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Digital systems Digital imaging technology permits a wide range of exposure parameters (and therefore patient doses) to be used without significantly affecting the perceived image quality order eriacta 100mg erectile dysfunction treatment nasal spray. It is therefore essential that appropriate exposure parameters are established and adhered to in order to ensure minimum patient dose generic eriacta 100 mg with mastercard erectile dysfunction yahoo. Ideally the kV/mAs combination used should be sufficient to ensure that the noise in the image is just low enough for the image quality to be diagnostically acceptable. Automatic exposure control Many automatic exposure control (AEC) systems commonly available are not suitable for paediatric imaging due to the large and relatively fixed position of the ionisation chambers. The constant growth that occurs during childhood results in changing body proportions and no fixed AEC device could be effec- tively used for all age ranges. Care also needs to be taken as many ionisation chambers are situated behind an anti-scatter grid and, if the grid is not removed prior to exposure, this will result in an increased patient dose. The use of expo- sure charts relating radiographic technique to patient weight (or age for extrem- ity radiography) is likely to be a better option if dose reduction is to be successfully achieved. Automatic brightness control Fluoroscopy can result in large patient doses if unnecessary grids are not removed (see ‘Anti-scatter grids’ above) or the radiologist or radiographer does not correctly use or apply their knowledge of the equipment. A simple method of reducing patient dose if imaging a large area containing contrast agent (e. Summary This chapter aimed to highlight the current radiation protection legislation and suggest practical ways in which radiation protection of children can be improved within the clinical setting. It is not intended to be an exhaustive or prescriptive 28 Paediatric Radiography list of radiation protection measures but a summary of the responsibilities of the radiographer and a revision of easily implemented radiation protection strategies. National Radiation Protection Board (1994) At A Glance Series – Radiation Protection Standards. Queen Mary’s Hospital for Children, The St Helier NHS Trust, Carshalton, Surrey and The Radiological Protection Centre, St George’s Healthcare NHS Trust, London. Despite the relative frequency with which paediatric chest radiography is undertaken, it is still regarded as one of the most clinically challenging examinations to perform adequately and, as a result, many chest radiographs are of reduced image quality, in particular those 3 undertaken on children under 6 years of age. The aim of this chapter is to discuss radiographic technique appropriate to the paediatric chest examination and to consider common technical difficulties that may be encountered in clinical prac- tice. An introduction to paediatric respiratory anatomy and common pathologies has also been included to assist the radiographer in their understanding of pae- diatric respiratory disease and guide them in their choice of radiographic tech- nique and exposure factors. Structural and functional anatomy The thorax, lungs and respiratory tract At birth, the respiratory system is relatively small and under-developed with the normal full-term infant having approximately 25 million alveoli. This number increases to nearly 300 million alveoli by the age of 8 years4, but after this age the alveoli grow in size rather than number. From this information it can be deduced that a relatively minor respiratory pathology in an 8-year-old child can cause severe respiratory distress in an infant and therefore radiographers should be aware of the varied appearances and clinical presentations of common respi- ratory disorders. Growth of the respiratory system is generally faster than growth of the cervi- cal and thoracic spines and therefore anatomical landmarks used to assess an adult chest radiograph are inappropriate for the paediatric patient (e. Pelvic growth also affects the size, shape and function of the lungs and thoracic 29 30 Paediatric Radiography cavity. As the pelvis grows, the abdominal organs descend into the pelvic cavity and reduce the internal pressure the abdomen exerts on the thorax, thereby facili- tating flattening of the abdominal walls and lowering of the diaphragm. As a result, the chest shape alters from one that is essentially cylindrical, with the ribs horizontal, to one that is flattened antero-posteriorly with the anterior aspects of the ribs lower than the posterior aspects. This change in chest shape also alters the breathing action of the child from abdominal to diaphragmatic. The thymus The thymus is a lymphoid organ found in the superior aspect of the anterior mediastinum. It is prominent on the chest radiograph of an infant as a result of the thoracic cavity being relatively small; however normal variations in radiographic appearances are common (Figs 4. It grows during early childhood to reach a maximum at approximately 15 years of age after which it undergoes regression. It is intensely active during childhood, producing thymus lymphocytes which form part of the human leukocyte antigen mechanism by which the body establishes its system of immunity. The heart The heart is prominent on the chest radiograph of an infant as a result of it lying transversely and occupying approximately 40% of the thoracic cavity.

