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1

Continuous improvement of healthcare services through the systematic eveluation of processes

Quality improvement (QI)

2

A set of philosophies, methods, and tools for continuously quality improvement factors (ex: Lean and Six Sigma programs)

Continuous quality improvement (CQI)

3

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)

4

3 things quality improvement (QI) does

Decrease costs, increase efficiency
Increase customer satisfaction
Ensure quality throughout the healthcare organization

5

4 problems quality improvement (QI) responds to

Increased competition
Escalating costs
Quality concerns
Demands for increased accountability = know who's responsible (ex: computer logins)

6

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

7

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)

8

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

9

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)

10

Operational techniques and activities used to fulfill those requirements for quality (tests, procedures, etc.)
Ex: 9 penny test for congruence

Quality control (QC)

11

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)

12

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)

13

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)

14

3 other names for quality improvement (QI)

Continuous quality improvement (CQI)
Continual improvement (CI)
Total quality management (TQM)

15

What is the daily quality indicators (QI) output?

3%

16

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

17

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

18

Initial or images taken through treatment to make sure the right place is still being treated

Port film/portal image

19

What are the responsibilities of the physics team on the quality improvement (QI) team?

Equipment, weekly chart check

20

What are the responsibilities of the radiation therapists on the quality improvement (QI) team?

"Gatekeepers"; morning warmups, sim QA, verifying prescriptions

21

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.)

22

2 things TJC requires the medical directors to do

Make sure staff is qualified (trained, credentials)
Establishment and continuation of quality improvement (QI) plan

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

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

32

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

33

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

34

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

35

What is the frequency and tolerance of the QA procedure for the localizing lights of fluoroscopy-based simulators?

Frequency: daily
Tolerance: 2mm

36

What is the frequency and tolerance of the QA procedure for the field size indicator of fluoroscopy-based simulators?

Frequency: monthly
Tolerance: 2mm

37

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

38

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)

39

Daily tolerance of the alignment of gantry lasers with the center of the imaging plane for QA procedures of CT simulators

+/-2 mm

40

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

41

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

42

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

43

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

44

Monthly tolerance of the table vertical and longitudinal motion for QA procedures of CT simulators

+/-1 mm over the range of table motion

45

Semiannual tolerance of the sensitivity profile width of QA procedures of CT simulators

+/-1 mm of nominal value

46

Annual tolerance of table indexing and position of QA procedures of CT simulators

+/-1 mm over the scan range

47

Annual tolerance of gantry tilt accuracy of QA procedures of CT simulators

+/-1 degree over the gantry tilt range

48

Annual tolerance of gantry tilt position accuracy of QA procedures of CT simulators

+/-1 degree or +/-1 mm from nominal position

49

Annual tolerance of scan localization of QA procedures of CT simulators

+/-1 mm over the scan range

50

Annual tolerance of radiation profile width of QA procedures of CT simulators

Manufacturer specification

51

Tolerance after replacement of major generator components of QA procedures of CT simulators

Manufacturer specification or AAPM report 39 recommendations

52

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%

53

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

54

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

55

Daily mechanical tolerance for IMRT machines of laser localization for QA procedures of medical accelerators

1.5 mm

56

Daily mechanical tolerance for SRS/SBRT machines of laser localization and collimator size indicator for QA procedures of medical accelerators

1 mm

57

Daily mechanical tolerance for SRS/SBRT machines of the distance indicator (ODI) at isocenter for QA procedures of medical accelerators

2 mm

58

Grainy appearance of an image

Image noise

59

Clarity of an image; relationship between the number of pixels or voxels

Resolution

60

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)

61

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)

62

Process for continuously monitoring the movement of tumors during the patient's breathing

Respiratory gating

63

The software and hardware requirements of a linac which provides the user daily image verification capabilities

On-board imaging (OBI)

64

First step in treatment planning that localizes a target volume and helps physician's and staff come up with treatment planning

Simulator

65

About what percent of cancer patients will be treated with radiation at some point?

