Chapter 1

Preliminary Steps in Radiography

 Outline (1 of 4)
 The Radiographer
 Radiography Practice Standards
 Ethics in Radiologic Technology
 Advanced Clinical Practice
 Care of the Radiographic Room
 Control of Pathogen Contamination
 Standard Precautions
 Minor Surgical Procedures
 Control of Contamination Outside the Radiology
Department

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 Outline (2 of 4)
 Interacting with Patients
 Clinical History
 Diagnosis and the Radiographer
 Bowel Preparation
 Patient Clothing, Jewelry, and Surgical Dressings
 Motion and Its Control
 Preexposure Instructions
 Image Receptor
 Radiographic Positioning and Procedure
 Initial or Routine Procedure
 Common Steps for a Radiographic Procedure
 Accessory Equipment
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 Outline (3 of 4)
 Technical Factors
 Foundation Exposure Techniques and Charts
 Adaptation of Exposure Technique to Patients
 Gonad Shielding
 Placement and Orientation of Anatomy on the Image
Receptor
 Placement and Direction of the Central Ray
 Source-to-Image Receptor Distance (SID)
 Source-to-Skin Distance (SSD)
 Collimation of Radiation Field

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 Outline (4 of 4)
 Anatomic Markers
 The Radiograph
 Display of Radiographs
 Identification of Radiographs
 Working Effectively with Obese Patients
 Abbreviations

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 The Radiographer
 Radiologic technology is a health care profession that
includes all diagnostic imaging technologists and
radiation therapists
 A radiographer is a radiologic technologist who
administers ionizing radiation to perform radiographic
procedures
 Produces radiographic images at the request of a licensed
medical practitioner
 Requires technical skills combined with knowledge of:
• Physics
• Anatomy and Physiology
• Pathology

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 Radiography Practice Standards
 Written and maintained by the American Society of
Radiologic Technologists (ASRT)
 Define the practice of radiography, describe necessary
education and certification, and include the
Radiographer Scope of Practice
 Also includes Clinical Performance Standards, Quality
Performance Standards, and Professional Performance
Standards
 Most current version found on the ASRT website at
ASRT.org

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 Ethics
 Defined as:
 Health professional’s moral responsibility
 Science of appropriate conduct toward others
 American Registry of Radiologic Technologists
(ARRT) created and maintains the Standards of
Ethics for Radiologic Technologists
 Purpose: describe professional values that translate
into practice

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 ARRT Standard of Ethics
 Standards of Ethics includes a Code of Ethics
and the Rules of Ethics
 Code of Ethics
• Consists of 10 statements that serve as a professional
behavior guide for RTs
 Rules of Ethics
• 22 Rules of Ethics
• Mandatory standards of minimally acceptable professional
conduct
 Full lists and descriptions can be found on the
ARRT website at www.arrt.org

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 CAMRT Member Code of Ethics
and Professional Conduct

 Developed by the Canadian Association of

Medical Radiation Technologists (CAMRT)
 Purpose – articulate the expected ethical
behavior of all RTs
 Complete and current document can be found
on the CAMRT website at CAMRT.ca

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 Advanced Clinical Practice
 Advanced clinical role allows radiographers to act as a
“radiologist extender” to perform or assist with:
 Patient care activities
 Select radiologic procedures
 Initial image observations
 Radiographers with advanced clinical roles are titled:
 radiologist assistant (RA)
 radiology practitioner assistant (RPA)
• The title of RA or RPA may be used only after passing an advanced-level
certification examination
 Requirements include ARRT radiography certification,
additional education, and clinical experience under the
supervision of a radiologist preceptor

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 Care of Examination Room
 Radiographer responsible for:
 Keeping room and all equipment clean to minimize
transmission of infection and provide for patient
confidence
• X-ray machine
• Tabletop
• Accessories
 Prepare room prior to patient arrival:
• Clean and organized
• Fresh pillowcase
• Accessories needed

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Control of Pathogen Contamination
(1 of 2)
 CDC provides directives for infection control.
 The foundation is Standard Precautions for All Patient
Care
 Standard precautions include the following aspects of
professional practice:
 Perform hand hygiene
 Use personal protective equipment (PPE) whenever there
is an expectation of possible exposure to infectious
material
 Follow respiratory hygiene/cough etiquette principles
 Ensure appropriate patient placement

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Control of Pathogen Contamination
(2 of 2)
 Properly handle and clean and disinfect patient care
equipment and instruments/devices
• Clean and disinfect the environment appropriately
 Handle textiles and laundry carefully
 Follow safe injection practices; wear a surgical mask
when performing lumbar punctures
 Ensure health care worker safety including proper
handling of needles and other sharps
 Transmission-based precautions are used in addition
to standard precautions for patients with known or
suspected infections

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 Standard Precautions
 Radiographers should know:
 Way to handle isolation status patients without
contaminating their hands, clothing, or equipment
 Method of disinfecting contaminated items

 Designed to reduce the risk of transmission of

unrecognized sources of pathogens

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 Handwashing (1 of 2)
 Easiest and most convenient method of preventing the
spread of microorganisms
 Radiographers should wash their hands before and
after working with each patient

(A) Radiographers should practice scrupulous cleanliness, which includes regular handwashing. (B)
Radiographic tables and equipment should be cleaned with a disinfectant according to department policy.

