Implanted Port Use

Implementation

Assisting With Insertion

Conduct a preprocedure verification to make sure that all relevant documentation, related information, and equipment are available and correctly identified to the patient’s identifiers.¹⁹
Confirm that informed consent has been obtained and that the signed consent form is in the patient’s medical record.²⁰^,²¹^,²²^,²³^,²⁴
Gather and prepare the necessary equipment and supplies.
Use an insertion checklist to adhere to infection prevention and safety practices during insertion.⁶^,⁸^,⁹^,¹⁰^,²⁴^,²⁵ Stop the procedure immediately if you observe any breaks in sterile technique.
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Confirm the patient’s identity using at least two patient identifiers.³³
Provide privacy.³⁴^,³⁵^,³⁶^,³⁷
Reinforce to the patient the practitioner’s explanation to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.²¹^,²²^,²³^,²⁴^,³⁸
Answer questions about movement restrictions, cosmetic concerns, and management regimens to allay the patient’s fears.
Administer an antibiotic, if prescribed, following safe medication administration practices.¹⁵^,¹⁷^,³⁹^,⁴⁰
Close the door to the room, and place a sign on the door that reads STERILE PROCEDURE IN PROGRESS. DO NOT ENTER.⁵^,¹²
Raise the bed to waist level before providing care to prevent caregiver back strain.⁴¹
Put on a cap and mask.⁵^,⁶
Place a fluid-impermeable pad under the patient to protect the bed from becoming soiled.
If the intended site is visibly soiled, clean the area with antiseptic soap and water.¹²^,²⁵
Remove excess hair from the intended insertion site, if needed, using single-patient-use scissors or disposable-head surgical clippers to facilitate dressing application.¹²^,²⁵
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Establish a sterile field on a table, and assemble supplies on the sterile field.
Label all medications, medication containers, and other solutions on and off the sterile field.⁴²^,⁴³
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Put on a gown and sterile gloves to comply with maximal barrier precautions.⁵^,⁶^,⁸^,¹⁰^,⁴⁴^,⁴⁵^,⁴⁶
Assist the practitioner as needed with administration of a local anesthetic. Keep in mind that a general anesthetic may occasionally be administered instead.⁴⁷
Prepare the insertion site using chlorhexidine-based antiseptic sponges, and allow it to dry completely.⁶^,⁹
Before beginning the procedure, the practitioner will put on a mask and a cap, perform hand hygiene, put on a sterile gown and gloves, and drape the patient from head to toe to comply with maximal barrier precautions.⁶^,⁹ During the procedure, you may be responsible for handing equipment and supplies to the practitioner.
Conduct a time-out immediately before the procedure starts to perform a final assessment that the correct patient, site, positioning, and procedure are identified and, as applicable, all relevant information and necessary equipment are available.¹⁹
If requested by the practitioner, using sterile technique, hand the practitioner the ultrasound device with the sterile probe cover and apply sterile ultrasound gel. The practitioner locates the vessel using the device to reduce the risk of insertion-related complications.⁴⁸^,⁴⁹
Assist as needed while the practitioner inserts the device. The practitioner makes a small incision and introduces the guide wire and catheter, which the practitioner typically advances into the subclavian vein, terminating in the superior vena cava. After X-ray or fluoroscopy confirms correct placement of the catheter tip, the practitioner creates a subcutaneous pocket over a bony prominence in the chest wall. The practitioner then tunnels the catheter to the pocket. Next, the practitioner connects the catheter to the reservoir, places the reservoir in the pocket, flushes it with preservative-free saline solution, and then instills heparin flush solution. Lastly, the practitioner sutures the reservoir to the underlying fasciae and closes the incision with the preferred skin closure device.
Access the implanted port with a noncoring needle and attach the primed extension set and needleless connector as ordered. If available at your facility, place a disinfectant-containing end cap on the needleless connector.⁵⁰^,⁵¹
Apply a chlorhexidine-impregnated sponge dressing, if required by your facility, to reduce the risk of central line–related bloodstream infection.⁵⁰
Apply a sterile occlusive dressing over the site.⁴
Discard used supplies in appropriate receptacles.⁴⁶^,⁵²
Return the bed to the lowest position to prevent falls and maintain patient safety.⁵³
Remove and discard your personal protective equipment.⁴⁴^,⁴⁶^,⁵²
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Document the procedure.⁵⁴^,⁵⁵^,⁵⁶^,⁵⁷^,⁵⁸

