1. Facts about PICC Line Consent Form
What You Should Know About “Registered Nurses Obtaining PICC Line Consents”
Peripherally Inserted Central Catheter (PICC) is a form of intravenous access that is used for a prolong period of time.
It is used for chemotherapy regimen, extended antibiotic therapy, or total parenteral nutrition (TPN).
Facts about PICC Line Consent Form
1. A physician’s order is required for PICC line insertion
2. Only PICC line nurses that have successfully completed all requirements to ensure competency may obtain consent.
The “Peripherally Inserted Central Catheter Consent Form” should be used to obtain the consent for PICC placement by the RN.
The PICC Consent Form is specifically designed for PICC RNs to obtain consent.
3. PICC line RN should explain the procedure to the patient or legal representative prior to insertion of PICC line
4. The PICC RN should answer any questions that the patient or legal representative may have
5. The PICC RN should explain the risks, benefits and alternatives for PICC line insertion
6. The PICC RN should document that the consent has been obtained
***INSTRUCTIONS ON HOW TO APPLY IMAGE MASKING***:
STEP 1: Insert picture of choice.
STEP 2: Make sure inserted picture covers the entire width of the slide by dragging it from the lower right-hand corner handle.
STEP 3: Right-click the picture and choose Order > Send to Back.
PICC Line is NOT the last RESORT…. BE a patient advocate, obtain an order for PICC line
when appropriate 1

2. Peripherally Inserted Central Catheter Consent Form
Risks During PICC Insertion
1. Air embolism Hematoma
2. Catheter fracture Phelebitis
3. Catheter embolism Catheter migration
4. Catheter rupture Catheter dislodgement
5. Arterial puncture Catheter infection
6. Fibrin sheath Bloodstream infection
7. Nerve damage Infiltration
8. Catheter occlusion Thrombosis
***INSTRUCTIONS ON HOW TO APPLY IMAGE MASKING***:
STEP 1: Insert picture of choice.
STEP 2: Make sure inserted picture covers the entire width of the slide by dragging it from the lower right-hand corner handle.
STEP 3: Right-click the picture and choose Order > Send to Back.
Available in Spanish 2