Sekolah Tinggi Ilmu Kesehatan

BINA USADA BALI

SK MENDIKNAS RI. NOMOR 122/D/O/2007
TERAKREDITASI BAN PT.NOMOR 351/SK/BAN-PT/ Akred/ PT/IV/2015
Kompleks Kampus MAPINDO Jl. