against their will without justification; caution must be taken when immobilizing patients for exams so that it does not become false imprisonment. Invasion of privacy - Includes violation of confidential information, unnecessary exposure of a patient’s body, inappropriate touching of a patient’s body, or photography of a patient without their consent. Libel - Written information resulting in defamation of character and/or damage to a person’s reputation. Slander - Spoken information resulting in defamation of character and/or damage to a person’s reputation. Tort (personal injury law) - Civil law violations. Intentional misconduct - When a person knowingly commits a tort. Includes assault, battery, false imprisonment, invasion of privacy, libel, and slander. Negligence (unintentional misconduct) - Includes neglect or omission of reasonable care. Harm caused without intent or purpose to do so. Based on how a “reasonably prudent person” would behave in the same situation. ○ Gross negligence - Acts that show reckless disregard for life and limb, but still without clear intent to cause harm. ○ Contributory negligence - The injured person or victim of negligence also unintentionally contributed to their own injury. ○ Reasonably prudent person doctrine - Based on how a person with similar education and experience would behave under similar circumstances. Malpractice - Professional negligence that results in injury to a patient as a result of lack of professional knowledge, skill, and practice that could reasonably be expected from others in the same profession. In order to establish malpractice, the following conditions must be met: Establishment of a standard of care. Demonstration that the standard of care was violated. Demonstration that the loss or injury was caused by the individual being sued. Demonstration that the loss or injury actually occurred as a result of the alleged negligence. Rule of personal responsibility - Individuals are responsible for their own actions. 5 Restraint vs Immobilization Restraints are used to restrict patient movement to protect the patient from harming themself or others. Use of restraints requires a physician's order. Patients with restraints should not be left unattended. Restraints should be removed only when absolutely necessary and should be replaced as soon as possible. Immobilization is used to prevent unwanted patient motion in images. This includes compression bands, tape, sandbags, or physical holding. This is not considered to be restraint and does not require a physician order. Documentation Charting refers to records added to a patient's chart. Most documentation within imaging departments consists of requisitions or an ordering system of some sort. Patient history should be taken and documented with each exam. Any special notes regarding medical occurrences or any unusual circumstances during the exam should be documented. Changes made to x-ray orders should always be done with the approval of the ordering physician and documented. The majority of charting is done electronically in this age; however any written records should be legible and accurate, and adhere to the following rules: ○ Do not erase or use white out on written records. Saw a single line through any incorrect information. ○ Initial and date any corrections. ○ Forms may not have any blanks; NA or 0 must be input on any blanks that are not filled out. ○ No loose or gummed sheets should be included in the chart. ○ Include all 4 digits of the year when writing patient DOB. ○ Entries should be dated and signed (with credentials) by the entrant. Never leave computers logged in and unattended. 6  Patient Care Chapter 2 Direct Patient Care Identification Communication Patient Transfer Medication Administration Venipuncture Vital Signs Medical Emergencies 7 Patient Identification The Joint Commission requires two patient identifiers be used when verifying patient identity; the patient’s name, date of birth (DOB), or medical record number (MRN). X-ray images must include at minimum the patient’s name and the date of the exam. Patient Education & Communication Verbal communication is spoken language that is understandable by the patient. Nonverbal communication is body language; facial expressions, eye contact, gestures, etc. Nonverbal communication, especially touch, must be carefully used so as to not be misinterpreted by the patient. Patients from different backgrounds may interpret body language differently from one another. If an interpreter is needed for a patient, only a certified interpreter should be used to communicate with the patient. This may be in person or via video or audio services. Family members should not be used to interpret medical information for the patient; they may paraphrase or leave out information that can cause misunderstanding between the physician and the patient. Radiographers as medical professionals should be aware and respectful of cultural differences and diversity among patients: ○ Age ○ Gender ○ Race/Ethnicity ○ Sexual preference ○ Marital status ○ Social status ○ Political affiliation ○ Religion ○ Geographic origin ○ Generation ○ Disability (physical or mental) ○ Language ○ Family lifestyle & relationships Procedures should be explained to patients clearly in lay terms that the patient can easily understand so they will know what to expect from start to finish. Pre/post examination instructions should also be given when explaining the procedure. The patient should confirm understanding with you until there are no further questions. Gathering good history from the patient is extremely important. Subjective history is information provided to you by the patient; objective history is the things that you observe about the patient. Radiographers may educate patients about their examinations, radiation, and inform them of their rights, including the right to refuse an exam. All of this is within the radiographer’s scope of practice. It is not within our scope of practice to inform patients whether or not an exam is medically necessary, nor give out any results or diagnosis to the patient. 8  ○ Educating patients about radiation safety should be done using simple comparisons that are understandable by the average patient. The background equivalent radiation time (BERT) is a way to compare radiation dose from diagnostic exams to background radiation that the patient would receive naturally. Radiographers should be able to give basic information regarding other modalities and other departments and medical services. Patient Scheduling ○ Schedule procedures in a way that they will not interfere with one another. ○ If a patient has multiple procedures that have been ordered, schedule them on the same day if reasonably possible given the type of exam and patient condition. ○ Patients who are receiving sedation should be scheduled first, and if doing multiple studies, should be recovered prior to any fluoroscopic study. ○ Diabetic and/or NPO patients should be scheduled first. ○ Pediatric and elderly patients should be scheduled early as possible. When deciding on the sequence of exams on the same patient, the rule is non-contrast studies first; barium studies last. Barium will stick around in the system for several hours to days in some cases, and will cause artifacts in other studies. The lower GI system is done prior to the upper GI because the upper GI will take the longest time to make its way through the alimentary canal. 1. Endoscopic studies 2. Urinary studies 3. Biliary studies 4. CT 5. Lower GI 6. Upper GI Patient Transfer Always check identification prior to transfer; ask patients for their name and date of birth. Explain how you are going to transfer them to avoid surprises and get better cooperation. Use proper body mechanics at all times. The log roll method is used for moving patients with pelvic or spinal injuries; keeps the patient completely straight and prevents turning or twisting. It requires at least 3 people. Wheelchair to table: ○ Wheelchair parallel to table (some sources recommend a 45 degree angle). ○ Ensure brakes applied. ○ Stand face-to-face with the patient, and have them pivot until their back is against the table, and have them sit on the edge of the table. ○ Support the patient's shoulders with one arm, and their knees with the other; assist them into the supine position. 9  Table to wheelchair: ○ Ensure brakes are applied. ○ Assist the patient to sit up, and have them sit on the edge of the table for a couple of minutes. Ask them if they are feeling dizzy or lightheaded; never attempt to transfer patients until they regain their bearings. ○ Ambulatory patients should be assisted with standing; then have them pivot until their back is to the chair. Have the patient place both hands on the arms of the wheelchair and sit. ○ Nonambulatory patients should stand face to face with you. Reach under the arms and place a hand on each scapula. Lift the patient upward, and pivot until their back is to the wheelchair. The back of the patient’s legs should touch the chair. Ease the patient into the chair. Stretcher transfer: ○ Never attempt a stretcher transfer alone. ○ Position the stretcher near the table; adjust table or stretcher height so that the height is even or just slightly lower on the side the patient is being transferred to. ○ A transfer sheet or draw sheet should be used, and a slide board if available. ○ One person supports the upper body at the head, a second person supports the lower body at the foot. There should be individuals on the left and right of the patient to support the sides. ○ Signal should be given with warning when to move; the transfer should be done in one smooth motion. Transfer Devices Draw sheets Single plain sheet folded in half and placed under the patient to assist with transfer to/from beds and stretchers. Slide boards Smooth plastic boards that are slightly flexible that are used under a draw sheet to help facilitate easier patient transfer. Particularly helpful if there is some height difference between the areas being transferred between. Slide mats Thick fabric mats that are placed under a patient to assist with transfer to/from beds and stretchers. Gait belts Nylon or other heavy fabric that fasten around the patient's waist, possibly with hand holds. Allow for a secure place to hold onto patients when assisting standing and walking. Hydraulic lifts Mechanical lifts that use a special nylon or heavy fabric sling under the patient, and use mechanical power to lift and transfer the patient from a chair or wheelchair to a bed or table, and vice versa. 