Friday, July 1, 2011

Consent Information for Septoplasty


CONSENT INFORMATION – PATIENT COPY

SEPTOPLASTY

PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having a Septoplasty. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.

What is “nasal septum”?
The nasal septum is the partition inside the nose that separates the two nostrils. It is a vertical wall that divides the right nasal cavity from the left nasal cavity. It is made of gristle (cartilage) in the front and bone at the back. Usually the septum is straight and upright, and in the middle of the nose.

What is “Septoplasty”?
Septoplasty is a surgical procedure to correct the shape of the septum of the nose. The goal of this procedure is to correct defects or deformities of

the septum. Septal deviations are either congenital (present from birth) or develop as a result of an injury. Most people with deviated septa do not develop symptoms. It is typically only the most severely deformed septa that produce significant symptoms and require surgical intervention.

Why is it done?

The main reasons for this surgery are:
* Nasal airway obstruction: Nasal airway obstruction is usually the result of a septal deformity. Persons with this condition usually breathe by mouth and have sleep apnea and recurrent nasal infections.
* Septal spur headache: A septal spur headache is a headache caused by pressure from the inside of the nose (septal impaction), which goes away when a numbing medicine (anesthetic) is placed on the area.
* Uncontrollable nosebleeds
* Deformity of the nasal septum
* People who snort drugs such as cocaine in large quantities for long periods of time may require septoplasty if drug use has damaged the septum.

Benefits:

Straightening out your septum will improve your nasal breathing and reduce any related problems with your sinuses and ears. Any headaches or pain caused by the bent septum will go.
 
Are there any alternatives?

Nasal drops, sprays or tablets will not relieve an obstruction caused by a bent nasal septum. They may improve nasal breathing a little, but problems return when the treatment stops. Using nasal drops for a long time may actually damage the lining of the nose (mucosa) and make the blockage worse. The only way to repair a deviated nasal septum is through surgery.

Preparation: 
Before performing a septoplasty, the surgeon will evaluate the difference in airflow between the two nostrils. In children, this assessment can be done very simply by asking the child to breathe out slowly on a small mirror held in front of the nose. As with any other operation under general anesthesia, patients are evaluated for any physical conditions that might complicate surgery and for any medications that might affect blood clotting time. If a general anesthetic is used, then the patient is advised not to drink or eat after midnight the night before the surgery. In many cases, septoplasty can be performed on an outpatient basis using local anesthesia.
What happens during the procedure?
A cut is made inside the wall of one side of the nose. The mucous membrane is lifted up and away, and anything that is blocking the area is removed or repositioned as necessary. Then, the mucous membrane is returned to its original position. The tissues covering the wall are held in place by either stitches or packing.
Aftercare:
The operation usually takes 30 to 45 minutes. Patients who receive septoplasty are usually sent home from the hospital later the same day or in the morning after the surgery. All dressings inside the nose are usually removed before the patient leaves.
* The head needs to be elevated while resting during the first 24-48 hours after surgery.
* Patients will have to breathe through the mouth while the nasal packing is still in place.
* A small amount of bloody discharge is normal but excessive bleeding should be reported to the physician immediately.
* Antibiotics are usually not prescribed unless the packing is left in place more than 24 hours.
* Most patients do not suffer significant amounts of pain, but those who do have severe pain are sometimes given narcotic pain relievers.
* Patients are often advised to place an ice pack on the nose to enhance comfort during the recovery period.
* Patients who have splint placement usually return seven to 10 days after the surgery for examination and splint removal.
What are the do's and don'ts after Septoplasty?
* Allow for feeling more tired than usual for 1-2 weeks.
* You may find mild painkillers such as paracetamol helpful - avoid painkillers containing aspirin.
* You will be sleeping with your mouth open as your nose will feel blocked - drink plenty of fluids to stop dehydration. If this is awkward you may find a straw helpful.
* Sleeping more upright with extra pillows may make your nose feel less blocked and make you more comfortable.
* Avoid smoky environments.
* Do not blow your nose or stifle sneezing for the first week - you may sniff gently and dab or wipe the nose carefully.
* Do not travel for two weeks, for example by boat or plane, if this means you will not have access to medical care. Significant bleeding during this period is rare but is a possibility.
* Avoid physical exertion such as heavy gardening, running or the gym for 2 weeks and resume gently after this period. You may swim after 2 weeks but not if this risks your nose being accidentally knocked.
General Risks of having the procedure:
These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.
What are the risks of the procedure?
While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:
There are some risks/ complications, which include:
1. Bleeding. This may occur either at the time of surgery or in the first few weeks after surgery. Bleeding after surgery may require packing of the nose under local anesthesia or may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost
2. Infection which may require antibiotics and may cause bleeding
3. Persistence or recurrence of the original problem with an unsatisfactory cosmetic appearance or lack of satisfaction with the new cosmetic appearance of the nose
4. Abnormal healing of external wounds with abnormal scar formation
5. Impaired or lost sense of smell and taste
6. Adhesions or scar tissue forming inside the nose requiring further surgery
7. Numbness of the top lip and / or upper front teeth
8. CSF leaks/Orbital Hematoma (bruising)/Septal Abscess/Hematoma
9. May cause increase in snoring or sleep disturbance
Consent Acknowledgement:
* The doctor has explained my medical condition and the proposed surgical procedure.
* I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
* I have been given an Anesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
* My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood / blood product transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.
On the basis of the above statements,
I REQUEST TO HAVE THE PROCEDURE.
Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………
Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date……………………………



























INFORMED CONSENT: SEPTOPLASTY


Patient Identification Label to be affixed here








A. INTERPRETER
An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter present.Yes_____________No___________

B. CONDITION AND PROCEDURE
The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
See patient information sheet- "Septoplasty” for more
C.ANAESTHETIC
Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.

D.RISKS OF THIS PROCEDURE
While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
1. Bleeding. This may occur either at the time of surgery or in the first few weeks after surgery. Bleeding after surgery may require packing of the nose under local anesthesia or may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost
2. Infection which may require antibiotics and may cause bleeding
3. Persistence or recurrence of the original problem with an unsatisfactory cosmetic appearance or lack of satisfaction with the new cosmetic appearance of the nose
4. Abnormal healing of external wounds with abnormal scar formation
5. Impaired or lost sense of smell and taste
6. Adhesions or scar tissue forming inside the nose requiring further surgery
7. Numbness of the top lip and / or upper front teeth
8. CSF leaks/Orbital Hematoma (bruising)/Septal Abscess/Hematoma
9. May cause increase in snoring or sleep disturbance

SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND
The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.
The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in Medical Record if necessary. Cross out if not applicable. )

PATIENT CONSENT: CONSENT
I acknowledge that:
* The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
* The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
* I have been given a Patient Information Sheet on Anesthesia.
* I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
* I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).
* I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the above statements,
I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..

I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….

Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………
FERENCES
INTERPRETER’S STATEMENT:
I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………

DOCTOR’S STATEMENTS
I have explained
* The patient ‘s condition
* Need for treatment
* The procedure and the risks
* Relevant treatment options and their risks
* Likely consequences if those risks occur
* The significant risks and problems specific to this patient

I have given the Patient/ Guardian an opportunity to:
* Ask questions about any of the above matters
* Raise any other concerns, which I have answered as fully as possible.

I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.

Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………




Patients Initials _____________

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