port-a-cath

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Written: 10/87 Nursing Policy: P-81 Reviewed: 1/88; LSUHSC-Shreveport, LA Revised: 1/89; 2/90; 1/91; 5/92; 8/93; 7/95; 8/97; 11/99; Revised: 7/04; 10/06; 8/09; 11/09 ______________________________________________________________________________

IMPLANTABLE PORTAL ACCESS DEVICE

PURPOSE: To permit repeated access for short or long-term infusions of medications, blood products, nutritional and other fluids, such as bolus injections, and venous blood sampling.

DEFINITIONS: 1. Implantable Portal Access Device: Totally implantable venous portal systems which allow

intravenous access for blood sampling and delivery of medications and fluids.

2. Bolus: usually refers to a technique for rapid intravenous injection of a concentration or amount of drug.

3. Normal Saline Flush: Sterile 0.9% Sodium Chloride Injection

4. Heparinized Saline Flush: (Heparin 100 units/ml) POLICY: 1. Physician’s Orders A.

B.

Adult Patients An order shall be written by the physician for the use of the device for blood sampling, bolus injections, long or short-term infusions of drugs, fluids, nutritional fluids, and blood products. Pediatric Patients All pediatric patients shall have separate, individualized physician orders that specify the fluid amounts, (saline flush, heparin flush, medications) which will be administered.

2. Patient/Family Education Prior to insertion of the device, the patient/family/significant other shall be educated regarding (education shall be documented in the medical record):

A. B. C. D. E.

What the device is and how it works. The purpose of the device in the patient’s plan of care. Activity restrictions. How to care for the site. And given a copy of the Central Line Infection Prevention Education Sheet.

3. Patient Home Care Instructions

P-81: Implantable Portal Access Device of 14 Port-A-Cath, P.A.S. Port, Life Port

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If the patient is to be discharged with an implantable portal access device in place, the patient shall be given instructions on home care prior to discharge. These instructions shall include at least:

A. B. C. D. E.

Unless the device is accessed (needle or tubing attached), no special care is needed. If the patient is to be discharged with an accessed portal device (needle and tubing attached), the physician must be aware that the port is accessed on discharge and why, and this information must be documented in the medical record. The site shall be covered with a bio-occlusive (transparent impermeable) dressing and the patient and significant other /family instructed to keep the dressing clean and dry and not to attempt to cut, remove and/or otherwise alter the dressing or access in any way. The site shall be regularly inspected for signs and symptoms of infection such as redness, leakage, purulent drainage, bruising, or tenderness and the patient instructed to watch for fever and generalized tiredness. Should any of these occur, the physician/clinic should be notified immediately. The physician should be consulted for instruction on any limitations of activity which may cause problems with the port. Patient Instruction Handout (Appendix A).

4. Competent RNs Performance Only registered nurses who have competency validated may perform the following procedures with Implantable Access Devices:

A. B. C. D.

flush the system. infuse medications, IV solutions, and blood products. blood sampling. deaccess needle from port

Note: Competency validation includes assessment by a qualified observer of the necessary knowledge, skills, and ability to perform said procedure, as well as appropriate documentation in the file of the registered nurse who performs the procedure. See Nursing Policy: N-38, Competency Assessment, for additional information.

5. Hand Hygiene Hands shall be washed with an antimicrobial soap before palpating, inserting, changing or dressing any intravascular device.

6. Administering IV fluids and Medications IV fluids and medications shall be administered via a controlled infusion device.


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Never exceed 40 psi pressure when delivering agents through the system.

7. IV Tubing and Insertion Site a.

b. c.

IV tubing, non-coring needles, and dressings shall be changed at least every 96 hours utilizing aseptic technique. Tubing and dressings shall be dated and timed when changed with appropriate documentation in the medical record. The insertion site shall be cleansed with chlorhexidine gluconate or ChloraPrep as the first choice and povidone iodine as a second choice, and a light dressing applied if desired.

(See IC 22.0, Skin Preparation for Invasive Procedures Guideline in the Infection Control Manual online for additional information). Exception: Outpatient Clinic patients discharged on extended therapy or unless otherwise ordered by a physician.

