ARRT Score Report: Patient Care INTERACTIONS (25)

Infection Control: Spread

- Requires overcoming of body's immune defense. - Degree of spreading is a function of the logistics of both the host and the microbe anatomy involved. - Site of microbial entry. - Mechanism of microbe travel. - Means of transmission (direct/indirect, droplet, vehicle, vector, airborne, sex, and needles). - Multiplication: The growth in microbe numbers as a function of mitosis. Many infectious agents undergo great multiplication before their impact is recognized by the host.

Infection Control: Modes of Transmission DIRECT

Host-to-host transmission such as handholding, coughing, or sexual contact. *Direct Contact*: Host physically touches the source of the infection. This is the most frequent spread of nosocomial infection. *Droplet*: Source of infection is transferred through air quickly, in large particles, and *short distances*. Ex> Talking, coughing, or sneezing. Rubella (German measles), colds, and influenza commonly transmitted this way.

Interpersonal Communications: Challenges in Communication (5) INTERACTIONS WITH OTHERS

(1 +2) LANGUAGE BARRIERS + CULTURAL/SOCIAL FACTORS - Over 24 million people, or 8.7% of the American population, speak English less than very well and should be considered limited English proficient for health care purposes. - The hospital should determine the preferred language of each patient and communicate this preference to all staff. - Although the practice of soliciting family members to ac t as translators between the therapist and the patient may be common place in some areas, care must be taken to avoid using family members for the interpretation and delivery of sensitive and/or private health information. - Gaining access to real time translation in many languages is made increasingly easier with emerging technologies and application software. Users of these technologies benefit from voice to voice or voice to text translations at point of care. The radiation therapist should investigate resources within the health care organization for language interpreters, as well as explore application software and employ these resources whenever possible. - *GBLT*: Health care professionals are becoming more knowledgable and aware of transsexualism and its related medical and surgical interventions. Practicing culturally competent care with this population includes measures such as, adding a selection option on intake surveys for transgender individuals, making nondiscriminatory disclosures visible, having unisex bathrooms, and promoting education and sensitivity training to health care professionals. - *Cultural Assessment*: Refers to the systematic appraisal of the cultural beliefs, values, and practices of individuals and communities. Being culturally sensitive is essential in caring for the whole patient. Values, beliefs, and customs are key factors. *Values* are most difficult and are established in early childhood through an unconscious process of socialization. *Beliefs* that include knowledge, opinions, and faith about life are built on an individual's values. *Customs* that are the result of values and beliefs are the most observable. - *Spiritual Assessment*: Defined as "man's inner resources especially his ultimate concern, the basic value around which all other values are focused, the central philosophy of life...which guides a person's conduct, the supernatural and nonmaterial dimensions of human nature." It gives meaning to life, death, and illness. Four areas related to meaning and spirituality in patient's life: 1) Patient's concepts of God or deity, 2) Their source of hope and strength, 3) The significant of their religious practices, and 4) The relationship between their spiritual beliefs and state of health. As a radiation therapist you should assist patients to experience their own spirituality, listen carefully to the patient's expression of belief, if possible - provide an appropriate environment and quiet time for reflection and contemplation, and assist patient in finding resources for spiritual fulfillment. *Hope* is the key concept and an essential ingredient in the religious and spiritual aspects of care as well as a major component in the healing process; hope is assessed by the Nowotny Hope Scale, Herth Hope Index, and Miller Hope Scale.

Interpersonal Communications: Challenges in Communication INTERACTIONS WITH OTHERS (5)

(3 + 4) AGE + PHYSICAL OR SENSORY IMPAIRMENTS - *Children*: To provide holistic care to a child with cancer, assessing the needs and concerns of the child's primary caregivers (usually the parents) is essential. Experiencing a life-threatening diagnosis for their child is an extremely stressful event for parents. - *Elderly*: An important problem to assess in older persons is the amount of sensory and cognitive impairments that may be present. Assessing the ability of older patients to hear, see, or understand is paramount in their care and in their overall safety. Recognizing any change from normal behaviors, usual routines, and social interactions is extremely important.

Interpersonal Communications: Challenges in Communication INTERACTIONS WITH OTHERS (5)

(5) EMOTIONAL STATUS The *Kubler-Ross Modified Phases of the Grieving Process* (7 stages of the grief cycle) 1. *Shock* 2. *Denial*: The patient uses the first response as a defense until he/she can become accustomed to the idea. Therapists - You should not be the one to inform a patient of impending death. 3. *Anger*: The patient in this phase may hurl criticism and abuse at family or health care workers. Releasing anger is therapeutic and should be permitted. Therapists - Do not take the abuse personally, do not argue with the patient. 4. *Bargaining*: In this phase the patient may become "the good patient" in order to be spared. The patient tries to follow all medical advices and becomes submissive. Therapists - Support patient who may seek or discuss alternative modes of treatment. 5. *Depression*: The patient accepts the reality of impending death, permanent disability, or disfigurement. The patient mourns his/her past life and all that is being lost. Therapists - Quiet support is the best response of the health care worker during this period. - Support services. - Social worker intervention. - Medical management for depression. We see patients ever day. We need to ask questions and *listen* to the patient's answers, assess physiologic changes, physical and psychological losses, and make the proper referrals. 6. *Testing*: Seeking realistic solutions, making decisions. 7. * Acceptance*: Coming to the realization of the situation and moving forward. If the patient is dying, he/she will lose interest in the outside world and become interested only in the immediate surroundings and the support of persons nearest to him/her.

