GERIATRIC MODULE
ICONS in the Module
This ICON indicates a connection activity for the module. If you do the connection activity, then you will be able to relate what is covered in the module to your current experience and knowledge.
This ICON indicates an exploration activity for an objective. If you do this activity, then you will learn the new skills and knowledge required to complete the objective.
This ICON indicates an experiential activity for an objective. If you do this activity, then you will get practice, with feedback, on the knowledge and skills for the objective.
This ICON indicates a practical application activity for the module. If you do this activity, you will be able to apply the knowledge and skills you learned in the module to new and practical situations.
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Resources Required to Complete This Module
Study Hints for Learning from the Module
As you go through the module, you should do the following to help you learn from the module:
- Elaborate on the information in the module.
- Make notes on the textbook readings as you go through the module.
- If you can score 80% or greater on the post assessment test, then proceed to the next module.
- *Terms are listed in the glossary at the back of the module.
MODULE RATIONALE
In this module you will learn about the special imaging adaptations required for geriatric patients. You will learn about the pathology unique of the aging. Psychosocial considerations will be addressed.
MODULE COMPETENCY AND LEARNING OBJECTIVES
Module Competency:
Upon completion of this module the learner will be able to effectively position a geriatric patient.
Module Learning Objectives
To successfully complete the module competency, the learner will be able to:
- 1. Identify the physical effects of aging and make adjustments to produce diagnostic radiographs.
- 2. Define conditions/pathologies common to geriatric patients, and make adjustments when producing radiographs.
- List and discuss the key psychosocial considerations when communicating with geriatric patients.
- Describe adjustments required to produce diagnostic radiographs on patients in a wheelchair or on a stretcher.
LEARNING ACTIVITIES
Module Competency
Upon completion of this module, the learner will be able to effectively assess and position a geriatric patient.
CONNECTION ACTIVITY
Most people never think of themselves as old. Old is a relative term. Some patients give warnings to “never get old”. What do you think they are really trying to say?
Think of yourself as an 85 year old. Describe what you will be like. What are some of the diseases or conditions you may have? Now picture yourself as a patient in radiology department for a barium enema. List your concerns.
OBJECTIVE 1
To successfully complete the module competency, the learner will be able to identify physical effects of aging, and make adjustments to produce diagnostic images.
EXPLORATION ACTIVITY
Read the following Module Notes.
GERIATRIC RADIOGRAPHY
The aging portion of the population has unique needs. They are often a challenge to technologists, not only to adapt their skills but also to treat the patient as a whole person. The technologist must assess each individual for their specific needs. Patients may present with any or all of the normal changes of aging, commonly seen pathologies, and psychosocial issues. Technologists must understand the differences and then use this knowledge to improve compliance to produce a diagnostic image.
From about age 60 years on, patterns of disease will begin to differ from those of young adulthood and middle age. Functional and reserve capacities of organs begin to decline. This will increase the likelihood of disease. However, this rate of decline will vary among individuals.
As a student technologist you will learn to adapt the normal radiographic examination to the elderly. You will read about the normal changes of aging and how these affect your interaction with your elderly patient. The images you produced of these patients will have a different appearance than those in young adults. You will learn to recognize diagnostic information on the images. This module focuses on how to produce diagnostic images of geriatric patients while maintaining the patient’s comfort.
Physical Effects of Aging
These include vision, hearing, balance/coordination, temperature, dressing/undressing, dressing*apraxia, skin, lung/respiration, calcifications and other deposits.
VISION
Normal changes with aging that affect vision include:
-increased density and yellowing of the lens
-decreased depth perception
-decreased peripheral vision
-decreased ability to distinguish intensities of light
-increase in time needed to adapt to changes in light
-increase in time needed for visual tasks
-blurring of vision
Pathological conditions can contribute to vision changes. Common causes in the elderly are: cataracts, diabetes, multiple sclerosis, and stroke.
These changes in vision necessitate some accommodation while the patient is in the Radiology Department. If the patient can see the technologist and the layout of the room they will be more secure and willing to cooperate.
To assist the patient:
- Speak within the patient’s field of vision and at eye level.
- Keep the room lights on while giving instructions.
- If the patient is on a stretcher, have them sit up in order to see the room.
- Assist patients on and off footsteps as their perception of height may be impaired.
- Some patients may request that you keep the room lights off if the light bothers their eyes.
- Allow the patient to wear their glasses if they don’t interfere with the examination.