8. Needle Usage Only 20 - 22 gauge non coring needles shall be used to access the system utilizing the following guidelines (Note: PowerLoc Safety Winged Infusion Needles shall be used with the Power Port Implantable Port):

a. b. c. d.

Ninety-degree needles shall be used for bolus or continuous infusions. The needle shall be inserted perpendicular to the portal septum. The needle shall never be tilted or rocked once the port has been entered. Positive pressure shall be maintained while clamping the tubing prior to withdrawing needle from the port to prevent reflux.

9. Inspection of Insertion Site The insertion site shall be palpated for tenderness through the intact dressing at least every eight hours. If tenderness develops, if there is fever with no obvious source, or symptoms of local and/or blood stream infection occur, the site shall be visually inspected and symptoms reported promptly to the physician.

10. Checking Patency Prior to Administration The system shall be checked for patency (blood return) prior to administration of any fluids, medications, or blood. The needle shall be inside the portal chamber and against the needle stop before starting the injection for infusion.

11. Blockage Unusually high resistance encountered while administering any agent through the system may indicate blockage. The physician shall be notified immediately when this occurs, and


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the administration of the fluid stopped. Blockage may be caused by: a.

b. c. d.

kinking of the catheter due to movement. lodging of the distal end against the wall of a vessel. occlusion by an intraluminal thrombus. growth of a fibrin sheath around the catheter end.

12. Flushing the System a. The system shall be flushed using sterile technique with 3 - 6 ccs normal saline

(using a 10 cc syringe) before and after medications are given.

b. The system shall be flushed with Heparinized Saline (100 units/ml) after each use. When there are extended periods between injections, infusions, or blood samplings the system shall be flushed using sterile technique with 5 cc Heparinized saline (using a 10 cc syringe) at least once every four weeks.

13. Nursing Documentation The registered nurse shall be responsible for appropriate documentation in the medical record to include patient education, the amount and type of any flush solution given through the port, as well as fluids administered.

EQUIPMENT AND SUPPLIES NEEDED FOR INFUSION OR INJECTION: 1. Sterile gloves 2. Chlorhexidine or Chloraprep prep stick 3. Sterile non-coring needles or PowerLoc Safety Winged Infusion Needles 4. IV administration set 5. Chemotherapy extension tubing with Luer lock 6. Normal saline flush solution 7. 5 cc (l00 units per cc) of heparinized saline solution (See 1B for pediatric patients). 8. Sterile dressing, either sterile gauze and tape, or a transparent impermeable dressing 9. 10 cc syringes


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I. ACCESSING THE PORT – IMPLANTABLE ACCESS DEVICE

RESPONSIBLE PARTY

ACTION RATIONALE

MD, RN, RN Applicant

1. 2. 3. 4.

Explains the procedure to the patient. Washes hands with approved antiseptic. Opens and prepares supplies. Dons sterile gloves.

5. Cleanses skin with chlorhexidine gluconate, chloraprep or povidone iodine if allergic to chlorhexidine, starting from center of septum and continuing outward to a diameter of 3 inches using a side to side motion .

6. 7. 8. 9. 10. 11.

Attaches non-coring needle to 10 cc syringe filled with at least 5 cc of normal saline (attaches a luer lock tip if needed). Clears air from tubing and needle, and clamps tubing. Removes gloves. Dons sterile gloves. Palpates/locates portal septum using nondominant hand. Stabilizes portal septum by using thumb and index finger.

12. Utilizing aseptic technique, accesses the system by inserting needle at a 90 degree angle to the septum, penetrating the skin and septum until contact is made with the bottom of the portal chamber.

13. Unclamps tubing.

MD, RN, RN 14. Confirms correct needle placement


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Applicant utilizing three factors: a.

b. c.

Blood returns on aspiration Priming solution infuses easily. No signs of infiltration.