Accessing a Top-Entry Port

Review the patient’s medical record to determine the type (such as a power-injectable device or single or double port) and location of the implanted port, whether it has been previously accessed, and the patient’s response to the procedure. If a power injection will be performed using the implanted port, the non-coring Huber needle used to access the port must be identified as power-injection compatible.¹²
Ensure that placement of the catheter tip has been confirmed.
Verify the practitioner’s order, if required by your facility.
Determine whether the patient has a history of allergies or contraindications to the antiseptic, anesthetic, or prescribed solution.¹²
Gather and prepare the necessary equipment and supplies.
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Confirm the patient’s identity using at least two patient identifiers.³³
Provide privacy.³⁴^,³⁵^,³⁶^,³⁷
Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.²¹^,²²^,²³^,²⁴^,³⁸
Assess the patient’s pain tolerance and discuss the patient’s preferences for using a local anesthetic before accessing the port.⁴^,⁵^,¹²
Administer a topical anesthetic, as needed and prescribed, following safe medication administration practices.⁵^,¹²^,³⁹^,⁴⁰^,⁴⁰^,⁵⁹^,⁶⁰
If appropriate, raise the bed to waist level before providing care to prevent caregiver back strain.⁴¹
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Put on gloves to comply with standard precautions.⁴⁴^,⁴⁵^,⁴⁶
Position the patient for comfort with head turned away from the implanted port.⁵^,¹²^,⁶¹ Alternatively, put a mask on the patient.⁶¹
Assess the skin overlying the port and the tissue surrounding the port.⁵ Observe for signs of infection or thrombosis. Don’t insert the noncoring needle if erythema, inflammation, exudate, supraclavicular swelling, or venous distention is present. Instead, notify the practitioner.
Palpate and locate the septum; assess for device rotation.⁵^,¹²^,⁶¹
Remove and discard your gloves.⁴⁴^,⁴⁶^,⁵²
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Put on a mask.⁵^,¹²^,⁴⁴^,⁶¹
Open the supplies and prepare a sterile field using a sterile drape. Using sterile technique, place the supplies on the sterile field.⁵^,¹²
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Put on sterile gloves.⁵^,¹²^,⁴⁴^,⁴⁶
Clean the implanted port access site with an antiseptic solution following the manufacturer’s instructions. For chlorhexidine (preferred), apply with an applicator using a vigorous side-to-side motion for 30 seconds, and allow to dry completely. For povidone-iodine solution, apply using a swab. Begin at the intended insertion site, moving outward in concentric circles. Allow the solution to dry completely, typically at least 2 minutes.⁵^,¹²^,²⁵
Attach a needleless connector to the extension set, which is connected to the noncoring needle.⁵^,¹²
Maintaining sterility of the syringe tip, attach a syringe containing preservative-free normal saline solution to the needleless connector and prime the extension set and noncoring needle with preservative-free normal saline solution.⁵^,¹² Clamp the extension tubing.⁶¹
With your nondominant hand, palpate and stabilize the implanted port.⁵^,¹²
Grasp the noncoring needle with your dominant hand, and insert the noncoring needle perpendicular to the skin through the septum of the port until the needle tip comes in contact with the back of the port.⁵^,¹²^,⁶¹ Consider orienting the bevel of the noncoring needle in the opposite direction from the outflow channel where the catheter is attached to the port body; this bevel orientation allows for removal of a greater amount of protein when flushing.⁴^,⁶²
Unclamp the extension tubing. Aspirate for blood return that’s the color and consistency of whole blood to confirm device patency. If you don’t obtain any blood return, take steps to locate an external cause of obstruction.¹³
If you obtain blood return, slowly inject preservative-free normal saline solution into the port. Use a minimum volume of twice the internal volume of the catheter system. Don’t forcibly flush the device; further evaluate the device if you meet resistance.⁵^,¹²^,¹³ Troubleshoot the system and notify the patient’s practitioner if you can’t confirm patency.

NURSING ALERT If you can’t aspirate blood return to confirm needle placement, have the patient change positions, raise the arms, cough, or perform the Valsalva maneuver to increase thoracic pressure and increase yield for a blood return. If you still can’t obtain blood return or confirm needle placement, clamp the tubing and notify the practitioner before proceeding.¹² (See Troubleshooting an implanted port.)

Secure the noncoring needle with sterile tape with an engineered stabilization device, if available. An engineered stabilization device is recommended to reduce vascular access device motion, which increases the risk of unintentional catheter dislodgement and complications requiring premature catheter removal.⁶¹^,⁶³ Support the wings of the noncoring needle (if present) with sterile gauze; make sure the gauze doesn’t prevent visualization of the needle insertion site.⁵^,¹²
If applicable, place a chlorhexidine-impregnated sponge dressing beneath the needle. The edges of the radial slit of the sponge dressing must touch to maximize antimicrobial action. Always follow the manufacturer’s directions.⁶^,⁶⁸^,⁶⁹^,⁷⁰
Apply a sterile transparent semipermeable dressing over the insertion site, noncoring needle, and upper portion of the extension tubing to maintain sterility of the system and enable visualization of the needle and insertion site.⁵^,¹²
Perform a vigorous mechanical scrub of the needleless connector device for at least 5 seconds with an antiseptic pad and allow it to dry completely.⁵^,⁸^,¹²^,⁵⁰
Attach the primed IV administration set to the needleless connector. Trace the tubing from the patient to its point of origin to make sure that you are attaching the tubing to the correct port before beginning the infusion.¹⁵^,⁷¹^,⁷² Route the tubing in a standardized direction if the patient has other tubing and catheters that have different purposes. Label the tubing at both the distal end (near the patient connection) and proximal end (near the source container) to reduce the risk of misconnection if multiple IV lines will be used.¹⁵ Begin infusion therapy, as ordered. Alternatively, lock the device with prescribed locking solution⁵^,¹³ and place a disinfectant-containing end cap on the needleless connector, if available, to reduce the risk of vascular catheter-associated infection.⁵¹^,⁵²
Label the dressing with the current date or the date the dressing is due to be changed, as directly by your facility.¹²
Discard used supplies in appropriate receptacles.⁴⁵^,⁵¹
Return the bed to the lowest position to prevent falls and maintain patient safety.⁵²
Remove and discard your gloves and mask⁴³^,⁴⁵^,⁵¹ and perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Document the procedure.⁵³^,⁵⁴^,⁵⁵^,⁵⁶^,⁵⁷

