Should I have accessed her port?

[guest947568]

When I came on shift today in the ER I had a sickle cell patient. Patient had a PIV 20G in the right AC placed in triage (BEFORE my arrival/shift). The PIV in question flushed and drew back fine. She go her fluids and PCA pump through this line without issue. The patient had 2 nurses before me all of which refused to access her port because she had the PIV. the nurse I got report from stated she did not access the port because it was not clinically indicated because the patient had an IV.

The patient requested it be accessed because she can feel the PCA better in the port than the PIV. I asked THREE other nurses who agreed I shouldn't access it due to risk of infection and she already had an IV.

Patient went to floor and ask the nurses there to access it. All of which refused to do so and notified their manager. Management calls me upset saying I gave poor customer service by not accessing the port in the ED when she requested. They said the floor cannot do it as theyre not trained. Mind you this was AFTER she had the PIV placed in triage last night. The PIV that worked fine.

My last hospital I was told not to access ports unless clinically indicated as its an infection risk.

What would you have done?

[Caprica6]

When I was still working in acute care, we needed provider orders to access a port. That was not considered to be within the scope of nursing judgment.

[optimis]

I agree with your rationale. I will always try to get a PIV in the ED before accessing a port. Risking a CLABSI for a better high is ridiculous. I dare management to write me up for that.

[Emergent, RN]

6 minutes ago, optimis said:

I agree with your rationale. I will always try to get a PIV in the ED before accessing a port. Risking a CLABSI for a better high is ridiculous. I dare management to write me up for that.

Why do you think people with chronic diseases have ports?

Answer: to be used.

[MAJCAC]

44 minutes ago, optimis said:

I agree with your rationale. I will always try to get a PIV in the ED before accessing a port. Risking a CLABSI for a better high is ridiculous. I dare management to write me up for that.

Ports are placed for things other then chemotherapy, including, such as in this case, for patients requiring pain relief, & to minimize venous damage from repeated exposure to needles.

She has S.C.E. and is chronically in the hospital, in chronic pain, and you have the tenacity to proclaim that you would not only deny her request, but then go further to judge her at face value as an individual "seeking a high"? This is a poor mentality to have as a nurse towards your patient.

To further that, what is the problem with a patient who has been diagnosed with a chronic disorder that merits pain relief enjoying psychological relief that a pain medication provides to them in addition to the physical relief, when there is a valid reason for needing it?

Chronic physical pain takes a toll on a person's psyche & ability to cope, & although you may consider her simply wanting to get "high", it is not a high she seeks, but the psychological relief that she will experience along with the physical relief when the pain lessens or fades, of which is equally important.

But even then, all of this is truly besides the point as a patient noticing that their medication works better through their port does not translate to a patient seeking a high.

More so, of course there is a chance of CLABSI when accessing the port, but once again, that has obviously been weighed against the pros by her physician, who deemed it worth the risk.

[CozyCatRN]

At the time, you didn’t have a good clinical reason to access the patient’s port. It could be argued that it may have been wise to access it once you knew the patient would be admitted, but even then, as an ER RN your time is limited, you’re being pushed to get patients up to the floor in a timely fashion, and sometimes you don’t have time to get all of your ducks in a row anyway. A functioning PIV is enough for a floor RN to work with until a qualified RN is able to access the port. As a floor RN, I think it’s kind of rotten that people are getting management involved in this. If I were in your position, I probably wouldn’t have accessed it either.

[DextersDisciple, BSN, RN]

23 hours ago, turtlesRcool said:

The PIV is in the right AC. Being able to get an IV into the most obvious vein of the, presumably, dominant side isn't an indication of good vasculature. In fact, it's usually where people go when they can't get anything else to pop up on a patient.

But it's also a seriously inconvenient place to have an IV with anything continuous running. Most SCD patient have fluids going in addition to any pain meds.

