RM.

Identitas Pasien

PEMANTAUAN REAKSITRANSFUSI DARAH

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

Jenis Reaksi : Demam Transfusi ke : .................................

Gatal
Urticaria
Hematuria
Syok
Hipotensi
Lainnya.........................

Perawat I Dokter yang Menetapkan Transfusi

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