An implanted port consists of a subcutaneous injection port attached to a catheter. The distal catheter tip dwells in the lower segment of the superior vena cava at or near the cavoatrial junction (CAJ) (the point at which the superior vena cava meets and melds into the superior wall of the right atrium), and the proximal end or port is usually implanted in a subcutaneous pocket of the upper chest (typical) or abdominal wall (Figure 1). Implanted ports placed in the upper arm (or less commonly, lower extremity) are referred to as peripheral access system ports. Confirmation of tip location either by postprocedure chest radiograph or by technology used during the placement procedure is required prior to use and should be documented in the patient's health record (Gorski et al., 2021).

When not in use, no external parts of the system are visible. When venous access is desired, the location of the injection port must be palpated. A special angled, noncoring needle is inserted through the skin and septum and into the port reservoir to access the system. Once accessed, patency is maintained by periodic flushing. The length and gauge of the needle used to access the port should be selected based on the patient's anatomy, amount of subcutaneous tissue at the site, and anticipated infusion requirements. Access the port with the smallest-gauge noncoring needle to accommodate the prescribed therapy (Gorski et al., 2021). The length of the noncoring needle should be such that it allows the external components to sit level with the skin and securely within the port (needle touches bottom of port upon insertion) (Gorski et al., 2021). Transparent semipermeable membrane (TSM) dressings that cover the needle and access site are maintained and changed as outlined in Skill 16-7.

Consider the use of methods to reduce pain and discomfort during port access, such as local anesthetic agents and nonpharmacologic interventions (cognitive, behavioral, and complementary therapies) (Gorski et al., 2021).

CVADs used for intermittent infusions should be flushed with preservative-free 0.9% sodium chloride solution and aspirated for a blood return prior to each infusion to assess catheter function (Gorski et al., 2021). Flushing of the device is also required after each infusion to clear the infused medication or other solution from the catheter lumen. CVADs should be locked with either a heparin solution (10 units/mL) or preservative-free 0.9% sodium chloride after each intermittent use, according to the directions for use for the specific CVAD and needleless connector (Gorski et al., 2021). If the device is not in use, periodic flushing according to facility policy is required to keep the catheter patent. Antimicrobial locking solutions are sometimes used in specific situations, such as with patients with long-term CVADs or in high-risk patient populations (Gorski et al., 2021).

Facility policy generally determines the type of dressing and the intervals for dressing change. Perform site care and replace TSM dressings at least every 7 days (except neonatal patients) or immediately if the dressing becomes damp, loosened, visibly soiled, or has a lifted/detached border; blood or drainage is present; or there is compromised skin integrity under the dressing (Gorski et al., 2021). Change sterile gauze dressings at least every 2 days, or if the integrity of the dressing is disrupted (damp, loosened, visibly soiled) (Gorski et al., 2021). Consider the use of sterile adhesive removers and skin barrier film to prevent medical adhesive-related skin injury (MARSI) (Fumarola et al., 2020; Gorski et al., 2021; Zhao et al., 2018).

Assessment

Assess the port site. Inspect the skin over the port, looking for any swelling, redness, or drainage. Assess the site over the port for any pain or tenderness, erythema, and drainage. These signs might indicate the development of localized infection. Ask the patient if they are experiencing any pain or discomfort related to the VAD, paresthesias, numbness, or tingling. Pain or discomfort can be a sign of infiltration, extravasation, phlebitis, thrombophlebitis, deep vein thrombosis, and/or infection. Refer to Fundamentals Review 16-3. Review the patient's history for the length of time the port has been in place. If the port has been placed recently, assess the surgical incision. Note the presence of adhesive skin closure strips, approximation, ecchymosis, redness, edema, and/or drainage. Evaluate the patient's history for any allergies or sensitivity to skin antiseptics (Gorski et al., 2021). Assess the patient's knowledge of CVAD therapy. Verify if the current locking solution dwelling in the CVAD needs to be aspirated and discarded or may be infused as part of the flushing procedure; all antimicrobial lock solutions, for example, must be aspirated and discarded (Gorski et al., 2021).

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

• Infection risk
• Knowledge deficiency
• Altered skin integrity risk

Outcome Identification and Planning

The expected outcomes to achieve when accessing an implanted port are that the port is accessed with minimal discomfort to the patient, the patient experiences no trauma to the site or infection, and the patient verbalizes an understanding of care associated with the port.

