PENGKAJIAN KEPERAWATAN KESEHATAN JIWA
PAGE
PENGKAJIAN KEPERAWATAN KESEHATAN JIWA
I. IDENTITAS KLIEN
Nama: .. (L/P)Tanggal Dirawat: .
Umur: .. Tanggal Pengkajian: .............Pendidikan:
................................... Ruang Rawat: .Agama:
................................... Sumber Informasi:
.................................Status:
...................................
Alamat:
Pekerjaan:
Jenis Kel.:
No RM:
II. ALASAN MASUKData Primer:
Data Sekunder:
III. FAKTOR PRESIPITASI
IV. FAKTOR PREDISPOSISI
RIWAYAT PENYAKIT LALU
1. Pernah mengalami gangguan jiwa di masa lalu ?
Jika Ya,Jelaskan:
2. Pengobatan sebelumnya
Jelaskan:
Masalah Keperawatan :
3. Pernah mengalami Penyakit Fisik (termasuk gangguan tumbuh
kembang)
Jelaskan :
Masalah Keperawatan :
RIWAYAT TRAUMA
TraumaUsiaPelakuKorbanSaksi
1. Aniaya fisik
2. Aniaya seksual
3. Penolakan
4. Kekerasan dalam keluarga
5. Tindakan kriminal
Jelaskan:
4. Pengalaman masa lalu yang tidak menyenangkan (Bio, Psiko,
Sosio, Kultural dan Spiritual)
Masalah Keperawatan
:...............................................................................................................
RIWAYAT PENYAKIT KELUARGA1. Anggota keluarga yang gangguan jiwa
?
Kalau ada :
Hubungan keluarga :
........................................................................................
............................................
Gejala : ..........................................
............................................
............................................
Riwayat pengobatan :
.......................................................................................
............................................
...........................................
............................................
............................................
Masalah Keperawatan
:..............................................................................................................V.
PEMERIKSAAAN FISIK
1. Keadaan umum :
2. Tanda vital:
Tekanan Darah: .mm/Hg
Nadi:..x/mnt
Suhu: . CPernafasan:..x/mnt
3. Ukur:
Berat Badan ......kg
Tinggi Badan:....cm
4. Keluhan fisik:
Jelaskan 5. Pemeriksaan Fisik : (head to toe)
Jelaskan :
Masalah Keperawatan
:..................................................................................................................VI.
PENGKAJIAN PSIKOSOSIAL (Sebelum dan sesudah sakit)
1. Genogram:
Jelaskan:
2. Konsep Diri
a. Citra tubuh:
..............................................
.
b. Identitas: ........................
.......................
.
c. Peran: .......................
.......................
.......................
d. Ideal diri: .......................
.......................
.......................
e. Harga diri: .......................
.......................
.......................
Masalah Keperawatan
:.............................................................................................................3.
Hubungan sosial
a. Orang yang berarti/terdekat:
b. Peran serta dalam kegiatan kelompok/masyarakat:
c. Hambatan dalam berhubungan dengan orang lain:
Masalah Keperawatan
:...........................................................................................................4.
Spiritual
a. Nilai dan keyakinan
b. Kegiatan ibadah
Masalah
Keperawatan:..........................................................................................................VII.
STATUS MENTAL
1. Penampilan
1. Tidak rapi
Penggunaan pakaian tidak seperti biasannya
2.
Lainnya.......................................................
Jelaskan:
Masaalah
Keperawatan:...............................................................................................................2.
Interaksi selama wawancara
Bermusuhan
Curiga
Tidak kooperatif
Defensif Mudah tersinggung
Lainnya.................................................. Kontak
mata kurang
Jelaskan:
3. Pembicaraan
Cepat
Keras
Gagap
Tidak mampu memulai pembicaraan
Lainnya..................................................Jelaskan:...
...
Masaalah
Keperawatan:................................................................................................................4.
Aktifitas Motorik Lesu
Fleksibilitas serea Tegang
Katatonik Gelisah
Agitasi
Kompulsif
Lainnya..................................................Jelaskan:
...
...
Masaalah
Keperawatan:................................................................................................................5.
Kesadaran
a. Kuantitatif Compos mentis
Apatis
Somnolensia
Sopor
Koma
Jelaskan:...
b. Kualitatif1. Relasi : A. diri sendiri B. lingkungan
2. Limitasi (Pembatasan)Jelaskan:
...
...
Masaalah
Keperawatan:................................................................................................................7.
Orientasi Waktu
Tempat
Orang
Jelaskan:
Masaalah
Keperawatan:................................................................................................................8.Perasaan
A. Emosi
Sedih
Gembira
Takut
Cemas
Lainnya..................................................B.
Afek
Adequat
Inadequat Tumpul
Labil Datar
Lainnya..................................................Jelaskan:
Masaalah
Keperawatan:................................................................................................................9.Persepsi
Sensorik
Halusinasi
Pendengaran
Penglihatan
Perabaan
Pengecapan
Penciuman
Lainnya..................................................Jelaskan:
Masaalah
Keperawatan:................................................................................................................10.
Proses Pikir
a. Arus Pikir
Koheren
Inkoheren
Sirkumstansial
Neologisme Tangensial
Logorea Flight of idea
Blocking
Lainnya..................................................Masaalah
Keperawatan:.................................................................................................................b.
Isi Pikir
Obsesif
Fobia Ekstasi
Fantasi Pikiran Bunuh Diri
Pikiran curiga Pikiran Isolasi sosial
Pikiran magis Pikiran Rendah diri
Lainnya..................................................
Waham
Agama
Sisip pikir Somatik
Siar pikir Kebesaran
Kontrol pikir Kejar atau curiga
Dosa Nihilistik
Lainnya..................................................Masaalah
Keperawatan:................................................................................................................c.
Bentuk Pikir
Realistik
Non Realistik
Relevan
Irrelevan
Logik
Non Logik
Rasional
Irrasional
Dereistik
Otistik
Lainnya..................................................
Jelaskan:
Masalah keperawatan:
...............................................................................................................11.
Memori
Gangguan daya ingat jangka panjang ( > 1 bulan) Gangguan daya
ingat jangka pendek ( 1 hari 1 bulan) Gangguan daya ingat saat ini
( < 24 jam) Amnesia
Lainnya..................................................Jelaskan:
Masalah
keperawatan:................................................................................................................12.
Tingkat konsentrasi dan berhitung
Mudah beralih
Tidak mampu berkonsentrasi
Tidak mampu berhitung sederhanaJelaskan:
13. Kemampuan penilaian
Gangguan ringan
Gangguan bermakna
Jelaskan:
Masalah
keperawatan:...............................................................................................................14.
Daya tilik diri
Mengingkari penyakit yang diderita
Menyalahkan hal-hal diluar dirinya
Jelaskan:
Masalah
keperawatan:................................................................................................................VIII.
KEBUTUHAN PERSIAPAN PULANG
1. Makan
Bantuan Minimal
Bantuan total
Jelaskan:................................2. BAB/BAK
Bantuan minimal
Bantuan total
Jelaskan:................3. Mandi
Bantuan minimal
Bantuan total
Jelaskan:.................4. Berpakaian/berhias
Bantuan Minimal
Bantuan total
Jelaskan:.......................................................................................................................................................................................................................................................5.
Istirahat dan tidur Tidur Siang, Lama : ____________ s/d
_____________
Tidur Malam, Lama : _____________ s/d _____________
Aktifitas sebelum/sesudah tidur : __________ , _________
Jelaskan:................6. Penggunaan obat
Bantuan Minimal
Bantuan total
Jelaskan:........................................................................................................7.
