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Although they have the clearest view of patients and one of the most complex roles in their care, radiology nurses can seem invisible to their colleagues. Most other nurses either confuse them with radiation oncology — a different specialty and department — or have a vague image of their role that’s far from the true picture.

Radiology nurses have replaced the anesthesiologist at the head of the table for many surgical procedures that moved from the OR to the radiology suite. They intervene to prevent onslaughts of potential errors from online orders and booking, such as scheduling procedures out of sequence and performing the wrong study. Their assessments may determine if patients can tolerate a treatment or need an ordered test.

And with the proliferation of technology for diagnostic tests and new interventional procedures, they can be an invaluable resource, particularly in oncology.

“Our 15 radiology nurses see 300 inpatients and outpatients five days a week, some for tests, and others for cutting edge service modalities, but since radiology nurses and radiology are typically separate entities from nursing and other hospital departments, most don’t have a clue what we do or patients go through,” says Ann Creamer, RN, CRN, ACLS, patient care supervisor at the Moffitt Cancer Center, Tampa.

“When we sent patients back with biliary nephrostomy tubes and gastrostomy tubes, nurses didn’t know where they go, what they do, or what to tell patients to do at home. We created a pre-op and discharge brochure on trans-hepatic embolization for patients and nurses, a skeleton showing where tubes go after insertion, and an abstract. We did a traveling road show with education on every unit, grand rounds and the Oncology Nurses Society.”

Getting to Know Patients

Radiology nurses know their patients inside and out, literally and figuratively. They see tumors in situ, and see patients as often as every two days, sometimes spending uninterrupted hours together. They evaluate how the patient’s condition, comorbidities and compliance with current therapies will interact with radiology modalities, medications, and treatment protocols. And they’re usually responsible for reversing the consequences if something goes wrong.

“You establish a close relationship when patients first present, and while some want quiet during procedures, others want to be distracted by small talk, and some want to talk about their history and treatment,” says staff nurse Steve Bourassa, RN.

Many come for diagnostic radiology including X-rays, barium studies, angiography, ultrasound, MRI, CT, and PET scans.

Others come for special procedures that use radiology as a guide to freeze, burn, slice, sample, pierce, and bypass tissues and tumors. Those interventions include ablation by cryofrequency (with nitrogen) and radiofrequency (by laser); biopsies; lumbar punctures; insertion of stents, shunts, tubes, and catheters; and injection of soft spheres and coils into blood vessels and organs to obstruct circulation.

Blood vessels may be blocked to decrease treatment risk and post-op complications, or to kill cancer cells outright. “We can take down the blood flow to the organ before surgery so there’s less bleeding. But even if we kill it, a surgeon will still have to go in to remove the tumor or organ,” says Creamer. “Nothing we do in radiology is a cure, but we can take care of some things.”

Among other research projects, Moffitt is one of a handful of hospitals studying the effectiveness of Melphalon chemotherapy as a perfusion, rather than peripherally, to reduce metastatic melanoma. During the six-hour procedure, venous and arterial lines are inserted, the drug is infused into the liver, then removed through a bypass system that filters and replaces blood.

“Two nurses participate to take chemotherapy precautions, calculate doses, load the drug delivery system, and coordinate procedures. We’re also monitoring urinary output and continuous labs” to evaluate kidney and liver function, says radiology staff nurse Diana Gaurkee, RN. “We’re hoping it will reduce liver metastases, and if approved, could be used for other liver cancers.”

Palliation and Sedation

Anesthesiologists are on call, but in most cases, radiology nurses medicate, sedate, and monitor patients undergoing procedures that can be painful, unpleasant, and terrifying.

Most radiology patients must be awake, and many must be alert so they can swallow, hold their breath, or shift position when told.

Anxious, angry, or claustrophobic patients may be unable or unwilling to comply. Strong emotions alter breathing, circulation, muscles, and the endocrine system, which can impact procedures and results.

“If a patient is uncomfortable, it affects the doctor, even if they’re holding still,” says Gaurkee. “With interventional procedures, blood pressure could rise too high to remove a catheter, and you could have a horrible bleed.”

Cancer makes it even harder to relax in radiology. “Each person’s pain and level of coping is unique, but our rule is wherever they are, we’ll do whatever it takes to help them get through procedures,” says Creamer.

That includes physical measures, such as a light massage and warm blanket; the psychological support of conversation and a warm hug; and expertise calibrating medications.

Depending on the procedure and personality, patients may need topical anesthetics, anti-anxiety agents, analgesics, sedatives, or a combination (usually Versed and fentanyl) that results in conscious sedation. “You don’t want to give too much or too little, and can’t make quick judgments,” says Gaurkee.

Patients may experience allergic reactions to contrast media, bleeds, cardiovascular crises, diabetic reactions, or suddenly slide into deeper sedation, losing their ability to breathe unaided. Most units are in isolated areas, with a single radiologist or technologist, far from code teams and other staff. The nurse on each case is self-reliant, and prepared to handle allergic reactions, bleeds, and life-threatening events, including full codes, using advanced cardiac life support, medications, and equipment on hand.

There’s another reason for their vigilance: The drugs wear off quickly. Nurses scrutinize vital signs, body language, and facial expressions. “You can’t always rely on monitors,” says Bourassa. “Effective nurse-patient communication is the best indicator for use of drugs.”

Patients may be the best judge of their pain level, but they aren’t always forthcoming, or fair to themselves.

“One man who insisted he wasn’t in pain finally said he was at eight, but that was good because he’s usually 10 on a one-to-10 scale,” says Gaurkee. “Patients may be in significant pain much of the time. We differentiate if it’s from cancer or a bad back, arthritis, or something unrelated, then use medications to reduce the overall pain level, including pre-existing pain from other causes. Pain meds aren’t selective, so they often feel better post-procedure.”

If patients are living with high levels of pain, radiology nurses discuss the drugs and doses they take, and how to control it. They explain why patients shouldn’t under-medicate, and may inform primary providers if patients deny their degree of pain or need an alternative.

Wendy Bonifazi, RN, CLS, APR, is a senior staff writer for Nursing Spectrum.

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