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Pre-Insertion PICC Checklist/Guideline

Does anyone have a Pre-PICC Insertion Checklist/Guidelines that they would be willing to share with me?




Richard Simpson RN, CCRN

Julianne Jabon
pre PICC insertion patient education handout

I left the hospital logo off but the information we give to patients and the families is below.  Feel free to use and add or change.  We are in the process of adding to it because of the new guidelines coming from JCAHO.  Hope this helps.  Following the education sheet is the form we use as our insertion procedure form/checklist.  It is a 4 section page on one sheet and we place it on the progress notes section.





1.                  WHAT IS A PICC LINE?

It is a thin tube called a catheter. It is actually an IV catheter which provides a way in to your blood and body for giving fluids, blood, medicine, or IV food


2.                  WHY DO I NEED IT?

It is a choice to use with patients who will be getting medicine through the IV for a long time, or for medications that can hurt your smaller veins.  A PICC line can cut down on the need for a lot of needle sticks.


3.                  HOW IS IT PUT IN?

It takes about 45 minutes and requires you to lie still with your arm out away from your body.

a.      First, you will need to sign a permission form that will allow an IV nurse to put in           the catheter. You should have any questions answered before agreeing.

b.      A needle is placed into the vein in your upper arm under germ-free conditions.

c.       A long thin tube is put through the needle into a large vein.  The tube stops in the vessel just before the heart.

d.      After the line is in place you will get an X-ray.


4.                  HOW WILL THE AREA LOOK?

A small hole will be seen in your skin where the PICC line comes out. If the tube remains in for a long time you may see a small red bump rising where the tube enters your skin. This is normal. There should be NO pain or drainage.



The catheter and insertion site should always be covered with a clean dressing. A gauze dressing will be applied the day the line is put in. This dressing should be changed after 24 hours and a clear dressing put on. The clear dressing will be changed every week or as needed. Each day you should check the site for redness, swelling, pain, or drainage. You should measure your upper arm every day to look for swelling.  If you see any of these problems call your doctor right away. You should wash your hands with soap and water before doing anything with your line to help prevent infection.



            After each medication, the line is cleared with saline. This stops the line from becoming blocked.  It is important to keep the area clean and dry and to keep the dressing safe.  You can bathe as long as the dressing stays dry.  You must take care of the line if it stays in place after treatment.  It will be important to clear the line so it does not become stopped up.



7.                  WHO WILL CARE FOR THE CATHETER?

You or a family member will be told how to care for the PICC line. If a Home Health agency will be used they will help. The IV team at SGMC is also available if you need more help or teaching. You may call the hospital operator during office hours and have her page an IV nurse for you.  333-1000.



Irritated or infected vein, swelling, swelling or infection of tissue near the site, leaking, site/skin infection, pain and clotting are all possible problems.  These problems can be taken care of as soon as possible by your doctor.  It is also possible to break the catheter.  To avoid breaking, nothing should be forced into the line.  If a medication does not go easily into the line, DO NOT force it.  Always use a large syringe to flush the catheter.



There are a few limits.  Do not do any heavy lifting.  Do not take blood pressures on the arm with the line. In case of mastectomy, use the mastectomy arm for the blood pressure. Do not allow anyone to draw blood from your arm that has the catheter unless it is from the PICC.  Avoid any pulling on the arm.


10.              HOW LONG CAN THIS LINE STAY IN?

This line can stay in place as long as it works well.  If it is to be removed for any problem or the end of its needed use, please call the IV nurse before removing. 



Your doctor. Doctor’s phone number:                                                     

Your Home Health Nurse (if Home Health provided):                                       

Hospital:    333-1000 

IV Nurse:   333-1000 ext. 2428


12.              PICC INFORMATION:


Date: ______________

Base line right/left upper arm circumference: _______ cm

PICC Type:  _______ Groshong        _______Power PICC

Catheter Size: _______ French

Lot No.: ______________

Catheter Length: _______ cm

PICC in   _______right    _______left    _______basilic    _______cephalic vein.           










If patient has had previous chest surgery or trauma, bilateral mastectomy, or is a

renal patient, PICC insertion is contraindicated unless approved by M.D.

Indication for line (check one): ____TPN ____Chemo ____Long term RX inpatient ____Long term RX outpatient ____Other:______________

Patient has history of (check one):

____Broken Clavicle



____Dialysis shunt


____Other __________

Ordering Physician:__________________________________

Section A


Select Arm (check one): ____Right ____Left

Manufactured catheter length ______cm

Catheter lot # ________________________

Internal catheter length ____ + 5 cm external length = _____cm

Arm Circumference: __________cm

Circle insertion site on diagram

(Check one of each)





____1.9 FR

____2.8 FR

____3 FR

____4 FR

____5 FR

____DUAL 5 FR

____DUAL 6 FR

____Triple 6 FR

Section B

Catheter Measurements

Insertion Date: ___________________

Verification of informed consent. _____(initials)

Chart review including history, medications, and

diagnostic results. _______(initials)

Time Out: ________ time ___________(initials)

Patient armband verified with Physician orders and

chart identity label. ______________ (initials)

Procedure performed by: _________________________

Assisted by: ____________________________________

Procedure was performed in: ____Radiology ____Oncology

____Emergency Room ____Inpatient Room ____Outpatient

Anesthetic preparation: ____Lidocaine 1% s.q. ____Emla Cream

Catheter trimmed: ____Yes________cm ____No

Number of Attempts: _______to access _______to thread

____unable to place ____placed without difficulty

____placed difficult to access ____placed-difficulty threading

Blood return: ____Yes ____No

Flushes easily: ____Yes ____No

Tolerated well without complaining of discomfort.____

Nurse Signature:____________________________________

Section C


Tip placement assessed by:________________________

Placement(check appropriate tip placement)____Superior Vena Cava

____Subclavian ____Midclavicular ____Atrium ____Ventricle


Catheter reposition necessary:____Yes ____No

Guidewire pulled (check one): ____Before X-Ray ____After X-Ray

By: __________________________ Comments:_____________



External catheter length after reposition: _______________cm

Dressing applied: ____ Biopatch

____24 hour check by: ____Home Health _____Staff

Sign posted on the wall to prevent venipuncture & blood pressures

on the limb with the catheter: ____Yes ____No

Patient instruction provided and education sheet given to

patient/family _________________________ with baseline arm

circumference, external catheter length and

flush status noted:_____Yes _____No

(circle one) (name of family member

Section D

Placement Verification

PICC = Peripherally Inserted Central Catheter FR = French G=Gauge


Chris Cavanaugh
Are you refering to an insertion checklist?

Hi, not sure what you are asking for...are you looking for an insertion checklist to follow the JC NPSG and/or IHI?  If so, see a previous post on this list.  Arrow includes one with a universal protocol/timeout section with every PICC line.  If you would like a copy, please email me directly at [email protected]


Chris Cavanaugh, RN, BSN, CRNI, VA-BC

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