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

337

Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 15-9

Deaccessing an Implanted Port

Goal:The needle is removed with minimal to no discomfort to

the patient; the patient experiences no trauma or infection; and

the patient verbalizes an understanding of port care. Comments

1. Verify medical order and/or facility policy and procedure.
   Often, the procedure for accessing an implanted port and
   dressing changes will be a standing protocol. Gather equip-
   ment and bring to bedside.


2. Perform hand hygiene and put on PPE, if indicated.


3. Identify the patient.


4. Close curtains around bed and close the door to the room,
   if possible. Explain what you are going to do and why you
   are going to do it to the patient.


5. Adjust bed to comfortable working height, usually elbow
   height of the caregiver (VISN 8 Patient Safety Center,
   2009).


6. Assist the patient to a comfortable position that provides
   easy access to the port site. Use the bath blanket to cover
   any exposed area other than the site.


7. Put on gloves. Stabilize port needle with nondominant
   hand. Gently pull back transparent dressing, beginning
   with edges and proceeding around the edge of the dressing.
   Carefully remove all the tape that is securing the needle in
   place.


8. Clean the end cap on the extension tubing and insert the
   saline-filled syringe. Unclamp the extension tubing and
   flush with a minimum of 10 mL of normal saline.


9. Remove the syringe and insert the heparin-filled syringe,
   flushing with 5 mL heparin (100 U/mL or per facility
   policy). Remove syringe and clamp the extension
   tubing.


10. Secure the port on either side with the fingers of your non-
    dominant hand. Grasp the needle/wings with the fingers
    of dominant hand. Firmly and smoothly, pull the needle
    straight up at a 90-degree angle from the skin to remove
    it from the septum. Engage needle guard, if not automatic
    on removal.

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

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