Why the nurse must be know?

0 The first person who read the radiologist report

0 Provide the interpretation to attending physician
0 In USA, ICU nurse implement specific standing orders,
including obtaining a CXR for unexpected issue such
as respiratory distress, unexplained hypoxemia
 Overview
0 CXRs are one of the oldest non invasive methods for
identifying abnormalities in the chest.
0 Evaluating CXR requires careful observation and a
good understanding of chest anatomy.
 PURPOSES
0 Interpret any structures inside of thorax cavity
0 Interpret of bone and soft tissue of the chest
0 Interpret any devices in the thorax cavity
 The 4 Basic density (Pezzotti,
2014)
0 Bone/metal  white (radiopaque)
0 Water (soft tissue)white to grey
0 Fat appears grey
0 Gas (air) Black (radiolucent)
 Five Radiographic Opacities

Air Fat Soft tissue Bone Metal

least opaque to most opaque

most lucent to least lucent
Black to White
 PROJECTION VIEW
 Posterior-Anterior (PA):
» Standard view & most reliable technique
» Erect films detect air under the diaphragm

 Lateral view:
» Done at the same time as the PA film
» Helps localize infiltrates
» For specific purposes

 Anterior-posterior (AP):
» Portable- patient is too ill to go to X-ray, usually patient is
sitting upright in bed
» Poor quality but may be the best you can do
» Remember- AP films may cause the mediastinum & heart to
appear larger than they are
PA vs AP
 Is the film correctly labelled?
Correct at
date n time

Correct
Patient’s ID

Correct
Projection
 Assessment of exposure quality
Is the film penetrated enough?
 Quality Assessment
 Assessment of exposure quality
Is the film penetrated enough?

The vertebral bodies should just be visible

through the heart.
 Patient-Dependent Factors
 Assessment of adequacy of inspiratory effort
FOTO YG BAIK
0 Simetris
0 Iga Posterior : 8-10
0 Iga Anterior : 6-8
0 Diafragma Flat
0 Vaskularisasi paru
terlihat
0 Inspirasi dalam 
sudut costovertebra ~
90°
 REVIEW ALL ASPECTS
USING ABCDEF APPROACH
A : Airway
Normal Thoracic Anatomy
B : Bones
0 Pay attention to the
clavicles, ribs, scapulae,
vertebrae any fracture
?
0 costal symmetry
0 Intercostal spaces
 COPD
NORMAL ABNORMAL
C : Circulation
0 The heart and mediastinum
A.Size CTR >50% (cardiomegaly or pericardial
effusion)
B.Shape boots, egg
  Heart and
mediastinum
Assessment of heart size

CTR = (A + B) / C
Normal: CTR <
0,5
 Heart and mediastinum
Assessment of cardiomediastinal contour
Pneumomediastinum
TOF
TGA
TAPVD
Plethora VS Oligemik
 D : Diaphragm
0 The right hemidiaphragm should be higher than the
left but no more than 3 cm
 Review of Important Anatomy
 Diaphragms
Assessment of the diaphragms
E :Edge
0 Look the costophenic
angles
Pleural Effusion
F : Fields
0 The lung fields consist of air and very little tissue or
blood
0 The lung fields should be equal density
Tension Pneumothorax
atelektasis
Atelektasis
Tension Pneumothorax
ETT Position
ETT Position
ETT masuk terlalu dalam masuk
ke bronkhus kanan
Komplikasi saat intubasi:
0 Intubasi yang terlalu
dalam ETT masuk ke
bronkhus kanan
0 Intubasi yang terlalu
proksimal beresiko
migrasi ETT
 Central Venous Cateter
0 Ujung CVC terletak di cavoatrial junction
0 CVC yang terlalu dalam akan masuk ke atrium kanan
sehingga mencetuskan aritmia
Naso Gastric Tube
0 Below the diapraghm
with tip and side holes
10 cm (3,94 inch) into
the stomach
 Swan Ganz Chateter
0 Ujung kateter tidak boleh lebih dari 1 cm dari
mediastinal margin
0 Ujung kateter yang terlalu distal akan meningkatkan
resiko infark paru dan perforasi arteri pulmonal.
Swan Ganz Position
0 Tip should be in the
proximal left ang right
PA about 2 cm (0.79 inc)
from hilum
Posisi swanganz yang terlalu
distal
IABP
0 Tip should be in the
desending aorta, distal
to the origin of the left
subclavian artery
Chest Tube
0 All openings of the chest
tube are inside the chest
wall
0 Tube place anteriorly
and superiorly for air
0 Posteriorly and
inferiorly for fluids
 Nursing Implication
0 Nurse can use CXR as an additional tool to confirm
physical assessment findings
0 Nurse with a basic understanding of CXR
interpretation can sharpen their assessment skill,
promote patient safety, and optimize care.