Obtaining a Blood Sample

Verify the practitioner’s order for blood sampling.⁷³
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Confirm the patient’s identity using at least two patient identifiers.³³
Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.²¹^,²²^,²³^,²⁴^,³⁸
If fasting is required before testing, verify that the patient has fasted. If any other preparations (such as administering or holding medication) are required before testing, make sure that they were completed.⁷³
Raise the bed to waist level before providing care to prevent caregiver back strain.⁴¹
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Unless contraindicated, place the patient in the supine position with head slightly elevated to allow for optimal access.
If they aren’t already marked clearly, label the preservative-free normal saline flush syringes.
If you’re using a needleless blood collection tube holder with the discard method, label the discard blood collection tube to prevent confusing it with the actual specimen. If you’re using a syringe with the discard method, label one of the preservative-free normal saline flush syringes as a flush-and-discard syringe and use it to both flush the port and obtain the discard sample to avoid re-accessing the needleless connector.⁷³
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Put on gloves; also put on protective eyewear or a mask with face shield if splashing is likely.⁴³^,⁴⁵^,⁴⁶
Locate the noncoring needle extension tubing.⁴
Stop infusions that are infusing through the port before drawing the blood sample to prevent inaccurate blood test results. Research hasn’t established the appropriate length of time for stopping fluid flow; one study suggests a 10-minute wait time before drawing the sample.⁷³ Trace the tubing from the patient to its point of origin to make sure you’ve stopped the proper infusion.⁷¹^,⁷² Close the clamp on the extension tubing, and clamp and disconnect the IV tubing, maintaining sterility. Cover the IV tubing end with a sterile cap.⁷³
Assess the skin overlying the port, the tissue surrounding the port, and the site of needle entry. Observe for signs of infection, thrombosis, device rotation, and skin erosion. Hold the procedure and call the practitioner if you observe any complications.⁷⁴
Close the clamp on the extension tubing.
If a disinfectant-containing end cap is covering the end of the needleless connector, remove and discard it.⁵⁰^,⁵¹
Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad and then allow it to dry completely.⁸^,⁵⁰^,⁷⁵
Maintaining the sterility of the syringe tip, attach a prefilled syringe containing preservative-free normal saline solution to the needleless connector. (Use a 10-mL syringe or a syringe specifically designed to generate lower injection pressure.) Unclamp the extension tubing and slowly aspirate for a blood return that is the color and consistency of whole blood. If you don’t obtain a blood return, take steps to locate an external cause of the obstruction.⁵^,¹²^,¹³
If you obtain a blood return, slowly inject preservative-free normal saline solution into the port. Use a minimum volume of twice the internal volume of the catheter system. Don’t forcibly flush the device; further evaluate the device if you meet resistance.⁵^,¹²^,¹³
Use the discard or push-pull method to obtain the blood sample.⁷³ If you’re obtaining a sample for blood cultures, see the "Blood culture sample collection" procedure.

Discard Method

Obtain a discard sample to clear the catheter’s dead space volume and remove any blood diluted with flush solution.
If you’re using a needleless blood collection tube holder: Reclamp the tubing, and then remove and discard the syringe in a puncture-resistant sharps disposal container.⁵² Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad; then allow it to dry completely.⁸^,⁵⁰^,⁷⁵ Attach the blood collection tube holder to the needleless connector, release the clamp, and engage the labeled discard blood collection tube. Limit the discard as directed by your facility to ensure that a minimal amount of blood is taken from the patient as waste.¹²
If you’re using a syringe: Use the attached syringe you used for flushing and aspirate the discard volume. Minimum discard volumes aren’t established, so limit discard volume as directed by your facility to ensure that a minimal amount of blood is taken from the patient as waste.¹²^,⁷³
Clamp the extension tubing, and then remove the labeled discard blood collection tube from the needleless blood collection tube holder, or remove the labeled discard syringe and discard it in a puncture-resistant sharps disposal container.⁴⁶^,⁵²
Obtain blood samples, as ordered. If you’re using a needleless blood collection tube holder, insert another blood collection tube into the needleless blood collection tube holder, unclamp the tubing, and follow the correct order of draw. If you’re using a syringe, perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad and allow it to dry completely,⁸^,⁵⁰ connect an empty syringe to the needleless connector, release the clamp, and withdraw the blood sample. Repeat the steps until you obtain all of the necessary blood samples.
Clamp the extension tubing and remove the needleless blood collection tube holder or the syringe.