Infection Control: Defense Mechanisms

*Nonspecific Defense Mechanisms*: Body comes with defense mechanisms; skin, cilia, in lungs, acetic lining of GI and urinary tracts, tears, and saliva. *Specific Defense Mechanisms*: Two forms; natural immunity and artificial immunity. Natural Immunity: Develops as a result of acquiring the disease. Artificial immunity (2 types): *Active* consists of vaccines altered with the pathogen, while *passive* consists of the transfer of protective antibodies from one host to a susceptible host. Active - The vaccine serves as the antigen (foreign substance) and triggers the human body's immune system to create antibodies. Antibodies are specific; they work against only a specific antigen. Antibodies are also known as titers.

Ethical + Legal Aspects: Legal Issues COMMON TERMINOLOGY

*Battery*: Actual act of harmful, unwarranted, or unconsented contact with an individual. *Assault*: Threat of touching in an injurious way. *Negligence*: Neglect or omission of reasonable care or caution. *Malpractice*: Can be a result of professional misconduct or an unreasonable incompetence or lack of skills. In a malpractice lawsuit the burden of proof is on the patient. The best way to avoid a malpractice lawsuit is to practice competently. Stay within your scope of care, meet all standards of care, and develop rapport with each patient. *Libel*: Written defamation of character. *Slander*: Verbal defamation of character. *Invasion of Privacy*: Violation of confidentiality or a patient's body has been improperly/unnecessarily exposed or touched. *False Imprisonment*: Intentional confinement without authorization by a person who physically constricts another with force, threat of force, or confining clothing or structures. *Beneficence*: Doing good, acting in the best interest of the patient even when it might be inconvenient or sacrifices must be made. *Justice*: Fairness and equal treatment for all. *Nonmaleficence*: Directs health care fivers to avoid harmful actions to patients. *Role Fidelity*: Health care professional must be faithful to their role. *Veractiy*: Truthfulness, within the realm of health care practice. *Health Care Proxy/Power of Attorney*: Patient appoints someone to make decisions for them when they cannot.

Medical Emergencies: Cardiac or Respiratory Arrest

*Cardiac or Respiratory Arrest*: - On realization that a patient has experienced cardiac arrest, the appropriate alert should be initiated before CPR is begun. - Perform CPR; chest compressions if the patient has no pulse, check the airway by tilting the patient's head, perform mouth to mouth breathing techniques.

Infection Control: CDC Standard Precautions TRANSMISSION-BASED PRECAUTIONS

*Contact*: - Wear gloves while in the room and water a gown if in contact with the patient or their linen. *Droplet*: - A surgical mask must be worn in and near the patient's room. - Wash hands before going into the patient's room and when leaving, as well as when handling the patient's body fluids. *Airborne*: - HEPA filter or negative air-pressure room is used for patients with TB. - Wash hands before going into the patient's room and when leaving, as well as when handling the patient's body fluids. - N95 or HEPA respirator masks for workers; standard masks for visitors.

Infection Control: Asepsis

*Disinfection*: Decreases the number of microorganisms. Ex> boiling water and chemical liquids. *Sterilization*: Completely destroys all microorganisms and spores. Ex> Dry heat, steam under pressure, and chemical sterilization. Difference between *medical asepsis* and *sterilization* Asepsis reduces the amount of microorganisms, but not spores. Examples of Medical Asepsis: Surgery and the insertion of IV lines, urinary catheters and drains. The goals of aseptic technique are to protect the patient from infection and to prevent the spread of pathogens and/or harmful microorganisms. *Means of Disinfection and Sterilization* Most common way to sterilize equipment is *steam autoclaves*. 1. *Heat*: Moist or dry is most reliable, available, and economical in destroying microorganisms. 2. *Gas*: Available for medical products that cannot withstand high temperatures, such as endoscopes and plastic items. 3. *Radiation*: Not routinely used in health care setting, but used widely in commercial industrial sites for medical products. 4. *Chemical Liquids*: Easy to use for sterilization or disinfection.

Ethical + Legal Aspects: Legal Issues LEGAL DOCTRINES

*Doctrine of Respondeat Superior*: Let the master answer; the employer is liable for negligent acts of employees. *Doctrine of Res Ipsa Loquitur*: The thing speaks for itself; requires the defendant to explain the events and convince the court that no negligence was involved. *Doctrine of Personal Liability*: Liable for his/her own negligent conduct. *Doctrine of Foreseeability*: Preventing something from occurring that was predictable.

Infection Control: CDC Standard Precautions PPE

*Gloves*: These are important in protecting yourself from contamination, creating a barrier as well as protecting the patient from any microorganisms that may be present on your own hands. Additionally, once gloves are removed and disposed of immediately after treating a patient, they no longer can serve as a fomite and infect other patients. *Gowns*: A clean, nonsterile gown is adequate for most purposes. Wear a gown to protect your skin and to prevent soiling your clothing where splashes or sprays are likely. Select one that is appropriate for the amount of fluid likely to be encountered (cloth vs plastic). Remove soiled gowns promptly. *Masks/Eye Protection/Face Shield*: Wear these devices to protect mucous membrane of your eyes and nose, and mouth during procedures likely to generate splashes or sprays of blood, bodily fluids, secretions, or excretions. Use care in removing mask, don't touch the front with your hands. Wear a mask when performing an aseptic task. Do not confuse a mask and a particulate respirator.