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 Handwashing (2 of 2)
 Hands must always be washed:
 After examining patients with known communicable
diseases;
 After coming in contact with blood or body fluids;
 Before beginning invasive procedures
 Before touching patients, who are at risk for infection.

(A) Radiographers should practice scrupulous cleanliness, which includes regular handwashing. (B)
Radiographic tables and equipment should be cleaned with a disinfectant according to department policy.
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 Basic Patient Care
 Radiographer is responsible for
patient care during an imaging
procedure
 Provide coherent patients an
explanation of the procedure
 They should understand exactly what is
expected, including any discomfort, and
made comfortable
 Critical for RT to obtain patient’s
clinical history Radiographer is often responsible for obtaining a
 Verify correct procedure ordered clinical history from the patient.

 Observe conditions or abnormalities to

relay to radiologist
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 Motion and Its Control
 Imaging of motion severely
degrades image quality
 Understanding the different
types of motion assists in
eliminating or controlling
motion
 Three types of motion:
 Involuntary
 Voluntary
 Equipment A, Forearm radiograph of a patient who moved
during the exposure. Note the fuzzy appearance of
the edges of the bones. B, Radiograph of patient
without motion.

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 Involuntary Motion
 Caused by:
 Heartbeat
 Chills
 Peristalsis
 Tremor
 Spasm
 Pain
 Primary control: Use short exposure time

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 Voluntary Motion (1 of 3)
 Lack of control of voluntary motion is caused by:
 Nervousness
 Discomfort
 Excitability
 Mental illness
 Fear
 Age
 Breathing

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 Voluntary Motion (2 of 3)
 Radiographer can control voluntary patient motion
on images by:
 Giving clear instructions
 Providing patient comfort
 Adjusting support devices
 Applying immobilization
 For patients who are unable to cooperate (young
children, elderly, and mental illness) the best
way to control is:
 Decreasing exposure time

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 Voluntary Motion (3 of 3)

A, Positioning sponges and sandbags B, Ferlic leg holder and immobilization device

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 Image Receptors
 Defined as the device that receives the energy of
the x-ray beam and forms the image of the body
part
 Four types of Image Receptors:
 Solid-state digital detectors
 Photostimulable storage phosphor image plate (PSP
IP)
 Fluoroscopic image receptor
 Cassette with film

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Solid-State Digital Detector

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Tethered or Wireless DR

Tethered Wireless

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PSP IP

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 Fluoroscopic IR

(E) Fluoroscopic image intensifier unit located under fluoroscopic tower (arrow) transmits x-ray image to a
camera and then to a television for real-time viewing. (F) Fluoroscopic solid-state flat-panel digital detector
transmits image directly to viewing monitor without the need for an intermediate video camera.

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 Accessory Equipment
 Positioning aids
 Used to ensure a body part remains in the appropriate
posture during exposure
 Grids
 Reduce scattered radiation to the IR
 Compensating filters
 Results in more uniform image brightness due to
varied tissue thickness and part density.

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Common Steps for a Radiographic
Procedure
 Radiographers follow a set of common steps for
each radiographic procedure
 This improves efficiency, ensures patient safety,
reduces mistakes, and minimizes patient
radiation exposure
 The order of these steps will vary by anatomy of
interest, patient condition, type of equipment
available, and by department protocol

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 Review Question (1 of 3)
What is the easiest method to control the spread of
pathogens?
A. Use of mask on patients
B. Radiographers wearing masks
C. Wearing gloves for all procedures
D. Hand hygiene

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 Review Question (2 of 3)
All of the following are examples of involuntary
motion, except:
A. Peristalsis
B. Heartbeat
C. Breathing
D. Chills

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 Review Question (3 of 3)
How do radiographers help reduce the risk of
imaging involuntary motion?
A. Use immobilization
B. Appropriate patient instructions
C. Clear communications
D. Use the shortest possible exposure time

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 Technical Factors
 Radiographers can control prime technical
factors such as:
 Milliamperage (mA)
 Kilovolt peak (kVp)
 Exposure time (seconds)
 Manual and automatic exposure control (AEC)
systems are used to set the factors
 Radiographer selects specific factors after
consulting a technique chart

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 Exposure Technique and Charts (1
of 2)
 Technique charts
should be in every
room and on mobile
machines
 Specifies projections
performed in room
 Includes exposure
factors for each
projection

Radiographic exposure technique chart showing manual

and AEC technical factors for the examinations identified

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 Exposure Technique and Charts (2
of 2)
 Primary factors must be considered to establish correct
foundation technique for each unit:
 Milliampere-seconds (mAs)
 Kilovolt (peak) (kVp)
 Automatic exposure controls (AECs)
 Source-to-image receptor distance (SID)
 Relative patient or part thickness
 Grid
 CR/DR exposure indicators or other digital exposure value
estimates
 IR or collimated field dimensions
 Electrical supply characteristics (phase, frequency)
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 Gonad Shielding
 Recent research by AAPM resulted in their position
statement which states that gonadal shielding can
negatively impact exam efficacy
 ACR and other professional imaging organizations
endorsed this position statement.
 Some states may still require gonadal shielding
 Students and Technologists must be aware of changes in
the practice of gonadal shielding

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 IR Placement
 Three general IR
positions
 Lengthwise
 Crosswise
 Diagonal
 Position name based
on IR relation to long
axis of the body
 Lengthwise placement (A) Lengthwise position of IR for AP projection of the abdomen.
(B) Crosswise position of IR for AP projection of the pelvis. (C)
Diagonal position of IR for AP projection of the leg to include the
most often used knee and ankle joints. (D) Position of built-in DR flat-panel IR
detector at 17 × 17 inches (43 × 43 cm). Flat-panel detector is
movable lengthwise with the grid under the table.
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 Central Ray Direction (1 of 2)
 The central or principal beam of rays is termed
the central ray (CR)
 CR is always centered to:
 Anatomy of interest
 IR
• Unless IR displacement is being used
 General goal is for central ray to be
perpendicular to the part and IR to minimize
distortion

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 Central Ray Direction (2 of 2)
 Angle the CR through the part of interest
to
 Avoid superimposition of structures
 “Straighten out” a curved structure
 Align the CR through an angled joint space
 Avoid distortion of an angled structure

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 Source-to-Image Receptor
Distance (SID)
 Otherwise known as SID
 Defined as the distance from the anode inside the
x-ray tube (source) to the IR
 Critical technical component because it affects
 Magnification
 Spatial resolution
 Patient dose

Radiographic tube, patient, and table illustrate SID

and SSD.
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 Source-to-Image Receptor
Distance
 Longer SID reduces magnification and increases
spatial resolution
 SID standardized for examinations and must be
indicated on technique charts
 40 inches (102 cm) traditionally used on most
examinations
 48 inches (122 cm) is recent increase in many
facilities
 72 inches (183 cm) used on examinations with
increased OID to reduce magnification

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 SID in Merrill’s Atlas
 Specific SIDs are identified on the page of the
projection
 Special SID projections range from 30 inches (76 cm)
to 120 inches (305 cm)
 If a specific SID is not mentioned for image
quality, a minimum of 40 inches (102 cm) is
recommended

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 Source-to-Skin Distance (SSD)
 Defined as the distance between anode inside the x-ray
tube (source) to the patient’s skin
 Affects the dose to the patient
 NCRP recommends that the SSD shall not be less than 12
inches (<30 cm) and should not be less than 15 inches
(<38 cm)

Radiographic tube, patient, and table illustrate

SID and SSD.
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 Collimation of Radiation Field
 The radiation field, also called the exposure field, must be
restricted to irradiate only the anatomy of interest
 This restriction of the radiation field, called collimation, serves
two purposes:
 Minimizes patient exposure
 Reduces scatter radiation, which in turn, reduces the risk of an
adverse effect on contrast resolution
 It is a violation of the ARRT Code of Ethics and ASRT Practice
Standards to collimate larger than the required radiation field
size

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 Collimation
 The collimator should be manually adjusted to a
field size that will include all anatomy pertinent
to the radiographic procedure
 These field dimensions and the extent of collimated
field edges in relation to the anatomy of interest are
included for all radiographic projections and positions
included in the Atlas

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 Shuttering
 Used for image display aesthetics only in DR systems
 Used to provide a black background around a collimated
exposure field
 RTs are often tempted to use a larger than necessary
exposure field, then shutter or “crop-in” to create the
appearance of proper collimation
 Results in increased patient dose, overexposure, and
increased scatter radiation
 Creates legal and ethical liability issue
• If the cropped image information causes a missed
diagnosis, the RT may be liable.