Implementation

Action	Rationale
1. Verify the prescribed intervention requiring port access and facility policy and/or procedure. Often, the procedure for accessing an implanted port and dressing changes will be a standing protocol. Gather equipment.	Checking the prescribed intervention and policy ensures that the proper procedure is initiated. Preparation promotes efficient time management and an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. Unclean hands and improper technique are potential sources for infecting a CVAD. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the bedside stand or overbed table or other surface within reach.	Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why. Ask the patient about allergies to tape and skin antiseptics. If considering using a local anesthetic, inquire about allergies for these substances as well. Consider use of nonpharmacologic interventions to reduce pain associated with PIVC insertion.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. Possible allergies may exist related to the tape or antiseptics. Injectable anesthetic can result in allergic reactions and tissue damage. Nonpharmacologic interventions suggested for use to reduce PIVC insertion-related pain and discomfort include distraction, relaxation, breathing exercises, and virtual reality (VR) (Basak et al., 2020; Gorski et al., 2021). The choices of interventions for pediatric patients include swaddling, breastfeeding, pacifiers, rocking, blowing bubbles, reading books, use of VR, and local vibrating cold devices and should be made with consideration of growth and development level (Gorski et al., 2021).
6. If using a local anesthetic, explain the rationale and procedure to the patient. Apply the anesthetic as indicated to the port site. Allow sufficient time for the anesthetic to take effect.	Explanations provide reassurance and facilitate engagement. Local anesthetic agents should be used to reduce pain in all adult and pediatric populations (Gorski et al., 2021). Local anesthetic agents to reduce pain associated with needle insertion include vapocoolant sprays, topical transdermal agents, jet injection of pressure-accelerated lidocaine (needle-free), application of hot or cold to the site, and intradermal injection of lidocaine or bacteriostatic 0.9% sodium chloride (Gorski et al., 2021; Korkut et al., 2020; Welyczko, 2020). Some anesthetics take up to an hour to become effective.
7. Place a waste receptacle or bag at a convenient location for use during the procedure.	Having a waste container handy means the soiled dressing can be discarded easily, without the spread of microorganisms.
8. Adjust the bed to a comfortable working height (VHACEOSH, 2016).	Having the bed at the proper height prevents back and muscle strain.
9. 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.	Patient positioning and use of a bath blanket provide for comfort and warmth.
10. Apply a mask. Ask the patient to turn their head away from the access site. Alternatively, have the patient put on a mask, depending on facility policy. Move the overbed table to a convenient location within easy reach. Set up a sterile field on the table. Open the dressing supplies and add them to the sterile field.	Masks are recommended to reduce the risk of droplet transmission of oropharyngeal flora (Gorski et al., 2021). The patient should wear a mask if they are unable to turn their head away from the site or based on facility policy. Many facilities have all sterile dressing supplies gathered in a single package.
11. Put on gloves. Palpate the location of the port; palpate and note the location of the outflow channel where the catheter is attached to the port body (refer to Figure 1). Assess the site. Note the status of any surgical incisions that may be present. Remove your gloves and discard them. Perform hand hygiene.	Knowledge of location and boundaries of the port are necessary to access the site safely. Orientation of the needle bevel in the opposite direction from the outflow channel is associated with a greater amount of protein removal during flushing of the port (Gorski et al., 2021).
12. Put on sterile gloves. Connect the needleless connector or end cap to the extension tubing on the noncoring needle. Using an antimicrobial swab, vigorously disinfect the connection surface and sides of each access site and allow them to dry. Insert a syringe with 10-mL normal saline into the needleless connector or end cap. Fill the extension tubing with normal saline and apply the clamp. Remove the syringe. Place it on the sterile field.	Port access is accomplished using sterile technique. Organisms on the skin can be introduced into the tissues or the bloodstream with the needle. VAD administration set entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness. Priming the extension tubing removes air from the tubing and prevents administration of air when connected to the port.
13. Use a single-use sterile applicator containing sterile antiseptic solution to cleanse the site with >5% chlorhexidine in alcohol solution or the solution identified in facility policy, making sure to cover at minimum the area to be covered with the dressing. Follow the manufacturer's directions for use to determine product application process and dry times (Gorski et al., 2021). Allow the antiseptic to dry naturally; do not wipe, fan, or blow on the skin (Gorski et al., 2021).	Cleansing is necessary because organisms on the skin can be introduced into the tissues or the bloodstream with the needle. Use of >0.5% chlorhexidine in alcohol solution is preferred for skin antisepsis (Gorski et al., 2021; Sarani et al., 2018). If there is a contraindication to alcoholic chlorhexidine solution, tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may instead be used (Gorski et al., 2021; Mimoz et al., 2015; O'Grady et al., 2017).
14. Pick up the noncoring needle and extension tubing. Coil the extension tubing into the palm of your hand. Using your nondominant hand, locate the port by palpating the edges through the patient's skin. Hold the port stable, keeping the skin taut (Figure 2).	Keeping the equipment contained in your hand prevents accidental contact with nonsterile surfaces and resulting contamination. The edges of the port must be palpated so that the needle can be inserted into the center of the port. Hold the port with your nondominant hand so that the needle is inserted into the port with your dominant hand.