Push-Pull Method

Using the attached syringe that you used for flushing, aspirate 4 to 6 mL of blood.⁷⁶
Keeping the syringe attached to the tubing, push to reinfuse the blood into the port.
Repeat the aspiration and reinfusion sequence three to five times (five cycles is most common).⁷³^,⁷⁶
Clamp the extension tubing, and then remove and discard the syringe in a puncture-resistant sharps disposal container.⁴⁶^,⁵²
Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad; then allow it to dry completely.⁸^,⁵⁰
Obtain blood samples, as ordered. If you’re using a needleless blood collection tube holder, attach the needleless blood collection tube holder to the needleless connector, release the clamp, and engage the blood collection tube into the needleless blood collection tube holder using the correct order of draw. If you’re using a syringe, connect an empty syringe to the needleless connector, release the clamp, and withdraw the blood sample. Repeat the steps until you obtain all necessary blood samples.
Clamp the catheter and remove the needleless blood collection tube holder or the syringe.

Completing the Procedure

Label the samples with the patient’s name, identification number, name of the test, and date and time of collection in the presence of the patient to prevent mislabeling.⁷³^,⁷⁷
Place all blood collection tubes in a laboratory biohazard transport bag and send them to the laboratory with a completed laboratory request form.⁴⁶
Discard used supplies in appropriate receptacles.⁴⁵^,⁵¹
Remove and discard your gloves and mask⁴³^,⁴⁵^,⁵¹ and perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Document the procedure.⁵³^,⁵⁴^,⁵⁵^,⁵⁶^,⁵⁷

Administering a Bolus Injection

Review the patient’s medical record to determine the location of the implanted port, whether it’s currently accessed with a noncoring needle, and the patient’s response to previous procedures.
Ensure that the placement of the catheter tip has been confirmed.
Compare the medication label with the order in the patient’s medical record.¹⁵^,¹⁷^,⁴¹^,⁶⁰^,⁷⁸
Check the patient’s medical record for an allergy or contraindication to the prescribed medication. If an allergy or contraindication exists, don’t administer the medication; instead, notify the practitioner.¹⁵^,¹⁷^,⁴⁰^,⁶⁰^,⁷⁸
Check the expiration date on the medication. If the medication is expired, return it to the pharmacy and obtain new medication.¹⁵^,¹⁷^,⁴⁰^,⁶⁰^,⁷⁸
Visually inspect the solution for particles, discoloration, or other loss of integrity; don’t administer the medication if its integrity is compromised.¹⁵^,¹⁷^,⁴⁰^,⁶⁰^,⁷⁸
Discuss any unresolved concerns about the medication with the patient’s practitioner.¹⁵^,¹⁷^,⁴⁰^,⁶⁰^,⁷⁸
Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route to reduce the risk of medication errors.¹⁵^,¹⁷^,⁴⁰^,⁶⁰^,⁷⁸

NURSING ALERT Some bolus injections are considered high-alert medications because they can cause significant patient harm when used in error.⁷⁹ If required by your facility, before administering a bolus injection, have another nurse perform an independent double-check to verify the patient’s identity and make sure you have the correct medication in the prescribed concentration, the medication’s indication corresponds with the patient’s diagnosis, the dosage calculations are correct and the dosing formula used to derive the final dose is correct, and the prescribed route of administration is safe and proper for the patient.⁸⁰^,⁸¹

Review the patient’s baseline vital signs and observe for changes that may indicate a local or systemic infection.
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Confirm the patient’s identity using at least two patient identifiers.³³
Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.²¹^,²²^,²³^,²⁴^,³⁸
If the patient is receiving the medication for the first time, teach the patient and family (if appropriate) about potential adverse reactions and any other concerns related to the medication.⁸
If your facility uses a bar code technology, use it as directed by your facility.⁸¹
Raise the bed to waist level before providing care to prevent caregiver back strain.⁴¹
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Put on gloves to comply with standard precautions.⁴⁴^,⁴⁵^,⁴⁶
If a disinfectant-containing end cap is in place at the end of the needleless connector, remove and discard it.⁵⁰^,⁵¹
Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad; then allow it to dry completely.⁸^,⁵⁰^,⁷⁵
Maintaining the sterility of the syringe tip, attach a prefilled syringe containing preservative-free normal saline solution to the needleless connector. (Use a 10-mL syringe or a syringe specifically designed to generate lower injection pressure.) Unclamp the extension tubing and slowly aspirate for a blood return that is the color and consistency of whole blood. If you don’t obtain a blood return, take steps to locate an external cause of the obstruction.⁵^,¹²^,¹³
If you obtain a blood return, slowly inject preservative-free normal saline solution into the port. Use a minimum volume of twice the internal volume of the catheter system. Don’t forcibly flush the device; further evaluate the device if you meet resistance.⁵^,¹²^,¹³
Examine the skin surrounding the needle for signs of infiltration, such as swelling and tenderness. If you note these signs, stop the injection and intervene appropriately.
Remove and discard the saline syringe.⁴⁶^,⁵²
Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad; then allow it to dry completely.⁸^,⁵⁰^,⁷⁵
Maintaining the sterility of the syringe tip, connect the syringe with the medication for the IV bolus injection into the injection port of the needleless connector.¹³

NURSING ALERT After confirming patency of the vascular access device by using a 10-mL syringe (or a syringe specifically designed to generate lower injection pressure) filled with preservative-free normal saline solution, the medication can be administered by IV bolus injection in a syringe of appropriate size to measure and administer the required medication dose.¹³^,⁸² Don’t transfer the medication to a larger syringe.¹³

