Form - Pemntauan Reaksi Transfusi

 

 

RUMAH SAKIT UMUM PURWOGONDO

Puring KM.8 Kalipurwo, Kec. Kuwarasan, Kab. Kebumen, JawaTengah 54366 Telp/Fax. (0287) 472588e-mail : [email protected]   No. RM :  Nama :

L/P

Tanggal : ........................................ Diagnosa Medis : ............................................... Gol. Darah : A/B/O/AB Nomor Kantong : ............................................... Jam Mulai Tranfusi : ....................................... WIB Jam Selesai Tranfusi : ....................................... WIB Pre Transfusi Post Transfusi Suhu : ....... Celcius : ........ Celcius Tekanan Darah : ....../...... mmHg : ....../...... mmHg Obat-obatan Anti Piretika Indikasi Transfusi  Diuretika Antihistamin Steroid Reaksi Silang Jenis Reaksi :

Perawat I

Mayor

PEMANTAUAN REAKSI TRANSFUSI DARAH 

Tgl. Lahir : Ruang : BB : ...........................................

Gol. Darah Donor : A/B/O/AB Komponen Darah : Whole Blood Pack Red Cell Thrembocyte Concentrate Fresh Frozen Plasma Waktu Transfusi Pre Operasi Durante Operasi Anemia Post Operasi Perdarahan Akut Non Operasi Gangguan Hemoetasis

: .................................. Demam Gatal Urticaria Hematuria Syok Hipotensi Lainnya .......................

Minor : ....................................... Transfusi ke : .............................

Perawat II

Dokter yang menetapkan Transfusi

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