Spsk pada Tn.

P dengan dx DHF dengan masalah keperawatan deficit perawatan diri

dengan tindakan keprawatan memandikan
FORMAT STRATEGI PELAKSANAAN DAN STRATEGI KOMUNIKASI DALAM
PELAKSANAAN TINDAKAN KEPERAWATAN
memandikan.
I.

FORMAT STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN (SP)

Nama Pasien :initial ( Tn.X)
Dx medis
: ..DHF
No RM
: ..131313
A. Kondisi klien :
1. Alasan masuk RS :.
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pasien datang mengeluh panas sejak 3 hari, badan ngilu, panas, muntah
.
2. Data fokus
DS - px mengatakan tidak bisa melakukan aktivitas sep
.
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DO - ADL dibantu ( makan, mandi dll)

:
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B. Diagnosa Keperawatan :
Syndrome deficit perawatan diri
.
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C. Tujuan & kriteria hasil
Setelah diberikan tindakan keperawatan , kebtuhan perawatan diri pasien
terpenuhi dengan criteria :
px terlihat bersih.
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D. Tindakan Keperawatan : tindakan apa yang akan dilakukan

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(Lampirkan ceklist tindakan) fotocopy yg d buku skill lab/ SPO di RS

II.

FORMAT STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN

KEPERAWATAN
A. Orientasi
1. Salam teurapeutik
Selamat pagi ,ibu,, sya ,,,, hari ini saya akan memandikan ibu, betul dengan
ibu ,, sya cek nomer RM waktu yang saya butuhkan 10
menit..
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2. Evaluasi/validasi
Ibu, bisa saya mulai,, apakah posisi ibu sudah nyaman?
..
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3. Kontrak (tujuan, prosedur, waktu, dan tempat)
Tujuan :agar menjaga kebersihan ibu, , ibu merasa lebih merasa nyaman
..
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Prosedur : ..........................................................................
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Waktu : ..............................................................................
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Tempat : .............................................................................
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B. Kerja (langkah langkah tindakan keperawatan) : komunikasi saat melakukan
tindakan
Sebutkan semua komunikasinya,,,,,
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C. Terminasi
1. Evaluasi respon klien terhadap tindakan keperawatan
Subjektif
Ibu bagaimana rasanya setelah saya mandikan?
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Objektif
Sya lihat ibu sudah bersih,
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2. Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan
yang telah dilakukan )
Bu, jika nanti ibu masih merasa lelah, sya akan posisikan ibu lebih
nyaman..............................................................................................................
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3. Kontrak yang akan datang (Topik, waktu, dan tempat)

( hubungkan langsung dengan tindakan yg sama / keterampilan lain)

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