HEARING
Normal changes in the aging ear can include:
-changes in the cochlea and inner ear
-decreased sensitivity to loud noises
-decreased sensitivity to high-frequency sounds
-increased difficulty in localizing sounds
-difficulty in distinguishing background noise from foreground noise
Instructions are a large part of an x-ray examination. If your patient can hear and understand the instructions, then the patient will be able to participate. Not all people are deaf. Assess for deafness by checking for hearing aids, or if the patient is spoken to in a normal voice note if they turn their head to one side to hear better. Ask the patient if you are speaking clearly rather than implying they are hard of hearing. Some patients resent the implication that they may be hearing impaired. Stand in front of the patient and look at them when you speak. Talk in a lower voice and speak carefully and slowly. Try to eliminate background noises.
If your patient does not appear to understand your instructions repeat your instructions without raising your voice. Lower your voice since high-frequencies can be difficult to hear. If it is your instructions, that are unclear try to rephrase them but don’t keep changing the instructions. The patient may take some time to process the information and may be thinking of how they can perform what is being asked. Some instructions may be assisted by demonstrating what you are requesting as showing them how to position their hand on the IR.
BALANCE/CO-ORDINATION
Normal aging changes can affect balance and co-ordination. Changes in the brain, inner ear, eye and musculoskeletal system that can lead to impaired balance and co-ordination are:
-loss of strength, less flexibility, less lean body mass (decrease in muscle size)
-decrease in sensory input to the brain
-dizziness and vertigo
-decrease in proprioception (sense of where one is in space)
-centre of gravity moves from the hips to the upper torso
-tendency to fall
-decreased depth perception
Always assist the patient to sit, to change positions and to get on and off the radiographic table. The technologist must reduce the patient’s anxiety of falling to improve the patient’s sense of security. Some patients will want to move themselves with their walker or cane. Allow them to keep their walking aids close by. Ask the patient if they need assistance and in which way you can help them. Let the patient rest a few minutes after sitting up from a reclining position to reduce dizziness. Provide hand grips where possible. Use caution at all times. If the patient seems unable to weight bear alone then provide an alternative for them. Reassurance and attention can go a long way toward reducing anxiety and ensuring an examination that is safe for both patient and technologist.
TEMPERATURE
Changes of normal aging include a diminished ability of the body to control temperature because the sweat glands may atrophy. Patients are more often cold than hot. Cold can be a problem for patients when the temperature drops below 20 degrees Celsius. This problem may exist in the Radiology Department since the rooms and hallways tend to be cooler. Traveling to a radiology department on a stretcher or wheelchair wearing a hospital gown will seem very cool to an elderly patient. Maintain a sheet over the patient whenever possible and expose only those areas that need be. Most geriatric wards dress their patients in street clothes for dignity and warmth. You mat have to help them change if they ward has not done this ahead of time. This allows the patient to remain as fully clothed as possible. Giving the patient a warm blanket will help the patient to stay warm and increase their comfort level during the exam.
DRESSING/UNDRESSING
DRESSING APRAXIA
Elderly patients cannot dress and undress with the speed of a teenager. They will tend to wear more clothes and are not able to move as quickly. Some physical conditions limit the range of movement of shoulder joints and hip joints. Therefore, undressing/dressing may be difficult or slow. Elderly patients have been dressing themselves for years and often do not need or want help. Determine if help is needed or wanted. If the patient is rushed, anxiety will increase and the degree of compliance will decrease.
If the patient does not follow instructions such as “remove your blouse”, it is possible that the patient has dressing apraxia. Apraxia is the inability to use objects correctly. The patient may not be able to undress as you have requested. Specific clues may help the patient understand your intent. Use different words or show the patient where the buttons are on the shirt.
For patients with a limited range of movement due to a stroke, undress the patient by removing the unaffected side first, then remove from the affected limb. The opposite holds true for dressing.
SKIN
Skin is another organ affected by normal aging. The skin of the geriatric patient is more fragile and is easily traumatized.
Some changes in skin include:
-atrophy of sweat glands
-loss of fat pads (subcutaneous fat) which can be painful for patients lying on a hard table. Those are sites for development of decubitus ulcers. Men lose more subcutaneous fat than women.
-skin becomes thin and fragile and is easily broken
-increase in overall body fat and skin folds, which can cause lines of increased density in images of abdomen and pelvis and can mimic fractures.
-decrease in response to pain
Skin and its accessory organs make up the body’s most visible and largest system. In the elderly the skin becomes more translucent and fragile as the dermis and epidermis are thinned. The collagen and elastic connective tissue becomes less uniform and are replaced with inelastic fibrous tissue, reducing the resilience of the skin.
A reduction in muscle mass and a decrease in subcutaneous fat also is noted as a person ages.
Theses factors combined with chronic conditions such as diabetes, renal failure and hard x-ray tables, lead to the potential for skin ulcers. A prolonged stay on a hard table may develop into a decubitis ulcer. Healing of that ulcer takes several months with the possibility of infection. To reduce the risk of ulcers use non-opaque mattresses with washable covers and be aware of the patient’s heels and elbows when transferring and positioning them for procedures. Adhesive tape should be avoided because it can be irritating and can easily tear the skin of a geriatric patient.
