Professional Practice in Patient Care Lesson 10 April 4th, 2013

Supine Position Patient on back with head and upper shoulders slightly elevated Used for examinations of the upper abdomen Elevating the patient’s right arm opens up intercostal spaces

Lateral Position Place a pillow between the legs at knee level for pregnant or elderly patients.

Prone Position Patient on his or her abdomen Arms flexed at either side or elevated alongside the head to widen the intercostal spaces Small pillows under the patient’s head, abdomen, and lower legs to relieve pressure

Upright/Erect Position Patient sits on the edge of the scanning table, right arm elevated above the head, left arm and hand providing support. Used to scan a gallbladder in an extremely high position under the rib cage For vascular studies, the patient may have to stand erect for portions of the study.

Modified Fowler Position Head elevated 25 degrees; knees slightly flexed Used in advanced pregnancy to avoid vena caval hypotension

Trendelenburg Position The patient’s pelvis is higher than her head. Used when fetal parts obscure the LUS or when fetal lie prevents imaging of the fetal head

Scanning Planes Sagittal plane—longitudinal Midsagittal plane divides the body into equal right and left sides Transverse plane—horizontal Coronal plane—vertical Divides the body into anterior and posterior portions Oblique—any plane not parallel to sagittal, transverse, or coronal

Ultrasound Specialties 1. Abdominal 2. Breast 3. Cardiac 4. Gynecologic 5. Obstetric 6. High-resolution 7. Neurosonography 8. Ophthalmologic 9. Vascular 10. Musculoskeletal

Study-Related Duties Get copies of any pertinent diagnostic or lab reports. Confirm that the patient’s preparation has been carried out. Get brief patient history; list present medications. Document laboratory data. Review prior ultrasound or other diagnostic tests. Record and archive examination images. Prepare sonographer’s technical report. 

Laboratory-Related Duties Quality assurance testing Transducer preparation and care Cleaning ultrasound equipment and preparing area for the next patient Maintaining supplies  

Sonographer’s Report Location of the scan plane Normal or abnormal echogenicity, or both, of the organs studied Measurements and their locations Presence of shadowing or acoustic enhancement Presence and location of any masses Presence and location of abnormal fluid collections Any technical difficulties encountered during the study

Computer-Assisted Programs PACS—electronically store, manage, distribute, and allow viewing of images RIS—streamline scheduling and ordering of appointments, patient registration, work lists, billing, and medical and management reporting EMR

Transducer Preparation and Care Clean transducers mechanically with an enzymatic cleanser after every patient study. Whenever a chance of contamination exists, clean the transducer using either a disinfectant or a sterilization process. Guidelines for cleaning and preparing endocavitary ultrasound transducers may be found at http://www.aium.org.

Maintaining Supplies Linens Coupling gels Bedpan, urinal, emesis basin IV stand Sterile trays

Abdominal and Retroperitoneal Sonography Used to examine: The abdominal cavity for fluid, abscesses, or lymph adenopathy The liver, spleen, pancreas, gallbladder, biliary tract, kidneys, and urinary tract Major abdominal vessels by using 2D, 3D, and Doppler ultrasound techniques. Abdominal sonography should be done before any diagnostic imaging tests that require contrast material.

Interventional Procedures Ultrasound guidance may be requested for various procedures or to help place tubes and drains. “Freehand” technique—transducer and the needle are not connected Used to drain ascites, pleural fluid, and in superficial lesions. Needle guide attached to the transducer Used for small lesions, deep lesions, and lesions near major vessels or structures.

Vascular Sonography Performed to determine the absence or presence of stenosis, aneurysm, thrombosis Used to evaluate patients with grafts or stents Duplex imaging used to determine hemodynamic status of the vascular system and to detect the presence of pathology

Obstetric and Gynecologic Sonography Used to evaluate pregnancy and the female reproductive organs Standard protocols for first, second, and third trimester examinations Limited study—used in emergencies or as a follow-up to a prior complete examination Specialized examination—done when an abnormality is suspected or found Biophysical profiles, fetal Doppler examination, or fetal echocardiography

Obstetric and Gynecologic Sonography Transabdominal probes Placed on the anterior abdominal wall or perineum 3.5 MHz or higher Transvaginal probes Closer to the area of interest 5.0 MHz or higher Intracavitary—requires the insertion of this specialized transducer into the vagina.

Transrectal/Transperineal Sonography Optional techniques for patients who are not candidates for a transvaginal exam Young, virginal patients Postmenopausal patients with a stenotic introitus  

Doppler Color, power, and spectral Doppler used to evaluate the vascular characteristics of ovarian and uterine masses Color Doppler can be used to identify and differentiate vascular structures from nonvascular entities.

Interventional Procedures Biopsy or aspiration procedures Patients with masses or free fluid in the pelvis Paracentesis Patients with severe abdominal/pelvic ascites Thoracenthesis Patients with fluid in the pleural cavity

Adult Echocardiography Transthoracic echocardiography (TTE) Noninvasive 2D, real-time Used to evaluate cardiac structure and function Transesophageal echocardiography (TEE) Invasive Places a specialized transducer within the esophagus

Adult Echocardiography Sonographic modalities most commonly used in echocardiography: 2D and 3D imaging M-mode tracings Doppler flow studies Tissue Doppler-imaging techniques Interventional procedures Injected contrast agents

Additional Applications of Echocardiography Serial echocardiography Intraoperative echocardiography Intracardiac-echocardiography (ICE) Intravascular echocardiography (IVUS) Stress echocardiography Pharmacologic echocardiography Pre- and post-ablation Pre- and post-cardioversion

Exercise Healthcare Trends!! Where are we going? With an older population and more Diagnostic tools at our disposal, what seems to be happening in terms of patient referrals?