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Professional Area: Radiography

Unit Number: P12109 1CRE3UD

Unit Name: Imaging Special Care Groups

Assignment Title:
With reference to either Paediatric or Geriatric patients, discuss the practical problems which may be
experienced, and the ways they can be minimised.

Item Number:

Confidentiality has been respected throughout this work and no names of people or places have been
included.

This assignment is entirely my own work.

Word Count: 3299

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With reference to either Paediatric or Geriatric patients, discuss the practical


problems which may be experienced, and the ways they can be minimised.

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(Consider such points as the use of specialised equipment and accessories, the
physical and psychological care of the patients, as well as the ethical issues related
to the examination of these patients).

Paediatric imaging produces challenges that are specifically linked to the paediatric patient.
In this essay, problems that occur in paediatric imaging will be discussed, with
recommendations made to reduce such issues. Areas that will be explored in order to
discuss potential problems include defining the stages of paediatrics, specialist
equipment , immobilisation in conjunction with consent, environment and play,
communication between all parties involved, staff training, special care paediatrics and
specific emotional and psychological care of patients.
Paediatrics are defined as ranging from birth to 18 years of age. (CoR, 2009). Further
stages of paediatrics are categorised as follows:

Pre-term – below 37 weeks of gestation


Neonates/babies – 37 – 40 weeks gestation, 0-28 days, 28 days to 24 months
Toddler/pre-school – 18 months to 2 & half, 2 & half to 5 years
Primary school – 5 years to 10 years
Pre-adolescent and adolescent – 10 years to 18 years

Paediatrics are major users of the NHS, with half of children aged under a year, and a
further quarter of all children aged from 1 to 18 years using A&E within a typical year.
(Mathers, et al, 2010).
It is probable that a large number of these children will be referred to the imaging
department as part of their treatment. (Mathers, et al, 2010). Not all hospitals provide
dedicated paediatric imaging departments, and it is within generic imaging departments
where some of the more challenging and unsupported situations exist. The diversity of the
age range that paediatrics cover reflects the diversity of their needs, and the range of skills
that the radiographer may have to pull upon to ensure that not only the best images are
produced with the maximum diagnostic yield and the minimum risk, but that the child is
handled appropriately. Imaging children is notoriously difficult, as they are variable in their
ability and behaviour, dependant on factors including stage of development, ability, type of
injury, mechanism of injury, level of pain and the procedure being undertaken. (Sury, et al,
2005), Furthermore, radiographers have a duty of care towards the paediatric patient.

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(CoR, 2005). With this in mind, it is important not to approach imaging paediatrics in the
same manner as imaging older patients, and not to treat children as just small adults.
(DOH, 2003).

Equipment
When imaging paediatrics, an element of equipment that is designed for purpose is useful,
not only for acquiring the best images, but also to keep radiation dose to a minimum
through immobilisation, good positioning and reducing repeat images, and to establish a
less threatening environment for the child. (Field, et al, 2010).
More often than not, the needs of children are not considered when procuring imaging
equipment in many radiography departments, (Mathers, et al, 2010) which is of concern
when children have increased sensitivity to ionising radiation. (Mathers, et al, 2010). The
Image Gently campaign in America, supported by the SOR, highlights the risk of over
radiation in paediatrics, especially when using CT and interventional radiography, through
using equipment not designed for paediatrics in mind. (Image Gently, 2010). The National
Framework for Children, (2003) clearly states that ‘equipment used for children must be the
correct size for a child, and its design tailored to different needs at different stages of their
development’.
It is in response to this that equipment, for example paediatric chest imaging chairs are
designed specifically for paediatric chest imaging, with positioning, speed and minimal
stress to the patient in mind. (Synergy, 2010). Most imaging departments will image
paediatric chests using an adult chest stand and maybe a chair, which, for children from
toddler stage to primary school age is not always suitable. Nonetheless, equipment readily
available in all imaging departments, such as foam wedges and sand bags are successfully
utilised whilst imaging children, incorporated with adaptation of technique by the
radiographer. (Synergy, 2010). More complex equipment may be needed for other
procedures, specifically MRI, CT and interventional procedures.