50-60%

66

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

67

6 basic elements of a simulator

Gantry
Patient support assembly (PSA)
X-ray tube
Collimator device
Imaging system of fluoroscopy unit
Optical devices

68

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)

69

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

70

Field defining lights/lasers

Optical devices

71

3 steps of treatment planning

Tumor localization
Computation of dose distributions (isodoses to tumor and critical structures)
Fabrication of treatment aids (ex: bolus)

72

Determine the extent of the tumor and location of critical structures

Tumor localization

73

Tells distance from source to depth of isocenter

Source skin distance (SSD)

74

Image from CT simulator

Digitally reconstructed radiograph (DRR)

75

Designed to simulate the mechanical, geometrical, and optical conditions of various treatment units

Conventional simulator

76

3 mechanical components of the gantry of a conventional simulator

Gantry arm
Gantry head
Image intensifying/film holder screen

77

C-shaped structure of the gantry of a conventional simulator

Gantry arm

78

2 edges of the beam

Divergent edges
Nondivergent = central axis

79

2 scales

IEC
Varian

80

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

81

6 gantry head components

Collimator assembly
ODI
Field defining wires
Beam restricting diaphragms
Fudicial plate
Accessory holder

82

6 steps of patient's process through the oncology department

Diagnosis
Consultation
Simulation
Treatment planning (dosimetrist)
Treatment
Follow-up

83

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

84

Compromises the gantry head and rotates around the isocenter

Collimator assembly

85

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

86

Defines size and axis of the x-ray beam

Beam restricting diaphragms
Collimators
Shutters
Blades

87

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

88

Holds blocks, cones, etc. for treatment; have to keep distance the same

Accessory holder

89

OFD

Object-film distance (larger = more magnification)

90

SFD/TFD

Source/target-film distance

91

Distance from the radiation source to the patient's skin

Source-skin distance (SSD)

92

DIstance from the source of radiation to the patient's skin

Source-axis distance

93

FAD

Focal spot-axis distance

94

Line perpendicular to the cross-section of the simulation or treatment field; not divergent

Central axis (CA)

95

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

96

Tabletop to isocenter

TT

97

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

98

The procedure room must be a minimum what square feet?

400 ft^2

99

4 room shielding materials

Lead
Concrete
Borated polyethylene
Aqueous materials (for neutrons)

100

How much the primary beam is pointed toward an area in the room (wall, floor, etc.)

Use factor (U)

101

Fraction of time an area is occupied by people; full = shielding increase

Occupancy factor (T)

102

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)

103

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

104

2 factors of permissible dose (P)

Controlled area
Uncontrolled area

105

Limit for controlled area

0.1 rad/wk

106

Any area in the environment (ex: lobbies, offices, waiting rooms, etc.); limits dose

Uncontrolled area

107

Limit for uncontrolled area

0.01 rad/wk

108

Distance from radiation source

Distance (d)

109

What's being allowed to transmit; transmission determines barrier thickness/shielding (radiation)

Barrier transmission (B)

110

Shielding has to be how high?

Up to 7 ft

111

Barriers/walls that intercept the primary beam
Portions of the floor, ceiling, and walls that receive the primary barrier

Primary barrier/wall

112

Barriers/walls that receive only leakage and/or scatter radiation

Secondary barrier/wall

113

Beam emitted directly from the accelerator that is "aimed" at the patient (i.e. the treatment field)

Primary beam
"Useful beam"

114

Radiation that arises from radiation interactions in the treatment head

Leakage radiation

115

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)

116

Barrier transmission (B) formula

B=Pd^2/WUT

P = permissible dose
d= distance
W = workload
U = use factor
T = occupancy factor

117

How big is the bore in CT simulation and why?

80-90 cm to fit treatment devices and different patient positions

118

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

119

Average slice thickness for CT simulation

3x3

120

Slice thickness of areas of non-interest for CT simulation

5x5 (less information, have to interpolate)

121

Estimate values between two measured values

Interpolate

122

Slice thickness of head and neck for CT simulation

1x1 (more anatomy but more data to store)

123

How fast patient is translating through the table

Pitch

124

Moving through the CT machine

Translating

125

Pitch formula

Couch movement in longitudinal direction per 360° rotation of the tube/ beam width or slice thickness

126

What dose an increase in pitch do?

