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Having aBlood
Transfusion
1
A doctor has
decided you need
some blood.
This is called a
blood transfusion.
The doctor will ask
you to sign a form
to say you are
happy to have the
blood.
This is called
consent.
2
2
A doctor has decided you need
to be given some blood.
This is called a blood
transfusion.
Signed: __________________________________________________________________________________ Date: _________________________________ (Patient or Representive)
I certify that this form was read over and the relevant procedures were explained by me to the signatory who signed it in my presence.
Signed: __________________________________________________________________________________ Date: _________________________________ (Doctor)
Blood Transfusions and Blood Products:
I have had the opportunity to read the attached blood product information sheet ................................
I give permission to receive transfusion of blood and blood products, if this is considered necessary ....
Tissue/Body Parts:
Tissue/body parts that have been removed as part of my treatment may be used for research and/or teaching ..........................................................
I have the following special request(s) regarding the return or disposal of any tissue/body parts that are removed, as acceptable under New Zealand legislation:
_____________________________________________________________________________________________________________________________________________________________
I (name) ________________________________________________________ agree to the following operation/procedure to be performed on:
(* Strike out option above that does not apply.)
Name of the procedure and simple explanation: (This should be written in by a medical practitioner and any relevant information sheet attached.)
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
I have discussed with ______________________________________________________________________________________________________________________________ the benefits, risks and the likely results of this treatment and the alternative options to it.
The possible consequences of not receiving the proposed treatment have also been explained to me.
It is expected that the doctor(s) performing this operation will be ___________________________________________________________ (name) but in unforeseen circumstances, this may change.
I have special requests and/or instructions regarding my operation/procedure .......................................
I do/do not give permission for __________________________________________________________________________________________________________________ (Note above anything specific relating to the above.)
OPERATION/PROCEDURE CONSENT FORMFor patients deemed competent and/or minors. Please print clearly – use BLOCK LETTERS.
PATIENT ID LABEL
SECTION A – to be completed in all circumstances.
SECTION B – to be completed only if appropriate. Cross out if not applicable.
SECTION C – to be completed in all circumstances.
PTO for patients deemed incompetent
Information collected about you during your admission, will be used to provide you with healthcare, treatment and for purposes of administration. Information regarding accidents will be given to ACC. Statistical information will be used by MidCentral
Health, Health Funding Authority and Ministry of Health. Information about you will be forwarded to your Primary Care Health Practitioner, any provider chosen to continue your treatment or your preferred contact, unless you indicate otherwise.
* myself
OR on* (name of patient) (state relationship eg son, daughter)
YES NO
YES NO
YES NO
YES NO
BIN
DIN
G M
AR
GIN
– N
O W
RIT
ING
BAR
CO
DE
AR
EA
The doctor will ask you to sign
a form to say you are happy to
have the blood.
This is called consent.
It is important that you have this
blood transfusion but you do
have the right to say no.
3
The nurse will tell you all about
having blood.
You can also read this leaflet.
Before you sign the consent
form, you may want to ask the
doctor some questions.
Before you have the blood
transfusion, you will need a
blood test.
This will be sent to find out your
blood group.
It is important
that you have this
blood transfusion
but you can say
no.
The nurse will tell
you all about
having blood.
Before you sign the
consent form, you
may want to ask
some questions.
3
Before you
have the blood
transfusion, you will
need a blood test.
This is to find out
your blood group.
You will need to be
in hospital
to have your blood
transfusion.
4
4
You will need to be in hospital
to have your blood transfusion.
You can bring someone with
you and something to do.
You can also eat and drink
while you have your blood
transfusion.
You can bring
someone with you
and something to
do.
You can also eat
and drink while
you have your
blood transfusion.
5
When you arrive
into the hospital,
the nurse will put a
band on your wrist
with your name
and birthday
written on it.
You will need a
tube in your hand
or arm.
It is called a
cannula.
5
When you arrive into the
hospital, the nurse will put a
band on your wrist with your
name and birthday written on it.
To be able to give you the
blood, you will need a tube in
your hand or arm.
This tube is like a needle for
blood tests but it stays in your
vein.
It is called a cannula.
The cannula will have a long
tube attached to it.
6
The cannula will
have a long tube
attached to it.
A bag of liquid
called saline will
be hung up on a
special hook by
your bed or chair.
7
6
A bag of liquid called saline
(which is like water) will be
hung up on a special hook by
your bed or chair.
The nurse will check your:
• Temperature
• Pulse and blood pressure
• Breathing
• Oxygen in the blood
The nurse will check your:
• Temperature
• Pulse and blood pressure
• Breathing
• Oxygen in the blood
8
7
After a little while the nurse will
take the saline off the tube and
attach the blood that matches
your blood group.
The nurse will stay close to you
for 15 minutes.
If everything is alright your
nurse will go and do some other
work leaving you with your call
bell.
When the blood
is ready, the nurse
will attach the
blood.
The nurse will stay
close to you for 15
minutes.
9
If everything is
alright your nurse
will go leaving you
with your call bell.
If your body feels
different
• itchy
• hot
• you hurt
somewhere
you must push
your call bell and
tell the nurse.
10
8
If your body feels different
• itchy
• hot
• you hurt somewhere
you must push your call bell
and tell the nurse.
The nurse will come back and
check on you during the blood
transfusion.
It will take 2 to 3 hours for a bag
of blood to go into your body
through the cannula.
8
If your body feels different
• itchy
• hot
• you hurt somewhere
you must push your call bell
and tell the nurse.
The nurse will come back and
check on you during the blood
transfusion.
It will take 2 to 3 hours for a bag
of blood to go into your body
through the cannula.
The nurse will
come back and
check on you
during the blood
transfusion.
It will take 2 to 3
hours for a bag of
blood to go into
your body through
the cannula.
11
6
A bag of liquid called saline
(which is like water) will be
hung up on a special hook by
your bed or chair.
The nurse will check your:
• Temperature
• Pulse and blood pressure
• Breathing
• Oxygen in the blood
The nurse will check your:
• Temperature
• Pulse and blood pressure
• Breathing
• Oxygen in the blood
12
You might have 1
bag of blood or
you might need to
have more.
When all the bags
of blood are
empty, the bags
and the long tube
will be removed.
If you are going to
stay in the hospital,
the cannula might
stay in your hand
or arm.
5
When you arrive into the
hospital, the nurse will put a
band on your wrist with your
name and birthday written on it.
To be able to give you the
blood, you will need a tube in
your hand or arm.
This tube is like a needle for
blood tests but it stays in your
vein.
It is called a cannula.
The cannula will have a long
tube attached to it.
13
If you are going
home the nurse will
take the cannula
out.
Sometimes people
have to have their
blood on different
days.
MondayTuesday
WednesdayThursday
FridaySaturdaySunday
Acknowledgment to Dina Whatnell CNS Lead Intellectual Disabilities for advice, Kiah Cole for drawings and Georgia for being the model patient in the images used.
111I04701 NZBCL185 06/16