Pemeliharaan kesehatan
Ya
Tidak
Perawatan Lanjutan
Sistem pendukung
8. Aktifitas dalam rumah
Ya
Tidak
Mempersiapkan makanan
Menjaga kerapihan rumah
Mencuci Pakaian
Pengaturan keuangan
9. Aktifitas di luar rumah
Ya
Tidak
Belanja
Transportasi
Lain-lain
Jelaskan :
Masalah
keperawatan:................................................................................................................IX.
MEKANISME KOPING
AdaptifMaladaptif
Bicara dengan orang lain
Mampu menyelesaikan masalah
Teknik relaksasi
Aktifitas konstruktif
Olah raga
Lain-lain. Minum alkhohol
Reaksi lambat/berlebihan
Bekerja berlebihan
Menghindar
Menciderai diri
Lain-lain..
Masalah
keperawatan:................................................................................................................X.
MASALAH PSIKOSOSIAL DAN LINGKUNGAN
Masalah dengan dukungan kelompok, spesifiknya ...
Masalah berhubungan dengan lingkungan, spesifiknya ....
........................................................................................................................................................
Masalah dengan pendidikan, spesifiknya ..
.........................................................................................................................................................
Masalah dengan pekerjaan, spesifiknya .
.........................................................................................................................................................
Masalah dengan perumahan, spesifiknya ..
.........................................................................................................................................................
Masalah dengan ekonomi, spesifiknya ..
.........................................................................................................................................................
Masalah dengan pelayanan kesehatan, spesifiknya ...
.........................................................................................................................................................
Masalah lainnya, spesifiknya .
.........................................................................................................................................................Masalah
keperawatan:................................................................................................................XI.
PENGETAHUAN KURANG TENTANG
Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan
yang kurang tentang suatu hal?
Penyakit/gangguan jiwa
Sistem pendukung
Faktor presipitasi
Mekanisme koping
Penyakit fisik
Obat-obatan
Lain-lain, jelaskan
Jelaskan:
......................................................................................................................................................................................................................................Masalah
keperawatan:................................................................................................................XII.
ASPEK MEDIS
Diagnosis medik:
Terapi medik:1) . ...... ....2) . ...... ....
3) . ...... ....
4) . ...... ....
XIII. ANALISA DATA
NODATADIAGNOSA KEPERAWATAN
1.DS:
DO:
2.DS:
DO:
3.DS:
DO:
XIV. POHON MASALAH
XV. DAFTAR MASALAH KEPERAWATAN1. ..
2. ..
3. ..
4. ..
5. ..
6. ..
7. ..
8. ..
9. ...
10. .......XVI. PRIORITAS DIAGNOSA KEPERAWATAN1. ..
2. ..
3. ..
Malang, .
Perawat yang mengkaji
______________________________
NIM: .................RENCANA TINDAKAN KEPERAWATAN
Nama : ......................................
Ruang :................................. RM
No:................................No DxRencana Tindakan
KeperawatanRasional
Tujuan dan kriteria EvaluasiTindakan Keperawatan
TUM:
TUK:
Kriteria Evaluasi:
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
Hari : Senin, tgl
:.......................................................
Interaksi IA. PROSES KEPERAWATAN.
1. Kondisi Klien:
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Diagnosa Keperawatan.
..........................................................................................................................................................
3. Tujuan Khusus (TUK)
...........................................................................................................................................................
4. Tindakan Keperawatan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
KEPERAWATAN
a. FASE ORIENTASI
1. Salam
Terapeutik.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Evaluasi /
validasi.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
3. Kontrak
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
b. FASE KERJA
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
c. FASE TERMINASI
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi Subyektif
(Klien)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Evaluasi
Obyekti (Perawat)
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................2.
Rencana Tindak Lanjut
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................3.
Kontrak yang akan datang
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
IMPLEMENTASI DAN EVALUASI
Nama : ......................................
Ruang :................................. RM
No:................................NO
DxTanggal & JamIMPLEMENTASI KEPERAWATANEVALUASI
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
Hari: Senin, tgl
:.......................................................
Interaksi IIA. PROSES KEPERAWATAN.
1. Kondisi Klien:
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Diagnosa Keperawatan.
