Test 1 Flashcards
Continuous improvement of healthcare services through the systematic eveluation of processes
Quality improvement (QI)
A set of philosophies, methods, and tools for continuously quality improvement factors (ex: Lean and Six Sigma programs)
Continuous quality improvement (CQI)
Professional performance standards that define activities in the areas of education, interpersonal relationships, personal, and professional self-assessment, and ethical behavior
Total quality management (TQM)
3 things quality improvement (QI) does
Decrease costs, increase efficiency
Increase customer satisfaction
Ensure quality throughout the healthcare organization
4 problems quality improvement (QI) responds to
Increased competition
Escalating costs
Quality concerns
Demands for increased accountability = know who’s responsible (ex: computer logins)
W.E. Deming’s 14 points of management
Create constancy of purpose for improving products and services
Adopt the new philosophy
Cease dependence on inspection to achieve quality
End the practice of awarding business on price alone; instead, minimize total cost by working with a single supplier
Improve constantly and forever every process for planning, production and service
Institute training on the job
Adopt and institute leadership
Drive out fear
Break down barriers between staff areas
Eliminate slogans, exhortations and targets for the workforce
Eliminate numerical quotas for the workforce and numerical goals for management
Remove barriers that rob people of pride of workmanship, and eliminate the annual rating or merit system
Institute a vigorous program of education and self-improvement for everyone
Put everybody in the company to work accomplishing the transformation
An independent, not-for-profit organization dedicated to improving the quality of healthcare settings
This accreditation is not required, but is desired by most healthcare organizations
Hospital may not receive reimbursement without accreditation (medicare)
The Joint Commission (TJC)
The totality of features and characteristics of a radiation therapy process that bear on its ability to satisfy stated or implied needs of patients
Quality
All those planned of systematic actions necessary to provide adequate confidence that a product or service will satisfy given requirements for quality
Important in therapy because you need to hit the right spot (lasers lined up) with right dose
Quality assurance (QA)
Operational techniques and activities used to fulfill those requirements for quality (tests, procedures, etc.)
Ex: 9 penny test for congruence
Quality control (QC)
Type of radiation therapy in which a very few high doses of radiation are delivered to small, well-defined tumors
Stereotactic body radiation therapy (SBRT)
Measurable dimensions of quality that defines what is to be monitored; get from QA
Measurement tool used to evaluate an organization’s performance
Quality indicators (QI)
Systematic collection of data and QI encompasses the activities directed to improve the quality of a system by reducing the error or variation of that system (same as quality assurance)
Quality assessment (QA)
3 other names for quality improvement (QI)
Continuous quality improvement (CQI)
Continual improvement (CI)
Total quality management (TQM)
What is the daily quality indicators (QI) output?
3%
5 members of the quality improvement (QI) team (all personnel who interact with patients and families)
Staff physicians Physics (physicists, engineers, dosimetrists) Radiation therapists Oncology nursing Support staff
What is the responsibility of the staff physicians on the quality improvement (QI) team?
Do weekly chart rounds with dosimetrists, therapists, etc. to see if treatment plan has changed (boost) and needs re-simmed
Initial or images taken through treatment to make sure the right place is still being treated
Port film/portal image
What are the responsibilities of the physics team on the quality improvement (QI) team?
Equipment, weekly chart check
What are the responsibilities of the radiation therapists on the quality improvement (QI) team?
“Gatekeepers”; morning warmups, sim QA, verifying prescriptions
What are the responsibilities of the oncology nurses on the quality improvement (QI) team?
Evaluate physical and psychology of patients; education of patients (skin care, diet, etc.)
2 things TJC requires the medical directors to do
Make sure staff is qualified (trained, credentials)
Establishment and continuation of quality improvement (QI) plan
5 QA activities that are the responsibilities of members of the QA committee
Develop and monitor a QA program Collect and evaluate data Determine areas for improvement Implement change as necessary Evaluate results of actions taken
What is the goal, frequency, and reporting mechanism of developing and monitoring a QA program
Goal: oversee departmental peer-review activities
Frequency: ongoing
Reporting mechanism: QA committee meeting minutes
What is the goal, frequency, and reporting mechanism of collecting and evaluating data for QA?
Goal: develop and implement new policies and procedures as needed
Frequency: monthly meetings
Reporting mechanism: chart rounds reports
What is the goal, frequency, and reporting mechanism of determining areas for improvement for QA?
