3.2 History Review, Contraindications & Monitoring

3.2 History Review, Contraindications & Monitoring

Quick Answer: Before and during imaging, match the order to the clinical story, screen for contraindications (pregnancy, contrast risk, unsafe preparation), monitor the patient’s condition, and adapt positioning for safety and comfort. If the history, order, and patient do not align—or the patient deteriorates—stop and escalate rather than “just completing the series.”

The Care Provider role on the CAMRT blueprint expects RTRs to review history, recognize contraindications, monitor patients, and respond to changing status. These competencies sit beside communication and clinical technique: you are the professional who sees the patient in real time and can prevent the wrong exam, the wrong dose, or an unrecognized emergency.

Review Clinical History Against the Order

A requisition is a medical order, but it is not infallible. Before exposure, reconcile three sources of truth:

1. The written/electronic order — examination, laterality, clinical indication, special instructions.
2. The patient’s (or caregiver’s) story — why they are here, what hurts, what happened, relevant prior imaging.
3. Available chart / prior images / alerts — allergies, isolation status, pregnancy flags, renal function notes, DNR status when relevant to emergency planning.

What “history review” looks like in practice

Use focused, respectful questions. You are not taking a full medical admission history, but you must capture what the radiologist and the safety process need:

• Chief complaint and mechanism (e.g., fall on outstretched hand vs. chest pain).
• Onset, location, and laterality of symptoms.
• Relevant surgery, implants, or trauma devices that affect positioning or technique.
• Ability to stand, hold breath, or lie prone/supine.
• Allergies and previous reactions if contrast or medications may be used.
• Possibility of pregnancy for exams that irradiate the abdomen/pelvis or nearby.

Discrepancy scenarios (high-yield)

Proceeding when the story and order conflict is a classic wrong answer. Your duty is to recognize and clarify, not to expand the exam on your own authority or to ignore the mismatch.

Verify Appropriateness

Appropriateness means the requested procedure is a reasonable next step for the clinical question, with benefit outweighing risk (including radiation). Entry-level technologists do not replace the referring practitioner or radiologist, but they do:

• Confirm the exam type matches the body region and indication.
• Notice missing preparation (e.g., patient not NPO for an upper GI when protocol requires it).
• Identify duplicate or clearly mistaken orders.
• Escalate when a high-dose or contrast exam is requested without required screening information.

Canadian practice is guided by justification principles consistent with radiation protection culture (ALARA and professional standards). If something feels unjustified or unsafe, pause and communicate—document the conversation when required.

Contraindications and Screening

A contraindication is a condition that makes a procedure unsafe or inappropriate unless modified or deferred. Screening is proactive: ask and check before the risky step (exposure to the pelvis, contrast injection, barium when perforation is suspected).

Pregnancy screening

For patients of reproductive potential undergoing examinations that irradiate the abdomen, pelvis, lumbar spine, hips, or nearby regions:

• Ask about the possibility of pregnancy in a private, respectful way.
• Follow facility policy—which may include last menstrual period (LMP), urine or serum hCG when indicated, and documentation.
• If pregnancy is confirmed or cannot be excluded and the exam is elective, defer or modify per radiologist/referrer guidance.
• If imaging must proceed, optimize technique (tight collimation, PA vs AP when beneficial, gonad shielding only when it does not obscure anatomy and policy supports it) and document.

Never assume “not pregnant.” Never shame or rush the conversation. For trauma and life-threatening indications, clinical necessity may override elective rules—but screening and team communication still occur as soon as feasible.

Contrast-related screening (foreshadow)

Full contrast pharmacology is covered in later Clinical Expert content, but Care Provider screening starts here:

• Prior iodinated contrast reaction is the most important allergy history—not “shellfish” alone.
• Asthma, significant allergies, and unstable asthma may increase risk; flag for the radiologist/protocol.
• Renal function: estimated glomerular filtration rate (eGFR) or creatinine is often required before intravascular iodinated contrast in at-risk patients (age, diabetes, known CKD, solitary kidney, etc.) per departmental protocol.
• Metformin: patients taking metformin who will receive intravascular iodinated contrast need protocol-based instructions (often involving holding metformin when renal function is impaired or per local guideline after the procedure). You do not invent the rule—you identify metformin use and follow the written pathway with the radiologist/pharmacy/nursing team.
• Pregnancy and breastfeeding considerations for contrast differ from plain radiography—again, flag and follow protocol.
• Barium vs water-soluble iodinated contrast for GI studies: suspected perforation generally contraindicates barium; water-soluble agents are preferred when leak is a concern.