15. Visualize the center of the port. Insert the needle with the needle bevel oriented in the opposite direction from the outflow channel where the catheter is attached to the port body. Holding the needle at a 90-degree angle to the skin, insert the needle through the skin into the port septum (Figure 3) until the needle hits the back of the port (Figure 4).	To function properly, the needle must be located in the middle of the port and inserted to the back internal wall of the port. Orientation of the needle bevel in the opposite direction from the outflow channel is associated with a greater amount of protein removal during flushing of the port (Gorski et al., 2021). Use of a noncoring needle of a length that allows the external components (e.g., wings) to sit level with the skin and securely within the port (needle touches bottom of port upon insertion) reduces the risk of needle dislodgement after access (Gorski et al., 2021).
16. Using an antimicrobial swab, vigorously disinfect the connection surface and sides of each access site and allow them to dry. Alert: if an antimicrobial locking solution was used when the port was last locked, withdraw the solution from the port prior to flushing and discard (Gorski et al., 2021). Insert the syringe with normal saline. Open the clamp on the 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.	VAD administration set entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness. Flushing an antibiotic solution into the patient's blood stream could increase development of antibiotic resistance and other adverse effects (Gorski et al., 2021). If the needle is not inserted onto the port correctly, fluid will leak into the tissue, causing the tissue to swell and producing signs of infiltration. Flushing without resistance is also a sign that the needle is inserted correctly.
17. Slowly pull back on the syringe plunger to aspirate for blood return (Figure 5). Do not allow blood to enter the syringe. If positive, instill the solution over 1 minute or by using a pulsatile flushing technique of 10 short boluses of 1 mL interrupted by brief pauses; flush the line according to facility policy. Remove the syringe. Using an antimicrobial swab, vigorously scrub the needleless connector or end cap on the extension tubing and allow them to dry. Insert the locking solution syringe and instill the volume of solution designated by facility policy over 1 minute or according to facility policy. Prevent connection/disconnection reflux by using the appropriate sequence for flushing, clamping, and disconnecting determined by the type of needleless connector being used (refer to Box 16-4 in Skill 16-5) (Gorski et al., 2021). Alternatively, if IV fluid infusion is to be initiated, do not flush with heparin.	The presence of a blood return upon aspiration and lack of resistance when flushing indicate patency of the VAD (Gorski et al., 2021). Not allowing blood to enter the syringe ensures that the needle will be flushed with pure saline. A pulsatile flushing technique of 10 short boluses of 1 mL interrupted by brief pauses may be more effective in removing solid deposits (e.g., fibrin, drug precipitate, intraluminal bacteria) (Gorski et al., 2021). VAD administration set entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness. The action of the positive pressure end cap is maintained with the appropriate sequence for flushing, clamping, and disconnecting determined by the type of needleless connector in use (Gorski et al., 2021). Clamping prevents air from entering the CVAD. Vascular access devices are locked after completion of the flush solution at each use to decrease the risk of occlusion (Gorski et al., 2021). CVADs should be locked with either a heparin solution (10 units/mL) or preservative-free 0.9% sodium chloride after each intermittent use, according to the directions for use for the specific CVAD and needleless connector (Gorski et al., 2021).
18. 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 your other hand (Figure 6).	A gripper facilitates needle insertion and needs to be removed before application of the dressing.
19. Apply antimicrobial dressing (chlorhexidine-impregnated) at the insertion site, based on facility policy. Apply the skin protectant to the same area, avoiding direct application to the antimicrobial dressing or the insertion site, and allow it to dry. Apply the securement/stabilization device, if used, and/or the TSM dressing, centering it over the insertion site. Refer to Skill 16-7.	Use chlorhexidine-impregnated dressing for all patients ages 18 years and older with short-term nontunneled CVADs (Gorski et al., 2021). Skin protectant under the antimicrobial dressing interferes with the action of the dressing. Skin protectant improves adhesion of the dressing and protects the skin from damage and irritation when the dressing is removed. The TSM dressing allows easy visualization and protects the site. Stabilization/securing devices preserve the integrity of the access device, minimize catheter movement at the hub, and prevent catheter dislodgement and loss of access (Gorski et al., 2021). Some stabilization devices also act as a site dressing.
20. Apply a passive disinfection cap to the needleless connector or end cap on the extension tubing (Figure 7). Remove your gloves and perform hand hygiene.	Passive disinfection caps contain an antiseptic-impregnated sponge that dispenses the antiseptic over the connector's top and threads and protects the hub from contamination by touch or airborne sources (Gorski et al., 2021; Stango et al., 2014). Removal of gloves reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
21. Label the dressing with the date, time of change, and your initials. Apply an IV securement/stabilization device if not already in place as part of the dressing, as indicated, based on facility policy. Explain to the patient the purpose of the device and the importance of safeguarding the site when using the extremity.	Other personnel working with the infusion will know what type of device is being used, the site, and when the dressing was last changed. The weight of the tubing and/or tugging on the tubing could cause catheter dislodgement. These systems are recommended for use on all venous access sites, and particularly central venous access sites, to preserve the integrity of the access device, minimize catheter movement at the hub, and prevent catheter dislodgement and loss of access (Gorski et al., 2021). Some devices also act as a site dressing and may already have been applied.
22. Remove equipment. Ensure the patient's comfort. Lower the bed, if it is not in the lowest position.	Positioning promotes patient comfort and safety.
23. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when the port has been accessed with minimal discomfort to the patient, the patient has not experienced trauma to the site or infection, and the patient has verbalized an understanding of care associated with the port.