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English
Catheter Information and Supply List
Patient Name: _____________________________ Date :____________
Base Line Right/Left Upper Arm Circumference was ___________ cm.
Catheter French Size: _____________________ Product Code: _____________________
Name of Catheter: _________________________ Catheter Length cm: _______________
Lot No.: ___________________ PICC was inserted via the Right/Left Basilic/Cephalic Vein.
Blood Return was Obtained/Not Obtained. _____________________ cm. of insertable
catheter length exposed from insertion site.
Hospital: _______________________________________ Phone: __________________
Doctor: ________________________________________ Phone: __________________
Nurse: _________________________________________ Phone: __________________
Supplier: _______________________________________ Phone: __________________
List of Supplies Needed:
Dressing Supplies:
Flushing Supplies:
____________________________________ _________________________________
____________________________________ _________________________________
____________________________________ _________________________________
____________________________________ _________________________________
____________________________________ _________________________________
____________________________________ _________________________________
Catheter Care Schedule: ______________________________________________________
SUN MON TUE WED THU FRI SAT
Site Care:
Flushing:
Cap Change:
Special Instructions: _________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Acknowledgement Card
(Place in patie nt medical record)
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I,
_____________________________________
have received the booklet -- How to Care for your PowerPICC SOLO*
Catheter -- From: ___________________________________________
(print name of person giving booklet to patient or care-giver)
______________________________________________________ ___________________
(Signed)
(Date)
______________________________________________________ ___________________
(Signed)
(Date)
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