STRATEGI PELAKSANAAN DAN STRATEGI KOMUNIKASI DALAM

PELAKSANAAN TINDAKAN KEPERAWATAN

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I. FORMAT STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN (SP)

A. Identitas Pasien

Nama Pasien :………………………………………………………………….

Dx medis : …………………………………………………………………

Kamar : …………………………………………………………………

B. Kondisi klien :

1. Alasan masuk RS :

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2. Data fokus

DS :

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DO :

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C. Tanda-Tanda Vital

TD :……….. mmHg

Suhu :…………oC

Nadi :………….x/menit

RR :…………x/menit

D. Diagnosa Keperawatan :

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E. Tujuan khusus (Tujuan yang akan dicapai & kriteria hasil

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F. Tindakan Keperawatan : tindakan apa yang akan dilakukan

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II. FORMAT STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN

KEPERAWATAN

A. Orientasi

1. Salam teurapeutik

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2. Evaluasi/validasi

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3. Kontrak (tujuan, waktu, dan tempat)

a. Tujuan:

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b. Waktu :

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c. Tempat :

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B. Kerja (langkah – langkah tindakan keperawatan) : komunikasi saat melakukan

tindakan

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C. Terminasi

1. Evaluasi respon klien terhadap tindakan keperawatan

a. Subjektif

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b. Objektif

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2. Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan

yang telah dilakukan )

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3. Kontrak yang akan datang (Topik, waktu, dan tempat)

a. Topik:

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b. Waktu:

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c. Tempat

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