Loss of muscle strength is greater in the legs than in the arms for patients who are inactive/bedridden. Joints become less flexible with age, creating minor stiffness and limited movement. These changes must be considered when undressing patients or asking them to move in certain ways for radiographs. Good body mechanic principles for the technologist must be used when assisting patients to stand. Never try to pull on a patient’s arm to help them up. Slight subluxation of a joint may occur resulting in long term pain for the individual.
When assisting a hemiplegic patient to undress, remove clothing from the unaffected side first then the affected side. To redress, place clothes on the affected side first.
The respiratory system and cardiovascular system may be working at less than full capacity due to various reasons. Decreased pulmonary efficiency in some elderly patients must be considered when performing long procedures that may require extensive positioning. The physical exertion required for an air contrast barium enema or a double contrast stomach exam may place some patients in a state of over exertion. Be aware of their condition during such procedures. Alert the radiologist to any change in their breathing, colour, or level of awareness.
LUNG/RESPIRATION
Normal aging changes can include:
-decrease in alveolar elasticity.
-impaired ciliary activity, changes in cough reflex.
-AP chest diameter tends to increase.
-Costo cartilages that connect ribs to sternum can become calcified “Thiboeau”
An increased incidence of pneumonia or other breathing problems are common in older patients. Lying patients prone for procedures may be somewhat difficult for patients because their breathing becomes laboured resulting in increased anxiety. Supine positioning should be the method of choice in patients with respiratory difficulties.
Asking a patient to hold their breath during an exposure may be difficult due to the combination of breathing problems, vision and hearing impairments. Practice methods suggested earlier when instructing patients. Ask the geriatric patient to hold his or her breath on the full second respiration to have adequate inspiration. Wasting of respiratory muscles decreases respiratory efficiency. “Thibodeau”
CALCIFICATIONS AND OTHER DEPOSITS
Atherosclerosis is a normal change in aging patients. This involves the deposition and calcification of atheromatous plaques in the intima of an artery in an irregular manner. (Medial wall calcification results in long tubular shadows.)
“Aging causes changes in the texture, calcification and shape of bones. Bone spurs develop around joints, bones become porous and fracture easily. Degenerative joint diseases such as osteoarthritis are common.” “Thibodeau”
EXPERIENTIAL ACTIVITY
Complete the following chart on physical effects of aging. State the changes and what you can do to help the patient during the examination.
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Physical Effect |
Changes |
Assistance |
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Vision
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Hearing
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Balance/Coordination
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Temperature
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Dressing/Undressing
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Skin
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OBJECTIVE 2
To successfully complete the module competency, the learner will be able to define the conditions and pathologies common to geriatric patient, and make adjustments when producing radiographs.
EXPLORATION ACTIVITY
Read the Following Module Notes.
The following notes describe conditions and diseases common to aging patients that would require adjustment or consideration when performing radiographs.
CARDIOMEGALY
An increase in heart size can be caused by a number of conditions including congenital heart disease, atherosclerosis, and mitral valve disease. The most reliable way to measure heart size is on a P.A. chest radiograph taken at 180 cm. The measurement of the diameter of the heart should be less than 50% of the diameter of the chest at the level of the diaphragm. On the lateral view, the size of the left ventricle is judged by its projection posteriorly. The right ventricle can be seen by the filling of the retrosternal space.
Radiographically the choice of A.P. or P.A. projection has implications for evaluating the heart size. The heart is magnified in A.P. projections. If the patient has extreme kyphosis, the P.A. projection will also be difficult for evaluation. Supine positions require a 100 cm SID, therefore the magnification remains a factor resulting in difficulty in comparing with upright images. In the recumbent position the abdominal organs push the diaphragm and heart up into the thoracic cavity producing some distortion. The position in which the images are taken should be identified on the image.
CONGESTIVE HEART FAILURE
The most common cause of heart disease in the elderly is arteriosclerotic heart disease.
Congestive heart disease (CHF) results from a decrease in blood flow to the myocardium due to constricted coronary arteries supplying the muscle. The heart cannot contract as efficiently as it should and results in a decreased cardiac output. This results in left ventricular failure and increased pulmonary venous pressure.
On chest images the veins of the upper lobe will be more prominent and larger than the veins of the lower lobe. Fluid will accumulate at lung bases. Acute pulmonary edema results in a “bat wing” pattern around the heart.
PNEUMONIA
Classically, pneumonia is a pulmonary infection resulting from a variety of bacterial or viral infections. Consolidation in a variety of patterns will be found in the lung parenchyma.