Immobilisation and consent


The practice of immobilisation is wide spread and sometimes necessary in imaging
paediatrics, in order to produce adequate diagnostic quality imaging, whilst minimising the
need for repeat images due to poor positioning, centering and movement, and keeping
dose to a minimum. Keeping radiation shielding in place is also another reason why
immobilising the patient is so important. (Kohn, et al, 1996). Again, radiographers have a

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duty of care to their patients, considering the patients injury, their level of pain, and
handling the patient carefully. Gaining a child’s trust and confidence is probably the most
challenging aspect of that duty of care. It is in conjunction with this, that immobilisation may
play a part. (Graham, et al, 2004).
Positioning of paediatrics can be far more challenging than that of adults, with
immobilisation achieved with the use of supplementary materials and equipment, carers
and parents. Skill, experience and adequate time should also be necessities, as equipment
should not be relied upon alone. (Kohn, et al, 1996).
Communication with the child and parents to explain the procedure, why immobilisation is
important and how the immobilisation device will work is essential to minimise this. (Kohn,
et al, 1996).
In some instances, parents may be required to restrain the child whilst imaging. This is a
particularly effective form of immobilisation, (whilst following relevant radiation protection
guidelines for the parent), and parents must be informed exactly what is expected of them.
(Kohn, et al, 1996). Hardy, et al, (2002), states that immobilisation devices are only useful
for children less than 3 months of age, as children above this age would need to be
unacceptably tightly strapped, contravening their human rights. In the case of neonates
and babies, swaddling is an effective immobilisation technique that needs no
supplementary equipment. In cases of children over 3 months of age, the best
immobilisation method is the utilisation of a parent or health professional. (Hardy, et al,
2002).
Building trust with the child through communication as detailed later, empowering the child
to think for themselves and using distraction methods are all techniques that can be
applied to assist in immobilisation. Some imaging modalities require sedation as well as
specialised equipment for immobilisation. MRI is particularly troublesome, due to the length
of the procedure, noise and the claustrophobic environment. (Sury, et al, 2005) A child of a
young age would find it difficult to stay still for a successful MRI procedure of diagnostic
quality.
The fine line drawn between restraint and immobilisation raises issues such as consent,
ethics and legislation. To restrain is to immobilise without consent with force, where as
immobilisation requires less force and is done with consent that is given for the
examination. (Allison, et al, 2008). The College of Radiographers 2005 document, ‘The
Child and the Law; Roles and Responsibilities of the Radiographer’, outlines correct
conduct radiographers should use when dealing with issues of immobilisation and restraint,

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and are guidelines that can be applied in practice, or implemented into local policies and
protocols. In an ideal world, plenty of time could be expended on difficult and strong willed
paediatrics to immobilise without any kind of restraining technique, but in most hospital
settings, this is not the case, and on some occasions restraint has to be used. The choice
to restrain has to be made on an individual basis, taking all the factors into consideration
and as a last resort, and must always be in the child’s best interest. (Allison, et al, 2008).
Consent before any kind of procedure is a legal requirement. (DOH, 2001). The issue of
consent can be complicated, and it is important for the radiographer to be fully informed in
these matters. (CoR, 2005).
The College of Radiographers define consent to be valid and legal when:

i) The patient is legally competent;


ii) The consent is freely given;
iii) The person consenting is suitably informed. (CoR, 2005).

The College of radiographers regard the Gillick competence unclear on its guidance to
consent, and that each child should be judged individually, and dependant on the
procedure. (CoR, 2005).
The Department of Health state that under some circumstances, under 16’s can give
consent, as long as they fully understand what they are giving consent for. Regardless of
this, the parents should always be fully involved in this process, and it is ultimately a
parent’s decision to accept treatment for their child if the child is under 18. (DOH, 2001).
When dealing with young adult females, a degree of sensitivity and confidentiality needs to
be considered when determining LMP dates whilst parents are present, and the interests of
the child should be of the utmost importance. (CoR, 2005).
The Human Rights Act (1998), article 3, states that everyone has the right not to be abused
or tortured, and some restraining techniques could, in a court of law, been seen as
contravening the Human Rights Act. (Allison, et al, 2008). It is important in these cases that
parents are communicated to thoroughly before any kind of forceful technique is used.
The Mental Health Act (1999), states that staff are allowed to use restraint in cases of non-
compliance of treatment, which is a situation that may occur in paediatric imaging,
especially with young adults, and is a case where a parent would have to intervene and
give consent. (Allison et al, 2008).

