LAPORAN PENDAHULUAN

A. Kasus ( Masalah utama ) :

B. Proses terjadinya masalah :

C. 1. Pohon masalah :

2. Masalah keperawatan dan data yang perlu dikaji :

D. Diagnosa Keperawatan :

E. Rencana tindakan keperawatan :

STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN SP

…………………………………………. Pertemuan ………….

Tanggal…………………………

Pertemuan : Hari/ Tanggal : Nama Klien (Inisial) : Ruangan :

A. Proses Keperawatan 1. Kondisi Klien :

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2. Diagnosa Keperawatan :

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3. Tujuan Khusus :

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4. Tindakan Keperawatan :

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Buku Panduan Keperawatan Jiwa-Profesi UEU Page 48

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B. Strategi Komunikasi 1. Orientasi a. Salam terapeutik :

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b. Evaluasi/validasi :

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c. Kontrak (topik, waktu dan tempat) :

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d. Tujuan :

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2. Kerja (menjabarkan langkah-langkah tindakan keperawatan secara operasional)

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3. Terminasi a. Evaluasi (respon klien terhadap tindakan keperawatan)

Buku Panduan Keperawatan Jiwa-Profesi UEU Page 49

1) Evaluasi Subyektif :

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........................................................................................................................... 3) Evaluasi

Obyektif : ........................................................................................................................... 4)

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b. Rencana tindak lanjut (yang perlu dilatih klien sesuai hasil tindakan yang dilakukan)

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c. Kontrak yang akan datang ((topik, waktu dan tempat)

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