RUMAH SAKIT UMUM PURWOGONDO

Puring KM.8 Kalipurwo, Kec. Kuwarasan,

Kab. Kebumen, JawaTengah 54366 PEMANTAUAN REAKSI
Telp/Fax. (0287) 472588e-mail : TRANSFUSI DARAH
rsu.purwogondo@yahoo.co.id

No. RM : Tgl. Lahir :

Nama : L/P Ruang :
Tanggal : ........................................ BB : ...........................................
Diagnosa Medis : ...............................................
Gol. Darah : A/B/O/AB Gol. Darah Donor : A/B/O/AB
Nomor Kantong : ............................................... Komponen Darah :
Jam Mulai Tranfusi : ....................................... WIB Whole Blood
Jam Selesai Tranfusi : ....................................... WIB Pack Red Cell
Pre Transfusi Post Transfusi Thrembocyte Concentrate
Suhu : ....... Celcius : ........ Celcius Fresh Frozen Plasma
Tekanan Darah : ....../...... mmHg : ....../...... mmHg Waktu Transfusi
Obat-obatan Anti Piretika Indikasi Transfusi Pre Operasi
Diuretika Anemia Durante Operasi
Antihistamin Perdarahan Akut Post Operasi
Steroid Gangguan Hemoetasis Non Operasi

Reaksi Silang Mayor : .................................. Minor : .......................................

Jenis Reaksi : Demam Transfusi ke : .............................
Gatal
Urticaria
Hematuria
Syok
Hipotensi
Lainnya .......................

Perawat I Perawat II Dokter yang menetapkan Transfusi

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