CHEST X-RAY

 Chest X-ray (Chest radiography, CXR) is one of the most frequently performed radiological examination.
 A chest x-ray is a painless, non-invasive test uses electromagnetic waves to produce visual images of the heart,
lungs, bones, and blood vessels of the chest. Air spaces normally seen in the lungs appear dark on the chest
films. A basic chest x-ray includes posteroanterior (PA) view, in which x-rays pass from the back to the front of
the body, and a left lateral view. Other projections such as lateral decubitus, lordotic views, or oblique view can
be requested also.
 Chest images should be examined in full inspiration and erect if feasible to reduce cardiac magnification and
demonstrate fluid levels. Expiration images may be needed to identify a pneumothorax or locate foreign
materials. Rib detail images may be taken to delineate bone pathology, helpful when chest radiographs illustrate
metastatic lesions or fractures. In the onset of the disease process of asthma, tuberculosis, and chronic
obstructive pulmonary disease, chest x-ray results may not correlate with the patient’s clinical status and may
even be normal.

Preparation

 Items are removed

- Patients will be asked to remove any clothing, jewelry, or other articles that may interfere with the study.
 Appropriate clothing is given
- Patients will be provided by an X-ray gown to wear.
Procedure

 The X-ray occurs in a special room with a movable X-ray camera attached to a large metal arm. You will stand
next to a “plate.” This plate may contain X-ray film or a special sensor that records the images on a computer.
You’ll wear a lead apron to cover your genitals. This is because your sperm (men) and eggs (women) could be
damaged from the radiation.
 The X-ray technician will tell you how to stand and will record both front and side views of your chest. While the
images are taken, you’ll need to hold your breath so that your chest stays completely still. If you move, the
images might turn out blurry. As the radiation passes through your body and onto the plate, denser materials,
such as bone and the muscles of your heart, will appear white.

Nursing Intervention

Before Chest X-ray

1. Remove all metallic objects. Items such as jewelry, pins, buttons etc. can hinder the visualization of the chest.
2. No preparation is required. Fasting or medication restriction is not needed unless directed by the health care
provider.
3. Ensure the patient is not pregnant or suspected to be pregnant. X-rays are usually not recommended for
pregnant women unless the benefit outweighs the risk of damage to the mother and fetus.
4. Assess the patient’s ability to hold his or her breath. Holding one’s breath after inhaling enables the lungs and
heart to be seen more clearly in the x-ray.
5. Provide appropriate clothing. Patients are instructed to remove clothing from the waist up and put on an X-ray
gown to wear during the procedure.
6. Instruct patient to cooperate during the procedure. The patient is asked to remain still because any movement
will affect the clarity of the image.
After Chest X-ray
1. No special care. Note that no special care is required following the procedure
2. Provide comfort. If the test is facilitated at the bedside, reposition the patient properly.
 BRONCHOSCOPY

 Bronchoscopy is an invasive procedure that permits the direct examination of the larynx, trachea, and bronchi
using either a flexible fiberoptic bronchoscope or a rigid metal bronchoscope (see gallery below). It is performed
by a trained practitioner (pulmonologist or thoracic surgeons). A non-invasive approach called virtual
bronchoscopy includes a series of computed tomography (CT) scan to visualize the tracheobronchial tree.
 While a flexible fiberoptic bronchoscope is used more often and provides a wider view, the rigid metal
bronchoscope, on the other hand, is a method of choice for foreign body removal, endobronchial lesion
excision, and massive hemoptysis control. A bronchial brush, forceps, and needle may be passed through the
bronchoscope to get samples for cytological determination.

Diagnostic Bronchoscopy
 Direct visualization of the tracheobronchial tree for any abnormalities such as inflammatory process, tumors, or
strictures
 Direct visualization of the larynx to determine the presence of a vocal cord paralysis
 Aspiration of a specimen for culture and sensitivity and for cytological examination
 Biopsy of tissue from suspected lesions

Therapeutic Bronchoscopy
 Removal of excessive secretions, mucus plugs, benign or malignant tumors to clear airways
 Removal of foreign objects or other obstructions
 Control of bleeding in the bronchi
 Palliative laser therapy or radiation therapy for bronchial tumors

Procedure

Bronchoscopy may utilize fluoroscopic guidance for evaluation of distal lesions for a tracheobronchial biopsy involving
alveolar areas. However, a routine bronchoscopy procedure is as follows:

1. Apply local anesthetic.

- A local anesthetic is flushed into the throat patient’s throat on a sitting upright or lying supine position.
2. Insert bronchoscope.
-As the sedative takes effect, a bronchoscope is inserted through the patient’s mouth or nose.
3. Additional anesthetic is applied.
-When the bronchoscope reaches above the vocal cords, about 3 to 4 mL of 2% to 4% lidocaine is sprayed
through the scope’s inner channel to the vocal cords to anesthetize distant areas.
4. Examine the area.
-The practitioner examines the anatomic structure of the trachea and bronchi, notes the color of the mucosal
lining, and inspects for tumors or inflamed areas.
5. Collect tissue samples.
-Tissue samples may be collected from a suspect area; A bronchial brush is needed to collect sample cells from
the surface of a lesion, and a suction apparatus to remove foreign materials or mucus plugs may be used.
Bronchoalveolar lavage may be performed to diagnose the infectious causes of infiltrates in an
immunocompromised patient or to remove copious secretions.
Nursing Responsibilities
 The nurse’s responsibility during a bronchoscopy includes maintaining a viable airway and closely monitoring the
patient’s respiratory status. Another role of the nurse during the bronchoscopy is to relieve patient anxiety by
providing information on what to expect and what to avoid.

