|Hello, I am Debra Neiman, RN BSN.
I have worked in Neonatal Care, at Beauregard Memorial Hospital, DeRidder for over four years. My college experience at Louisiana State University at Alexandria, resulted in a great deal of research papers, which are gathering dust in my office. My curriculum at Northwestern State University also added to this wealth of information.
I hereby begin this series to provide a way to get this information to those in the nursing field and any other person with a passing interest in these subjects.
Feel free to reference or use this information in your practice. However, Please respect my Copyright and do not "BORROW" for your HOMEWORK assignments.
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Pain Evaluation Tool
For Use During
Debra Neiman, RN, BSN, Spring 1995
Prepared as Research Proposal
for Nursing Professional Transition Seminar
Northwestern State University
CHAPTER ONE - INTRODUCTION
CHAPTER TWO - LITERATURE REVIEW
CHAPTER THREE - METHODOLOGY
Circumcision Consent Form
Consent Form for Circumcision Procedure
Consent for circumcision of newborn and acknowledgement of receipt of information. State law requires that your physician obtain your informed consent to all medical and surgical treatment. What you are being asked to sign is a confirmation that your physician has discussed the nature and the purpose of and the alternatives to circumcision of the newborn and the risks associated with the procedure and that your physician has answered all your questions in a satisfactory manner. Please read the form carefully. Ask your physician about anything that you do not understand. He or she will be pleased to explain.
Nature and the purpose of the procedure. I understand that, in general terms, circumcision of a newborn is an operation in which the skin that covers the end of the penis, the foreskin, is cut away. I understand that circumcision is elective surgery and a personal choice of the parent. It is usually performed for religious, cultural, traditional or hygienic reasons. There is seldom a medical need for circumcision. There is no law or hospital rule that requires that a baby be circumcised.
Risks and complications. I have been advised that, although good results are expected, complications sometimes occur and I acknowledge that no guarentee as to the results to be expected from treatment have been given to me. The following risks known to be associated with circumcision, including the associated anesthesia, have been explained to me in lay terms.
- Bleeding: which a newborn infant may be prone to and which can
I have been told that if one or more of these complications occur, my
result in serious complications: conceivably death.
- Infection; Poor Healing; Injury to the Penis
- Removal of an Inadequate or Excessive Amount of Foreskin
- Abnormalities of the Flow of Urine
- Inflammation and Scaring of the Penis
- Pain on Intercourse, Painful Errections, and Painful Urination
newborn child may be required an extended hospitalization, blood
transfusions with associated risks from Hepatitis and AIDS, and
Acknowledgement. I acknowledge that I have read and understand this
consent form or that it has been read to me. That I understand the
information contained in it, including all the medical terminology,
about which I have asked if unsure. That I have been given adequate
opportunity to ask my physician whatever questions I had about the
procedure. That all of my questions about circumcision of the newborn
have been answered in a satisfactory manner. That I understand the
nature and purpose of the procedure, its risks, and the alternatives
to the procedure, and that all the blanks in this form were filled in
prior to my signing it.
Consent for circumcision of newborn. I hereby authorize and direct
Doctor _______________________ and/or associates or assistants of his
or her choice to perform circumcision on ___________________ .
I further authorize and direct him or her to perform any other
procedure with the exception of___________, which in his or her
judgement is advisable for my well being, and to provide such
additional services as he or she may deem appropriate, including but
not limited to administration of any anesthetic agent. This consent
form is valid until it is expressly revoked and the revocation is
communication to my physician. I understand and agree that it is my
responsibility to communicate any revocation of this consent to my
Signature of Parent
Signature of Witness
Signature of Physician
Copyright, ©1997 Debra Kay Neiman, RN BSN
E-Mail me at: firstname.lastname@example.org