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By sitting for a period of time in a waiting area or imaging room and looking at the environment with critical eyes it may be possible for simple order eriacta 100mg online erectile dysfunction drugs generic names, cheap improvements to be identified that will provide comfort to children of all ages without causing concern to other more mature patients generic 100 mg eriacta with visa erectile dysfunction cause of divorce. It has also been important to intro- duce the concept of family centred care and emphasise the role of the family in the physical care and emotional support of a child as being of paramount impor- tance in the modern National Health Service (NHS). Department of Health (1991) Welfare of Children and Young People in Hospital. The perception of quality is subjective and dependent upon the individual needs of the patient, therefore it is essential that radiographers work together with patients towards achieving a level of appropriate care. The ethos of family centred care currently underpins and drives high-quality patient care within dedicated paediatric units (see Chapter 1) but the application of this principle within the acute setting is not without difficulties. However, it is the responsibility of every health care practi- tioner (including radiographers) to ensure that the standard of care delivered is of high quality and is appropriate to the age and level of understanding dis- played by the paediatric patient. This chapter aims to consider the legal aspects of health care, with particular regard to children’s rights and immobilisation, and will consider distraction and alternative holding techniques as a method of reducing the need for forced immobilisation of the young child and ultimately improving the quality of patient care. Children’s rights Perceptions of children’s rights are not universally consistent and it was the goal of the United Nations Convention on the Rights of the Child 1989 to clarify children’s rights. Three important articles for health care workers within this convention are identified in Box 2. Article 3: In all actions concerning children, the best interests of the child shall be a primary consideration. Article 12: Parties shall assure to the child who is capable of forming his/her own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with age and maturity of the child. Article 24: Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children. The fundamental ideology of UK government policy is that of the protectionist, assuming that children need protecting from themselves4. The result of this is a belief that children are usually incapable of exercising choice and that children’s rights should be invested in those with parental responsibility5. However, current inter- pretations of health care law do not fully support this view and recent govern- ment publications have acknowledged that patients have a right to be involved in the medical decision-making process (Kennedy Report, 2001) although it is unclear how and if this will affect the child patient. As a consequence, radiog- raphers need to be aware of, and appreciate, both the concepts of patients’ rights and children’s rights within the health care setting and their current (and future) incorporation into health care law. Health care law Under UK law, every competent adult has a right to give or to refuse consent to medical treatment and, in the absence of consent, the fact that an action was taken in the ‘best interests of the patient’ would not be a valid defence6. UK law also allows an adult to make an ‘irrational’ decision (that is one that would not accord with the decision of the vast majority of people), without this leading to the conclusion that the person lacks the capacity to make a valid choice7. The Family Law Reform Act 1969, section 8, gives 16 and 17 year-olds the right to consent to medical, dental and surgical treatment. Such consent cannot be overridden by those with parental responsibility for the child. For children under 16 years of age, no pro- vision to consent to medical treatment was given in law until 1985 when the UK law lords determined that a ‘Gillick competent’ child did have the capacity to consent to medical treatment (Gillick v. It requires an appreciation of the consequences of treatment, including side effects and anticipated consequences of a failure to 8 treat , but it does not introduce the need for moral maturity. The test for ‘under- standing’ is not whether a wise decision would be made but whether the child is capable of making a choice9. Despite the term ‘test’, there is no objective tool to measure a child’s compe- tence. In most circumstances, it is the responsibility of the health care profes- sional to make a judgement10 based upon subjective personal opinions and there lies the fundamental flaw. It has been suggested that, rather than try to prove competence, we should assume competence and attempt to disprove it11 and in 1996, Alderson and Montgomery proposed the adoption of a Children’s Code of Practice for Healthcare Right’s which assumed children of compulsory school age were competent, therefore placing responsibility on the health care profes- Consent, immobilisation and health care law 11 sional to justify ‘ignoring’ the views of the child12. The Children Act laid down that ‘children who are judged able to give consent can not be medically examined and treated without their consent’13. The implication of this was that com- petent children could refuse to be medically examined or treated. Since the introduction of the Children Act, the issue of consent by the compe- tent child has arisen on numerous occasions and with it have been considera- tions of the rights and responsibilities of the parents of a ‘Gillick competent’ child. Lord Scarman stated that ‘the parental right to determine whether or not their minor below the age of 16 will have medical treatment terminates if and when the child achieves a sufficient understanding and intelligence to fully understand what is being proposed’. Lord Donaldson challenged this interpre- tation and suggested that there was still the power for parents to approve treat- ment in the face of the child’s refusal and he asserted his view that ‘parents do not lose the power to consent when children become competent’9.

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