For the sake of argument, let's assume she's really "not that difficult of a stick." Presumably, she'd like to keep it that way. The wear and tear on her peripheral veins associated with multiple sticks throughout repeated hospital stays will lead her to have crap veins over time, if she doesn't already.

She has a port. She wants to use it. I'm sure her physicians discussed the risks and benefits before placing the port. If it makes you feel better, go ahead and reeducate her regarding the risks of infection, but ultimately it's her body and her informed choice should be respected.

I do not disagree with you at all. I did say I would be the first person to access the port and skip the peripheral all together. I kinda forgot it was in the AC as I was writing that so yes I agree that is a crap spot for all the reasons stated throughout the thread.

If I was the floor nurse I would have accessed the port and used that right away and used the peripheral as a second line. Ive had pts in the ICU(!) who had an unaccessed port and multiple IVs. It really aggravated me and i would access it as long as it wasn’t contraindicated(being discharged tomorrow, etc).

my best friend and roommate has sickle cell so I know how extremely painful it is.

I was just saying I don’t think accessing the port was something to be up in arms about if she already has a well functioning line and did not need additional access. HOWEVER I would have questioned why it wasn’t accessed and the pt had to be stuck for a PIV in the first place.

[Workitinurfava, BSN, RN]

Did you tell the charge nurse?

[gonzo1, ASN, RN]

So glad this subject came up, I've got a new perspective on the situation. Some hospitals do require a physician order to access. But that should be easy to get in ER.

Thanks

[brownbook]

19 hours ago, Emergent said:

Why do you think people with chronic diseases have ports?

Answer: to be used.

Can or should a nurse who has never accessed a port access a port? That is what my rationale was in saying don't access it. Hopefully accessing ports is, or will, become common knowledge, maybe an annual competency check off class.

[JKL33]

28 minutes ago, brownbook said:

Can or should a nurse who has never accessed a port access a port?

No - but it should be an orientation and annual competency for areas more likely to encounter them (which would include med-surg), and thereafter people should avail themselves of opportunities to learn and become more confident.

They scare people but in the end are not difficult. Most of them are easy to access; all things considered they are easier to successfully gain access to than a slightly difficult PIV (such as roll-y veins).

I think they freak people out due to the appearance/feeling of pushing a needle strait down into someone's chest cavity - which of course is not reality. I always encourage people to take a look at pictures of the devices (ports) themselves or an actual one, if you can get your hands on one. If you can put a needle into the middle of a circle, you can do it.

The issue with this posted scenario was not the situational circumstances but the overall rationale for not worrying about it.

[Forest2]

Maybe that would have been something to discuss with the physician in charge of the patient. If doc gives OK to access per patient request and writes the order. Then OK by me.

[turtlesRcool]

5 hours ago, brownbook said:

Can or should a nurse who has never accessed a port access a port? That is what my rationale was in saying don't access it. Hopefully accessing ports is, or will, become common knowledge, maybe an annual competency check off class.

No, but I don't think a nurse who has never done a skill should attempt to do it for the first time on his or her own. Accessing a port should be done by people who are trained to do so.

But, if you're not trained to do something, you get someone who is!

And this doesn't seem to be the case for OP. OP states that the ED nurses REFUSED to access the port because they decided it wasn't clinically indicated. No explanation as to what they thought would make a port "clinically indicated" in a SCD patient, if not hydration and pain meds, which is presumably what the patient was there for. The floor nurses refused to access a port because they don't have the training, which is a different issue.

In my hospital, the only floor where the nurses are signed off on port access is oncology because the rest of the med-surg floors don't have this come up very often. If I were the med-surg nurse who received this patient from the ED, I wouldn't access the port myself, but I would call someone who could. This might take a while, depending on what those other nurses have going on, and would lead to a delay in care.

I would also not be particularly happy with the ED nurses putting me in that position when they had the skill to access the port and chose not to. And, yes, I would probably speak with the floor manager because the managers round daily on our patients. I'm certain this patient would bring up this issue when the manager asked her about her care, and I'd rather the manager hear about it from me.