Goal: oversee implementation of and adherence to departmental policies and procedures
Frequency: monthly meetings
Reporting mechanism: policies and procedures
What is the goal, frequency, and reporting mechanism of implementing chance as necessary and evaluating results of actions taken for QA?
Goal: oversee implementation of and adherence to departmental policies and procedures
Frequency: monthly meetings
Reporting mechanism: incident reports
8 components of a continuous quality improvement (CQI) plan
Evaluation of both quality and appropriateness of care (peer review)
Evaluation of patterns or trends
Assessment of individual clinical events
Action to be taken to resolve identified problems
Identification of important aspects of care for assessment
Identification of indicators to monitor and of acceptable thresholds
Methods of data collection
Annual review of quality improvement plan for effectiveness
What is the frequency, tolerance and who is responsible for the quality checks of the collision/door interlocks and warning lights and sounds for kilovolt and megavolt in-room CT imagers?
Frequency: daily
Tolerance: functional
Person responsible: therapist
What is the frequency, tolerance and who is responsible for the quality checks of the laser/image/treatment isocenter coincidence and phantom localization and couch shift for kilovolt and megavolt in-room CT imagers?
Frequency: daily
Tolerance: +/-2 mm
Person responsible: therapist
What is the frequency, tolerance and who is responsible for the quality checks of the kV/MV/laser alignments and accuracy of couch shift motion for kilovolt and megavolt in-room CT imagers?
Frequency: monthly
Tolerance: +/-1 mm
Person responsible: therapist or physicist
What is the frequency, tolerance and who is responsible for the quality check of the high-contrast spatial resolution of kilovolt and megavolt in-room CT imagers?
Frequency: monthly
Tolerance: ≤2 mm
Person responsible: physicist
What is the frequency, tolerance and who is responsible for the quality checks of the CT number accuracy and noise and uniformity of kilovolt and megavolt in-room CT imagers?
Frequency: monthly
Tolerance: baseline
Person responsible: physicist
What is the frequency, tolerance and who is responsible for the quality checks of the imaging dose and x-ray generator performance (kV only) of kilovolt and megavolt in-room CT imagers?
Frequency: annually
Tolerance: baseline
Person responsible: physicist
What is the frequency and tolerance of the QA procedure for the localizing lights of fluoroscopy-based simulators?
Frequency: daily
Tolerance: 2mm
What is the frequency and tolerance of the QA procedure for the field size indicator of fluoroscopy-based simulators?
Frequency: monthly
Tolerance: 2mm
What is the frequency and tolerance of the QA mechanical checks of the collimator, gantry, and couch rotation isocenter of fluoroscopy-based simulators?
Frequency: annually
Tolerance: 2-mm diameter
What must the homogeneity results be for CT scanners as recommended by the American Association of Physicists in Medicine (AAPM)?
Must be within 5 Hounsfield units (HU)
Daily tolerance of the alignment of gantry lasers with the center of the imaging plane for QA procedures of CT simulators
+/-2 mm
Monthly and after laser adjustments tolerance of the orientation of gantry lasers with respect to the imaging plane for QA procedures of CT simulators
+/-2 mm over the length of laser projection
Monthly and after laser adjustments tolerance of the spacing of lateral wall lasers with respect to lateral gantry lasers for QA procedures of CT simulators
+/-2 mm and scan plane
Monthly and after laser adjustments tolerance of the orientation of wall and ceiling lasers with respect to the imaging plane for QA procedures of CT simulators
+/-2 mm over the length of laser projection
Monthly or when daily laser QA tests reveal rotational problems tolerance of the orientation of the CT scanner tabletop with respect to the imaging plane of CT simulators
+/-2 mm over the length and width of the table top
Monthly tolerance of the table vertical and longitudinal motion for QA procedures of CT simulators
+/-1 mm over the range of table motion
Semiannual tolerance of the sensitivity profile width of QA procedures of CT simulators
+/-1 mm of nominal value
Annual tolerance of table indexing and position of QA procedures of CT simulators
+/-1 mm over the scan range
Annual tolerance of gantry tilt accuracy of QA procedures of CT simulators
+/-1 degree over the gantry tilt range
Annual tolerance of gantry tilt position accuracy of QA procedures of CT simulators
+/-1 degree or +/-1 mm from nominal position