Less time but lose information/more interpolation

127

What gives us image by converting radiation to light

Detector

128

___-___ 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

129

Solid-state = ____% efficient

90%

130

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

131

3 disadvantages of helical/spiral CT

Increased processing time
Increased noise/artifacts
Lower axis resolution along Z-axis (restrictions)

132

Any systematic discrepancy between the CT numbers in the reconstructed image, undesired

Artifacts

133

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

134

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

135

Fuse a scan with patient in one position (ex: diagnostic position) with a scan in a different position (ex: treatment)

Deformable fusion

136

Attenuation rates or tissue density differences displayed as pixels of different shades of gray
Range from +1000 to -1000

Hounsfield units (HU)
CT numbers

137

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

138

Missing the tumor __-__ times or ___% of the dose can result in treatment failure or recurrence of the disease

1-2 times
10%

139

___% of patients treated had errors (pelvis, abdomen, chest more common areas because they're bigger)

15%

140

Aid in setup (hold patient still and maintain position)
Allow patient positioning
Make treatment more accurate
Durable (last whole treatment)

Immobilization devices

141

2 reasons immobilization devices are used

Reproducibility
Accuracy

142

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)

143

3 categories of immobilization devices

Patient positioning aids
Simple immobilization devices
Complex immobilization devices

144

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

145

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

146

Individualized devices that restrict patient movement and ensure reproducibility

Complex immobilization devices

147

Supports chest and holds head; need to put arms in same place every time

Prone pillow

148

Abducts affected arm and shoulder from chest wall

Breast board

149

Abducts both arms from chest wall (CT simulation)

Wingboard

150

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

151

Move and position tongue

Bite block

152

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

153

2 simple immobilization devices

Bite block
Arm stretcher

154

Can be used to pull arms/shoulders out of head/neck field

Arm stretcher

155

4 complex immobilization devices

Alpha cradle
Vac bag
Aquaplast mask
Aquaplast breast

156

Complex immobilization device created from styrofoam shell and foaming agents

Alpha cradle

157

Complex immobilization device that consists of a cushion and has vacuum compression pumps

Vac bag

158

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

159

Complex immobilization device that keeps large breasts from falling
Cups disadvantage: can get sticky/hot and make it harder to maneuver breast

Aquaplast breast

160

2 imaging modalities used in simulation and tumor localization; both needed to visualize all structures

Ionizing
Non-ionizing

161

Use ionizing radiation to produce images that primarily show anatomy
X-ray, CT, nuclear medicine, PET, PET/CT

Ionizing imaging modality

162

Use alternative means of imaging the body such as magnetic fields (MRI) and echoed sound waves (US)

Non-ionizing imaging modality

163

Ionizing bipedal (contrast administered in feet) angiogram good for visualizing Hodgkins

Lymphangiogram

164

Uses radioisotopes and ionizing radiation to provide information about physiology (function) and anatomic structures

Nuclear medicine bone scan

165

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

166

Towards the abdomen, anterior

Ventral

167

Towards the back, posterior

Dorsal

168

Divides body vertically into right or left sides

Sagittal plane

169

Divides body into two symmetric right and left sides

Median/midsagittal plane

170

Vertical plane that is parallel to the median sagittal and divides into right and left unequal components

Parasagittal plane

171

Vertical plane that divides the body into anterior (front) and posterior (back) sections; perpendicular (at right angle) to the sagittal plane

Coronal/frontal plane

172

Divides the body into superior and inferior parts; perpendicular to midsagittal, parasagittal, and coronal planes

Transverse/horizontal plane

173

Physique varies internal anatomy

Body habitus

174

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

175

Well-built; slightly lower stomach
Highest occurance at 50%

Sthenic

176

Average physique
35% of the population
Abdominal cavity falls between sthenic and asthenic

Hyposthenic

177

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

178

Spaces within the body that contain internal organs

Body cavities

179

2 main body cavities

Posterior/dorsal
Anterior/ventral

180

2 cavities the posterior/dorsal cavities divides into

Spinal/vertebral
Cranial (brain)

181

Cavity protected by the vertebrae and contains the spinal cord

Spinal/vertebral

182

2 cavities the anterior/ventral cavity is divided into by the diaphragm

Thoracic
Abdominopelvic

183

2 cavities of the thoracic cavity

Pericardial (heart)
2 pleurals (right and left lungs)

