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Pre‐procedural considerations

The patient should be physically and psychologically prepared for the procedure so they understand the procedure and give their informed consent (O'Dwyer et al. [117]). The following aspects should be considered prior to the procedure.

Patient considerations

Pregnant women will generally not be scanned. When essential tests must be undertaken, the patient must sign a consent form and receive a reduced dose of radionuclide. This is to avoid unnecessary irradiation to the abdominal/pelvic region which will include the embryo or fetus (Ionizing Radiation Regulations 1999).
The person accompanying the patient should not be pregnant, or bring young children or babies with them, so that unnecessary exposure in the time period immediately after the radionuclide administration can be avoided (DH [36], HPA [62]).
In women of reproductive age, the possibility of pregnancy must be excluded routinely via a urine test and the patient asked if her menstrual period is late. Patients receiving iodine‐131 or any other radioactive agent with a long half‐life should not become pregnant for a minimum of 3 months after the procedure (Sharp et al. [147]) to ensure that unnecessary irradiation to the abdomen of a woman who may be pregnant is avoided (HPA [62]).
If mothers are breastfeeding, then advice from the Radiation Protection Adviser should be sought. Radioactivity can be excreted in breast milk. Therefore, breastfeeding may need to be suspended (HPA [62]) and the mother encouraged to avoid unnecessary cuddling of the child during this time (DH [36]).
Patients with pain should be provided with effective pain control to ensure they are pain free so that immobility during scan time can be maintained.
If the patient is incontinent, the test may not go ahead; however, if a decision is made to do so, proceed with caution. Incontinence pads should be worn and universal precautions are to be adopted, to limit the spread of contamination. Disposable gloves and apron should be worn and hand washing performed following patient contact, as these will prevent contamination of staff in close contact with the patient (DH [36]). Urine bags must be emptied regularly to remove the radioactivity from the patient area. Items must be disposed of in hospital approved body fluid and clinical waste.
Debilitated patients may require prolonged close contact. Nursing staff should share the care of these patients, by regular rotation of staff. This will keep doses to staff as low as possible and avoid prolonged exposure to any one member of staff (DH [36]).
Patients should keep to a minimum prolonged close contact (less than 1 metre) with anyone who is pregnant.
Patients should keep to a minimum prolonged close contact (less than 1 metre) with any child under the age of 5 years.
Patients should pay extra attention to their own personal hygiene, washing their hands thoroughly after each visit to the lavatory.
Drink plenty of fluids and empty their bladder frequently, as this will hasten the removal of the radioactive tracer from the body (DH [36], HPA [62], Sharp et al. [147]).

Ward considerations

Although the amount of radioactivity administered is low, the patient will emit a small amount of radiation for some time after the radioactive tracer has been given. The amount of radioactivity within the patient decreases in two ways. The first way is by the natural physical decay of the radioisotope used, which we cannot change. The second way is by excretion of the radioactive tracer from the patient's body, usually via the urine and occasionally the faeces (HSE [71], HPA [62], Vialard‐Miguel et al. [166]).

All patients who have been administered a radiopharmaceutical will be issued a yellow wrist or ankle band. The purpose of the yellow band is to act as a visual, easily recognized indicator of the fact that a patient has attended for a nuclear medicine investigation. The band should only be worn on the day of the scan unless the patient is specifically instructed to the contrary and has been given clear radiation protection instructions. Patients wearing a yellow band will also have been issued with a card outlining basic precautions and listing contact telephone numbers if they (or a ward/department) have any queries. When nursing patients who have received a radiopharmaceutical, nurses and other healthcare providers should adhere to the following guidelines.

Patient care

Nurse in an appropriate controlled area of the hospital designed to manage patients with radioactive sources.
Encourage their patient to take in plenty of fluid and empty their bladder frequently.
Wear gloves when emptying catheter bags or bedpans, but dispose of the urine/faeces in the usual way.
Try to empty catheter bags (if in use) frequently and not allow them to get too full.
Minimize time spent in close proximity of patients.
All emergency procedures such as cardiac arrest or deterioration must continue to be provided with adequate safeguards in place such as healthcare professional monitoring, rotation of emergency responders and the ability to manage patients in other settings such as critical care or operating theatres (HPA [62], Resuscitation Council [135]).

Blood samples and further tests

Where possible, all blood tests should be performed prior to administration of the radiopharmaceutical.
Only clinically urgent blood tests may be performed on patients with yellow wrist bands.
If samples are to be taken from patients with yellow bands, then both the sample and the form must have a radioactive sticker placed on them. The pathology department must contact radiation protection to collect and dispose of the sample after testing has been performed.
Further examinations such as X‐ray or CT may be carried out on patients; however it is best practice for the patient to inform the nuclear medicine team of their appointments prior to administration of the radiopharmaceutical (Larkin et al. [88]).

Contaminated sharps or dressings

When removing inserted devices from patients wearing yellow bands, the waste items should be placed in an orange bag or sharps bin (radioactive specific) and taken to the nuclear medicine department.

These items can then be handed to a member of staff for disposal.
When handing the item over, please ensure the receiving staff member is told of the patient's details so that it may be disposed of correctly (DH [35], HSE [68]).

Body fluid and body fluid spillage management

In the event of a patient's incontinence or a spill from a bedpan, catheter bag or other body fluid:

The soiled linen should be placed in an orange clinical waste bag, and clearly labelled ‘Radioactive – Do not dispose’.
Contact the department of nuclear medicine or Radiation Protection Service to arrange for collection or further advice. It is important to follow local hospital guidelines as local variation may occur (DH [35], HSE [68]).

Equipment

There are various additional pieces of equipment that are required to safely undertake the procedure. These include lead‐lined receptacles and monitoring devices.

Lead‐lined equipment

Lead‐lined equipment is required to protect the clinician or operator and the environment from radioactive sources.

Lead shields. All syringes containing radiopharmaceuticals should be in a shielded compartment. This is a lead shield to protect the fingers of the operator.
Lead‐lined disposal bins. All clinical waste should be disposed of in lead‐lined clinical waste and sharps bins. The disposal of this waste must be followed as per hospital policy (DH [36], HPA [62]).

Monitoring equipment

Staff radiation protection. All staff administering radiopharmaceuticals should be provided with body thermoluminescent dosimeter (TLD) film badges (Figure 20.5).
Contamination monitors to check hands and feet of staff (Figure 20.6). The contamination monitors are required to check the environment at the end of each day or more frequently if a spill occurs. Local hospital guidelines must be followed in the event of a spill of a radiopharmaceutical or contaminated body fluid (HPA [62]).