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N
orsk
Kateterinformasjon og Forsyningsliste
Pasientens navn: ________________________________ Dato: ________
Grunnlinje til høyre/venstre overarmomkrets var ________________ cm.
Kateter, fransk størrelse: _____________________ Produktkode: ___________________
Navn på kateteret: _____________________________ Kateterlengde cm: ___________
Lot nr.: _______________________ PICC ble satt inn via høyre/venstre basilica/cephalica-
vene. Blod ble fremstilt/ikke oppnådd. ________________ cm sav kateterlengde utsatt
fra innstikkstedet.
Sykehus: _______________________________________ Telefon: __________________
Lege: __________________________________________ Telefon: __________________
Sykepleier: ______________________________________ Telefon: __________________
Leverandør: _____________________________________ Telefon: __________________
Liste over nødvendige forsyninger:
Bandasjerekvisita:
Skyllerekvisita:
____________________________________ _________________________________
____________________________________ _________________________________
____________________________________ _________________________________
____________________________________ _________________________________
____________________________________ _________________________________
____________________________________ _________________________________
Tidsplan for kateterstell: _____________________________________________________
SØN MAN TIRS ONS TORS FRE LØR
Stell av innsettingsstedet:
Skylle:
Hetteskift:
Spesielle Instruksjoner: ______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
8
73
Erkjennelseskort
(Plasser i pasientens journal)
i,
_____________________________________
har fått heftet -- Slik behandler du PowerPICC SOLO*-kateteret --
fra ______________________________________________________
(Navn på personen som gir heftet til pasienten eller omsorgspersonen)
______________________________________________________ ___________________
(Signert)
(dato)
______________________________________________________ ___________________
(Signert)
(dato)
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