An oncology client arrives at the outpatient infusion clinic to receive an intravenous antibiotic. The client has an implanted central venous access device (port) that is currently de-accessed. Place the nursing actions for accessing and preparing the port in the correct chronological sequence.
- 1Place a surgical mask on both the client and the nurse, and perform hand hygiene.
- 2Don sterile gloves and cleanse the skin over the port with chlorhexidine using back-and-forth friction.
- 3Allow the cleansed area to air-dry completely without fanning or blotting.
- 4Stabilize the port using the non-dominant hand and insert a non-coring needle perpendicular to the septum.
- 5Aspirate the attached syringe to check for a blood return to confirm correct needle placement.
- 6Flush the port with 10 mL of 0.9% sodium chloride to assess patency and clear the line.
Answer
The correct sequence prioritizes infection control and patient safety: mask/hand hygiene, don sterile gloves and cleanse, allow to air-dry, insert a non-coring needle, aspirate for blood return, and finally flush with saline.
Accessing an implanted port requires strict aseptic technique and safety verification. Masking the client and nurse prevents respiratory droplet contamination. Hand hygiene and sterile gloves are mandatory for central line procedures. Chlorhexidine with friction effectively reduces skin flora, but it must air-dry completely to be bactericidal. A non-coring (Huber) needle is required to prevent damaging the port's silicone septum. Crucially, before injecting any fluids, the nurse must aspirate for a blood return to verify the needle is within the port reservoir and the catheter tip is in the central vasculature. Flushing with saline only occurs after placement is confirmed, ensuring patency and clearing any locking solutions.
Step-by-Step Solution
Key Concept
Implanted Venous Port (Port-a-Cath) Access Sequence and Central Line Infection Prevention