Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 15-8

Accessing an Implanted Port (Continued)

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11. Using the chlorhexidine swab, cleanse the port site. Press
    the applicator against the skin.Apply chlorhexidine using
    a back and forth friction scrub for at least 30 seconds.
    Moving outward from the site, use a circular, scrubbing
    motion to continue to clean, covering at least a 2- to 3-
    inch area. Do not wipe or blot. Allow to dry completely.


12. Using the nondominant hand, locate the port. Hold the
    port stable, keeping the skin taut.


13. Visualize the center of the port. Pick up the needle. Coil
    extension tubing into palm of hand. Holding needle at a
    90-degree angle to the skin, insert through the skin into
    the port septum until the needle hits the back of the port.


14. Cleanse the end cap on the extension tubing with an
    antimicrobial swab and insert the syringe with normal
    saline. Open the clamp on extension tubing and flush
    with 3 to 5 mL of saline, while observing the site for
    fluid leak or infiltration. It should flush easily, without
    resistance.


15. Pull back on the syringe plunger to aspirate for blood return.
    Aspirate only a few milliliters of blood; do not allow blood
    to enter the syringe. If positive, instill the solution over 1
    minute or flush the line according to facility policy. Remove
    syringe. Insert heparin syringe and instill the solution over
    1 minute or according to facility policy. Remove syringe and
    clamp the extension tubing. Alternately, if IV fluid infusion is
    to be started, do not flush with heparin.


16. If using a “Gripper” needle, remove the gripper portion
    from the needle by squeezing the sides together and lifting
    off the needle while holding the needle securely to the port
    with the other hand.


17. Apply the skin protectant to the site, avoiding direct appli-
    cation to needle insertion site. Allow to dry.


18. Apply tape or Steri-Strips in a star-like pattern over the
    needle to secure it.


19. Apply transparent site dressing or securement/stabilization
    device, centering over insertion site.


20. Label dressing with date, time of change, and initials. If IV
    fluid infusion is ordered, attach administration set to exten-
    sion tubing and begin administration. Refer to Skill 15-1.


21. Remove equipment. Ensure patient’s comfort. Lower bed,
    if not in lowest position.


22. Remove additional PPE, if used. Perform hand hygiene.

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