184

2 sections of the abdominopelvic cavity

Upper abdomen
Lower pelvic

185

Houses the peritoneum, liver, gallbladder, pancreas, spleen, stomach, and most of the large and small intestines

Upper abdominal cavity

186

Houses the rest of the large intestine and the rectum, bladder, and internal reproductive system

Lower pelvic cavity

187

4 abdominal quadruants

Right upper quadrant (RUQ)
Left upper quadrant (LUQ)
Right lower quadrant (RLQ)
Left lower quadrant (LLQ)

188

Hypo-

Under/belo

189

-chondriac

Ribs

190

9 regions of the abdomen

Right hypochondriac
Epigastric
Left hypochondriac
Right lumbar
Umbilical
Left lumbar
Right iliac
Hypogastric
Left iliac

191

Region of abdomen centrally located around the naval

Umbilical

192

Regions of abdomen to the right and left of the naval; lower back

Lumbar

193

Central region of abdomen superior to the umbilical region

Epigastric

194

Regions of the abdomen to the right and left of the epigastric region and inferior to the cartilage of the ribcage

Hypocondriac

195

Central region of the abdomen inferior the the umbilical region

Hypogastric

196

Regions of the abdomen to the right and left of the hypogastric region; hip bones

Iliac

197

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

198

Excessive tissue fluid that consists mostly of water and plasma

Lymph

199

____ of body's lymph nodes in neck

1/3

200

Bring in/to

Afferent

201

Bring lymph into lymphatic vessel, many points of entry

Afferent vessels

202

Carry lymph away; larger but fewer to slow the flow through the nodes, permitting the node to effectively filter the lymph

Efferent vessels

203

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

204

__________ 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

205

3 lymphatic organs

Spleen
Thymus
Tonsils

206

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

207

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

208

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

209

2 lymphatic ducts

Thoracic duct
Right lymphatic duct

210

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

211

1-2 cm long lymphatic duct; drains right arm and right side of head and neck into right subclavian vein

Right lymphatic duct

212

____ bones in the body; _____ in infant

206; 350

213

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)

214

Spinal cord ends at _______ and cauda equina begins

L1-L2

215

Excessive curvature of the vertebral column that's convex posteriorly

Kyphosis

216

Cervical vertebrae that holds the skull

Atlas/C1

217

Cervical vertebrae that head pivots on

Axis/C2

218

Junction of manubrium and sternal body at T4

Sternal angle/angle of Louis

219

Cartilage that connects the sternum to the ribs

Costal cartilage

220

______ of ribs connects to vertebrae

Head

221

Manubrium articulates with ribs _____

1 & 2

222

Sternal body articulates with ribs _______

2-10

223

Ribs 1-7 articulate posteriorly with vertebrae and anteriorly with sternum directly through costal cartilage

True/vertebrosternal ribs

224

False ribs

8-12

225

Ribs that join with vertebrae posteriorly and anteriorly with the cartilage of the immediately anterior rib; share common cartilaginous connection to sternum

8-10

226

Ribs 11 & 12 attach to the vertebrae only

Floating/vertebral ribs

227

Extends from the base of the skull to the esophagus

Pharynx (throat)

228

The lowest point of the pharynx to trachea

Larynx (voice-box)

229

8 bony landmarks of the skull

Glabella
Nasion
Superciliary arches
Superior orbital margin
Maxilla
Mastoid process
External occipital protuberance
Angle of the mandible

230

Secretes the aqueous layer of the tear film

Lacrimal gland

231

Drains conjunctiva to the nose; tears drained through this duct into the lacrimal duct

Punctum lacrima

232

Expanded outer wall of cartilage on each side of the nose

Ali nasi (lateral and inferior)

233

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)

234

Lips; exposed pink or reddish margin of a lip

Vermillion border/surface

235

Vertical groove between the base of the nose and the border of the upper lip

Philtrum

236

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

237

External/visible part of ear

Auricle/pinna

238

Rounded portion of ear

Helix

239

Bony anterior 2/3 of the mouth

Hard palate

240

Fleshy, upper posterior portion of oral cavity/mouth

Soft palate

241

Bone that aids in the movement of the tongue

Hyoid

242

Blocks nasal cavity and assists with speech

Uvula

243

Muscle attached to the mastoid and occipital bones superiorly and sternal and clavicular heads inferiorly; lateral movement of neck

Sternocleidomastoid muscle

244

SSN is at the level of

T2

245

Sternal angle is at the level of

T4

246

Xiphoid is at the level of

T9-10

247

Outer portion of breast that extends into the axilla (muscle)

Tail of Spence

248

Inferior point of breast attachment; where fold is, helps set treatment borders and skin breakdown is commonly seen here

Inframammary sulcus

249

4 quadrants of the breast

Upper outer
Upper inner
Lower outer
Lower inner

250

Most common breast quadrant for disease

Upper outer

251

If breast tumor is located in an inner quadrant, what nodes are usually involved?