Inject the medication at the rate indicated on the label; consult with the pharmacist before injection if a rate isn’t present.⁵^,¹²
Remove the syringe from the needleless connector.
Thoroughly disinfect the needleless connector of the access tubing with an antiseptic pad.
Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad; then allow it to dry completely.⁸^,⁵⁰^,⁷⁵
While maintaining the sterility of the syringe tip, attach a prefilled syringe containing preservative-free normal saline solution to the needleless connector. (Use a 10-mL syringe or a syringe specifically designed to generate lower injection pressure). Unclamp the catheter and inject preservative-free normal saline solution into the catheter at the same rate of injection as the prescribed medication. Use the amount of flush solution needed to adequately clear the medication from the administration set lumen and the catheter. Don’t forcibly flush the device; further evaluate the device if resistance is met. Consider using a pulsatile flushing technique, because short boluses of the flush solution interrupted by short pauses may be more effective at removing deposits (such as fibrin, drug precipitate, and intraluminal bacteria) than a continuous low-flow technique. Alternatively, if the medication is incompatible with normal saline solution, use dextrose 5% in water (D₅W), followed by preservative-free normal saline solution. Don’t allow D₅W to remain in the catheter lumen, because it provides nutrients for biofilm growth.¹³
Remove and discard the syringe.⁴⁶^,⁵²
Proceed with locking the device, if necessary. Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad; then allow it to dry completely.⁸^,⁵⁰^,⁷⁵ While maintaining the sterility of the syringe tip, attach a syringe containing locking solution (such as a heparin lock solution) to the needleless connector.¹³ Slowly inject the locking solution.¹³
Close the clamp on the access tubing according to the type of needleless connector used to reduce blood reflux. For a positive-pressure needleless connector, clamp the catheter after disconnecting the syringe.⁵^,¹² For a negative-pressure needleless connector, maintain pressure on the syringe while clamping the catheter.⁵^,¹² For a neutral needleless connector, clamp the catheter before or after disconnecting the syringe.⁵^,¹² For an antireflux needleless connector, clamp the catheter and disconnect the syringe; specific clamping sequence isn’t required.⁸³^,⁸⁴
Place a new disinfectant-containing end cap, if available,⁵⁰^,⁵¹ or de-access the implanted port, if indicated.
Discard used supplies in appropriate receptacles.⁴⁵^,⁵¹
Return the bed to the lowest position to prevent falls and maintain patient safety.⁵²
Remove and discard your gloves.⁴³^,⁴⁵^,⁵¹
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Monitor the patient for adverse reactions to the prescribed medication.¹²^,⁸⁵
If the patient is receiving IV opioid medication, frequently monitor the patient’s respiratory rate, oxygen saturation level by pulse oximetry, end-tidal carbon dioxide level by capnography (if available), and sedation level using a standardized sedation scale to decrease the risk of adverse events associated with IV opioid use.⁸⁵^,⁸⁶ Explain the assessment and monitoring process to the patient and family. Tell them to alert a staff member if any breathing problem or sedation occurs.⁸⁵
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Document the procedure.⁵³^,⁵⁴^,⁵⁵^,⁵⁶^,⁵⁷

Administering a Continuous Infusion

Make sure that confirmation of the placement of the catheter tip has been obtained.
Verify the practitioner’s order for the type of infusion to be administered.
Review the patient’s baseline vital signs and observe for changes that may indicate a local or systemic infection.
Gather and prepare the necessary equipment and supplies
Compare the IV solution label with the order in the patient’s medical record.¹⁵^,¹⁷^,³⁹^,⁴⁰^,⁶⁰
Check the patient’s medical record for an allergy or contraindication to the prescribed solution or medication. If an allergy or contraindication exists, don’t administer the medication; notify the practitioner.¹⁵^,¹⁷^,³⁹^,⁴⁰^,⁶⁰
Discuss any unresolved concerns about the solution or medication with the patient’s practitioner.¹⁵^,¹⁷^,³⁹^,⁴⁰^,⁶⁰
Check the expiration date on the IV solution. If the solution is expired, return it to the pharmacy and obtain a new soliton.
Visually inspect the IV solution for particulates, discoloration, or other loss of integrity, and check the expiration date. Replace the solution if the integrity is compromised or if it’s expired.¹⁵^,¹⁷^,³⁹^,⁴⁰^,⁶⁰
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Confirm the patient’s identity using at least two patient identifiers.³³
Provide privacy.³⁴^,³⁵^,³⁶^,³⁷
Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.²¹^,²²^,²³^,²⁴^,³⁸
Raise the bed to waist level before providing care to prevent caregiver back strain.⁴¹
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Locate the noncoring needle extension tubing under the patient’s gown.
Assess the skin overlying the port, the tissue surrounding the port, and the site of needle entry. Observe for signs of infection, thrombosis, device rotation, and skin erosion. Hold the procedure and notify the practitioner if you observe any complications.
If your facility uses a bar code technology, use it as directed by your facility.
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Put on gloves to comply with standard precautions.⁴⁴^,⁴⁵^,⁴⁶
Close the clamp on the IV administration set tubing, remove the protective cover from the administration set’s spike and the IV infusion container, insert the spike into the solution container, and hang the container on an IV pole.⁵^,¹²
Prime the administration set tubing of the IV administration set to purge the tubing of air. (See the "IV therapy preparation" procedure.)
If a disinfectant-containing end cap is in place, remove it from the end of the needleless connector and discard it.⁵⁰^,⁵¹
Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad; then allow it to dry completely.⁸^,⁵⁰^,⁷⁵
Maintaining the sterility of the syringe tip, attach a prefilled syringe containing preservative-free normal saline solution to the needleless connector. (Use a 10-mL syringe or a syringe specifically designed to generate lower injection pressure.) Unclamp the catheter and slowly aspirate for a blood return that is the color and consistency of whole blood. If you don’t obtain a blood return, take steps to locate an external cause of the obstruction.⁵^,¹²^,¹³ Have the patient change positions, raise the arms over the head, take a deep breath and hold it, or cough to increase intrathoracic pressure and increase yield for blood return.¹² If you still can’t obtain a blood return or confirm noncoring needle placement, notify the practitioner.
If you obtain a blood return, slowly inject preservative-free normal saline solution into the port. Use a minimum volume of twice the internal volume of the catheter system. Don’t forcibly flush the device; further evaluate the device if you meet resistance.⁵^,¹²^,¹³
Remove the syringe.
Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad; then allow it to dry completely.⁸^,⁵⁰^,⁷⁵
Connect and secure the IV administration set tubing of the prescribed IV solution to the needleless connector of the extension tubing.
Trace the tubing from the patient to its point of origin to make sure it’s connected to the proper port before beginning the infusion.¹⁵^,⁷¹^,⁷² Route the tubing in a standardized direction if the patient has other tubing and catheters that have different purposes. Label the tubing at both the distal end (near the patient connection) and proximal end (near the source container) to reduce the risk of misconnection if multiple IV lines will be used.⁷²
Following the directions for the specific infusion device, turn on the device and enter the desired infusion rate and volume according to the practitioner’s order.⁵^,¹²
Confirm that the infusion device’s display screen is displaying the correct information.
Set the correct electronic device parameters according to the practitioner’s orders and the manufacturer’s instructions.⁵^,¹² Make sure that the alarm limits are set properly, and that alarms are turned on, functioning properly, and audible to staff.⁸⁷^,⁸⁸^,⁸⁹
If the infusion is a high-alert medication,⁷⁹ have another nurse perform an independent double-check (if required by your facility) to verify the patient’s identity and to make sure that the correct medication is hanging in the prescribed concentration, the medication’s indication corresponds with the patient’s diagnosis, the dosage calculations and the dosing formula used to derive the final dose are correct, the route of administration is safe and proper for the patient, the pump settings are correct, and the infusion line is attached to the correct port.⁸⁰
Compare the results of the independent double-check with the other nurse, if required, and begin the infusion if there are no discrepancies. If discrepancies exist, rectify them before beginning the infusion.⁸⁰
Examine the skin surrounding the implanted port for signs of extravasation or infiltration, such as swelling and tenderness. If you note these signs, or if the patient complains of stinging, burning, or pain at the site, stop the infusion and intervene appropriately.⁶⁷
Label the IV tubing with the date of initiation or the date it’s due to be changed, as directed by your facility.¹⁵
Return the bed to the lowest position to prevent falls and maintain patient safety.⁵²
Discard used supplies in appropriate receptacles.⁴⁵^,⁵¹
Remove and discard your gloves and mask⁴³^,⁴⁵^,⁵¹ and perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Monitor the patient’s intake and output and electrolyte levels, as ordered, to promptly recognize fluid and electrolyte imbalances.¹⁷^,⁸⁵
Monitor the rate of infusion, site condition, and patency at a rate indicated by the prescribed infusion or patient factors.⁵^,¹²
Document the procedure.⁵³^,⁵⁴^,⁵⁵^,⁵⁶^,⁵⁷

Dressing Change

Review the patient’s medical record for information related to the implanted port and allergies to the planned antiseptic or any adhesives.¹²
Gather and prepare the necessary equipment and supplies.
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Confirm the patient’s identity using at least two patient identifiers.³³
Provide privacy.³⁴^,³⁵^,³⁶^,³⁷
Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.²¹^,²²^,²³^,²⁴^,³⁸
Raise the bed to waist level before providing care to prevent caregiver back strain.⁴²
Put on a mask.¹²
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Assemble the supplies on a sterile field.¹²
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Put on gloves to comply with standard precautions.⁴⁴^,⁴⁵^,⁴⁶
Assess the implanted port site for bleeding, redness, swelling, tenderness, induration, and drainage. Notify the practitioner of any concerns.¹²
Remove the existing dressing by lifting the edge of the dressing and gently pulling the dressing perpendicular to the skin toward the access site to prevent needle dislodgment and tearing or stripping of fragile skin.¹³
Discard the dressing in an appropriate receptacle.⁴⁶^,⁵²
If a chlorhexidine-impregnated sponge dressing is in place to provide sustained antimicrobial action at the insertion site, remove it and discard it in an appropriate receptacle.⁴⁶^,⁵²
Remove the engineered stabilization device (if used and appropriate) according to the manufacturer’s instructions, and then discard it in an appropriate receptacle.¹²
If you are changing the noncoring needle, deaccess the implanted port and then reaccess the port.