Infection Control: CDC Standard Precautions HAND HYGIENE

*Hand Hygiene*: *The single most crucial and effective weapon for reducing health care associated infections*. Use hand agents routinely and frequently. *Fingernails are the primary reservoir of microflora on the hands, even after intense washing*. Wash hands with soap and water (40- 60 secs) if visibly soiled (blood, body fluid) and after caring for patients with known or suspected diarrhea. *Alcohol-based hand rub is preferred with exceptions noted above* because of superior microbial activity, faster acting, more effective, more accessible than sinks, reduced skin drying and convenience. When to Wash Hands: - Before touching a patient or performing an aseptic task, even if gloves will be worn. - Immediately after glove removal and after final contact with patient. - If hands will be moving from contaminated-body site to clean-body site during patient's care. - After contact with inanimate objects in the immediate vicinity of where the patient was (i.e. the treatment table).

Infection Control: Pathogens and Microorganisms

*Infectious Microorganisms*: Includes bacteria, viruses, fungi, and protozoa. - If a microorganism is known to produce disease, it is called a *pathogenic microorganism*, or *pathogen*. - Pathogen: An infectious agent. Bacteria and virus (most common) Fungi Protozoa Algae Chlamydiae, rickettsiae, and prions (less common) - Pathogenicity: The ability of an infectious agent to cause clinical disease. - Virulence: The severity of a clinical disease, typically expressed in terms of morbidity and mortality. What Do Pathogens Do? EXOTOXINS. Can produce certain side effects, such as an extremely high body temperature, nausea, vomiting, or shock. So when we experience these symptoms we can blame it on the exotoxins. Pathogens multiple in large numbers and cause an obstruction. Can cause tissue damage. Can secrete organic substances.

Infection Control: CDC Standard Precautions ADDITIONAL PRECAUTIONS

*Neutropenic Precautions* - *"Reverse isolation"*, the purpose is to protect the patient from any germs the staff or visitors are carrying. - Patients who have a decreased immune system, usually from chemotherapy, may be placed in reverse isolation. - If you have a patient in reverse isolation, you need to wear gloves, a mask and a gown. *Health Care Associated (Nosocomial) Infections* - Traditionally describes infections that developed in the hospital or to describe infections that were acquired in the hospital but did not develop until after discharge. - Today the term "hospital" is too restrictive and has been expanded to include outpatient care facilities and other health care settings. - HAIs may be acquired not only by patients, but also by HCWs and visitors. - When a patient contracts an infection before a hospital admission, this is not considered an HAI; this is a community-related rather than hospital-related infection. - The primary goal of the epidemiology team is to decrease all preventable HAIs. - The *most common* strains in hospitals are: *Vancomycin-Resistant Enterococci (VRE), Methicillin-Resistant Staphylococcus Aureus (MRSA), and Clostridium Difficile (C. Diff)*. - Contributing factors to the rise in new pathogens causing nosocomial infections: 1. Overuse of antibiotics by physicians. 2. Wrong antibiotics being prescribed. 3. Patients demanding antibiotics. 4. Patients not finishing antibiotics have all been. - Environmental factors attribute to HAIs including things such as: *Carpet, upholstery, flowers, flower pots, etc.* - Environmental factors specific to radiation therapy include: *Custom-made bite blocks, treatment tables and slide boards, tattooing or placing permanent marks on patient, bolus sheets, pen or marker used on patient, and thermoplastic masks and water baths used to make them*. *Health Care Facility Epidemiology* - To be accredited by The Joint Commission, hospitals must have an epidemiology division. - State laws govern reporting of specific diseases and disposal of medical waste. - OSHA is focusing more on health care workers. - Hospitals are being mandated to have employees undergo physicals, epidemiology-related health and safety orientations, TB testing, and infection control quality assessment (QA) or QI programs. *Vaccines Recommended for HCWs*: - Hepatitis B virus (HBV) Vaccine became available in 1982. Recombinant deoxyribonucleic acid (DNA) vaccine. - Influenza - MMR (Mumps, measles, and rubella viruses) - Varicella (Chicken pox) - Tetanus/diphtheria/pertussis *Diseases that Require HCWs Removal*: - Conjunctivitis (pink eye) - Epidemic diarrhea - Streptococcosis - HAV - Herpes simplex of exposed skin - Measles - Mumps - Rabies - Staphylococcus aureus skin lesions - Varicella zoster (of these listed, most crucial in radiaiton therapy department) - Pertussis (whooping cough) - Rubella

Infection Control: Terms

*Pathogen*: Any of a wide range of small, primitive life forms. ex> bacteria, viruses, fungi, protozoa, algae, etc. *Reservoir Host*: Where the microorganism lives and reproduces. Ex> Polio's reservoir is within humans and not animals, as rabies is within animals but not humans *Portal of Exit*: Necessary for a disease to be passed to others (transmitted). Ex> skin, blood, respiratory tract, GI tract, etc. *Portal of Entry*: To cause a disease, the infectious agent must gain entrance to the body. Ex> skin, GI tract, respiratory tract, urinary tract, transplantation, medications, equipment such as catheters and scopes.