Annual tolerance of scan localization of QA procedures of CT simulators
+/-1 mm over the scan range
Annual tolerance of radiation profile width of QA procedures of CT simulators
Manufacturer specification
Tolerance after replacement of major generator components of QA procedures of CT simulators
Manufacturer specification or AAPM report 39 recommendations
Daily dosimetry tolerance for non-IMRT, IMRT, and SRS/SBRT machines of x-ray output constancy (all energies) and electron output constancy (if not equipped, then weekly) for QA procedures of medical accelerators
3%
Daily mechanical tolerance for non-IMRT machines of laser localization, distance indicator (ODI) at isocenter, and collimator size indicator for QA procedures of medical accelerators
2 mm
Daily mechanical tolerance for IMRT machines of the distance indicator (ODI) at isocenter and collimator size indicator for QA procedures of medical accelerators
2 mm
Daily mechanical tolerance for IMRT machines of laser localization for QA procedures of medical accelerators
1.5 mm
Daily mechanical tolerance for SRS/SBRT machines of laser localization and collimator size indicator for QA procedures of medical accelerators
1 mm
Daily mechanical tolerance for SRS/SBRT machines of the distance indicator (ODI) at isocenter for QA procedures of medical accelerators
2 mm
Grainy appearance of an image
Image noise
Clarity of an image; relationship between the number of pixels or voxels
Resolution
Pixels of gray on image; represent various tissue densities and linear attenuation coefficients
Range from +1000 to -1000
Air = -1000, water = 0, bone = about 650-1000
Hounsfield Units (HU)
Projects a scale onto the patient’s skin that corresponds to the SSD used during the simulation or treatment process; tells us how deep we’re going
Optical distance indicator (ODI)
Process for continuously monitoring the movement of tumors during the patient’s breathing
Respiratory gating
The software and hardware requirements of a linac which provides the user daily image verification capabilities
On-board imaging (OBI)
First step in treatment planning that localizes a target volume and helps physician’s and staff come up with treatment planning
Simulator
About what percent of cancer patients will be treated with radiation at some point?
50-60%
Conventional = mechanical C-shaped device that supports the x-ray tube and collimator device at one end
CT = circular ring housing the x-ray tube and solid state detectors
Rotates 360°
Rotates around a fixed point in space known as the isocenter (100 cm)
Gantry
6 basic elements of a simulator
Gantry Patient support assembly (PSA) X-ray tube Collimator device Imaging system of fluoroscopy unit Optical devices
Allows the tabletop its mobility, permitting the precise and exact positioning of the isocenter during simulation or treatment
Couch/table
Where patient is positioned
Don’t want it to attenuate beam
Conventional CT table is curved so you have to place a hard, flat insert if you’re using it for simulation
Patient support assembly (PSA)
Arrangement of shielding material used to define the “x” and “y” dimensions of the beam of radiation
Attached to gantry and rotates 360°
Collimator device
Field defining lights/lasers
Optical devices
3 steps of treatment planning
Tumor localization
Computation of dose distributions (isodoses to tumor and critical structures)
Fabrication of treatment aids (ex: bolus)
Determine the extent of the tumor and location of critical structures
Tumor localization
Tells distance from source to depth of isocenter
Source skin distance (SSD)
Image from CT simulator
Digitally reconstructed radiograph (DRR)
Designed to simulate the mechanical, geometrical, and optical conditions of various treatment units
Conventional simulator
3 mechanical components of the gantry of a conventional simulator
Gantry arm
Gantry head
Image intensifying/film holder screen
C-shaped structure of the gantry of a conventional simulator
Gantry arm
2 edges of the beam
Divergent edges
Nondivergent = central axis
2 scales
IEC
Varian
Does the SSD or SAD method of treatment take longer?
SSD takes longer because the tumor is still in the patient and distance is further than SAD
6 gantry head components
Collimator assembly ODI Field defining wires Beam restricting diaphragms Fudicial plate Accessory holder
6 steps of patient’s process through the oncology department
Diagnosis Consultation Simulation Treatment planning (dosimetrist) Treatment Follow-up
Daily QA safety tolerance for NON-IMRT,IMRT, and SRS/SBRT machine of the door interlock (beam-off), door closing safety, and audio/visual monitors?