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Environment and play


The 2009 document ‘Practice standards for the imaging of Children and Young People’
includes as standard 3 details on facilities, equipment and environment in the imaging
department, to support the quality of the image.
The role of play and the environment is essential in caring for children in hospitals. (Hardy,
et al, 2003). Providing a child focused environment makes the child feel more comfortable,
both physically and psychologically, puts them at ease and subsequently helps the
radiographer when performing the procedure.
Providing equipment such as light projectors, mobiles or appropriate toys help with
distracting and calming children in the examination room during the procedure. (Hardy, et
al, 2003). Wherever possible, books and toys in the waiting area provide a familiar
environment for children, lowering anxiety and the waiting area itself should feel welcoming
and attractive. (Hardy, et al, 2003). Ideally, children’s waiting areas should remain separate
from adult waiting areas, with separate changing facilities. It is important to remember that
children attending the imaging department may also be young adolescents, and provision
should be made for this age group, perhaps in the form of suitable reading material.
(Hardy, et al, 2003).
Play specialists are common in the hospital setting, but are rarely found in the imaging
department. As part of general paediatric care in wards and clinics, they can explain and
demonstrate procedures to paediatric patients, using toys or dolls, and in a manner that a
child would understand and be put at ease by. (Hardy, et al, 2003). In an article published
by Synergy in 1999, it was stated that ‘a child who has been prepared for x-ray in a way
that is normal to them and that they understand i.e. play, will be less anxious, feel more in
control and be more co-operative simply because he/she has sorted out the examination in
his/her mind’. (Cox, 1999). Play specialists can also advise the imaging department on best
practice with regards to communication and distraction techniques when dealing with
children.

Communication
Communication, both verbal and non-verbal, is vital in gaining trust and confidence,
ascertaining levels of pain and reducing anxiety for both the child and the parent whilst
increasing the outcome of good quality diagnostic images. (O’Connor, et al, 2003). In
cases of known and suspected non-accidental injury, the child may be more cautious of

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adults than usual, and good communication skills are essential in getting a co-operative
and calm child. (Hancock, et al, 1997).
The Department of health document, The National Service Framework for Children, states
as standard 3 of its 10 year programme, that ‘appropriate information should be provided
for children and parents, that they should be listened and responded to, and that their
views should be supported and taken into account when decisions are made’. (DOH,
2004).
Research indicates that children want information on the care and treatment that they
receive in hospital. (Mathers, et al, 2010). Leaflets like the one available on the SOR
website, ‘Sarah’s x-ray Adventure’, (SOR, nd), are useful to communicate to children of a
younger age on their level, reassuring them so that they know what to expect.
Information has to be tailored specifically for its target audience. Not only could information
be available in paper form, but could also be accessible online for children and parents, as
well as specific websites aimed at the imaging patient. (Mathers, et al, 2010). Child friendly
posters within the department, with information relating to imaging are also a good way of
communicating information.
When verbally communicating with younger children, it is important to get on their level and
gain eye contact, using positive and easy to understand language. (O’Connor, et al, 2003).
Verbal praise boosts confidence in the child, without patronising, and accessories such as
certificates and stickers make the overall experience more positive. Older children should
be given privacy and respect, whilst gaining trust through verbal communication relevant to
their age.
Body language, speech and actions of the radiographer should remain positive to ensure
the child remains happy and confident during the examination and when leaving the
department. (O’Connor, et al, 2003).
Equal emphasis should be applied to listening to the patient as well as talking to the
patient. Non-verbal communication also includes appropriate personal contact. For
younger children, a comforting hand on their shoulder or a warm smile goes a long way in
making them feel relaxed. (O’Connor, 2003). Dealing with parents can prove problematic
when imaging their child. A certain level of concern is to be expected, and anxiety is
something that needs to be alleviated so that the child does not pick up on their parent’s
anxiety. Involving the parent in what needs to be done and ensuring that they are fully
informed of what is happening helps with this. Knowledge is empowering, and can help in
making the parent feel that they are more in control.

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Mathers, et al, (2010), reported as part of their survey, that there is little evidence of
engaging with children to support future plans in imaging services. Hardy, et al, (2003),
states that involving children and their parents is essential in delivering a quality imaging
service, through communication and consideration of the child’s needs throughout the
imaging process. As a result of this, a better experience for the child can be achieved, with
any potential problems minimised.
Communication is also important not just between the radiographer, the child and the
parents, but also between other departments, sharing best practice. (Mathers, et al, 2010).

