Azienda Provinciale per Servizi Sanitari

Document Sample
Azienda Provinciale per Servizi Sanitari Powered By Docstoc
					         Azienda Provinciale                                    per i Servizi Sanitari
                               Provincia Autonoma di Trento
                                               ______________


                                  Distretto Giudicarie e Rendena
                                Via Ospedale, 8 - 38079 Tione (TN)

              OPERATIVE UNIT OF ANAESTHESIA AND INTENSIVE CARE
                        Tel. 0465/331384 – fax 0465/331254
                              Director: Dr. Fabio Ianeselli



                                ________________________________




    ANAESTHESIOLOGICAL ASSESSMENT AND INFORMED
   CONSENT FORM FOR PATIENTS UNDERGOING SURGERY




Dear Sir, Dear Madam,
with reference to the surgery operation you will undergo, there is the need to gather information
useful for you and for the anaesthetists working in this hospital.

        This form is divided into three parts; one for the gathering of information about the patient’s
health conditions and about previous surgery operations, if any; the second part refers to the
patient’s informed consent, as envisaged by the Società Italiana di Anestesia, Analgesia,
Rianimazione e Terapia Intensiva (S.I.A.A.R.T.I. 1992) (Italian Anaesthesia, Analgesia and
Intensive Care Society); the third part contains general recommendations for the patient.

       I kindly invite you, in your interest and in the interest of the physician who shall administer
anaesthesia, to carefully read this form, to fill it in and hand it over to the anaesthetist who will visit
you before surgery.


       Thank you for your collaboration.




                                                                   THE ANAESTHETIST
                                                                                                         1
PART ONE


     Are you currently under treatment by your
1)   family doctor?                            11) Do you have varicose veins? ____________________
     If yes, why?_________________
     ___________________________________
                                               12)   Do you have respiratory problems (frequent cough,
                                                   periodical bronchitis, emphysema, asthma…?)
2)   Do you suffer from allergies, to what?        ______________________________________
     ___________________________________           ______________________________________
     ___________________________________

                                                 13) Have you ever suffered from these diseases?
3)   Do you regularly take drugs? _________          a) renal colic □      renal calculus □
     Which
     ones?______________________________                 renal infections □        other □
     ____________________________________
                                                       b) liver colic □     liver calculus □
                                                          hepatitis (jaundice) □        other □
     Have       you     ever     undergone
4)   surgery?__________________
     If      yes,    what      kind     of
     surgery?_________________                         c) ictus □    paralysis □    Parkinson □
     ___________________________________                 Muscle diseases □     other □

                                                       d) ulcer □             gastritis □
5)   Did you tolerate the anaesthesia well?_________     goitre □          thyroid malfunction □
     ___________________________________

                                                 14) Do you have diabetes? Yes □               No □
     Are there any cases of “incidents due to
6)   anaesthesia”                                      If yes, what kind of drugs do you take?________________
     in your family? ___________________               ______________________________________
     ___________________________________
                                                 15) Do you smoke ? □ yes □ no, How many cigarettes?________
                                                     If you quit, when? ______________
7)   Have you ever had blood transfusions?           ______________________________________
     ___________________________________
                                                 16) Do you drink alcoholic drinks?                   □yes          □no

     Are you informed about the surgery
8)   operation you will                                More than 1l. wine a day        □yes            □no
     undergo? _________________________
     ___________________________________               More than 3 beers a day               □yes         □no

                                                       Strong drinks                □yes            □no
     Have you heart problems (breathlessness,
9)   cough
     when you go up the stairs, dyspnoea,
     chest pain)?                                      Your height is of     cm ________________
     ___________________________________
     ___________________________________               Your normal weight is kg _______________

                                                       Have you taken on weight recently?_______________

                                                                                                                2
10)   Your blood pressure is:
      normal □ - high □         - low □                Have you lost weight recently? ________________




PART TWO

                 INFORMED CONSENT TO ANAESTHESIA
                                  (S.I.A.A.R.T.I Recommendations 1992)
Anaesthesiological assessment   of   surgery   risks   for   the   operation   of
______________________________________________________________________________

ASA CLASSIFICATION
1. HEALTHY PATIENT                                                                                 
2. PATIENT SUFFERING FROM A MILD SYSTEMIC DISEASE                                                  
3. PATIENT SUFFERING FROM A SEVERE SYSTEMIC DISEASE THAT                                           
  HAMPERS HIS/HER ACTIVITY ALTHOUGH NOT INCAPACITATING
4. PATIENT SUFFERING FROM A SEVERE SYSTEMIC INCAPACITATING DISEASE,                                
  THAT IS A CONSTANT THREAT TO LIFE
5. PATIENT IN VERY SERIOUS CONDITIONS,                                                             
  NOT EXPECTED TO LIVE 24 HOURS IRRESPECTIVE OF OPERATION
SURGERY RISK
 MILD           MODERATE                MODERATE-HIGH                 VERY HIGH 


I, the undersigned________________________________________, in view of the scheduled
surgery intervention declare to have obtained exhaustive information about the kind of anaesthesia I
will undergo and about the monitoring techniques of vital functions.
I likewise declare to be aware that my general conditions put me at risk for the following
complications:

______________________________________________________________________________________________

______________________________________________________________________________________________


I agree that the anaesthetist changes the technique agreed upon if circumstances require it.
I also declare of having authorised transfusions with homologous blood and/or blood derivatives
and to be aware of risks connected to transfusions.
Upon careful consideration of the situation, I accept all necessary procedures and confirm that I had
exhaustive answers to my questions.
Remarks : _________________________________________________________________________________
________________________________________________________________________________________________
Date _____________

                                 Signature of the patient ________________________________________


                                                                                                    3
                               Signature of the guardian   ________________________________________

                               Signature of the anaesthetist ____________________________________________


PART THREE



                    There are a few rules that should be observed before undergoing anaesthesia, both
local or general.


   1. Drugs regularly taken by the patient shall be communicated to the unit medical staff or to
          the anaesthetist. These shall inform the patient whether he/she can continue to take them or
          shall suspend them and how much before the operation.
   2. Do not eat after midnight of the day preceding surgery.
   3. Smoking is strictly forbidden on the day of surgery.
   4. Before surgery make sure not to wear: dental prostheses, contact lenses, rings, earrings and
          piercing, glasses and watches which shall be given to a trustworthy person.
   5. Before surgery remove lipstick, make-up, mascara and nail polish.
   6. Relatives shall not crowd the patient’s room on the day of surgery. The unit staff shall
          inform about who can or must stay for assistance, if necessary.


Notes :




                                                                                                       4

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:2
posted:11/27/2011
language:Italian
pages:4