A nurse is preparing to access an implanted venous port (port-a-cath) for a client who is scheduled to receive intravenous chemotherapy. Arrange the following actions in the correct sequence to safely access the device. (All steps must be used).
- 1Don a face mask and instruct the client to turn their head away from the port site.
- 2Don sterile gloves and scrub the port site with chlorhexidine using back-and-forth friction.
- 3Allow the chlorhexidine solution to air dry completely.
- 4Stabilize the implanted port reservoir securely with the non-dominant hand.
- 5Insert a non-coring needle at a 90-degree angle until it touches the bottom of the reservoir.
- 6Aspirate for a brisk blood return and flush the catheter with 0.9% sodium chloride.
Answer
The correct sequence is: (1) Don a mask and position the client's head, (2) Don sterile gloves and scrub with chlorhexidine, (3) Allow to air dry completely, (4) Stabilize the port, (5) Insert the non-coring needle at 90 degrees, and (6) Aspirate for blood return and flush.
The standard of care for accessing an implanted venous port prioritizes infection control and device integrity. The nurse first protects the site from respiratory droplets by masking and positioning the client. Next, sterile technique is initiated by donning sterile gloves and cleansing the site with chlorhexidine. The antiseptic must air dry completely to be effective. Once dry, the nurse stabilizes the port to prevent movement and inserts a non-coring needle perpendicularly to protect the septum from damage. Finally, before any fluids are administered, the nurse must aspirate for blood to confirm correct intravascular placement.
Step-by-Step Solution
Key Concept
Accessing an implanted venous port requires strict aseptic technique, the use of a non-coring (Huber) needle to preserve the septum, and verification of blood return prior to administration of any fluids or medications.
Estimated Time:1m 30s