15. Injects saline into system. II. ACCESSING THE PORT – POWER PORT IMPLANTABLE PORT

RESPONSIBLE PARTY

ACTION RATIONALE


1. Verifies the port by the steps listed below. If unable to confidently verify the power port or if the radiologists requires additional verification a scout image may be taken when the patient is on the CT scanner prior to injection of the contrast.

A. Checks the patient’s chart for a Power Port device patient record sticker.

B. Palpates top of port to identify three palpation points (bumps) on the septum, arranged in a triangle. Palpation points may be difficult to palpate for 24-48 hours post- insertion due to swelling of tissue in the port pocket area.

C. Palpates the sides of the port to identify triangular port housing.

D. Asks the patient if they have an identification card, ID bracelet or key ring to help remind them they have a Power Port device.

2. 3.

Explains the procedure to the patient. Washes hands with approved antiseptic.

4. Positions patient in comfortable reclining position; palpate PowerPort device site to locate septum.

5. Palpates outer perimeter of PowerPort device (note unique triangular shape and three palpation points)


5.

Assesses skin over and around the PowerPort device.


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6. Nurse reports and documents signs of complications such as redness, swelling, or induration.

7. 8.

Opens and prepares supplies. Dons sterile gloves, mask and other PPE. Places a mask on the patient.

9. Cleanses skin with chlorhexidine gluconate, chloraprep or povidone iodine if allergic to chlorhexidine, starting from center of septum and continuing outward to a diameter of 2 – 4 inches using a side to side motion . Do not palpate the insertion site after the skin has been cleansed.

10. 11. 12. 13. 14. 15.

Attaches PowerLoc Safety Wing infusion needle to 10 cc syringe filled with at least 5 – 10 cc of normal saline (attaches a luer lock tip if needed). Clears air from tubing and needle, and clamps tubing. Removes gloves. Dons sterile gloves. Palpates/locates portal septum using nondominant hand. Stabilizes portal septum by using thumb and index finger.

16. Utilizing aseptic technique, accesses the system by inserting needle at a 90 degree angle to the septum, penetrating the skin and septum until contact is made with the bottom of the portal chamber.


17. Attach PowerPort compatible callout tag to PowerLoc Safety Wing Needle.


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18. Unclamps tubing.

19. Confirms correct needle placement utilizing three factors:

a. b. c.

Blood returns on aspiration Priming solution infuses easily. No signs of infiltration.

20. Injects saline into system.

21. Applies sterile dressing including Biopatch or Primapore per hospital/unit policy.

22. Instructs the patient to assume the position they will be in during the power injection procedure, before checking for patency. If possible, the patient should receive power injection with his or her arm vertically above the shoulder with the palm of the hand on the face of the gurney during injection. This allows for uninterrupted passage of injected contrast media through the axillary and subclavian veins at the thoracic outlet.

III. HEPARINIZING THE PORT:


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RESPONSIBLE PARTY

ACTION RATIONALE


1. Explains the procedure to the patient. Washes hands.

2. Follows the procedure for accessing the port using sterile technique.

3. Confirms the correct needle placement (See #14 above).

4. Attaches to a 10 cc syringe with 5 cc of heparinized saline (100 units/ml) and instills all but 0.5 cc.

4. Use of a 10 cc syringe helps to reduce PSI to the system. The smaller the syringe, the higher the pressure that can be generated.

5. Clamps the tubing prior to withdrawing needle from the port.

5. Helps to create positive pressure thus minimizing retrograde blood flow into the catheter tip.

6. Cleanses site with chlorhexidine gluconate, chloraprep or povidone iodine if allergic to chlorhexidine and applies light dressing, if desired.

7. Removes gloves and washes hands.

8. Records procedure on MAR and./or in the 24 Hour Nurses Record as appropriate.

IV. CONTINUOUS INFUSIONS


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RESPONSIBLE PARTY

ACTION RATIONALE


1. Explains the procedure to the patient.

2. Follows procedure for accessing the port using aseptic technique.

3. Flushes IV extension tubing with saline and clamps.

4. Accesses port with right angled non- coring needle attached to the IV extension tubing with clamp and Luer Lock feature.