Functional
Compromises the gantry head and rotates around the isocenter
Collimator assembly
Not on treatment machine, represent diaphragms
If blocks were used on conventional simulation, you couldn’t see as much anatomy on the x-ray film
Field defining wires
Defines size and axis of the x-ray beam
Beam restricting diaphragms
Collimators
Shutters
Blades
Plate with hash marks that is used to measure on port films
Allows us to make shifts (point of measurement) and helps measure magnification
Made of plexiglass or plastic and is removeable (if it is left in the treatment field, it will absorb some of the radiation and the patient won’t receive the right dose)
Fiducial plate/reticule
Holds blocks, cones, etc. for treatment; have to keep distance the same
Accessory holder
OFD
Object-film distance (larger = more magnification)
SFD/TFD
Source/target-film distance
Distance from the radiation source to the patient’s skin
Source-skin distance (SSD)
DIstance from the source of radiation to the patient’s skin
Source-axis distance
FAD
Focal spot-axis distance
Line perpendicular to the cross-section of the simulation or treatment field; not divergent
Central axis (CA)
Patient thickness; measurement used for treatment planning purporses to determine the thickness of a body part from entrance to exit point, often measured along the CA
Intrafield distance/separation
Tabletop to isocenter
TT
Lasers that project a small red or green beam of light toward the patient during the simulation process; provide the therapist several external reference points in relationship to the position of the isocenter
Positioning laser
The procedure room must be a minimum what square feet?
400 ft^2
4 room shielding materials
Lead
Concrete
Borated polyethylene
Aqueous materials (for neutrons)
How much the primary beam is pointed toward an area in the room (wall, floor, etc.)
Use factor (U)
Fraction of time an area is occupied by people; full = shielding increase
Occupancy factor (T)
How often treatment machine is running
Time integral of the absorbed dose rate (cGy per minute or rad/min) determined at the depth of maximum absorbed dose, 1 m from the “source”
Workload (W)
Limited access area in which the occupational exposure of personnel to radiation producing equipment or radioactive materials is supervised by an individual in charge of radiation protection (ex: treatment room, control console); allows more dose
Controlled area
2 factors of permissible dose (P)
Controlled area
Uncontrolled area
Limit for controlled area
0.1 rad/wk
Any area in the environment (ex: lobbies, offices, waiting rooms, etc.); limits dose
Uncontrolled area
Limit for uncontrolled area
0.01 rad/wk
Distance from radiation source
Distance (d)
What’s being allowed to transmit; transmission determines barrier thickness/shielding (radiation)
Barrier transmission (B)
Shielding has to be how high?
Up to 7 ft
Barriers/walls that intercept the primary beam
Portions of the floor, ceiling, and walls that receive the primary barrier
Primary barrier/wall
Barriers/walls that receive only leakage and/or scatter radiation
Secondary barrier/wall
Beam emitted directly from the accelerator that is “aimed” at the patient (i.e. the treatment field)
Primary beam
“Useful beam”
Radiation that arises from radiation interactions in the treatment head
Leakage radiation
Operates with treatment planning computer; make marks and set up treatment field
Creates DRR; physician can define target volume in 3D
Virtual simulation (current method)
Barrier transmission (B) formula
B=Pd^2/WUT
P = permissible dose d= distance W = workload U = use factor T = occupancy factor
How big is the bore in CT simulation and why?
80-90 cm to fit treatment devices and different patient positions
The delivery of interventions aimed at relieving symptoms and side effects of the disease and treatment and improving quality of life for the patient
Palliative
Average slice thickness for CT simulation
3x3
Slice thickness of areas of non-interest for CT simulation
5x5 (less information, have to interpolate)
Estimate values between two measured values
Interpolate
Slice thickness of head and neck for CT simulation
1x1 (more anatomy but more data to store)
How fast patient is translating through the table
Pitch
Moving through the CT machine
Translating
Pitch formula
Couch movement in longitudinal direction per 360° rotation of the tube/ beam width or slice thickness
What dose an increase in pitch do?
