7/26/2019 12.7 Travelling Patient Questionare

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RSUP SANGLAH DENPASAR RM.12.7/HD/2011

TRAVELING DIALYSIS PATIENT QUESTIONAIRE

Nama :NameTgl.Lahir : L/P M/FDOBNo RM :MR no

Ruangan : Tgl : Jam :

Nama pasien : Umur : tahun

Patiens name Age Years

Jenis kelamin :Sex

Alamat :Address

Diagnosis & Riwaat penakit :Diagnosis and Hystory

Apakah pasien !i "entral #emo!ialsis Unit $Is the patient on entra! Hemodia!ysis "nit

%erapa lama pasien su!ah menalani !ialsis$

Ho# !ong has the patient $een on dia!ysis%Jenis o'at ang !ipakai sekarang$&hat medi'ations is the patient present!y ta(ing%

#asil la'oratorium ( 'ulan terakhir:)a$oratory *a!+es o*er the past month,

Tekanan !arah : mm#gB!ood Press+re

)omposisi !ialisat :omposition o- Dia!y.ate

Jenis !ialiser !an Deli*er sstem ang 'iasa !igunakan$&hat Dia!y.er and De!i*ery system is the patient '+rrent!y +sing%

)omplikasi ang !iketahui selama menalani !ialisis:no#n 'omp!i'ations #hi!e dia!ysis r+ns,

Apakah pasien mempunai A+ ,hunt atau -istula$Does the patient ha*e a sh+nt or -ist+!a%

Tipe heparinisasi ang !igunakan: i* Pemeliharaan : i*/am0ype o- heparini.ation +sed maintanena'e i*/ho+rs

%erapa kali !ilakukan !ialsis selama seminggu :N+m$er o- r+ns per #ee(,

Lama setiap kali !ialsis : amHo# !ong per r+n ho+rs

TMP : Positi*e pressure : Negati*e pressure:0MP +sed

#',Ag: Anti#"+: #"+ RNA:H$SAg Anti1H2 H2 RNA

Trans-usi !arah :B!ood trans-+sion

Diet: kal Protein: g/hariDiet Protein

Alergi:A!!ergies

%erat %a!an kering : )gPatients dry #eight

"atatan :F+rther 'omment

Dokter ang merawatAttending Physi'ian

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