Radiographically, light density areas may be interpreted as either air space disease or interstitial pneumonia. A good inspiration is very important to fully aerate the bronchioles.
ASPIRATION PNEUMONIA
Older patients occasionally aspirate because the normal coughing defence mechanisms is decreased.
*Aspiration of gastric juices results in chemical pneumonitis seen as consolidation.
UPPER GASTROINTESTINAL TRACT
Normal aging changes affect the esophagus by altering muscle tone and motor function, resulting in impaired peristaltic activity with tertiary contractions.
When examining the stomach and esophagus, determine if the patient can stand unassisted. The image intensifier in front of the patient may be enough security for them or the patient may need the security of hand grips. Tilting the table may make the patient dizzy.
The patient’s limited range of movement will determine the positions you can achieve.
Turning on an x-ray table may be difficult and confusing for geriatric patients, which results in double contrast studies taking longer to perform. The patient will require your assistance at their side during the examination. Keep in mind the amount of exertion required to move during such a procedure. Moving requires a great amount exertion on the patient’s behalf.
For additional readings refer to Merrill 11th Vol. 3 pg 221.
DYSPHAGIA
A disturbance in the swallowing mechanism may be due to neoplasms, inflammatory lesions, or neurologic disorders. A swallowing function study with a speech therapist may be used to evaluate the swallowing mechanism to provide recommendations for diet modification.
Caution should be taken during swallowing examinations as aspiration could occur in elderly patients, especially when recumbent. Gastrografin should not be used if there is a possibility of aspiration as it is toxic to lung tissue.
OSTEOPOROSIS
Bone changes are normal in the aging person. The most common change is osteoporosis (reduction in normal bone tissue). In women, the process starts just before menopause and accelerates rapidly after menopause. This is due to a decrease of estrogen, low calcium intake, and lack of exercise. The condition is also accentuated by smoking and alcohol consumption. In order for osteoporosis to be demonstrated on an image the patient must have a bone loss of 50% (decrease of 50% of normal calcium levels). Bone Densitometry is a study used to assess bone density. It uses T-scores to assess bone health for osteoporosis.
TABLE 36-5 World Health Organization classifications of bone density by T-score
(Frank, Eugene D.. Merrill’s Atlas of Radiographic Positioning and Procedures, 11th Edition. Mosby)
The cortical bone will be thinned resulting in an increased risk for fractures. Care must be taken when moving a patient with osteoporosis.
For additional reading on BMD Merrill 11th Vol 3 p. 454-493.
FRACTURES
Fractures are more common in elderly patients. This can result from osteoporosis or other conditions as stroke and weakness causing unsteadiness of the patient. Spine fractures may require a mattress and/or sponges for support and comfort for the patient. Upright positions may be easier for the patient. Common fracture sites are the vertebrae, humeri, hips, pelvis, and wrists (Colles’ fracture).
Positioning of older patients with fractures can be difficult as the bones are often brittle and easily displaced. Cross-table views are routine to avoid unnecessary movement.
KYPHOSIS
Osteoporosis and compression fractures of the spine can result in severe kyphosis of the thoracic spine. Pain will increase with the severity of the disease. It will be difficult for patients to sit fully upright for P.A. chests and to lie flat on their backs for supine positioning. This poses a problem since patients won’t be able to hold a position for very long and rotation will be a major positioning hurdle. Setting the room up prior to the examination will help reduce the patient’s time spent in a painful position. Sponges and other positioning aids to support patients are beneficial.
PAGET’S DISEASE
This disease of unknown etiology involves abnormal bone modelling. There is marked osteoclastic activity causing bone resorption and active osteoblastic activity resulting in calcium deposition. As the bone enlarges, it develops an irregular pattern. The bone is quite soft and this results in bowing of the long bones. The skull and the vertebral bodies may become larger. Common sites for Paget’s are the spine, pelvis, tubular bones. This disease is rare in women and people under 40 years of age.
DIABETES MELLITUS
Diabetes mellitus is a chronic disease of carbohydrate metabolism in which insulin is deficient or ineffective. Long-term complications include renal disease, retinopathy, atherosclerosis, and other neuropathy. The foot is the primary target for neuropathic involvement and vascular complications. There is neuropathic bone destruction without demineralization. Superimposed infection and decreased vascularity add to the destruction. The most important causes of the destruction are loss of pain sensation or proprioception and repetitive minor or severe trauma.
See additional information under CT.
CONTRACTURES
Neuromascular diseases, cerebrovascular accidents, trauma (fractures), and burns can result in abnormal muscle tone. If the tone increases then spasticity ensues, leaving the joints stuck in either flexion or extension, known as a contracture. The patient cannot control movement of the contracted limb and it will appear as resistance to a technologist when positioning. This is not a lack of compliance. The spasticity can be affected by pain, fear, and effort.
