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STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Nama Pasien : ……………………….... No. RM : …………………….


Umur : ……………………….... Tgl. MRS : …………………….
Jenis Kelamin : ………………………… Tgl. Pelaksanaan : ............................
Ruangan : ........................................ Dx Medis :........................................

a. Kondisi Klien
Alasan masuk RS :
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Data Fokus :
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b. Diagnosa Keperawatan
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Tujuan Khusus. (Tujuan yang akan dicapai, kriteria hasil)
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c. Tindakan Keperawatan (Tindakan yang akan dilakukan, SOP/Checklist)
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STRATEGI KOMUNIKASI DALAM PELAKSANAAN
TINDAKAN KEPERAWATAN

1. ORIENTASI
Salam Terapeutik
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Evaluasi / Validasi
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Kontrak :
 Topik
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 Waktu
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 Tempat
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2. FASE KERJA (Langkah - langkah tindakan keperawatan) : Komunikaasi
saat melakukan tindakan)
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3. TERMINASI
Evaluasi respon klien terhadap tindakan keperawatan
Subjektif
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Objektif
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Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan
yang telah dilakukan)
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a. Kontrak yang akan datang
Topik
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Waktu
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Tempat
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Mengetahui,

Pembimbing Ruangan, Mahasiswa,

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Pembimbing Akademik

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