Physical Assistance: Assisting Patients with Medical Equipment INFUSIONS

*Ports + Pumps* - *Infusion Pumps*: There are a variety of types: Kangaroo for TPN, CADD for pain meds, chemo etc. Should be plugged in whenever possible to preserve battery. Do not change infusion rates, know the alarm signals (may be listed on the back of the pump and how to trouble shoot). Check policy on disengaging pump to assist patient with gown change. Complications: Air embolism, hematoma, infection, infiltration and phlebitis. - *Infusion Port*: Implanted under the skin and it is a self-sealing injection port within a plastic or metal case. AKA port-a-cath. Implanted by a doctor under local anesthesia in the O.R. The catheter is inserted through the skin into a large vein in the chest. The catheter tip advances into the right atrium. csThe other end of the catheter tunnels under the skin, usually near the shoulder. The port is placed under the skin through an incision and attached to the catheter. Once the incision is closed, the entire device is under the skin. Uses: Continuous infusions of fluids, blood products, medications, chemotherapy, and total parenteral nutrition (TPN). Complications: Infection and clotting.

Medical Emergencies: Other Medicine Disorders SEIZURES + SHOCK

*Seizures*: - Remain with the patient. - Loosen tight clothing. - Turn patient's head to side. - Monitor for respiratory distress. - Alter environment to promote safety. - Do not restrain movement or put objects in mouth. - Monitor for another seizure before complete recovery from previous one. - When a seizure occurs, observe and document the following: Date, time of onset, and duration Activity at time of onset Level of consciousness (confused, dazed, excited, unconscious) Presence of aura (if known) Movements *Shock*: Symptoms - Restlessness - Anxiety - Weakness - Anxious or dull expression - Disoriented (often precede other signs and symptoms) - Weak and rapid (thread like) pulse - Cold, clammy, moist skin - Profuse sweating - Initially, a dull, chalk-like appearance to the patient's skin, regardless of color - Later, a bluish (cyanotic) color to the skin - Shallow, irregular breathing; may be labored, rapid or gasping - Closed or partially closed eyelids; dull, lusterless eyes; dilated pupils - Extreme thirst - Nausea and possible vomiting - Gradual and steady drop in blood pressure (to 90/60 or lower); eventually blood pressure that is unobtainable - Possible fainting in cases of rapidly developing transient shock - Shaking and trembling of the arms and legs, as if chilled - Feeling of impending doom MEDICAL INTERVENTION FOR SHOCK: Stop procedure, call MD and emergency assistance. Do not leave patient unattended. Keep patient npo, apply pressure if visible wound. Keep patient warm, and slightly elevate their feet to improve venous blood return to the heart while you wait for a physician. If patient vomits, turn their head to the side to prevent aspiration of the emesis. Assess vitals q 5 mins. TREATMENT: May include the administration of oxygen, fluids, blood, and medications to promote vasoconstriction, which elevates the BP and promotes perfusion to vital organs.

Ethical + Legal Aspects: Patient's Rights

*These rules establish limits on how health care providers may use and disclose individually identifiable health information or PHI as well as steps that must be taken to protect the information*. - *Informed Consent*: A procedure in which patients may agree to or refuse treatment based on information provided to them by their physician or designee(s). The patient must be fully informed concerning the nature of the procedure or treatment - the associated risks, including complications; side effects and potential mortality; desired outcome; and possible alternative procedures or treatments. Must be secured in writing for all procedures, treatments, and research considered invasive and/or that pose significant risk(s). - *Confidentiality (HIPAA)*: The knowledge and information revealed by a patient to a health care provider, or information that is learned in the course of a health care provider performing his/hers duties, is private and should be held in confidence (kept secret). In 1996, the federal government passed the Health Insurance Portability and Accountability Act (HIPAA) which states that health care facilities, providers, and employees are mandated under penalty of law to publish rules to ensure (1) standardization of electronic patient administrative, financial, and health data; (2) creation of unique health identifiers for employees, health care providers, and health plans; (3) security standards that protect the confidentiality and integrity of "individually identifiable health information," past, present, and future. - *American Hospital Association (AHA) Patient Care Partnership (Patient Bill of Rights)*: In 1992 and 1998 the AHA constructed and adopted what became known as "A Patient's Bill of Rights" which was further refined, revisd, and copyrighted. More recently it's been revised and renamed "The Patient Care Partnership". This document is intended to provide patients with an explanation of what to expect during their hospital stay, and to explain their rights and responsibilities such as - High-quality patient care A clean and safe environment Patient's involvement in his/her care Protections of the patient's privacy Help when the patient leaves the hospital Help with the patient's billing claim Goal of care (palliative vs definitive) Advanced directives (i.e. living will, or health care proxy) Research participation