5. Opens clamp and flushes with 5cc normal saline to confirm placement.

6. Clamps tubing and applies a transparent impermeable dressing.

7. Secures needle hub and proximal part of tubing with sterile steri-strips.

8. Connects IV administration set up and opens clamp to infuse solution.

9. Clamps tubing when infusion is completed.

10. Disconnects IV administrations set. 10. To maintain aseptically between usages.

11. Flushes port with 5cc saline to clear line, then heparinizes the port.

12. Changes tubing, needle, and dressing at least every 96 hours.


RN, RN Applicant

14. Records procedure on MAR and/or in 24-Hour Nurses Record as appropriate.


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V. BLOOD SAMPLING RESPONSIBLE

PARTY ACTION RATIONALE


1. 2. 3.

Explains procedure to patient. Follows procedure for accessing port using sterile technique. Closes clamp on extension tubing.

4. Disconnects IV tubing (if during a continuous infusion) and attaches a 10 cc syringe, unclamps tubing.

5. 6.

Withdraws at least 5cc of blood, clamps tubing and discards syringe and blood (if ordered by the physician, the blood may be returned to the patient using aseptic technique). Attaches a new 10 cc syringe, unclamps tubing and withdraws required blood.

7. Clamps the tubing, attaches syringe with 20 cc normal saline, releases clamp and flushes the system, clamps tubing.

8. Reestablishes IV infusion or heparinizes the line with 5cc Heparin flush if the infusion is completed.

9. Clamps the tubing prior to withdrawing needle from the port.

10. Applies light dressing, if desired.


RN, RN Applicant 12. Records procedure on MAR and/or in the 24-Hour Nurses Record as appropriate.

APPENDIX A Patient Instruction

Implantable Portal Access Device


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For Oncology Clinic Patients 1. A Port-A-Cath, P.A.S. Port or Life Port is a tube that lets us draw blood and give you

medicine or fluids right into your bloodstream.

2. No special care to the site is needed unless an access (needle and tubing) is in place. A bandage is not usually needed.

3. The site should be watched for signs of infection such as redness, leakage, purulent drainage, bruising, and tenderness, and watch for fever, and generalized tiredness. If any of these occur, call the unit/clinic telephone number provided at discharge.

4. If the site has a needle or tube in place at discharge, it should be covered with a special bandage. The bandage and the access (needle and tubing) should be kept clean and dry and no attempt should be made to cut, remove, and/or otherwise change the dressing, needle, or tubing.

5.

Should be flushed every 4-6 weeks; no appointment needed. Please come before 4:00 pm.

For Patient Care Services - Oncology Patients 1. A Port-A-Cath, P.A.S. Port or Life Port is a tube that lets us draw blood and

give you medicine or fluids right into your blood.

2. No special care to the site is needed unless an access (needle and tubing) is in place. A bandage is not usually needed.

3. The site should be watched for signs of infection such as redness, leakage, purulent drainage, bruising, and tenderness, and watch for fever, and generalized tiredness. If any of these occur, call the unit telephone number provided at discharge.

4. If the site has a needle or tube in place at discharge, it should be covered with a special bandage. The bandage and the access (needle and tubing) should be kept clean and dry and no attempt should be made to cut, remove, and/or otherwise change the dressing, needle, or tubing.

References:


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Handbook of Nursing Procedures (2001) Springhouse, Pennsylvania. ( added) Infection Control Policy, IC 16.0: Methods to Prevent Healthcare Associated Intravascular Device-Related Infections. Clinician Information Port-A-Cath and P.A.S. Port Implantable Access System - Pharmacia Deltec. Hospital Policy, 4.8: Skin Preparation. Infection Control Policy 22, Skin Preparation for Invasive Procedures


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________________________________________ _________________ Jamie Jett, MBA, RN Date Administrative Nursing Director Psychiatry, Coordinated Care and Professional Practice ________________________________________ _________________ Jean DiGrazia, MBA, RN Date Assistant Hospital Administrator and CNO Patient Care Services

port-a-cath

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