NURSING ALERT The noncoring needle should be changed at least every 7 days when the implanted port is being used for infusion.¹²

Remove and discard your gloves.¹²^,⁴⁶
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Put on sterile gloves.¹²
Clean the site with chlorhexidine using a back-and-forth motion for at least 30 seconds to provide skin antisepsis. Chlorhexidine is the preferred antiseptic.¹² If the patient is sensitive to chlorhexidine, use tincture of iodine, povidone-iodine, or alcohol swabs.⁷⁴ If you use povidone-iodine solution, apply it using swabs, and allow it to remain on the skin for at least 1½ minutes or, if necessary, a longer time until it dries. Take care not to dislodge the noncoring needle. Allow the area to air-dry completely.¹²
If used in your facility, place a chlorhexidine-impregnated sponge dressing beneath the noncoring needle according to the manufacturer’s instructions.²⁷
Apply a skin barrier solution according to the manufacturer’s instructions to reduce the risk of medical adhesive–related skin injury. Don’t use compound tincture of benzoin, because it may increase the bonding of adhesives to the skin, causing skin injury when removal of the adhesive-based engineered stabilization device occurs. Don’t apply skin barrier solution beneath the chlorhexidine-impregnated sponge dressing or the gel component of the dressing (if used).³²
Secure the noncoring needle and tubing with an engineered stabilization device, if available and used at your facility.¹² Guidelines recommend using an engineered stabilization device because it reduces vascular access device motion; such motion increases the risk of unintentional catheter dislodgment and complications that can lead to the need for premature catheter removal.⁶³
Support the wings of the noncoring needle with sterile gauze or foam, if needed; make sure that the gauze doesn’t prevent visualization of the needle insertion site.²⁶
Apply a sterile transparent semipermeable dressing over the insertion site, noncoring needle, and upper portion of the extension tubing to maintain the sterility of the system while enabling visualization of the needle and insertion site.¹² Alternatively, apply a sterile 4" × 4" (10 cm × 10 cm) gauze dressing in place of the semipermeable dressing.¹²^,⁴⁶ If the patient has fragile skin, use dressings and tape specially formulated for fragile skin to prevent skin stripping and tearing during removal.⁹⁰
Label the dressing with the current date or the date the dressing is next due to be changed, as directed by your facility.¹²
Return the bed to the lowest position to prevent falls and maintain patient safety.⁵²
Discard used supplies in appropriate receptacles.⁴⁵^,⁴⁶
Remove and discard your gloves and mask.¹²^,⁴⁶
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Document the procedure.⁵³^,⁵⁴^,⁵⁵^,⁵⁶^,⁵⁷

