chest X-ray


chest X-ray

Chest film, see there.

Chest X-Ray

Synonym/acronym: Chest radiography, CXR, lung radiography.

Common use

To assist in the evaluation of cardiac, respiratory, and skeletal structure within the lung cavity and diagnose multiple diseases such as pneumonia and congestive heart failure.

Area of application

Heart, mediastinum, lungs.

Contrast

None.

Description

Chest radiography, commonly called chest x-ray, is one of the most frequently performed radiological diagnostic 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 (PA) 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 (AP) 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 erect 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.

This procedure is contraindicated for

  • high alertPatients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.

Indications

  • Aid in the diagnosis of diaphragmatic hernia, lung tumors, intravenous devices, and metastasis
  • Evaluate known or suspected pulmonary disorders, chest trauma, cardiovascular disorders, and skeletal disorders
  • Evaluate placement and position of an endotracheal tube, tracheostomy tube, nasogastric feeding tube, pacemaker wires, central venous catheters, Swan-Ganz catheters, chest tubes, and intra-aortic balloon pump
  • Evaluate positive purified protein derivative (PPD) or Mantoux tests
  • Monitor resolution, progression, or maintenance of disease
  • Monitor effectiveness of the treatment regimen

Potential diagnosis

Normal findings

  • Normal lung fields, cardiac size, mediastinal structures, thoracic spine, ribs, and diaphragm

Abnormal findings related to

  • Atelectasis
  • Bronchitis
  • Curvature of the spinal column (scoliosis)
  • Enlarged heart
  • Enlarged lymph nodes
  • Flattened diaphragm
  • Foreign bodies lodged in the pulmonary system as seen by a radiopaque object
  • Fractures of the sternum, ribs, and spine
  • Lung pathology, including tumors
  • Malposition of tubes or wires
  • Mediastinal tumor and pathology
  • Pericardial effusion
  • Pericarditis
  • Pleural effusion
  • Pneumonia
  • Pneumothora
  • Pulmonary bases, fibrosis, infiltrates
  • Tuberculosis
  • Vascular abnormalities

Critical findings

  • Foreign body
  • Malposition of tube, line, or postoperative device (pacemaker)
  • Pneumonia
  • Pneumoperitoneum
  • Pneumothorax
  • Spine fracture

  • It is essential that a critical finding be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. Notification processes will vary among facilities. Upon receipt of the critical value the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, Hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical value, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • Factors that may impair the results of the examination

    • Metallic objects within the examination field.
    • Improper adjustment of the radiographic equipment to accommodate obese or thin patients, which can cause overexposure or underexposure.
    • Incorrect positioning of the patient, which may produce poor visualization of the area to be examined.
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.

  • Other considerations

    • The procedure may be terminated if chest pain or severe cardiac arrhythmias occur.
    • Consultation with an HCP should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
    • Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the examination room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing the heart and lungs for disease.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex.
  • Obtain a history of the patient’s cardiovascular and respiratory systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • Review the procedure with the patient. Address concerns about pain and explain that no pain will be experienced during the test. Inform the patient that the procedure is performed in the radiology department or at the bedside by a registered radiological technologist, and takes approximately 5 to 15 min.

  • 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. 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. The child should be assured that he or she will be allowed to bring a favorite comfort item into the examination room, and if appropriate, 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. If the child will be asked to maintain a certain position for the test, encourage the child to practice the required position, provide a CD that demonstrates the procedure, and teach strategies to remain calm, such as deep breathing, humming, or counting to himself or herself.

  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Instruct the patient to remove all metallic objects from the area to be examined.
  • Note that there are no food, fluid, or medication restrictions unless by medical direction.

Intratest

  • Potential complications: N/A
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure that the patient has removed all external metallic objects from the area to be examined.
  • Patients are given a gown, robe, and foot coverings to wear.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
  • Place the patient in the standing position facing the cassette or image detector, with hands on hips, neck extended, and shoulders rolled forward.
  • Position the chest with the left side against the image holder for a lateral view.
  • For portable examinations, elevate the head of the bed to the high Fowler’s position.
  • Ask the patient to inhale deeply and hold his or her breath while the x-ray images are taken, and then to exhale after the images are taken.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Recognize anxiety related to test results and be supportive of impaired activity related to respiratory capacity and perceived loss of physical activity. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be performed to evaluate and determine the need for a change in therapy or progression of the disease process. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include biopsy lung, blood gases, bronchoscopy, CT thoracic, CBC, culture mycobacteria, culture sputum, culture viral, electrocardiogram, Gram stain, lung perfusion scan, MRI chest, pulmonary function study, pulse oximetry, and TB tests.
  • Refer to the Cardiovascular and Respiratory systems tables at the end of the book for related tests by body system.