..........................................................................................................................................................
3. Tujuan Khusus (TUK)
...........................................................................................................................................................
4. Tindakan Keperawatan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
KEPERAWATAN
a. FASE ORIENTASI
1. Salam
Terapeutik.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Evaluasi /
validasi.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
3. Kontrak
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
b. FASE KERJA
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
c. FASE TERMINASI
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi Subyektif
(Klien)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Evaluasi
Obyekti (Perawat)
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................2.
Rencana Tindak Lanjut
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................3.
Kontrak yang akan datang
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
IMPLEMENTASI DAN EVALUASI
Nama : ......................................
Ruang :................................. RM
No:................................NO
DxTanggal & JamIMPLEMENTASI KEPERAWATANEVALUASI
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
Hari: Selasa, tgl
:.......................................................
Interaksi IA. PROSES KEPERAWATAN.
1. Kondisi Klien:
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Diagnosa Keperawatan.
..........................................................................................................................................................
3. Tujuan Khusus (TUK)
...........................................................................................................................................................
4. Tindakan Keperawatan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
KEPERAWATAN
a. FASE ORIENTASI
1. Salam
Terapeutik.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Evaluasi /
validasi.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
3. Kontrak
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
b. FASE KERJA
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
c. FASE TERMINASI
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi Subyektif
(Klien)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Evaluasi
Obyekti (Perawat)
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................2.
Rencana Tindak Lanjut
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................3.
Kontrak yang akan datang
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
IMPLEMENTASI DAN EVALUASI
Nama : ......................................
Ruang :................................. RM
No:................................NO
DxTanggal & JamIMPLEMENTASI KEPERAWATANEVALUASI
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
Hari: Selasa, tgl
:.......................................................
Interaksi IIA. PROSES KEPERAWATAN.
1. Kondisi Klien:
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Diagnosa Keperawatan.
..........................................................................................................................................................
3. Tujuan Khusus (TUK)
...........................................................................................................................................................
4. Tindakan Keperawatan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
KEPERAWATAN
a. FASE ORIENTASI
1. Salam
Terapeutik.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Evaluasi /
validasi.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
3. Kontrak
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
b. FASE KERJA
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
c. FASE TERMINASI
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi Subyektif
(Klien)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Evaluasi
Obyekti (Perawat)
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................2.
Rencana Tindak Lanjut
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................3.
Kontrak yang akan datang
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
IMPLEMENTASI DAN EVALUASI
Nama : ......................................
Ruang :................................. RM
No:................................NO
DxTanggal & JamIMPLEMENTASI KEPERAWATANEVALUASI
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
Hari: Rabu, tgl
:.......................................................
Interaksi IA. PROSES KEPERAWATAN.
1. Kondisi Klien:
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Diagnosa Keperawatan.
..........................................................................................................................................................
3. Tujuan Khusus (TUK)
...........................................................................................................................................................
4. Tindakan Keperawatan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
KEPERAWATAN
a. FASE ORIENTASI
1. Salam
Terapeutik.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Evaluasi /
validasi.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
3. Kontrak
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
b. FASE KERJA
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
c. FASE TERMINASI
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi Subyektif
(Klien)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Evaluasi
Obyekti (Perawat)
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................2.
Rencana Tindak Lanjut
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................3.
Kontrak yang akan datang
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
IMPLEMENTASI DAN EVALUASI
Nama : ......................................
Ruang :................................. RM
No:................................NO
DxTanggal & JamIMPLEMENTASI KEPERAWATANEVALUASI
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
Hari: Rabu, tgl
:.......................................................
Interaksi IIA. PROSES KEPERAWATAN.
1. Kondisi Klien:
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Diagnosa Keperawatan.
..........................................................................................................................................................
3. Tujuan Khusus (TUK)
...........................................................................................................................................................
