Chest X-ray (Chest Radiography) - Nursing Responsibilities

Image in full inspiration and erect when feasible to reduce cardiac magnification and show fluid levels. Expiration images help identify a pneumothorax or locate foreign material. Rib detail images delineate bone pathology, useful for metastatic lesions or fractures. Early in asthma, tuberculosis, and COPD, the film may not match the patient's clinical picture and can even read normal.

Your role is patient comfort and cooperation. Some patients are in pain from injury or disease, and most are anxious about what the film will show. A good image depends on the patient holding still and holding a breath, so a calm environment matters.

Indications

• Help diagnose diaphragmatic hernia, lung tumors, and metastasis
• Detect known or suspected pulmonary, cardiovascular, and skeletal disorders
• Identify chest trauma
• Confirm placement of an endotracheal tube, tracheostomy tube, chest tubes, central venous catheters, nasogastric feeding tube, pacemaker wires, intraaortic balloon pump, Swan-Ganz catheters, and automatic implantable cardioverter defibrillator
• Evaluate a positive purified protein derivative (PPD) or Mantoux test for pulmonary tuberculosis
• Monitor progression, resolution, or stability of disease
• Evaluate response to therapy (antibiotic, chemotherapy)

Contraindication

• Pregnancy or suspected pregnancy, unless the benefit outweighs the risk of maternal and fetal damage

Interfering Factors

• Metallic objects in the field
• Excessive patient movement during the exam
• Incorrect patient position, producing poor exposure
• Inability to take a full inspiration
• Equipment not adjusted for thin or obese patients, causing under or overexposure

Procedure

1. Remove items. The patient removes clothing, jewelry, or anything that interferes with the study.
2. Gown the patient. The patient puts on an x-ray gown.
3. Position the patient. For the PA view, the patient stands or sits facing the image detector with hands on hips, inhales deeply, and holds the breath until the image is taken. For the lateral view, the left side faces the image holder with hands raised above the head.
4. Take the images. The technician stands behind a protective shield. Films develop within a few minutes.

Nursing Responsibilities

Before the procedure

• Remove all metallic objects. Jewelry, pins, and buttons obscure the chest.
• No special prep. No fasting or medication restriction unless the provider orders it.
• Confirm the patient is not pregnant. X-rays are not recommended in pregnancy unless the benefit outweighs the risk to mother and fetus.
• Assess breath-holding ability. Holding the breath after inhaling shows the lungs and heart more clearly.
• Provide a gown. Have the patient remove clothing from the waist up and put on an x-ray gown.
• Coach cooperation. The patient must stay still, since movement blurs the image.

After the procedure

• No special care is needed after the exam.
• Provide comfort. If done at the bedside, reposition the patient properly.

Normal Results

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

Abnormal Results

• Atelectasis (collapse or incomplete expansion of pulmonary parenchyma)
• Bronchitis (inflammation of the bronchial tube)
• Cardiomegaly (enlargement of the heart)
• Flattened diaphragm with lung hyperinflation (indicator of COPD)
• Foreign bodies in the pulmonary system seen as a radiopaque object
• Irregular patchy infiltrates in the lung fields (suggestive of pneumonia)
• Lung tumors (irregular abnormal white shadow on the lung fields)
• Malposition of tubes or wires
• Misalignment or break of bones (fracture)
• Pericardial effusion (fluid around the heart)
• Pericarditis (inflammation of the pericardium)
• Pleural effusion (fluid in the pleural space)
• Pneumothorax (air in the pleural space)
• Pulmonary base infiltrates and fibrosis
• Scoliosis (curvature of the spinal column)
• Swollen lymph nodes
• Tuberculosis (patchy, nodular infiltrates usually in the upper lobe lung fields; cavities in the lung)
• Widened mediastinum (suggesting neoplasm or aortic aneurysm)

Frequently Asked Questions

How much radiation does a chest x-ray deliver? A single adult chest x-ray gives about 0.1 mSv, roughly the same as 10 days of natural background radiation, according to RadiologyInfo.org. The dose is low, but providers still weigh the benefit against the exposure.

Does the patient need any special preparation? No. There is no fasting or medication restriction for a routine chest x-ray. The patient removes clothing, jewelry, and metallic objects from the chest area and puts on a gown.

Why is the patient asked to hold a breath? Imaging in full inspiration expands the lungs and reduces cardiac magnification, which makes the heart, lungs, and any fluid levels clearer. Holding still during the exposure prevents a blurred image.

Is a chest x-ray safe during pregnancy? X-rays are generally avoided in pregnancy unless the benefit outweighs the risk to mother and fetus. Confirm the patient is not pregnant and follow facility shielding policy when imaging is necessary.

What is the difference between a PA and an AP view? A standard PA view sends x-rays from back to front with the patient upright, which minimizes heart magnification. A portable AP view is taken at the bedside for patients who cannot leave the unit and tends to magnify the heart slightly.

Why might an early chest x-ray look normal in lung disease? Early in asthma, tuberculosis, and COPD, the film may not match the clinical picture and can even read normal. A normal x-ray does not rule out disease, so it is interpreted alongside symptoms and other tests.