Synonym/Acronym
Chest radiography, CXR, lung radiography.
Rationale
To assist in the evaluation of cardiac, respiratory, and skeletal structure within the lung cavity and diagnose multiple diseases such as pneumonia and heart failure.
Patient Preparation
There are no food, fluid, activity, or medication restrictions unless by medical direction.
Normal Findings
- Normal lung fields, cardiac size and shape, mediastinal structures, thoracic spine, ribs, and diaphragm.
Specific infectious organisms are required to be reported to local, state, and national departments of health. Lists of specific organisms may vary among facilities. State health departments provide information regarding reportable diseases which can be accessed at each state health department Web site. The CDC provides information regarding national notifiable diseases at https://ndc.services.cdc.gov/search-results-year/.
Study type: X-ray, plain; related body system: Circulatory, Musculoskeletal, and Respiratory systems.
Chest radiography, commonly called chest x-ray, is one of the most frequently performed diagnostic imaging studies. This study yields information about the pulmonary, cardiac, and skeletal systems. The lungs, filled with air, are easily penetrated by x-rays and appear black on chest images. A routine chest x-ray includes a posteroanterior projection, in which x-rays pass from the posterior to the anterior, and a left lateral projection. Additional projections that may be requested are obliques, lateral decubitus, or lordotic views. Portable x-rays, done in acute or critical situations, can be done at the bedside and usually include only the anteroposterior projection with additional images taken in a lateral decubitus position if the presence of free pleural fluid or air is in question.
Chest images should be taken on full inspiration and while upright when possible to minimize heart magnification and demonstrate fluid levels. Expiration images may be added to detect a pneumothorax or locate foreign bodies. Rib detail images may be taken to delineate bone pathology, useful when chest radiographs suggest fractures or metastatic lesions. Fluoroscopic studies of the chest can also be done to evaluate lung and diaphragm movement. In the beginning of the disease process of tuberculosis, asthma, and chronic obstructive pulmonary disease, the results of a chest x-ray may not correlate with the clinical status of the patient and may even be normal.
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Factors That May Alter the Results of the Study
- Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
- Inability of the patient to cooperate or remain still during the procedure, because movement can produce blurred or otherwise unclear images.
Abnormal Findings Related to
Potential Nursing Problems: Assessment & Nursing Diagnosis
| Problems | Signs and Symptoms |
|---|
| Fluid volume (deficit—related to fluid loss from fever, diaphoresis; inadequate fluid intake; increased metabolic rare secondary to fever) | Decreased urinary output; weight loss, dry oral mucous membranes, dehydration, poor skin turgor, fever, weakness, changes in mental acuity, increased Hgb, complaints of thirst, decreased venous filling, concentrated urine | | Gas exchange (inadequate—related to inflammation of lung tissues, impaired alveolar membrane with decreased oxygen supply, lung consolidation; mucous in airways; ventilation-perfusion mismatch) | Restlessness; irritability; altered level of consciousness; confusion; disorientation; tachypnea; shortness of breath; hypoxia; cyanosis; activity intolerance; nasal flare; use of accessory muscles; adventitious, diminished breath sounds; dyspnea; tachycardia; hypotension | | Infection (related to inflammation, trauma, invasion of a viral bacterial or fungal organism) | Fever, chills, elevated WBC count, cough, purulent sputum, positive sputum culture, tachycardia, increased respiratory rate, dyspnea |
|
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in assessing the heart and lungs for disease.
- Explain that the procedure takes about 5 to 15 min and is performed in the radiology department or at the bedside.
- Review the procedure with the patient.
- Explain that pregnancy testing may be required.
- Explain that no pain should be experienced during the test.
- Pediatric Considerations: Preparing children for a chest x-ray depends on the age of the child.
- Encourage parents to be truthful about what the child may experience during the procedure and to use words that they know their child will understand.
- Note that toddlers and preschool-age children have a very short attention span, so the best time to talk about the test is right before the procedure.
- Allow the child to bring a favorite comfort item into the examination room, and if appropriate, inform the child that a parent will be with the child during the procedure.
- Provide older children with information about the test, and allow them to participate in as many decisions as possible (e.g., choice of clothes to wear to the appointment) in order to reduce anxiety and encourage cooperation.
- Encourage the child to practice the required position. If the child will be asked to maintain a certain position for the test, provide a type of visual media that demonstrates the procedure.
- Teach strategies to remain calm, such as deep breathing, humming, or counting to oneself.
General
- Positioning for a routine chest view is in the standing position, facing the cassette or image detector, with hands on hips, neck extended, and shoulders rolled forward.
- Positioning for a lateral view is with the chest positioned with the left side against the image holder.
- Positioning for a portable examination entails elevating the head of the bed to the high Fowler position (90 degrees).
- During the portable examination the patient is asked to inhale deeply and hold the breath while the x-ray images are taken, and then to exhale after the images are taken.
Potential Nursing Actions
- Verify the patient will be able to cooperate fully and to follow directions.
- Emphasize the importance of remaining still when specific positions are assumed because movement produces unreliable results.
After the Study: Implementation & Evaluation Potential Nursing Actions
Treatment Considerations
Fluid Volume
- Facilitate management of fluid volume deficit.
- Monitor intake and output and trend results, report output of less than 30 mL/hr over 2 hr.
- Assess for dehydration (poor turgor, dry skin, furrowed tongue, concentrated urine).
- Perform a daily weight.
- Fluid intake can be increased by oral or parenteral means or a combination of both.
- Keep mucous membranes (oral) moist with good oral care.
Gas Exchange
- Facilitate management of inadequate gas exchange.
- Administer ordered oxygen and monitor saturation with pulse oximetry.
- Monitor and trend ABG results and CXR results.
- Position the patient with the head elevated to improve ventilation.
- Pace activities and assess respiratory effort, rate, and work of breathing.
- Monitor heart rate and blood pressure, noting changes.
- Monitor for changes in level of consciousness.
- Anticipate the need for mechanical ventilation.
Infection
- Evaluate current immunizations.
- Monitor and trend WBC count and vital signs (blood pressure, pulse, temperature, heart rate), and note alterations.
- Administer ordered antibiotics and antipyretics.
- Monitor breath sounds and ensure any ordered sputum culture and sensitivity has been submitted to the laboratory.
- Evaluate hydration and consider the use of cooling measures for elevated temperature.
- Facilitate ordered sputum and blood cultures.
- Monitor CXR results.
- Encourage frequent hand washing.
Safety Considerations
- Avoid overly aggressive fluid replacement.
- Observe for symptoms of fluid overload: shortness of breath, tachycardia, hypertension, positive jugular vein distention, edema, and sodium/potassium electrolyte imbalance.
Clinical Judgement
- Consider how heightened anxiety contributes to ongoing respiratory distress and what calming techniques can be most effective in mitigating fear.
Follow-Up and Desired Outcomes
- Demonstrates how to accurately perform and document daily weight and intake and output.
- Acknowledges the importance of good hand hygiene to decrease infection risk.
- Choose activities that decrease the risk of fatigue leading to a compromised respiratory status.
- Demonstrates effective cough and deep-breathing techniques to improve oxygenation and understands the importance of keeping oxygen on to support respiratory status.