4. Tindakan Keperawatan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
KEPERAWATAN
a. FASE ORIENTASI
1. Salam
Terapeutik.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Evaluasi /
validasi.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
3. Kontrak
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
b. FASE KERJA
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
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...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
c. FASE TERMINASI
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi Subyektif
(Klien)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Evaluasi
Obyekti (Perawat)
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................2.
Rencana Tindak Lanjut
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................3.
Kontrak yang akan datang
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
IMPLEMENTASI DAN EVALUASI
Nama : ......................................
Ruang :................................. RM
No:................................NO
DxTanggal & JamIMPLEMENTASI KEPERAWATANEVALUASI
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
Hari: Kamis, tgl
:.......................................................
Interaksi IA. PROSES KEPERAWATAN.
1. Kondisi Klien:
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Diagnosa Keperawatan.
..........................................................................................................................................................
3. Tujuan Khusus (TUK)
...........................................................................................................................................................
4. Tindakan Keperawatan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
KEPERAWATAN
a. FASE ORIENTASI
1. Salam
Terapeutik.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Evaluasi /
validasi.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
3. Kontrak
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
b. FASE KERJA
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
c. FASE TERMINASI
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi Subyektif
(Klien)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Evaluasi
Obyekti (Perawat)
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................2.
Rencana Tindak Lanjut
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................3.
Kontrak yang akan datang
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
IMPLEMENTASI DAN EVALUASI
Nama : ......................................
Ruang :................................. RM
No:................................NO
DxTanggal & JamIMPLEMENTASI KEPERAWATANEVALUASI
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
Hari: Kamis, tgl
:.......................................................
Interaksi IIA. PROSES KEPERAWATAN.
1. Kondisi Klien:
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Diagnosa Keperawatan.
..........................................................................................................................................................
3. Tujuan Khusus (TUK)
...........................................................................................................................................................
4. Tindakan Keperawatan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
KEPERAWATAN
a. FASE ORIENTASI
1. Salam
Terapeutik.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Evaluasi /
validasi.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
3. Kontrak
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
b. FASE KERJA
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
c. FASE TERMINASI
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi Subyektif
(Klien)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Evaluasi
Obyekti (Perawat)
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................2.
Rencana Tindak Lanjut
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................3.
Kontrak yang akan datang
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
IMPLEMENTASI DAN EVALUASI
Nama : ......................................
Ruang :................................. RM
No:................................NO
DxTanggal & JamIMPLEMENTASI KEPERAWATANEVALUASI
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
Hari: Jum'at, tgl
:.......................................................
Interaksi IA. PROSES KEPERAWATAN.
1. Kondisi Klien:
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Diagnosa Keperawatan.
..........................................................................................................................................................
3. Tujuan Khusus (TUK)
...........................................................................................................................................................
4. Tindakan Keperawatan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
KEPERAWATAN
a. FASE ORIENTASI
1. Salam
Terapeutik.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Evaluasi /
validasi.....................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
3. Kontrak
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
b. FASE KERJA
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
c. FASE TERMINASI
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi Subyektif
(Klien)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Evaluasi
Obyekti (Perawat)
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................2.
Rencana Tindak Lanjut
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................3.
Kontrak yang akan datang
Topik:
............................................................................................................
Waktu:
...........................................................................................................
Tempat:
...........................................................................................................
IMPLEMENTASI DAN EVALUASI
Nama : ......................................
Ruang :................................. RM
No:................................NO
DxTanggal & JamIMPLEMENTASI KEPERAWATANEVALUASI
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
Hari: Jum'at, tgl
:.......................................................
Interaksi IIA. PROSES KEPERAWATAN.
1. Kondisi Klien:
......................................................................................................................................................................................................................................................................................................................
...........................................................................................................................................................
2. Diagnosa Keperawatan.
..........................................................................................................................................................
3. Tujuan Khusus (TUK)
...........................................................................................................................................................
4. Tindakan Keperawatan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
KEPERAWATAN
a. FASE ORIENTASI
1. Salam
Terapeutik.....................................................................................................................................................................................................................................................................................................................
..........................................