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 Anatomic Markers (1 of 2)
 Each radiograph must include an appropriate
marker that clearly identifies the patient’s right
(R) or left (L) side
 Medicolegal requirements mandate that these
markers be present
 Annotation on digital images after image
acquisition is not recommended due to the
great potential for error

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 Anatomic Markers (2 of 2)
 Basic marker conventions are:
 R or L markers on all radiographs
 The marker should never obscure anatomy
 The marker should always be placed in the
exposure field on the edge of the collimation
border
 The marker should always be placed outside
of any lead shielding
 R and L markers must be used with CR and
DR digital imaging
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 The Radiograph (1 of 3)
 The image recorded by exposing any of the
image receptors to x-rays is called a radiograph
 Each procedural step must be accurate to
ensure the maximum amount of recorded image
information
 The information obtained by radiographic
procedures shows the presence or absence of
abnormality or trauma
 Assists in diagnosis and treatment of the
patient
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 The Radiograph (2 of 3)
 The radiographer must evaluate each
radiograph to determine:
 Acceptability of image features
 Proper radiation safety practices
 Whether the objectives for performing the procedure
have been met

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 The Radiograph (3 of 3)
 Additional image evaluation criteria to be
considered include:
 Presence of patient identification
 Proper radiographic marker placement
 Proper collimation
 Evidence of required patient shielding
 Absence of artifacts
 Image evaluation requires an understanding of
anatomy, image geometry, image display
characteristics, and image appearance of
pathology
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 Image Display
 Radiographs usually viewed
in anatomic position
 Exceptions include:
 Hands
 Fingers
 Wrists
 Feet
 Toes
 These exceptions are viewed
from perspective of the x-ray
tube with distal ends toward
ceiling

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 Image ID
 Required information on all
radiographs
 Date
 Patient’s name or ID number
 Right or left side marker
 Institution identity
 Many ways to imprint ID on
radiographs

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 Review Question (1 of 2)
All of the following are required identification on a
radiographic image, except the:
A. Side marker
B. Patient name or ID number
C. Referring physician’s name
D. Name of the facility

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 Review Question (2 of 2)
A technique chart must include all of the following,
except:
A. Pathology type
B. kVp
C. AEC
D. Grid

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 Working Effectively with Obese
Patients (1 of 5)
 Research shows that obesity has doubled in the last 15
years
 71% of Americans are overweight, obese, or morbidly
obese
 Obesity is defined as an increase in body weight by an
excessive accumulation of fat
 Measured by body mass index (BMI)
 30 to 39.9 is obese
 40+ is morbidly obese
 Body diameter and weight are both determinants on
whether a radiographic examination can be performed

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 Working Effectively with Obese
Patients (2 of 5)
 Equipment considerations
 Radiographic table has weight limits
 Fluoroscopy towers have a maximum diameter
 IR units are more popular in imaging obese patients
due to greater distance between the tube and table
 CT and MRI scanners have diameter limits
 Without appropriate equipment patients weighing
more than 350lbs to 450lbs cannot be imaged
 Manufacturer redesigns of radiographic and
fluoroscopic table weight limits have doubled to
700lbs.

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 Working Effectively with Obese
Patients (3 of 5)
 Transportation considerations
 Larger wheelchairs and transport
beds or stretchers needed
 Consider risk of injury to the
radiographer and health care
team during movement and
positioning
 Use of proper body mechanics is
essential
 Always be sure adequate
personnel are available to assist
 Transfer by sliding or high-
capacity power lifts
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 Working Effectively with Obese
Patients (4 of 5)
 Communication considerations:
 Communication is key in all imaging procedures
 Empathic communication is essential
• Avoid mentioning weight
• Explain personnel required to safely move and/or transfer
 Communicate each part of the transfer process to
patient
 Explain personnel required to safely move and/or
transfer
 Explain positioning required for imaging procedure.
• Provide support and assistance to maximize patient comfort
and security
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 Working Effectively with Obese
Patients (5 of 5)
 Imaging challenges exist
 Most palpable landmarks are not
accessible in the morbidly obese
 Never push or prod patient
unnecessarily
 Locate jugular notch
 Measure from the jugular notch
to find the pubic symphysis:
(based on patient height) Radiographer measuring jugular notch–to–
pubic symphysis plane
• <5 feet: 21 inches
• 5 to 6 feet: 22 inches
• >6 feet: 24 inches

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 Review Question (1 of 2)
Which of the following will affect whether a
radiographic examination can be performed on an
obese patient?
A. Height
B. Weight
C. BMI
D. Communication skills

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 Review Question (2 of 2)

Which guideline is used to locate the pubic

symphysis on an obese patient who is approximately
5 feet, 5 inches tall?
A. 15 inches from the jugular notch
B. 21 inches from the jugular notch
C. 22 inches from the jugular notch
D. 24 inches from the jugular notch

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