interpretasi x ray

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INTENSIVE CARE SERVICE

NURSING POLICY & PROCEDURES

NAME OF POLICY: CHEST XRAY INTERPRETATION

GOAL: TO SAFELY AND EFFECTIVELY ACCESS AND INTERPRET

CHEST FILMS.

Introduction: Chest x-rays are a commonly used tool in the ICU. They can provide

confirmation of clinical observations, show anatomical landmarks, confirm placement of lines,

tubes, catheters and leads. They are also used to monitor changes in the lung pathology.

Procedure:

Using the PACs x-ray viewer correctly identify the patient, date and time that you wish

to access

Note the view of the film, either AP or PA. In ICU the x-ray is taken using a mobile x-ray

machine at the bedside. The view that is taken is known as an AP (Anterior Posture) view.

An x-ray taken in the radiology department with the patient standing independently is a

PA (Posterior Anterior) view. The main difference between the two views is the AP (taken

in the unit with mobile x-ray machine) is not as sharp, and the anatomical landmarks are

magnified. I.e. the heart appears larger and the mediastinum appears widened. This is due

to the change in distance from the x-ray plate to the machine. In ICU the distance is

approximately 90cm as apposed to 180 cm when taken in radiology.

Patient position.Chest X-rays are usually taken with the patient in the erect position.

Supine films alter the position and shape of the mediastinal structures and may make

pleural effusions and a pneumothorax more difficult to identify.

Check to see how the x-ray has been exposedas this may alert you to problems. If the x-

ray has been under or over exposed lung pathology may not be as easily identified. To

determine if the x-ray is correctly exposed you should be able to identify the tear drop

appearance of the spinal process, and the outline of the vertebral column through the heart

shadow but not the intervertebral spaces.

Inspiratory or Expiratorychest x-ray. When a person inspires the diaphragm drops andthe lungs expand. It is therefore important to take the x-ray when the maximum amount of

lung is visible i.e. on inspiration. By counting the visible ribs you can determine when the

film was taken. In the normal lung you should be able to count 10 Posterior and 6 Anterior

ribs if the x-ray was taken on inspiration. Occasionally an erect x-ray is taken in expiration

specifically to help identify a pneumothorax (which looks larger on an inspiratory film).

Orientation.How to get your bearings. You need to identify that the clavicles are

symmetrical (the spinous processes should be mid-way between the two clavicular heads),

the trachea is midline and all of the structures in the thoracic cage are visible. If these

structures can not be seen it may mean that the patient was positioned poorly for x-ray. As

a rule the trachea should be midline if not there may be areas of collapse, mass or

pneumothorax. Identify the normal structures on the x-ray, eg the heart, clavicles, ribs and spinal

processes. By doing this you are identifying the four densities bone or metal, fat, water

ROYAL PRINCE ALFRED HOSPITAL INTESNIVE CARE SERVICE


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and air. Bone or metal are the most dense, they absorb the largest amount of x-ray and so

appear white on the film. Fat is less dense and appears off white, eg breast tissue. Water is

also less dense than bone, it appears as off white/grey. Eg Blood in the heart and vessels.

Air is the least dense, appearing almost black on x-ray, eg. lung tissue.

While identifying the different structuresand different densities observe the following:-

The heart should be visible in the left anterior mediastinal cavity. It should be less than

half the width of the chest wall on a PA film and slightly larger on an AP film. Anincrease in the cardiac shadow may mean congestive heart failure, pericardial effusion or

pulmonary oedema. The lung fields and bronchi are not usually visible except for the

lung markings in the periphery. Abnormal findings in the lung fields can include air

bronchograms the difference in density between air filled bronchi and adjacent areas of

consolidation. Patchy infiltrates or streaky densities could mean pneumonia or atelectasis

while fluffy infiltrates or Kerley B lines show pulmonary oedema. Look also for

collapse, consolidation and air or fluid in the pleural space. The diaphragmshould appear

rounded at the bottom of the lung fields with right side being 1 2cm higher than the left

due to the liver under the right hemidiaphragm. The heart lies on the left hemidiaphragm.

Costaphrenic anglesshould appear clear and sharp, the presence of a pleural effusion,

collapse and/or consolidation could be the reason for obliteration of the angles. Observethe ribs for fractures, osteoporosis, malignancy or other bony changes.

Note the placement of lines, tubes, catheters and leads.

Endotracheal tube 2 - 3cm above the carina

Nasogastric/ Orogastric tube tip and side holes must in the stomach

Central Venous Catheter tip sits in the Superior vena cava outside the right atrium

Tracheostomy tip should be half to two thirds from the stoma to the carina

Intra Aortic Balloon Pump the distal tip should be visible in the proximal descending

thoracic aorta, distal to the aortic notch and above the level of the left main bronchus

Pacing leads usually sit at the apex of the right ventricle.

Pulmonary Artery Catheters pass through the right side of the heart, main pulmonary

artery and a short way into the lung.

Lastly comparethe x-ray to previous films taken.

Bear in mind the following sites of commonly missed pathology:

Lung apex

Lung periphery/pleura

Behind the heart

Costophrenic areas

Quick Steps

Correct patient, date and time PA or AP view

Erect or supine



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Exposure

Inspiratory/Expiratory phase

Orientation get your bearings, identify densities, identify structures

Identify lines and tubes

Look at mediastinum, lung, bones, soft tissues etc. in systematic way

Compare

Posterior Anterior Chest View

REFERENCES:Bucher, L; Melander, S. 1999: Critical Care Nursing 1stEdition, 1999 pp 405 - 407Darovic, G. Shades of Grey: Understanding chest X-rays, Nursing 98; 28 (7): 32cc1-32cc5Darovic, G. Understanding chest X-rays, part II: How To Recognise Changes Caused by Cardiac Disease, Nursing99; December: 32cc10 32cc11Darovic, G. Understanding chest X-rays, part III: How To Recognise changes Caused by Pulmonary Problems,

Nursing 99; March: 32cc6 32cc7

Occupational Health and Safety: Universal precautions taken in the preparation, administration of drug anddisposal of equipment and sharps.

Cross Referenced: RPAH Occ. Health & Safety Manual and Infection Control ManualNSW Infection Control Policy 98/99

Revised by: Vivienne East (CNS) July 2002Reviewed by: Chanelle Innes (CNC)

Authorised by: Paul Phipps (Intensivist)

Revision July 2004

With the introduction of Powerchart online ordering, a clinical agreement has been set up with the Director

of ICS and other Staff Specialists. Nursing Management, with the agreement of the hospital executive, have

made arrangement that allows all permanently employed RPAH Nursing Staff to place orders for a variety of

tests on their behalf. It is a Health Insurance Commission (HIC) directive that all orders placed by nursing

staff are countersigned by the responsible MO within 14 days.

1. Trachea

2. Right Main Bronchus

3. Left Main Bronchus

4. Left Pulmonary Artery

5. Right Upper Lobe Pulmonary

Vein

6. Right Interlobar Artery

7. Right Lower and MiddleLobe Vein

8. Aortic Knob

9. Superior Vena Cava

10. Carina



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interpretasi x ray