To position a chest radiograph move the arms off the chest and lift the elbows up and laterally. Place a positioning sponge between the forearms, to keep them off the chest area.
Cross-table views may have to be done instead of forcing the limbs, being aware of the possible risk to the patient if limbs are forced.
EXPERIENTIAL ACTIVITY
Questions:
- What are the special considerations required when performing an ES&D on an elderly patient?
- What pathological condition requires a very good inspiration chest x-ray and why?
- What are the causes of osteoporosis?
- How can a radiographer deal with a patient who has severe kyphosis?
- Describe some techniques used to overcome contractures when positioning patients.
OBJECTIVE 3
To successfully complete the module competency, the learner will be able to discuss the technical issues associated with radiographic technique for the aging patients.
EXPLORATION ACTIVITY
Read the following Module Notes.
TECHNICAL ISSUES
ANATOMICAL LANDMARKS
As a person ages, their body changes in stature which will alter their anatomic landmarks. Normal aging with osteoporosis will increase spinal curvatures which will decrease the patient’s height. It is important to be aware that centering points may change.
The posture will change resulting in the patient stooping forward, head tilted backward, and the elbows, hips, and knees flexed. Shoulder width decreases, whereas the chest, pelvic cavity, and abdominal areas increase in diameter. The center of gravity changes from the hips to the upper torso affecting balance. This is a factor to consider when asking patients to stand from their wheelchair or getting off and on the x-ray table.
FAT
Normal aging affects the distribution of body fat. The changes include an increase in intracellular, intercellular, and organic fat, with a decrease in subcutaneous fat. The loss of subcutaneous fat can cause decubitus ulcers. There may be a doubling of fat composition from age 25 to 75 years, although the body weight can remain the same. The diagnostic quality will be reduced since there will be an increase in fat and a decrease in contrast on the image.
CONTRAST AND DENSITY
Contrast is needed to discern edges of structures on an image. The degree of subject contrast will decrease with age.
Osteoporosis is a major factor in the subject-contrast issue. When there is loss of bone material, less radiation is absorbed and a more homogeneous image is produced.
RADIATION PROTECTION
Radiation protection of the older patient must still be considered. Collimation and proper exposure factors are of paramount importance for consideration of patient dose and image quality. Proper instructions to patients to secure cooperation during the procedure will eliminate the need to repeat images. This will meet the need for a good quality image, reduce radiation exposure to the patient, and reduce the discomfort of the patient by decreasing the time spent on the x-ray table.
POSITIONING AIDS/RESTRAINTS
All patients cannot be expected to maintain a desired position for any length of time. Depending on the position, some patients may have difficulty holding the position. A variety of positioning aids must be available, including sponges, sandbags, grips, and bands. A rubberized material can prevent cassettes from slipping on the table top, especially when the patient is applying pressure.
The use of restraints is discouraged and often restricted in some clinical policies. Restraints can increase anxiety and decrease compliance. If a patient cannot lie still or is at risk of injury, you may want to stop the examination or ask for assistance from a family member to help keep the patient still.
A.P. POSITION-CROSS-TABLE POSITION
Most geriatric patients don’t have the strength or ability to lie prone or even maintain a prone position for any length of time. Views must be adapted to allow the patient to remain supine. Lateral views can be done cross-table. The position of the patient should be marked on the image to provide information to the radiologist and also for future comparisons of images.
Developing critical thinking skills are important when dealing with the Geriatric patient.
-hip, when the opposite hip is fractured or contracted
-head of humerus, when opposite is immobile
-lateral cervical spine, when shoulders are immobile
MODULE POST ASSESSMENT
- Should restraints be used on geriatric patients?
- How can we adapt our positioning to image a severely kyphotic patient for a lumbar spine
examination?
- Should Geriatric patients be left alone on an x-ray table in a specific position?
OBJECTIVE 4
To successfully complete the module competency, the learner will be able to list and discuss key psychosocial considerations when communicating with the geriatric patient.
EXPLORATION ACTIVITY
Read the following Module Notes.
PSYCHOSOCIAL CONSIDERATIONS
An important factor in producing diagnostic images on geriatric patients is understanding the patient human factor. The geriatric patient is special in many ways. It is also a time of life in which loss is a major player. Losses include death of a spouse and friends; loss or work (retired), income, home; health; and control over their own lives. The patient arrives in our department for examinations but did anyone explain the reason why? Is someone making decisions for this patient even though they may be able to make his or her own decisions? Loss of control in any situation can make a patient fearful. The radiographer’s responsibility is to focus on the patient as an individual and not a category or disease. Know if there is fear and anxiety. The friendly touch, warm smile, and conversation can help relax an anxious patient.
