A nurse is preparing to access a client's implanted venous access device (port) using a non-coring needle to administer intravenous chemotherapy. The nurse has gathered the necessary supplies, explained the procedure to the client, and performed hand hygiene. Arrange the following steps in the correct order to access the device safely.
- 1Don a surgical mask, instruct the client to turn their head away from the insertion site, and don sterile gloves.
- 2Cleanse the skin over the port site with a chlorhexidine applicator using friction and allow it to air dry completely.
- 3Immobilize the port securely between the thumb and index finger of the non-dominant hand.
- 4Insert the non-coring needle firmly at a 90-degree angle through the skin and septum until the needle hits the back of the port.
- 5Aspirate gently with an attached syringe to confirm a blood return.
- 6Flush the device with 10 mL of sterile normal saline.
Answer
The correct sequence for accessing an implanted venous port is: donning masks and sterile gloves, cleansing the site with chlorhexidine, immobilizing the port, inserting the needle at a 90-degree angle, aspirating for blood return, and finally flushing with normal saline.
Accessing an implanted port requires strict sequential adherence to sterile technique and safety verification. The nurse must first protect the site from respiratory droplets (masks) and contact (sterile gloves). Disinfection with chlorhexidine follows, requiring complete air drying. Once sterile, the nurse stabilizes the port to prevent movement and inserts the non-coring needle at a 90-degree angle to avoid damaging the septum. Before injecting any fluid, placement must be verified by aspirating for blood return. Only after confirming a blood return can the nurse safely flush the line with saline to establish patency.
Step-by-Step Solution
Key Concept
Implanted Venous Access Device (Port) Safe Access Procedure