Infection Control: Handling and Disposal of Toxic or Hazardous Material

*Types of Materials*: *Types of Materials* 1. *Metals* - Shielding blocks are made of bismuth, lead, tin, and cadmium. Lipowitz metal or Cerrobend. - The most toxic materials are *lead and cadmium* Cadmium dust can affect the lungs and kidneys. Lead can affect the brain. - Toxicities may transpire if the materials are breathed in or absorbed through the skin, or if someone eats or drinks contaminated foods. - When handling blocks or cutouts, protective clothing, eyewear, and gloves must be worn. - Workers must wash their hands after touching the blocks or cutouts. - The melting pot should be kept below a fume hood to properly filter the toxic fumes from the air. - There are more toxic fumes as the temperature of the melting pot increases. - The temperature of the melting pot should not be any higher than 80 degrees Celsius. - Standards for handling of an exposure to toxic materials are set by OSHA. 2. *Chemicals* - Chemicals are examples of carcinogens. - DNA can be mutated as a reaction to chemicals. - Protective gear should be worn when handling chemicals. 3. *Radioactive Materials* - Must abide by ALARA (time, distance, and shielding) when around radioactive materials to keep exposure to a minimum. - Must wear proper personal protection when handling radioactive materials. - Eating and drinking in areas where radioactive materials are being handled is not allowed. 4. *Chemotherapy* - When preparing and administering chemotherapy, personnel must wear gloves, gowns, and face shields. - If spilled on the skin, some chemotherapy drugs may cause blisters or ulcers. - After a spill of liquid chemotherapy, a *towel or a spill kit* is used to clean up and is then disposed of in a biohazard bag. The area must be cleaned with *detergent*. *Material Safety Data Sheet (MSDS)* - Data sheets that give information about how to use and handle specific chemicals and materials in a safe way. - Provides information about: 1. Healthy effects that can be caused by materials. 2. The chemical's physical property, like the melting point of the material. 3. The reactivity of the chemicals. 4. How to store and dispose of the materials.

Infection Control: Terminology

*Typical Infection*: Clinical signs and symptoms externally (pain, fever, swelling, redness, etc.); body initiates an immune response internally. *Subclinical Infection*: No external signs or symptoms and body does not initiate an immune response. An individual can pass it along to someone else and infect them still. *Colonization*: The reproduction of an infectious microorganism with no interaction between the body and the microorganism that would result in a detectable immune response. "Harboring", growing in a medium without showing signs/symptoms. Ex> Most common is HPV (cold sores) A person who is colonized but not ill is a *carrier*. *Nosocomial Infections*: Acquired within a health care facility. Most infections are caused by bacteria or virus. *Host*: If disease develops, host goes through three phases. 1) Incubation: Growth period (gets into body, grows, internal between exposure and appearance of symptoms). 2) Clinical Disease: Individual expresses clinical signs/symptoms. 3. Convalescence: Recovery of disease, no longer contagious.

Medical Emergencies: Allergic Reactions CONTRAST MEDIA

- *Contraindications*: The patient has had reactions in the past, patient is older, patient has diabetes, patient had heart disease and limited kidney function. - *Adverse Reactions*: *Minor*: Nausea, hives, mild vomiting, weakness, warmth, and pallor. Stop the infusion and notify the MD or nurse. Remain with the patient and offer reassurance. Prepare to assist in the administration of an antihistamine or SQ epinephrine. *Moderate*: Bradycardia, tachycardia, hypotension, hypertension, and dyspnea. Stop the infusion, notify the MD or nurse, call for emergency team if symptoms progress rapidly. Remain with the patient and offer reassurance. Prepare to administer oxygen and IV medications. If patient is in respiratory distress place in a semi-Fowler's position. Position the patient who is vomiting in a position to prevent aspiration. *Severe*: Anaphylactic shock, convulsions, respiratory arrest, and vascular shock. Medications: Epinephrine, diphenhydramine, hydrocortisone, and aminophylline. Call for emergency response team (Cody Blue), notify the radiologist and radiology nurse. Prepare the use AED (automated external defibrillator), prepare to administer oxygen and IV medication. - *Other*: For example, latex. - *Contrast agents are categorized as drugs because they can be absorbed into the systemic circulation and may produce a physiologic response on the body*. - *Iodinated Contrast Agents*: Are used in examinations of the GI tract, kidneys, gallbladder, pancreas, heart, brain, adrenal glands, arteries, veins, and joints. - Baseline: Ask the patient about food, medication, asthma, and any other allergies. - Code Chart: Know where the emergency cart ("crash cart") is located. Make sure that the contents are up to date and stocked. - *Physical Injury or Trauma*:

Medical Emergencies: Other Medicine Disorders DIABETIC REACTIONS (HYPOGLYCEMIA vs HYPERGLYCEMIA)

- *Diabetic Ketoacidosis* is when there is not enough insulin and to treat this they're either given an IV or insulin. - *Hypoglycemia* is an increase in *insulin* in the bloodstream, usually when a patient hasn't eaten or drank. It makes a patient extremely hungry, weak, shaky, sweat excessively, confused and irritable, and sometimes aggressive. - *Hyperglycemia* is excessive *sugar* in the blood. Blood glucose over 240 mg/dl, more urine output than usual, increased thirst, dry skin and mouth, decreased appetite, nausea, or vomiting, fatigue, drowsiness or no energy.