Less time but lose information/more interpolation
What gives us image by converting radiation to light
Detector
___-___ generations of CT machines based on the number of detectors; ___-___ detectors per cm or ___-___ per degree
4-5 generations of CT machines based on the number of detectors; 1-8 detectors per cm or 1-5 per degree
Solid-state = ____% efficient
90%
Patient is positioned at a fixed point and while the x-ray tube is rotating, the patient moves into the aperture to create a scan patterns that resembles a coiled spring
Helical/spiral CT
3 disadvantages of helical/spiral CT
Increased processing time
Increased noise/artifacts
Lower axis resolution along Z-axis (restrictions)
Any systematic discrepancy between the CT numbers in the reconstructed image, undesired
Artifacts
2 main functions of CT simulation
Target localization and critical structures (make marks on patient’s skin and use BB’s to see on CT)
DRR’s printed out
Use multiple imaging sources to get anatomical information for patient (PET scan over CT)
CT defines edge of structures more clearly than MRI but MRI shows soft tissue better
Fusion
Fuse a scan with patient in one position (ex: diagnostic position) with a scan in a different position (ex: treatment)
Deformable fusion
Attenuation rates or tissue density differences displayed as pixels of different shades of gray
Range from +1000 to -1000
Hounsfield units (HU) CT numbers
HU of air, water, cerebrospinal fluid (CSF), blood, graymatter, muscle, bone, and dense bone (ex: enamel)
Air = -1000 Water = 0 CSF = 15 Blood = 20 Graymatter = 40 Muscle = 50 Bone = 650 Dense bone = up to +1000
Missing the tumor __-__ times or ___% of the dose can result in treatment failure or recurrence of the disease
1-2 times
10%
___% of patients treated had errors (pelvis, abdomen, chest more common areas because they’re bigger)
15%
Aid in setup (hold patient still and maintain position)
Allow patient positioning
Make treatment more accurate
Durable (last whole treatment)
Immobilization devices
2 reasons immobilization devices are used
Reproducibility
Accuracy
What is the most advantageous thing to do with the patient is on the table in the right position in simulation?
Make sure they are comfortable (communication and consent are also important)
3 categories of immobilization devices
Patient positioning aids
Simple immobilization devices
Complex immobilization devices
Devices that place the patient in a particular position for treatment but don’t ensure that patient doesn’t move; general/not customized, used for all patients
Patient positioning aids
Devices that restrict movement but require a patient’s voluntary cooperation; customized and restrict patient movement
Commonly used in addition to positioning aids
Simple immobilization devices
Individualized devices that restrict patient movement and ensure reproducibility
Complex immobilization devices
Supports chest and holds head; need to put arms in same place every time
Prone pillow
Abducts affected arm and shoulder from chest wall
Breast board
Abducts both arms from chest wall (CT simulation)
Wingboard
Commonly used to treat pelvic malignancies with patient in prone position; has adjustable inserts to accommodate a variety of patients and provides a means of reducing the amount of small bowel in the treatment field
Belly board
Move and position tongue
Bite block
5 patient positioning aids
Head holder TX sponges for head and neck support (C-sponge opens lymph nodes, F-sponge is more comfortable and less flat) Prone pillow Arm board Rubber rings/bands
2 simple immobilization devices
Bite block
Arm stretcher
Can be used to pull arms/shoulders out of head/neck field
Arm stretcher
4 complex immobilization devices
Alpha cradle
Vac bag
Aquaplast mask
Aquaplast breast
Complex immobilization device created from styrofoam shell and foaming agents
Alpha cradle
Complex immobilization device that consists of a cushion and has vacuum compression pumps
Vac bag
Complex immobilization device; thermoplastic that becomes pliable in a hot water bath
Patient markings can be made directly on it
Nose point and zygomatic arches important
Attenuates some of beam (minimal)
Casts may be cut further to increase patient comfort but this reduces the integrity of this immobilizer
Aquaplast mask
Complex immobilization device that keeps large breasts from falling
Cups disadvantage: can get sticky/hot and make it harder to maneuver breast
Aquaplast breast
2 imaging modalities used in simulation and tumor localization; both needed to visualize all structures
Ionizing
Non-ionizing
Use ionizing radiation to produce images that primarily show anatomy
X-ray, CT, nuclear medicine, PET, PET/CT
Ionizing imaging modality
Use alternative means of imaging the body such as magnetic fields (MRI) and echoed sound waves (US)
Non-ionizing imaging modality
Ionizing bipedal (contrast administered in feet) angiogram good for visualizing Hodgkins
Lymphangiogram
