PEMERINTAH KABUPATEN SITUBONDO

DINAS KESEHATAN
UPT RUMAH SAKIT UMUM DAERAH dr. ABDOER RAHEM
Jl.Anggrek No.68 Telp.(0338) 673293 Fax (0338)671028
SITUBONDO 68321

TRAVELLING DIALYSIS
Nama Pasien : Ny Siti Fatima
Patient’s Name :
Umur : 49 Tahun
Age :
Riwayat Penyakit : CKD
Diagnosis and History :
Obat – Obatan : Epodion 3000 ui
Medications :
Laboratorium : Hb 8,6 mg/dl, s.creatinin 6,38, BUN 61 mg/dl, Albumin 3,1 g/dl
Laboratory :
Tekanan Darah : 150/90 mg/dl
Blood Pressure :
Dialisat : Bicarbonat
Dialysate :
Dializer : NIPRO ELISSIO 13H
Dialyzer :
Komplikasi : (-) Negatif
Complications :
Heparinisasi : Awal : 2000 ui
Heparinization : Continue : 1000 ui/jam
Frekuensi : 2 kali seminggu
Frequently :
TMP/Ultrafiltrasi : 3000-4000 ml
TMP/Ultrafiltration :
HbsAg : (-) Negatif
Diet : 2100 kkal
Alergi : (-) Negatif
Alergies :
Berat Badan Kering : 53 kg
Dry Weight :

Situbondo, 9 Agustus 2018

dr. Ach. Baihaqi, SpPD

NIP. 196209245 198903 1 010
 PEMERINTAH KABUPATEN SITUBONDO
DINAS KESEHATAN
UPT RUMAH SAKIT UMUM DAERAH dr. ABDOER RAHEM
Jl.Anggrek No.68 Telp.(0338) 673293 Fax (0338)671028
SITUBONDO 68321

TRAVELLING DIALYSIS
Nama Pasien : ..........................................................................................................
Patient’s Name
Umur : ..........................................................................................................
Age
Riwayat Penyakit : CKD.................................................................................................
Diagnosis and History
Obat – Obatan : ..........................................................................................................
Medications
Laboratorium : ..........................................................................................................
Laboratory
Tekanan Darah : ..........................................................................................................
Blood Pressure
Dialisat : Bicarbonat
Dialysate
Dializer : NIPRO ELISSIO 13H
Dialyzer
Komplikasi : (-) Negatif
Complications
Heparinisasi : Awal :............... ui
Heparinization Continue : .................ui/jam
Frekuensi : .................... seminggu
Frequently
TMP/Ultrafiltrasi : .................................ml
TMP/Ultrafiltration
HbsAg : (-) Negatif
Diet : .................................kkal
Alergi : (-) Negatif
Berat Badan Kering : .................................. kg

Situbondo, .................. 2018

dr. Ach. Baihaqi, SpPD

NIP. 196209245 198903 1 010