Assisting With Removal

Review the patient’s medical record to determine the type and location of the implanted port, the patient’s response to previous procedures, any history of allergies or medical conditions that would contraindicate heparin use, and the patient’s baseline vital signs and any changes that may indicate a local or systemic infection.
Gather and prepare the necessary equipment and supplies.
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Confirm the patient’s identity using at least two patient identifiers.³³
Provide privacy.³⁴^,³⁵^,³⁶^,³⁷
Assess the cognitive levels of the patient and family as well as their readiness and ability to process information. Be aware that the ability to learn may be impaired as a result of age, stress, or anxiety.
Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.²¹^,²²^,²³^,²⁴^,³⁸
Raise the bed to waist level before providing care to prevent caregiver back strain.⁴¹
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Locate the noncoring needle extension tubing under the patient’s gown.
Assess the skin surrounding the implanted port and the noncoring needle for signs of infection, thrombosis, device rotation, skin erosion, and other complications. Stop the procedure, and notify the practitioner if you observe any signs of complications.⁷⁴
Establish a clean work area, and open the supplies using sterile technique.
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Put on gloves to comply with standard precautions.⁴⁴^,⁴⁵^,⁴⁶ If the implanted port has an IV solution infusing, trace the tubing from the patient to the point of origin to ensure that you’re handling the correct tubing,⁷¹ close the clamp on the extension tubing, stop the infusion, and then disconnect the IV tubing while maintaining sterility. If you’re replacing the noncoring needle, cover the IV tubing end with a sterile cap for the next IV infusion. Alternatively, if a disinfectant-containing end cap is in place, remove it from the end of the needleless connector.⁵⁰^,⁵¹
Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad. Allow it to dry completely.⁸^,⁵⁰^,⁷⁵
While maintaining sterility of the syringe tip, attach a prefilled syringe containing preservative-free normal saline solution to the needleless connector. (Use a 10-mL syringe or a syringe specifically designed to generate lower injection pressure.) Unclamp the catheter and slowly aspirate for a blood return that’s the color and consistency of whole blood. If you can’t obtain a blood return, take steps to locate an external cause of obstruction.⁵^,¹²^,¹³ If you can’t obtain a blood return and needle placement is correct, don’t proceed; instead, clamp the tubing and notify the practitioner immediately to ensure prompt intervention. Diagnostic tests may be required to identify the cause of internal obstruction.¹³
If you obtain a blood return, slowly inject preservative-free normal saline solution into the catheter. Use a minimum volume of twice the internal volume of the catheter system. Don’t forcibly flush the device; further evaluate the device if you meet resistance.⁵^,¹²^,¹³
Inspect the skin surrounding the noncoring needle for signs of infiltration or extravasation, such as swelling and tenderness.
Close the clamp on the extension tubing.
Remove and discard the syringe.⁴⁶^,⁵²
Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad. Allow it to dry completely.⁴⁶^,⁵²
While maintaining sterility of the syringe tip, attach the syringe of prescribed locking solution to the needleless connector, unclamp the extension tubing, and then slowly inject the solution.⁵^,¹²^,¹³ Use a volume of locking solution equal to the internal volume of the catheter and add-on devices plus 20%; follow the catheter manufacturer’s instructions for use.¹³
To reduce blood reflux, follow the appropriate clamping sequence according to the type of needleless connector that you used. For a positive-pressure needleless connector, clamp the device after disconnecting the syringe.⁵^,¹² For a negative-pressure needleless connector, maintain pressure on the syringe plunger while closing the clamp on the device or extension set before disconnecting the syringe.⁵^,¹² For a neutral needleless connector, clamp the device before or after disconnecting the syringe.⁵^,¹² For an antireflux needleless connector, clamp the catheter and then disconnect the syringe; a specific clamping sequence isn’t required.⁸³^,⁸⁴
Remove the existing semipermeable transparent dressing carefully while stabilizing the port and noncoring needle. Remove the dressing by pulling the dressing perpendicular to the skin gently toward the insertion site to prevent the skin from tearing or stripping.⁵^,¹²^,⁹⁰
Visually inspect the needle insertion site and surrounding skin, and note the presence or absence of redness, swelling, drainage, or tenderness. Notify the practitioner of any signs of skin breakdown, infection, infiltration, extravasation, or occlusion.⁶^,¹²
With your nondominant hand, stabilize the port reservoir between your thumb and forefinger on the overlying skin.¹²
Grasp the noncoring needle with your dominant hand, holding the hub of the needle between your thumb and forefinger, and remove the device.¹²
Engage the safety mechanism and then discard the needle in a puncture-resistant sharps container.¹²^,⁴⁶^,⁵²
Blot the needle insertion site with a sterile gauze pad, and apply a sterile gauze dressing if bleeding occurs.¹²
Discard used supplies in appropriate receptacles.⁴³^,⁴⁵^,⁵¹
Return the bed to the lowest position to prevent falls and maintain patient safety.⁵²
Remove and discard your gloves.⁴³^,⁴⁵^,⁵¹
Perform hand hygiene.⁶^,¹⁰^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²
Determine whether the patient or caregiver has any concerns.
Document the procedure.⁵³^,⁵⁴^,⁵⁵^,⁵⁶^,⁵⁷

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Standard 13. Medication verification. Infusion therapy standards of practice. (8th ed.) (2021). Journal of Infusion Nursing, 44, S46–S49. (Level VII)
Institute for Safe Medication Practices (ISMP). (2015). Safe practice guidelines for adult IV push medications. https://www.ismp.org/guidelines/iv-push (Level VII)
HullG. J., et al. (2018). Quantitative assessment of reflux in commercially available needle-free IV connectors. Journal of Vascular Access, 19, 12–22. (Level VI)
JasinskyL. M., & WursterJ. (2009). Occlusion reduction and heparin elimination trial using an antireflux device on peripheral and central venous catheters. Journal of Infusion Nursing, 32, 33–39. (Level VI)
Centers for Medicare and Medicaid Services. (2014). Requirements for hospital medication administration, particularly intravenous (IV) medications and post-operative care of patients receiving IV opioids. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-15.pdf
The Joint Commission. (2021). Standard PC.01.02.07. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
GrahamK. C., & CvachM. (2010). Monitor alarm fatigue:
Standardizing use of physiological monitors and decreasing nuisance alarms
. American Journal of Critical Care, 19(1), 28–37. https://doi.org/10.4037/ajcc2010651
The Joint Commission. (2021). Standard NPSG.06.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
The Joint Commission. (2013). Sentinel event alert 50: Medical device alarm safety in hospitals. https://www.jointcommission.org/assets/1/6/SEA_50_alarms_4_26_16.pdf (Level VII)
LeBlancK., et al. (2013). International skin tear advisory panel:
A tool kit to aid in the prevention, assessment, and treatment of skin tears using a simplified classification system
. Advances in Skin & Wound Care, 26, 459–476. (Level IV)
Standard 43. Administration set management. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44(Suppl. 1), S123–S125. (Level VII)
Standard 52. Air embolism. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44(Suppl. 1), S160–S161. (Level VII)

section name header

Introduction ⬇

Equipment ⬆ ⬇

Preparation of Equipment ⬆ ⬇

Implementation ⬆ ⬇

Special Considerations ⬆ ⬇

Patient Teaching ⬆ ⬇

Complications ⬆ ⬇

Documentation ⬆ ⬇

References ⬆