Uses radioisotopes and ionizing radiation to provide information about physiology (function) and anatomic structures
Nuclear medicine bone scan
Uses short-lived radioisotopes (carbon-11, nitrogen-13, oxygen-15) which circulate through the body and emits positrons (positively charged electrons) which collide whatever in body tissues and cause the release of gamma rays that are detected and recorded by a gamma camera
PET
Towards the abdomen, anterior
Ventral
Towards the back, posterior
Dorsal
Divides body vertically into right or left sides
Sagittal plane
Divides body into two symmetric right and left sides
Median/midsagittal plane
Vertical plane that is parallel to the median sagittal and divides into right and left unequal components
Parasagittal plane
Vertical plane that divides the body into anterior (front) and posterior (back) sections; perpendicular (at right angle) to the sagittal plane
Coronal/frontal plane
Divides the body into superior and inferior parts; perpendicular to midsagittal, parasagittal, and coronal planes
Transverse/horizontal plane
Physique varies internal anatomy
Body habitus
Short wide trunk, great body weight and heavy skeleton
Long abdomen with great capacity, high alimentary tract, and almost thoracic stomach
Small pelvic cavity
5% of the population
Hypersthenic
Well-built; slightly lower stomach
Highest occurance at 50%
Sthenic
Average physique
35% of the population
Abdominal cavity falls between sthenic and asthenic
Hyposthenic
Slender physique, light weight, and light skeleton
10% of the population
Thorax has long, narrow lung fields with its widest portion in upper zones
Heart seems to “hang” almost like a pendant in the thoracic cavity
Longer abdomen and pelvis with great capacity
Lowest alimentary tract
Asthenic
Spaces within the body that contain internal organs
Body cavities
2 main body cavities
Posterior/dorsal
Anterior/ventral
2 cavities the posterior/dorsal cavities divides into
Spinal/vertebral
Cranial (brain)
Cavity protected by the vertebrae and contains the spinal cord
Spinal/vertebral
2 cavities the anterior/ventral cavity is divided into by the diaphragm
Thoracic
Abdominopelvic
2 cavities of the thoracic cavity
Pericardial (heart) 2 pleurals (right and left lungs)
2 sections of the abdominopelvic cavity
Upper abdomen
Lower pelvic
Houses the peritoneum, liver, gallbladder, pancreas, spleen, stomach, and most of the large and small intestines
Upper abdominal cavity
Houses the rest of the large intestine and the rectum, bladder, and internal reproductive system
Lower pelvic cavity
4 abdominal quadruants
Right upper quadrant (RUQ)
Left upper quadrant (LUQ)
Right lower quadrant (RLQ)
Left lower quadrant (LLQ)
Hypo-
Under/belo
-chondriac
Ribs
9 regions of the abdomen
Right hypochondriac Epigastric Left hypochondriac Right lumbar Umbilical Left lumbar Right iliac Hypogastric Left iliac
Region of abdomen centrally located around the naval
Umbilical
Regions of abdomen to the right and left of the naval; lower back
Lumbar
Central region of abdomen superior to the umbilical region
Epigastric
Regions of the abdomen to the right and left of the epigastric region and inferior to the cartilage of the ribcage
Hypocondriac
Central region of the abdomen inferior the the umbilical region
Hypogastric
Regions of the abdomen to the right and left of the hypogastric region; hip bones
Iliac
3 main functions of the lymphatic system
Drains tissue spaces of interstitial fluid that escapes from the blood capillaries and loose connective tissue, filters it, and returns it to the bloodstream
Absorbs fat and transports them back to bloodstream
Plays major role in body’s defense and immunity
Excessive tissue fluid that consists mostly of water and plasma
Lymph
____ of body’s lymph nodes in neck
1/3
Bring in/to
Afferent
Bring lymph into lymphatic vessel, many points of entry
Afferent vessels
Carry lymph away; larger but fewer to slow the flow through the nodes, permitting the node to effectively filter the lymph
Efferent vessels
Excessive accumulation of fluid in a tissue that produces swelling
Can occur when excessive foreign bodies, lymph, and debris are engulfed in the node or when altered lymphatic pathways cause greater than normal amounts of lymph filtration
Ex: swelling after mastectomy of arm on affected side
Edema
__________ leaves the cellular interstitial spaces and becomes ________; as it enters a ___________ it merges with other capillaries to form an _________ which enters a __________ where lymph is filtered. It then leaves the node via an __________, which travels to other nodes, then merges with other vessels to form a ___________ which merges with other trunks and joins a _______________, either to the right lymphatic or the thoracic, which empties into a _________ where lymph is returned to the bloodstream
Tissue fluid leaves the cellular interstitial spaces and becomes lymph; as it enters a lymphatic capillary it merges with other capillaries to form an afferent lymphatic vessel which enters a lymph node where lymph is filtered. It then leaves the node via an efferent lymphatic vessel, which travels to other nodes, then merges with other vessels to form a lymphatic trunk which merges with other trunks and joins a collecting duct, either to the right lymphatic or the thoracic, which empties into a subclavian vein where lymph is returned to the bloodstream