This caring approach towards a patient begins as soon as the patient arrives in the department. Greet the patient by name, smile and have a brief conversation. This will help evaluate if the patient can hear you and what type of mood she or he is in. You can perform a visual check for hearing aids, mobility devices, splints or paralyzed limbs. Allow the patient to keep whatever external devices they have with them so they can be as self-sufficient as possible. Do not make them feel defenseless or incapable of helping themselves. The checking of a patient identification band, name, birthdate or hospital identification is extremely important. Two patient identifiers for name and birth date must be used for all outpatient and emergency patients.
Converse directly with the patient with as little background noise as possible. Does the patient understand you? The tone of your voice will have an effect on the patient. If it is calm and friendly the patient feels included and important. The conversation must be directly related to the patient and the examination. Repeat the patient’s name when talking to them to reassure them. Avoid using generic terms as “Dear”, “Honey”, “Ma-am” or “Sir”.
A technologist’s responsibility to the patient does not always end with the x-ray procedure. The patient may need directions to their next destination or may want to know when they will get the results of the procedure. Offer as much information to the patient as possible – keeping within Hospital policy. This will reduce anxiety on the whole and reduce the mystery often associated with radiology departments. This may help the patient feel more in control with their own health.
EXPERIENTIAL ACTIVITY
The following scenario is fictional. It is, however, possible. Read it, then make comments and suggest changes that could improve this situation.
Laurie and Joanne are technologists working together in the general duty room in a very busy radiology department. Laurie and Joanne are also very good friends outside of work.
An outpatient requisition comes to the room for a Mrs. Betty Rutherford, age 81 for radiographs of the thoracic spine. The clinical information is pain.
Joanne goes to the waiting room to get Mrs. Rutherford. She calls into the waiting room, Mrs. Rutherford@. A small woman, wearing a winter coat, hat, boots and carrying a cane is waving to her from a wheelchair.
Joanne goes over to her and says,”Hello”. She immediately takes her to the radiographic room and states “We have to change her”. Laurie starts to pull off Mrs. Rutherford’s coat while saying, “Now Betty, we have to change”. Mrs. Rutherford puts up a bit of a struggle, with her cane being pushed to the side. In the process of changing her body is exposed to both technologists. She is lifted out of the chair and placed on the x-ray table. Rolling slightly to the side, Mrs. Rutherford clings to the sides of the table with both hands. The phone rings and Laurie answers it while Joanne continues to straighten Mrs. Rutherford on the table.
After Laurie hangs up the phone she proceeds to tell Joanne of her personal problems with her husband.
Mrs. Rutherford is unsure of the breathing instructions resulting in a repeat of the radiograph.
The examination is completed and Mrs. Rutherford is lifted off the x-ray table. She is unsure what will happen next and asks what she should do next. Laurie says, “Well dear, you will have to ask the receptionist at the desk”.
Comments:
OBJECTIVE 5
To successfully complete the module competency, the learner will be able to describe the adjustments required to produce diagnostic radiographs on a patient in a wheelchair or on a stretcher.
EXPLORATION ACTIVITY
Read the following Module Notes.
RADIOGRAPHIC POSITIONING FOR GERIATRIC PATIENTS
The objective of any examination is to produce a diagnostic image. In geriatrics you will, in some cases, find routine examinations can be performed, but in some examinations, entirely new positions are created.
Maintaining awareness of the unique radiographic demands of the aged patient and the solutions that are possible will help the radiographer achieve diagnostic radiographs.
Many examinations can be performed with the patient remaining in the wheelchair or on the stretcher; always lock the wheels of a stretcher or wheelchair when starting to perform any examination. The patient in the wheelchair is often familiar with how the chair works and can be a resource for you if you need to remove leg or arm rests.
When talking to a patient in a wheelchair, bend down and speak at their level. Make the patient aware you are going to move them in the wheelchair rather than walking behind the chair and start pushing.
ANKLE
For the AP and oblique, fully extend the leg and rest the ankle on an IR on a stool. For a lateral view, do a cross table lateral with the ankle raised on a sponge and a sandbag or film holder to keep the cassette in a vertical position. The patient can remain in the wheelchair for this examination. Angle medially for oblique mortise view if patient unable to put ankle in oblique position.
Note: Same position of IR and leg on stool may be used for examinations of the tibia and fibula, and knee.
FOOT
Difficulties encountered: – sore feet due to gout, diabetes, ulcer
– decreased image quality due to osteoporosis
Solutions:
– place foot on step stool while patient remains in wheelchair
– use positioning sponges to medically rotate foot or angle medially
– cross table lateral foot
KNEE
Difficulties encountered: – reduced movement and flexibility
– pain
– anatomical distortion for AP projection because of inability to
straighten leg
Solutions:
– stretcher patients can remain on stretcher with IR placed under knee or in a lateral cross table.