Medially located nodes (ex: inframammary)

252

If breast tumor is located in an outer quadrant, what nodes are usually involved?

Axillary nodes (principal pathway)

253

Breast lymph nodes at 2nd-3rd intercostal space

Axillary/principal pathway

254

Breast lymph nodes that go through pectoralis major and drains supra- and infraclavicular fossa nodes

Transpectoral

255

An intermediate breast lymph node in the infraclavicular fossa

Rotter's node

256

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

257

Supraclavicular breast lymph node often biopsied on ipsilateral side of disease

Scalene

258

On same side

Ipsilateral

259

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

260

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

261

Lower border of larynx and is only complete ring of cartilage in the respiratory passage

Cricoid cartilage

262

Point of bifurcation of the trachea that forms beginning of the right and left main bronchi

Carina

263

Dome-shaped muscle that separates the thorax and abdomen at T10-T11

Diaphragm

264

Prevents lungs from overinflating into throax

Pleural cavity

265

Right has 3 lobes and left has 2 because of the heart

Lungs

266

Level of base of the heart

T4

267

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

268

5 structures the superior mediastinal/tracheal/superior tracheobronchial lymph nodes of the thorax drain

Thymus
Heart
Pericardium
Mediastinal pleura
Anterior hilum (wedge-shaped area)

269

Lymphatics of the thorax that drain lungs: right into right lymphatic duct and left into thoracic duct

Inferior mediastinal nodes

270

3 inferior mediastinal nodes

Inferior tracheobronchial/carinal
Bronchopulmonary/hilar (commonly involved in lung cancer)
Pulmonary/intrapulmonary

271

Para-

Around/near

272

Cuts through the pylorus of the stomach, the tips of the ninth costal cartilagesm and the lower body of L1

Transpyloric plane

273

BIT

Bottom of ischial tuberosity

274

BOF

Bottom of obturator foramen

275

Muscle that attaches to the scapula and humerus

Teres major muscle

276

Largest muscle in the back

Latissimus dorsi

277

Why is the right kidney lower than the left kidney?

Due to the large size of the liver on the right side

278

Kidneys can move as much as _____ during respiration

2cm

279

Digestive organs

Alimentary organs

280

Level of pancreas

L1

281

Lymphatics of the abdomen and pelvis that drain the stomach, greater omentum, liver, gallbladder, spleen, pancreas, and duodenum

Celiac

282

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

283

Lymphatics of the abdomen and pelvis that drain the descending colon, left side of the mesentary, sigmoid colon, and rectum

Inferior mesenteric

284

Lymphatics of the abdomen and pelvis that drain the bladder, prostate, cervix, and vagina

Common iliac

285

Lymphatics of the abdomen and pelvis that drain the bladder, prostate, cervix, vagina, testes, and ovaries

External iliac

286

Lymphatics of the abdomen and pelvis that drain the vagina, cervix, prostate, and bladder

Internal iliac/hypogastric nodes

287

Lymphatics of the abdomen and pelvis that drain the vulva, uterus, ovaries,vagina, scrotum, and penis

Inguinal/superficial

288

Use factor (U) for 0 degree (down) [IEC]

31%

289

Use factor (U) for 90 and 270 degree (IEC)

21.3%

290

Use factor (U) for 180 degree (IEC)

26.3%

291

Occupancy factor (T) for full occupancy areas

1

292

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

293

Occupancy factor (T) for adjacent treatment room, patient examination room adjacent to shielded vault

1/2

294

Occupancy factor (T) for corridors, employee lounges, staff rest rooms

1/5

295

Occupancy factor (T) for treatment vault doors

1/8

296

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

297

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