3 lymphatic organs
Spleen
Thymus
Tonsils
Largest lymph node in the body, about 12 cm in length
Located posterior to and to the left of the stomach in the abdominal cavity, between the stomach’s fundus and diaphragm
Actively filters blood, removes old red blood cells (RBCs), manufactures lymphocytes (particularly B cells which develop into antibody-producing plasma cells) for immunity surveillance, stores blood; doesn’t filter lymph
Spleen
Located along trachea superior to heart and posterior to sternum in the upper thorax
Larger in kids than adults (goes from size of orange to pea) and is more active in kids because their immune system is developing
Where T lymphocytes can mature
Thymus
Series of lymphatic nodules embedded by a mucous membrane located at the junction of the oral cavity and pharynx; protect against foreign body infiltration by producing lymphocytes
Tonsils
2 lymphatic ducts
Thoracic duct
Right lymphatic duct
Lymphatic duct on the left side of the body, usually larger
About 35-45 cm long; starts at from and L2 at cisterna chyli
Serves the lower extremities, abdomen, left arm, and left side of head and neck into the left subclavian vein
Thoracic duct
1-2 cm long lymphatic duct; drains right arm and right side of head and neck into right subclavian vein
Right lymphatic duct
____ bones in the body; _____ in infant
206; 350
3 parts of the axial skeleton
Skull (29 = cranial, facial, and ossicles [ear]) Vertebral column (33 = C7, T12, L5, S5, and Co4) Thorax (sternum, ribs, T-spine)
Spinal cord ends at _______ and cauda equina begins
L1-L2
Excessive curvature of the vertebral column that’s convex posteriorly
Kyphosis
Cervical vertebrae that holds the skull
Atlas/C1
Cervical vertebrae that head pivots on
Axis/C2
Junction of manubrium and sternal body at T4
Sternal angle/angle of Louis
Cartilage that connects the sternum to the ribs
Costal cartilage
______ of ribs connects to vertebrae
Head
Manubrium articulates with ribs _____
1 & 2
Sternal body articulates with ribs _______
2-10
Ribs 1-7 articulate posteriorly with vertebrae and anteriorly with sternum directly through costal cartilage
True/vertebrosternal ribs
False ribs
8-12
Ribs that join with vertebrae posteriorly and anteriorly with the cartilage of the immediately anterior rib; share common cartilaginous connection to sternum
8-10
Ribs 11 & 12 attach to the vertebrae only
Floating/vertebral ribs
Extends from the base of the skull to the esophagus
Pharynx (throat)
The lowest point of the pharynx to trachea
Larynx (voice-box)
8 bony landmarks of the skull
Glabella Nasion Superciliary arches Superior orbital margin Maxilla Mastoid process External occipital protuberance Angle of the mandible
Secretes the aqueous layer of the tear film
Lacrimal gland
Drains conjunctiva to the nose; tears drained through this duct into the lacrimal duct
Punctum lacrima
Expanded outer wall of cartilage on each side of the nose
Ali nasi (lateral and inferior)
Where vermillion border connects to the mucous membrane of the mouth; located at the junction of the vermillion border of the lip with the skin of the face
Mucocutaneous junction (MCJ)
Lips; exposed pink or reddish margin of a lip
Vermillion border/surface
Vertical groove between the base of the nose and the border of the upper lip
Philtrum
Lower portion of nose connected to mouth; located at the junction of the skin of the nose with the skin of the face at the superior end of the philtrum
Columella
External/visible part of ear
Auricle/pinna
Rounded portion of ear
Helix
Bony anterior 2/3 of the mouth
Hard palate
Fleshy, upper posterior portion of oral cavity/mouth
Soft palate
Bone that aids in the movement of the tongue
Hyoid
Blocks nasal cavity and assists with speech
Uvula
Muscle attached to the mastoid and occipital bones superiorly and sternal and clavicular heads inferiorly; lateral movement of neck
Sternocleidomastoid muscle
SSN is at the level of
T2
Sternal angle is at the level of
T4
Xiphoid is at the level of
T9-10
Outer portion of breast that extends into the axilla (muscle)
Tail of Spence
Inferior point of breast attachment; where fold is, helps set treatment borders and skin breakdown is commonly seen here
Inframammary sulcus
4 quadrants of the breast
Upper outer
Upper inner
Lower outer
Lower inner
Most common breast quadrant for disease
Upper outer
If breast tumor is located in an inner quadrant, what nodes are usually involved?
Medially located nodes (ex: inframammary)
If breast tumor is located in an outer quadrant, what nodes are usually involved?