HIP AND PELVIS
Difficulties encountered: – transferring of patient from a chair to the x-ray table or from a stretcher to the table.
– pain due to possible fracture.
Solutions:
– transfer patient with smoothest method – sheet transfer, slider preferred
– support feet with sandbags
– place sponges under hips on lateral aspects if patient rotated
– A.P. pelvis should be routinely done on all hip trauma
– cross table lateral projection of the hip is done when unaffected leg can be
raised
HAND AND WRIST
Difficulties encountered: – reduced flexibility
– contractures
– shaking
– osteoporosis
Solutions: – for wheelchair patients, use the feeding tray or position patient up to the end of the x-ray table
– use small wedge sponges or finger blocks for patients to rest on for obliques
ELBOW
Difficulties encountered: – contracture, inability to supinate
– decreased range of motion in shoulder
Solutions:
– attempt to elevate the arm on sponges when patient is in a wheelchair for lateral view
– equal angle AP projection view may be performed, or humerus in contact with IR and forearm in contact with IR
– the necessity of cross-table images may be required on some reduced mobility
patients
FOREARM
Note: Combine A.P. elbows with A.P. forearm, if both examinations are required.
However a separate lateral view on the elbow must be performed besides a lateral forearm
SHOULDER
Difficulties encountered: – decreased range of movement
Solutions: – ask the patient how much movement can be done to avoid injury by you
– wheelchair patients can have A.P. projections done in the wheelchair, by placing the IR behind them. Their weight supports the cassette in place.
Transcapular Y-views of the shoulder can be attempted in the wheelchair
For patients on a stretcher or x-ray table oblique the patient 45 degrees away from the affected side (affected side is raised). Center over the head of the humerus.
If abduction is possible inferosuperior projections can be done as well.
SCAPULA
See Shoulder
CERVICAL SPINE
Difficulties encountered: – extreme lordosis
– increased kyphosis with raised shoulders
– arthritis, osteoporosis and degenerative disk disease
Solutions: – lateral views can be done upright in the wheelchair, with angulation of the tube to displace shoulder down
– cross-table lateral views can be done with the patient on the stretcher
– an A.P. projection can also be done on the stretcher
– explain fully the open mouth view prior to removing the dentures
THORACIC SPINE
Difficulties encountered: – compression fractures, osteopenia, and pain
– increased kyphosis
– limited movement of upper shoulders
Solutions:
– use a breathing technique
– work quickly to reduce pain and movement
LUMBAR SPINE
Difficulties encountered: – severe lordosis
– severe kyphosis, scoliosis
– osteopenia and pain
Solutions: – bend knees up to reduce lordosis
– on lateral view use lead sheeting to reduce scatter
CHEST – STANDING
Difficulties encountered: – unsteadiness while standing
– decreased balance
– decreased flexibility of shoulders
– hyperkyphosis
Solutions: – allow patients to wrap arms around chest stand for stability – mount handles
– provide an overhead bar or strap for patients to bring their arms up and forward for lateral views
CHEST – SITTING (Wheelchair)
Difficulties encountered: – slouching in chair (lordotic)
– hyperkyphosis (chin obscuring)
– A.P. versus P.A.
– large abdomen obscuring bases
Solutions: – use positioning sponges with an angle to fit behind patient
– or place IR supported by sponges behind patient
– mark films as A.P. for comparison
– raise the chin as much as possible
– lateral views can be done in chair if sponge placed behind back, arms suspended on bar
– remove arms from wheelchair if needed
BARIUM ENEMA
Difficulties encountered: – decreased mobility
– poor sphincter control
– condition of patient from preparation
Solutions – always have enough sheets under patient to aid in movement during the enema
– make sure all accessories are ready and available to decrease the time of exam
– drain as much barium from the patient into the bag prior to removing the tip
– always have help
– be aware of patient’s condition – move slowly when possible to alleviate dizziness
EXPERIENTIAL ACTIVITY
- Describe the difficulty a patient and technologist may have when positioning for an ankle, foot and knee when the patient is in a wheelchair. What adaptations can be made to overcome these difficulties?
- Why is it important to internally rotate the feet for an AP pelvis? How can this be done successfully on patients with limited control?
- Describe the adaptations you would make in positioning a patient in a wheelchair for a chest x-ray A.P. and lateral.
- List the steps you would take prior to a barium enema on an elderly patient.
Patient Care in Computed Tomography
Special considerations regarding the geriatric patient and CT
To alleviate patient’s anxiety prior to a CT examination the technologist should explain what the patient may experience throughout the course of the procedure.
