Picc Line Insertion Record

PICC LINE INSERTION RECORD

Ordering Physician: ______

Informed Consent Signed?  Yes  No

Insertion Nurse(s) Name & Signature: ______/______

Date of Insertion: _____/_____/_____ Time of Procedure: ______

Pre-procedure teaching (handout given) ______

Hand hygiene before starting procedure Yes No

Insertion Dr/Nurse wearing mask, cap, sterile gown and gloves Yes No

Catheter Information:

Manufacturer______Lot Number______

Lumen(s) ______French Size______

Original length of catheter ______Length outside insertion site______

Catheter tip round______

Upper arm circumference ______

Clean site with: Chlorahexadine ___

Sterile Technique ___ sterile drape head to toe ______

Local anesthesia: type & amount ______

Vein accessed ______

Other site(s) attempted ______

Method of securing catheter ______

(StatLock/Steri-Strips/sutures)

Problems/complications encountered ______

and nursing/medical action taken:

Intended insertion length reached? ______

X-ray confirmation of central tip placement Yes  No

Able to flush with arm straight? Yes  No

Able to flush with arm flexed after

dressing applied? Yes  No

Dressing used: ______

Hand hygiene after removing gloves Yes No

Post-procedure teaching (handout given)

·  Tip location ______

·  Heat/elevation ______

·  Next dressing change ______

·  Subsequent dressing changes ______

·  Signs & symptoms requiring medical ______

evaluation

·  Exercise ______

·  Medication administration (who, when, how)______

PP/nur/PICC-insertion 1-11 (part 1) Patient Label

PICC SUPPLY LIST

3 – Table drapes (1/2 drapes)

1 – Drape under arm

2 – Fenestrated PICC insertion drape

3 – Masks with shields

3 – Masks

3 – Sterile gowns

4 – Surgical caps

4 – Pairs of sterile gloves

1 – Pack of sterile gauze 4x4

2 – Packs of 2x2

1 – PICC sterile dressing change kit

1 – Clean tape measurer

6 – 10 ml sterile syringes

2 – 1 ml TB syringes

4 – Clave connector caps

6 – Filter needles

6 – 18” gauge needles

1 – Sterile iris scissors

1 – Sterile hemostat

2 – Sterile packages Chlorahexadine (Chlora Prep)

1 – Large Tegaderm

1 – Power PICC (for Radiologist)

1 – PICC tray (for nurse to insert)

2 – Tourniquets – not sterile (sterile one in Power PICC for Rad)

RADIOLOGY PROCEDURE

(performed in Radiology Department)

1.  Suture

2.  Start 20 or 22 gauge IV – one in each wrist for fluora

NURSE PROCEDURE

1. PICC insertion kit from Omnicell Med-Surg

2. Three 30 ml caps for multi-dose vial. Chest x-ray after procedure.

3. One folder with P&P, 3 consent forms & 3 checklists

PP/nur/PICC-insertion 1-11 (part 2)

1