Transcript PPTChapter_18Urinary evolve

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