Example:
Being alone in the room.
Table/gantry movement.
Stressing importance for patient not to move during scan.
Issues regarding administration of contrast media; metallic taste, nausea, warmth and flushed feeling.
Alert
If the patient is a diabetic and is prescribed metformin medication, it must be withheld 48 hours post injection after CT scan procedure. A combination of contrast agents and Metformin can induce renal failure. Creatinine level is not always an accurate indicator of renal function.
Contrast media is more likely to dehydrate the geriatric patient.
MODULE SUMMARY
The physical effects of aging affect vision, hearing, balance/co-ordination, dressing apraxia, and skin.
Conditions/pathologies common to geriatric patients are cardiomegaly, congestive heart failure, pneumonia, aspiration pneumonia, dysphagia, hiatus hernia, osteoporosis, fractures, kyphosis, Paget’s disease, diabetes mellitus, and contractures.
MODULE POST-ASSESSMENT
True or False
Read each of the following statements. If the statement is true, circle the T. If the statement is false, circle the F and change the underlined word to make the statement true. Place the new word in the blank space after the F. The false statement is correct when the new word corrects the statement.
- T F _____________ Normal changes in hearing in the elderly is a
decreased sensitivity to high-frequency sounds.
- T F _____________ The diminished ability to control body
temperature is due to sweat gland hypertrophy.
- T F _____________ For undressing patients with a stroke affecting the
left side, you should assist them to undress
starting with the right side.
- T F _____________ When undressing a patient for a chest x-ray, it is best to assist the patient or demonstrate than to totally take over the task.
- T F _____________ Transferring an elderly patient using a sliding board from a stretcher to an x-ray table may cause decubitus ulcers if not careful.
- T F _____________ Osteoporosis in the elderly patient will demonstrate on an image as an increase in bone density.
- T F _____________ One concern a technologist and radiologist must be aware of during an ES&D on an elderly patient is
.
- What is the concern with skin when transferring an elderly patient onto an x-ray table for a hip examination? Name two concerns and a solution for them.
- Describe in point form how to undress a patient for a chest x-ray if they are known to have right-sided hemiparesis?
GLOSSARY
apraxia: inability to use objects correctly
aspiration: the act of inhaling into lungs
atherosclerosis: deposition of yellowish plaques containing cholesterol and other lipid material, within arteries
atrophy: wasting away
cataracts: an opacity of the lens of the eye
cilia: minute hair-like processes that extend from a cell surface, to move fluid or mucus.
decubitus ulcers: bedsore, ulcer caused by prolonged pressure on a body area
hyperkyphosis: an increased curvature of the thoracic spine – convexity from the side (hunchback)
hyperostosis: excessive growth of bony tissue
idiopathic: self-originated, occurring without known cause
lordosis: forward curvature of the lumbar spine
subluxation: partial dislocation, out of joint
BIBLIOGRAPHY/REFERENCES
Merrill’s Atlas of Radiographic Positioning and Procedures, 11th Edition
Patient Care in Imaging Technology 7th Edition Lillian S Torres
Structure and Function of the Body 13th Edition. Gary A Thibodeau
Encyclopedia and Dictionary of Medicine, Nursing and Allied Health
Ferrini, Armeda F., Ferrini, Rebecca L., Health in the Later Years’, 2nd edition, WCB Brown and Benchmark, 1992
Novak, Mark, Aging and Society, a Canadian Perspective@, 2nd edition, Nelson Canada, 1992
The inverse square law lab
1. Do your observed values follow your expected values?
As shown on the table, the amount of radiation reaching to surface is nearly inversely proportional to the square of the distance between the source and the surface. My observed values in general almost follow my expected values but they are not exactly same that I accepted.
2. Do your observed values follow the inverse square law? Give an example from your readings.
Generally the inverse square law describes that the intensity of a radiation field is inversely proportional to the square of the distance from the source. In my observed value, where distance is 80 cm the mR is 126. With increasing distant to 160 cm we can see the mR changes to 26. That means with double increasing distance, the radiation intensity de creased almost 4 times.
3. List two important applications of the inverse square law for diagnostic imaging. (2 marks)
Consideration to patient does and employee dose are two important applications of the inverse square law for diagnostic imaging. Since the radiation spreads out as it moves away from the X-ray source. Therefore, the intensity of the radiation follows Inverse Square Law. As a result the intensity of radiation becomes weaker as it spreads out from the source since the same about of radiation becomes spread over a larger area. The intensity is inversely proportional to the distance from the source. In radiography, it is necessary to calculate the intensity at a second distance. The inverse square law can be used to analyse alters in intensity that happen as a result of changes in distance.
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Medical Radiology - Canada, Winnipeg 