If screening data are missing for a contrast exam, do not inject—obtain the labs, history, or radiologist clearance first.

Other common contraindications / cautions

• Unstable vital signs or active chest pain needing emergency care before elective imaging.
• Inability to consent when consent is required—follow substitute decision-maker and facility rules.
• Weight exceeding table limits.
• Positions that compromise external fixation, fresh grafts, or suspected unstable fractures without team approval.

Assess and Respond to Patient Condition

Assessment mixes objective signs with subjective reports:

Know approximate normal adult vital ranges so you can recognize outliers:

• Heart rate about 60–100 beats/min at rest
• Respirations about 12–20/min
• SpO2 about 95–100% on room air in healthy adults (know the patient’s baseline—COPD patients may run lower)
• Blood pressure roughly 120/80 mmHg as a familiar reference; hypotension and symptomatic hypertension need attention
• Temperature near 37°C orally

Pediatric norms run faster for pulse and respirations; interpret age-appropriately. You are not expected to manage complex critical care alone, but you are expected to notice “this patient is not okay” and act.

Monitor Throughout the Procedure

Monitoring is continuous, not a single check at booking:

1. Baseline on arrival—colour, breathing, orientation, pain, oxygen in place.
2. During positioning—watch for dizziness on standing, respiratory distress when supine (orthopnea), pain on movement.
3. During long or contrast exams—recheck appearance and conversation; watch the IV site if injecting.
4. After—ensure the patient is stable to leave, especially after contrast, sedation assistance, or fall-risk transfers.

Immediate attention is required for chest pain with diaphoresis and dyspnea, sudden unresponsiveness, severe allergic signs, large extravasation, uncontrolled bleeding, or seizure. Stop the exam, ensure safety (side rails, prevent falls), call for help, and begin basic interventions within your training and scope while awaiting the team.

Adapt Positioning, Protocol, Comfort, and Individual Needs

Rigid adherence to “textbook only” positioning fails real patients. Adaptation is a scored Care Provider skill:

• Mobility limits: seated AP wheelchair chest instead of standing PA when the patient cannot stand safely.
• Pain / fracture: minimal movement; horizontal beam; support limbs; analgesia coordination with nursing when appropriate.
• Dyspnea: semi-erect imaging when fully supine is intolerable, documenting the adaptation.
• Pediatrics: age-appropriate explanation, caregiver presence, immobilization devices used humanely, minimize repeats.
• Older adults: allow time, prevent hypothermia, pad pressure points, watch for skin tears and orthostatic hypotension.
• Cultural safety and dignity: privacy for gowning, same-gender chaperone when requested and available, language interpretation rather than guessing, respect for modesty and spiritual needs without delaying emergency care inappropriately.
• Sensory or cognitive impairment: simple instructions, face the patient, reduce noise, allow extra processing time.
• Bariatric patients: equipment ratings, more helpers, respectful language, modified centering and exposure strategies.

Comfort measures—blankets, sponges under knees for lumbar relief, clear time estimates, warning before moving a painful limb—reduce motion and build trust. Individual needs also include isolation precautions (covered in the infection-control chapter): your monitoring plan must not break PPE rules.

Workflow Summary for the Exam

1. Identify the patient (two identifiers).
2. Review history vs order; fix discrepancies.
3. Screen contraindications for this procedure.
4. Plan adapted positioning and required assistance.
5. Monitor continuously; stop if status changes.
6. Document relevant screening, adaptations, and incidents per policy.

Choosing “continue the exam because the schedule is full” when the patient reports new chest pain or the order does not match the injury is never the best answer. The competent RTR protects the patient first, then completes justified imaging with an adapted, monitored plan.