Staff training
The College of Radiographers document, Practice Standards for the Imaging of Children
and Young People, (2009), is clear on its standard of education, stating that
‘Radiographers must be educationally prepared and clinically competent to undertake
examinations on any child or young person between birth and adulthood’. It goes on to
recommend undergraduate education and post registration education to maintain
competence in this area. Mathers, et al, (2010) found that these standards are not regularly
met, and that there is an assumption that no particular training is needed to deal with
paediatrics. Limited areas, such as resuscitation and child protection are more commonly
covered internal training subjects for radiographers, with little attention to fundamental
subjects such as those previously discussed, (communication, immobilisation and technical
skills). Without competence in these areas, radiographers do not have the skills to be able
to cope with the problems that arise through the imaging paediatrics, with detriment to the
child and the quality of image. A list of recommended standards of education are listed
below.

Safeguarding children and promoting the welfare of children; students need to be trained, updated, supported and
supervised
physical, psychological and emotional development stages in childhood
common paediatric pathologies and their radiographic manifestation
paediatric radiation protection, radiobiological risk factors and dose reduction strategies
awareness of national as well as local guidance and procedures on child protection
communication skills with children of different ages
developing listening skills including those specific to children with special needs
use of appropriate strategies to handle fearful and uncooperative children distraction techniques and how to use them to good
effect
rationale and application of immobilization
rights and responsibilities of the child (UNCRC)
awareness of professional accountability to take appropriate action in reporting concerns
childcare policies and techniques within a paediatric module and through clinical experience by attendance on a

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student placement (or an elective) at a specialist paediatric centre where possible.

Mathers, et al, (2010), recommend from their survey that staff should have individual plans
for professional development as part of their CPD, aimed at their skill gaps in imaging
children, which should be updated regularly. This is not only beneficial to staff
development, but also improves service to the paediatric patient.

Special care paediatrics


Imaging pre-terms or neonates has its own skill set for radiographers. Particular
considerations need to be made to ensure adequate diagnostic imaging, and for the safety
of the baby.
Equipment in the special care baby unit can be a challenge for the mobile image. Babies
can rarely be moved from the incubator, space is challenged, and monitor leads are
abundant. Positioning is one of the major problems with film adequacy, and special
attention needs to be paid to avoid rotation. It is advisable to always check with staff
regarding policy on ECG leads, and extra care needs to be taken when placing and
removing the IR in respect of tubing.
Minimal handling of the baby is advised, due to potential respiratory problems, risk of
infection and heat loss to the baby, and it is advisable to seek assistance from available
nurses when positioning image receptors. (Hardy, et al, 2003).
Risk of infection is high, due to the newborns underdeveloped immunity, so hand washing
and cleaning radiographic equipment before and after an examination is considered good
practice. (Hardy, et al, 2003).
Disabled children come with all the challenges of paediatrics, with the additional skills
needed to care for their particular disability. Every disabled patient needs to be treated as
an individual, with their individual needs assessed and addressed accordingly and with
empathy.

The Oncology Patient


Treating cancer patients in the radiography department is not solely confined to
therapeutics. Psychosocial requirements of the oncology paediatric patients differ from
other children coming to the imaging department. Interaction with the patient and the
parents will differ, as there is increased emphasis on including parents in the child’s care,
and respecting the parent’s decision as to how much they want to participate. (O’Connor,

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et al, 2003). In the case of very sick oncology patients, the parents have emotional needs
as well, and this should be considered. Good communication, positivity and empathy will
contribute towards a good diagnostic quality image.

Conclusion
Dealing with children and their diversities can be problematic. Obtaining a good diagnostic
image requires the radiographer to pull upon a whole different set of skills that are not
usually utilised with adult patients. The College of Radiographers 2005 document, ‘The
Child and the Law; Roles and Responsibilities of the Radiographer’, point 6.12 states that
‘Correct positioning of children is difficult in order to provide the quality of image to detect
often subtle signs of injury. The fact that the image was taken from a non-cooperative child
is no excuse for the production of an inferior quality film’. This encompasses the role of the
radiographer in the imaging of children. Special skills need to be applied to obtain the best
images, through methods such as communication and adaptation of technique within the
boundaries of consent. Training of staff, both undergraduate and post-registration,
including CPD is integral to delivering a high standard of service, care and treatment to
patients and to producing quality diagnostic images.

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