Interpersonal Communications: Support Services

- *Hospice and other professionals (e.g., dietitian, clergy, and social services)*. *Palliative and End-of-life*: The concept of cancer cure is believed to be when the patient has undergone standard therapeutic interventions and the disease has not returned. Some patients undergoing cancer treatment have diseases that are advanced and are deemed incurable by their health care providers. - *Palliative care is the delivery of interventions aimed at relieving symptoms and side effects of the disease and of the treatment, and improving quality of life for the patient*. Many patients undergo radiation therapy treatments that are designed with a palliative intent. Patients receiving palliative care including prescription and over-the-counter drugs, nutrition and hydration interventions, use of alternative medicines, and psychosocial supportive therapies, when combined with standard care demonstrate improved quality of life. *A common misconception is that palliative care is the same as end-of-life care*. *When the oncology medical professionals have determined that the therapeutic interventions have ceased to work and cancer control is not sustainable then end-of-life care may be initiated* Radiation therapists are often one of the first of the interprofessional team to assess changes in the patient that may indicate not only advanced side effects of treatment, but of advanced disease as well. Not only should the radiation therapist refer the patient to the nurse and physician, but they should discuss with the team the reasons for this referral. An example of this assessment and referral would be when a patient that is being treated for their primary lung cancer demonstrates neurological changes such as change in gait, personality, vision, or headaches. The physician may conduct a complete physical assessment and diagnostic work-up in this patient to look for advancing disease such as brain metastasis. - *End-of-life care is delivery of physical and psychosocial interventions when the aim of treatment moves to one of comfort care only*. Practitioners focused on treatment interventions and not on holistic care or quality of life for the patient and family can easily overlook this transition period. A referral to *hospice services* at this stage allows the patient and family to enjoy the time remaining, and to prepare for end-of-life, while not spending time on various invasive or painful medical interventions. The radiation therapist sees first-hand the physical and emotional toll on the patient receiving palliative radiation therapy, often times to multiple areas of the body, and may play a role in having a conversation with the physician about the appropriateness of a hospice referral. - The *clergy* are religious leaders who provide religious services. - *Social services* provide counseling and information to the patient and their families so they can understand and cope with the illness. - The *registered dietician* can help cancer patients among symptoms caused by radiation therapy or chemotherapy treatments and help maintain a healthy nutritional status.

Physical Assistance: Assisting Patients with Medical Equipment CATHETERS + IV LINES

- *IV Lines*: Provide patient's with fluids and electrolytes, meds/pain management, nutrition/hydration, blood products, or chemotherapy. Therapists are responsible to note where these lines are at all times. Failure to note kinked lines can harm the patient if they don't receive the medication, or if they are pulled out and cause harm to the patient. - *Urinary Catheters*: Used to empty the bladder, prevent infection, obtain urine specimens, post-op to monitor bleeding, and to keep bladder empty while the surrounding tissues heal, or to irrigate or instill medication to the bladder. Indwelling/retention catheters (AKA Foley catheters) have a double lumen with an inflatable balloon at one end. The balloon holds the catheter in place after it is inserted into the bladder. Sterile water is used to inflate the balloon to hold the catheter in place after it is inserted. A straight catheter (Robinson-single lumen) is used to empty the bladder and is then removed. Often MS patients perform this procedure on themselves. Patient Care: Keep the urinary drainage bag below the level of the patient's bladder to reduce the risk of urinary tract infections. This minimizes back flow from the urinary collection bag into the bladder. Never leave the bag on the cart or table or hold it above the patient's bladder level when ambulating.

Physical Assistance: Assisting Patients with Medical Equipment PACEMAKERS

- *Pacemakers*: Permanent pacemakers are electromechanical devices inserted under the patient's skin to regulate the heart rate. Pacemaker units are approximately 1in in width, in diameter, and in thickness, weighing just a little over 1 ounce. Newer pacemaker designs are MRI compatible. Therapists - Need to monitor the patient with a pacemakers if it's in the field of radiation. Each site will have a pacemaker protocol to be aware of. - *Pacemakers and Implantable Cardioverter Defibrillators (ICDs)*: It's crucial that you know your devices especially when they are in the treatment field. Know your pacemaker/IDC protocols in your institution. May initially need TLDs if they are in or near the treatment field.

Physical Assistance: Assisting Patients with Medical Equipment TUBES

- *Tubes, Catheters + Vascular Access Devices*: You must be able to differentiate among the uses and appearances of various access lines and tubes. Life-threatening complications may occur if life lines, tunes, or catheters are not cared for properly. Patency (the degree of openness of a tube, such as a blood vessel or catheter; the relative absence of blockage) px: Caused by patient movement, kinks/occlusion, improper IV height. - *Drainage Tubes*: Can include Jackson-Pratt drains for chest/breast drainage. JP drain is used postoperatively for surgical soft tissue wounds that are expected to produce significant amounts of drainage i.e. as with a mastectomy. The JP drain prevents assimilation of blood, fluids, and necrotic debris at the surgical site that, if allowed to accumulate, would hinder healing and increase risk of infection. Penrose drains are drainage tubes that are secured to the patient's skin with stitches that are later removed. - *Chest Tubes*: Promote fluid drainage after chest or lung surgery and prevent air or fluid from entering the pleural space. The tube may be connected to a low-suction device to re-expand the lung quickly or an underwater seal to create a vacuum that prevents any air or fluid from entering the pleura space. Need to stay in tact, upright, and remain below the level of the chest.