Axillary nodes (principal pathway)
Breast lymph nodes at 2nd-3rd intercostal space
Axillary/principal pathway
Breast lymph nodes that go through pectoralis major and drains supra- and infraclavicular fossa nodes
Transpectoral
An intermediate breast lymph node in the infraclavicular fossa
Rotter’s node
Breast lymph nodes that run toward the midline and passes through the pectoralis major and intercostal muscles close to the body of the sternum (T4-9); about 2.5 cm from midline and 2.5 cm deep
Internal mammary nodes
Supraclavicular breast lymph node often biopsied on ipsilateral side of disease
Scalene
On same side
Ipsilateral
With radical breast surgery, lymph flow is often compromised; this slowed drainage causes edema that’s sometimes seen in the arms
Exercise, elevation, and compression sleeves help drain stagnant lymph
Lymphedema
Part of the airway that begins at the inferior cricoid cartilage at C6
About 10 cm long and extends to carina at T4-5 and corresponds to the angle of Louis
Trachea
Lower border of larynx and is only complete ring of cartilage in the respiratory passage
Cricoid cartilage
Point of bifurcation of the trachea that forms beginning of the right and left main bronchi
Carina
Dome-shaped muscle that separates the thorax and abdomen at T10-T11
Diaphragm
Prevents lungs from overinflating into throax
Pleural cavity
Right has 3 lobes and left has 2 because of the heart
Lungs
Level of base of the heart
T4
Ascending aorta runs from aortic orifice at the medial end of the third left intercostal space up to the second right costochondral joint and continues above the right side of the sternal angle and then turns down behind the second left costal cartilage
Aortic arch
5 structures the superior mediastinal/tracheal/superior tracheobronchial lymph nodes of the thorax drain
Thymus Heart Pericardium Mediastinal pleura Anterior hilum (wedge-shaped area)
Lymphatics of the thorax that drain lungs: right into right lymphatic duct and left into thoracic duct
Inferior mediastinal nodes
3 inferior mediastinal nodes
Inferior tracheobronchial/carinal
Bronchopulmonary/hilar (commonly involved in lung cancer)
Pulmonary/intrapulmonary
Para-
Around/near
Cuts through the pylorus of the stomach, the tips of the ninth costal cartilagesm and the lower body of L1
Transpyloric plane
BIT
Bottom of ischial tuberosity
BOF
Bottom of obturator foramen
Muscle that attaches to the scapula and humerus
Teres major muscle
Largest muscle in the back
Latissimus dorsi
Why is the right kidney lower than the left kidney?
Due to the large size of the liver on the right side
Kidneys can move as much as _____ during respiration
2cm
Digestive organs
Alimentary organs
Level of pancreas
L1
Lymphatics of the abdomen and pelvis that drain the stomach, greater omentum, liver, gallbladder, spleen, pancreas, and duodenum
Celiac
Lymphatics of the abdomen and pelvis that drain the head of the pancreas, portion of the duodenum, jejunum, ileum, appendix, cecum, ascending colon, and most of the transverse colon
Superior mesenteric
Lymphatics of the abdomen and pelvis that drain the descending colon, left side of the mesentary, sigmoid colon, and rectum
Inferior mesenteric
Lymphatics of the abdomen and pelvis that drain the bladder, prostate, cervix, and vagina
Common iliac
Lymphatics of the abdomen and pelvis that drain the bladder, prostate, cervix, vagina, testes, and ovaries
External iliac
Lymphatics of the abdomen and pelvis that drain the vagina, cervix, prostate, and bladder
Internal iliac/hypogastric nodes
Lymphatics of the abdomen and pelvis that drain the vulva, uterus, ovaries,vagina, scrotum, and penis
Inguinal/superficial
Use factor (U) for 0 degree (down) [IEC]
31%
Use factor (U) for 90 and 270 degree (IEC)
21.3%
Use factor (U) for 180 degree (IEC)
26.3%
Occupancy factor (T) for full occupancy areas
1
Areas occupied by full-time individual; ex: work offices, treatment planning areas, nurses stations, attended waiting areas, occupied space in nearby building (same people in there everyday)
Full occupancy areas
Occupancy factor (T) for adjacent treatment room, patient examination room adjacent to shielded vault
1/2
Occupancy factor (T) for corridors, employee lounges, staff rest rooms
1/5
Occupancy factor (T) for treatment vault doors
1/8
Occupancy factor (T) for public toilets, unattended vending rooms, storage areas, outdoor waiting areas with seating, unattended waiting rooms, patient holding areas, attics, janitors’ closets
1/20
Occupancy factor (T) for outdoor areas with only transient pedestrian or vehicular traffic, unattended parking lots, vehicular drop off areas (unattended) stairways, and unattended elevators
1/40