Before Procedure
a. Secure informed consent. A signed consent form is obtained from the patient.
b. Obtain medical history. Ask for any history of allergies to anesthetic agents and list of medicines the patient is
taking.
c. Check for NPO status. Withheld food and fluids for 6 to 12 hours prior to the exam to decrease the risk of
aspiration.
d. Monitor vital signs. Obtain baseline vital signs and inform the practitioner of any abnormal findings.
e. Provide oral hygiene. Instruct the patient to do oral care and remove any dentures if appropriate.
f. Administer preoperative medications as ordered. Explain to the patient that an IV sedative such as Propofol
may be given as an anesthetic agent.
g. Prepare for local anesthesia. If the bronchoscopy is not conducted under general anesthesia, inform the patient
that a topical anesthetic (e.g., Lidocaine) will be sprayed on the pharynx to prevent coughing and gagging as the
scope is passed down through the throat. Explain that the spray may have a bitter taste to it.
h. Relieve anxiety. Reassure the patient that airway blockage won’t occur.
i. Prepare emergency resuscitation equipment at the bedside. Laryngospasm and respiratory distress may occur
following the procedure.

During Procedure
a. Position the client. Place patient in a sitting or supine position and provide supplemental oxygen as ordered.
b. Provide assistance with the diagnostic procedure and/or treatment. Assist with tissue specimen collection for
testing. Other procedures may be performed as needed such as removal of foreign body, bronchoalveolar
lavage, placement of a bronchial stent, and aspiration of retained secretions.
c. Secure specimen. Send the properly labeled specimen to the laboratory immediately.

After Procedure
The nurse should be aware of these post-procedure nursing interventions after bronchoscopy:
a. Assess bleeding episodes. Observe the patient’s sputum and report for any excessive bleeding. Explain that a
minimal amount of blood streak is expected and normal for few hours after the procedure.
b. Assess respiratory status. Watch out for signs of bronchial spasm or bronchial perforation such as facial
crepitus, hypoxemia, hemorrhage, and chest tightness.
c. Monitor vital signs. Changes in the vital signs or any discomforts felt by the patient may indicate a possible
complication.
d. Position the patient. Place the conscious patient in a semi-Fowler’s position while for an unconscious patient,
place on one side with the head of the bed slightly raised.
e. Reinforce diet. Maintain NPO status until the anesthesia has worn off and the gag reflex has returned. The
patient may resume his normal diet, starting with sips of water or ice chips.
f. Prevent aspiration. Provide an emesis basin, and instruct the patient to spit out saliva rather than swallow it.
g. Relieve anxiety and provide comfort measures. Reassure the patient that hoarseness, loss of voice and sore
throat may occur temporarily. Offer lozenges or a soothing liquid gargle to relieve discomfort until gag reflex
returns.
 LUNG BIOPSY
 A lung biopsy procedure is a type of medical operation, often involving removing tissue or growths from the
lungs.
 A lung biopsy procedure is often required to help diagnose a condition. It is usually recommended after
abnormalities in the chest are found during a computerized tomography (CT) scan or chest X-ray.
 The procedure may be required in cases where there is suspected cancer in the chest, such as lung cancer. A
lung biopsy can determine whether any unusual masses are malignant, meaning cancerous, or benign, meaning
noncancerous.
 If a mass on the lungs is found to be cancerous, the lung biopsy procedure can determine the stage the cancer is
at.
 A lung biopsy procedure may sometimes be carried out to diagnose as well as determine the cause of a
condition. For example, it may help to diagnose an infection or determine the cause of fluid collecting in the
lung.

Different types of lung biopsy procedure:

Needle biopsy procedure

 When abnormal tissue is located near to the chest wall, a needle biopsy may be used to collect this tissue. The
advantages to this type of biopsy are that general anesthesia is not required and the whole procedure does not
require a hospital stay.
 This procedure involves a needle being inserted into the lung through the skin, guided either by X-ray or CT. The
procedure can take up to an hour to complete and may require a patient to fast for up to 8 hours before the
procedure.
Open biopsy
 This procedure is used when a lump is being completely or partially removed. When the lump is removed
completely, the procedure may be referred to as a lumpectomy.
 An imaging test will be carried out to find the growth or lump, and a wire or needle may be placed in the area
for guidance during the procedure. This type of biopsy is performed by surgeons in an operating room. The
patient is placed under general anesthesia, and the chest cavity must be opened to retrieve the tissue.
Bronchoscopic biopsy
 This procedure is used to collect a sample of lung tissue. A device called a bronchoscope is inserted via the nose
or mouth to reach the lungs. This procedure can take up to an hour to complete.
 THORACENTESIS
 Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the
chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from the pleural space to
help you breathe easier. It may be done to determine the cause of your pleural effusion. Some conditions such
as heart failure, lung infections, and tumors can cause pleural effusions.
 The risks of thoracentesis include a pneumothorax or collapsed lung, pain, bleeding, bruising, or infection. Liver
or spleen injuries are rare complications.