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