Interpersonal Communications: Modes of Professional Communication

- *Types: Verbal, nonverbal, written, simple consent, expressed consent, implied consent, inadequate consent*. - Inability to communicate effectively can harm patients. *Verbal*: Gives the doctor permission with a verbal message. - Use clear, concise language when speaking to patients, families, and other health care professionals. - Use proper vocabulary, pacing, intonation, and clarity. - Your tone of voice can express enthusiasm, disgust, or indifference. - *This is all important because non-compliance with the treatment plan, instructions, and medications is often related to a breakdown in communication*. - Clarifying is used to obtain more information about vague, ambiguous, or conflicting statements. - Verbal messages are clear than nonverbal messages. - They are composed of *cognitive* and *affective* content. Affective communication involves feelings of anger, sadness, fear, and happiness. The radiation therapist needs to listen reflectively to the patient and identify what the patient is feeling. Reflective listening involves responding with empathy (identifying with the feelings, thoughts, or experiences of another person). *Nonverbal*: Read through body language (e.g. eye contact, touching). - It is believed that *more than 2/3 of any communication is transmitted nonverbally*. - Therefore, gestures, facial expressions, posture, personal appearance, and cultural characteristics must be interpreted to understand the patient. - *Nonverbal behavior provides clues to, but not conclusive proof of, underlying feelings*. However, *research has proved that nonverbal cues tend to be more reliable than verbal cues*. *Written*: An official agreement signed on paper/digitally by everyone involved. *Simple Consent*: Expressed or implied permission that's given for the procedure when the patient does not have enough information about the procedure. *Expressed Consent*: Patient does not stop the procedure (the patient wants the procedure to occur). *Implied Consent*: Implied that the patient would give consent if the patient's condition permitted. Used for emergency situations, consent should be given by another person if the patient is unable to give consent himself/herself. *Inadequate Consent*: Or "ignorant consent", is when the patient isn't given enough information to make the appropriate decision. *Assent*: Expressed willingness to participate by persons who are by definition too young to five informed consent but who are old enough to understand the proposed treatment/procedure in general, its expected risks and possible benefits, and the activities expected of them as patients.

Infection Control: CDC Standard Precautions SAFE HANDLING/DISPOSAL OF CONTAMINATED MATERIALS (linens, needles, patient supplies, blood and body fluids)

- Always handle very carefully to keep the contamination from spreading to other materials. - Contaminated equipment that is a single-use piece of equipment must be discarded properly. - Contaminated equipment that can be reused must be cleaned or sterilized before being used again. - Linens that have been contaminated must be handled with gloves and placed in a labeled biohazard bag that won't leak. - Contaminated linens are thrown away or placed in a labeled bag to be sent for decontamination. - Other linens used daily must be placed in a big located in the treatment room so that they can be cleaned before reuse. - Linens should be changed before treating each patient. - Sharp equipment that can be disposed of, such as needles, must be paced in a puncture-resistant container. - Supplies should be used for only one patient. - Used supplies should be sent to be re-sterilized or should be thrown away. - Alpha-cradles cannot be reused and must be thrown away. - Vac-loks can be reused but must be properly cleaned between patients. - *Patient blood and bodily fluid leaks should be cleaned up immediately. Use proper disinfectants or a bleach solution*.

Ethical + Legal Aspects: Legal Issues VERIFICATION

- At least 2 methods of identification are used to confirm patient identity (ex> name, date of birth, treatment site, wristband). Globally there is an increased awareness of safety and incidents or wrong site, wrong procedure and wrong person surgeries. Protocols are mandated in most countries bringing attention the "3 R's" (right) or "3 C's" (correct), patient, site, and procedure. - The TJC requires that all accredited organizations comply with the following universal protocol: Preprocedure verification (chart + room prep), verify procedure, verify patient site, identify items that must be available for procedure, and match items to patient Mark procedure site Time out, a time out procedure to identify the correct patient is performed each day the patient is treated. The actual process of identifying the right patient may very from department to department, but should include the following: A standardized process within the organization Initiated by a designated member of the team at every instance Immediate members of the team performed the procedure while actively communicating Correct patient is confirmed by using at least 2 methods Correct site, verification of markings Correct procedure to be done is verified Document, organization determines the amount and type of documentation

Medical Emergencies: Physical Injury or Trauma

- Immediately call for the doctor after an injury occurs. - Then continue to attend to the patient. - Carefully help the patient without causing further injury. - After the incident has occurred, an incident report may need to be filled out according to the facility's rules.

Physical Assistance: Assisting Patients with Medical Equipment OXYGEN

- Oxygen Delivery: Delivered by nasal cannula, face mask. - Can be portable tank or via wall outlets. - Monitor the patients for signs of respiratory distress. - Do not change the flow rate of the oxygen as it is a prescribed order. - COPD patients are carbon dioxide retainers and it's contraindicated to increase the oxygen amount for these patients. - Oxygen supports combustion; therefore no smoking or flammable materials near the tanks, and stand upright (when dropped can become like a missile and explode).