10 Medication Administration & Venipuncture There are multiple ways that medication can be administered. Some medications can be administered in different ways depending on patient condition and desired effect. Intravenous and intra-arterial injections enter the bloodstream directly and offer rapid effects. Other methods of delivery typically take longer to take effect. Injectable medications are stored in vials, which may be multi-dose, and ampules, which are single dose. The term bolus refers to the quantity of medication being injected. Medication Administration Routes Enteral Given directly into the GI tract via an nasogastric tube. Oral Given orally via pills or liquid that is swallowed. Inhalation Uses the respiratory system to deliver medications in the form of a mist or vapor that may be delivered by nose or mouth. Transdermal Given through creams or gels applied to the skin, or through medicated (topical) patches placed on the skin. Sublingual Medication is placed under the tongue and is absorbed through the oral mucosa. Similarly, buccal delivery places medication in the cheek for absorption through the oral mucosa. Parenteral Given via injection through multiple different routes of entry. Parenteral Routes of Administration Intravenous (IV Given through the venous system via venipuncture. Intra-arterial (IA) Given directly into the arterial system. Intrathecal Given directly into the spine. Intramuscular (IM) Given directly into the muscle. Subcutaneous (SC) Given just under the skin. Intradermal Given just between the superficial layers of skin. 11  Venipuncture procedures: ○ Wash or sanitize hands prior to beginning the procedure and don gloves. ○ Secure a tourniquet 6-8 inches above the injection site and select a vein. The antecubital vein is most common. ○ Cleanse skin using a circular motion according to facility or department protocol. ○ Ensure the syringe is free of excess air. ○ Insert needle; once blood return is observed, remove the tourniquet. ○ Begin injection, catheter insertion, or blood collection process. If using a butterfly IV set, tape the wings to the patient’s skin to prevent displacement. ○ After injection or collection is finished, remove the needle (unless a catheter has been placed) and wipe the injection site with a gauze wipe. ○ Never discard medication vials until the exam is complete and the patient has been released. ○ Never recap the needle; dispose of the entire syringe. Safety needles should be fully retracted or guard fully deployed. ○ An IV push is when medication is rapidly delivered or “pushed” via IV; whereas an IV infusion is delivered over a longer period of time slowly, usually from bags. IV bags must be hung 18-20 inches above the vein; if the bag is lower than the vein, blood return can flow back into the tube and potentially clot, blocking the line. ○ Extravasation occurs when medication leaks outside the vein during an IV injection; infiltration occurs when the medication that is outside the vein spreads into the surrounding tissues. This is potentially very painful for patients. ○ If extravasation or infiltration occur, remove the needle, apply pressure, and follow with a cold compress once any bleeding is controlled. 12 Patient Vitals Pulse should be taken at the radial or carotid artery when assessed manually. Blood pressure is taken with a sphygmomanometer. Pulse can also be taken with a pulse-oximeter that is placed on the patient’s finger, which also reads oxygen levels. Temperature may be taken orally, rectally, temporally (at the temple), or axially (at the armpit). Most adults have their temperature taken orally; for infants it is usually taken rectally, or axially. Terminology is easy to understand if you know your prefixes and suffixes: Term Meaning Brady- Low Tachy- High Hypo- Low Hyper- High -pnea Breath or respiration -cardia Action of the heart -tension Pressure -thermia Generation of heat Low body temperature is hypothermia, and high body temperature is hyperthermia but more commonly is referred to as a fever or febrile. Low heart rate is bradycardia, and high heart rate is tachycardia. Low blood pressure is hypotension, and high blood pressure is hypertension. Low breathing rate is bradypnea, and high breathing rate is tachypnea. Low oxygen is hypoxia, and high oxygen is hyperoxia. Vital Sign Normal High Low Temperature 98-99F >99F 100BPM 20 Breaths 120/80 mm/Hg