Anda di halaman 1dari 4

STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

SETIAP HARI
Tanggal/hari
Pertemuan
Diagnosa Kep.
SP ke

:
:
:
:

Proses Keperawatan
Kondisi Klien :
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Diagnose Keperawatan :
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Tujuan Khusus
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Tindakan Keperawatan :
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Proses Pelaksanaan Tindakan :
ORIENTASI

1. Salam terapeutik :
_______________________________________________________________________
_______________________________________________________________________
2. Evaluasi / validasi :
_______________________________________________________________________
_______________________________________________________________________
3. Kontrak : Topik :
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Waktu

:_______________________________________________________________
________________________________________________________________

Tempat :_______________________________________________________________
________________________________________________________________
KERJA ( langkah langkah tindakan keperawatan )
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
TERMINASI :
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi klien ( subjektif )
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Evaluasi perawat ( objektif setelah reinforcement )
____________________________________________________________________
____________________________________________________________________

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2. Tindakan lanjut klien ( apa yang perlu dilatih oleh klien sesuai hasil tindakan yang
dilakukan)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3. Kontrak yang akan datang :
4. Topik :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Waktu :
____________________________________________________________________
____________________________________________________________________
Tempat :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________