Infection Control: CDC Standard Precautions SAFE NEEDLE PRACTICES

- Wearing gloves when tattooing is optional (no consensus by professional groups exist at this time). - Do wear gloves if blood is anticipated or broken skin is present in the area where hands will be placed to perform tattoo. - Clean area with alcohol, wipe and allow area to dry. - Never administer a tattoo with the same ink syringe even if the needle is changed. - Dispose of syringe and needle at point of use in sharps container. - Prevention: *Avoid recapping needles*. Before beginning any procedure using needles, plan for safe handling and proper disposal. Help your employer select and evaluate devices with safety features. Use devices with safety features. Report all needlestick and other sharps-related injuries. *Dispose of used needles in appropriate sharps disposal containers*. Inform your employer of hazards from needles that you observe at work. Participate in bloodborne pathogen training and follow recommended infection prevention practices, including hepatitis B vaccination. - If *needle stick* occurs, it *must be reported immediately*. - Do not manipulate a used needle using both hands or use any technique that would involve directing the point of a needle toward any part of your body. - Do use either a one-handed technique or a mechanical device designed for holding the needle sheath. - Do not remove used needles from disposable syringes by hand and do not bend, break, or otherwise manipulate used needles by hand.

Physical Assistance: Patient Transfer + Movement

BODY MECHANISMS + PATIENT TRANSFER TECHNIQUES - Patient assessment, center of gravity, proper lifting, and locks. - Transferring: What's the number one work related injury for health care workers? *Back injuries*, and *neck/shoulder injuries* are the leading cause of work place disability for health care workers. - *Assessment*: Always assess the patient's cognitive status. Are they medicated, unconscious, semi-conscious, any language barriers. Can the patient transfer independently and/or how much assistance is needed. - *Center of Gravity*: When an object is balanced it is stable. Use a wide firm stance for your legs and stand close to the person or object. We want to keep objects close to the core of our body the torso. - *Lifting*: Avoid twisting from the waist. The lifter should stand with feet separated for a wide based and one foot should be in front of the other. The lifter should keep the weight of what they are lifting close to themselves. When bending, use the knees and hips, not the waist (use the muscles in the legs instead of the back). Biceps are the strongest arm muscles so it's always better to pull the patient toward you than push. If possible, have more people on the pulling side of the treatment couch for transfers. Even better, always use a slide board. Always have a draw sheet to avoid friction and sheering force that can damage the patient's skin. - *Locks*: Make sure that all looks on wheelchairs and stretchers are secured. Never leave the side rails down unless you are in position to protect the patient from falling. - *Fall Prevention*: When walking a patient into the treatment room, it is important to walk close to them just in case they lose their balance or trip. If a patient requires a wheelchair for assistance, make sure to use one to prevent a fall. When the patient is on the PSA, safety straps may be used to keep the patient in place and to prevent a fall. - *Wheelchair Transfers*: 1. Position the wheelchair parallel to the treatment table. If the patient has weakness or impairment on one side, position the stronger side of the patient in the direction of the movement. 2. Lock the chair wheels. 3. Raise foot rests and stand facing the patient. 4. With the patient's feet together and the assistant's feet on either side, lean forward bending at the knees and hips, while maintaining the natural curve of the lower spine. 5. The patient reaches around the lift assistant's shoulders while the lifter reaches under the patient's arms. The lifters arms are locked around the patient's back. 6. The patient is raised to his/her feet and pivoted 90 degrees so that the patient's back faces the table. 7. Next, the patient is eased into a sitting position. Once steadied with an arm behind the patient's shoulders and the other hand behind the knees, the patient is eased into the supine position in one smooth motion. - *Stretcher Transfers*: These types of transfers should be completed with a minimum of 2 caregivers. 1. The stretcher is placed alongside the treatment table with the rails lowered and the wheels locked. The table is positioned at the same level as the stretcher If the patient can slide over, one lift assistant may secure the stretcher while another stands opposite the treatment table, providing guidance and ensuring that the patient does not fall. 2. A draw sheet and slide board can assist the transfer, reducing the risk of injury to the people performing the transfer. 3. Patients are positioned with their hands on their chest. The board is positioned by rolling the patient from the treatment table and placing the board under the draw sheet. 4. After the patient is eased back onto the sliding board, the board is pulled to the treatment table or the patient is slid across the bridge created over the gap between the stretcher and the treatment table. 5. The slide board must be removed if it is in the path of the beam or if it will affect the treatment position.

Ethical + Legal Aspects: ARRT Standards of Ethics

Guidance and standards that promote a culture of ethical behavior within the profession. These areas include conduct, respect, diversity, technical applications, decision making, aid in diagnosis, radiation protection, ethical conduct, confidentiality, and education.

Infection Control: Cycle of Infection

Pathogen/Infectious agent -> reservoir host (incubation, clinical disease, convalescence) → portal of exit → transmission (5; contact, droplet, common vehicle, airborne, vectorborne) → portal of entrance → susceptible host.

Infection Control: Modes of Transmission INDIRECT

Touching objects (fomites); dressings, clothing, dishes, or anything containing live infectious microorganisms. *Airborne*: The source of infection is transmitted in *long distances* in the air as small particles. Particles can stay in the air for hours to days. Ex> TB *Vehicle-Borne*: "Fomite" People come in contact with a fomite (*inanimate objects* such as water, food, medications, and equipment) that is contaminated. Can contaminate multiple people. *Vector-Borne*: "Mechanical or biological". An infectious vector transports microorganisms. Ex> Ticks (Lyme disease and Rocky Mountain spotted fever), mosquitoes (malaria), and rats.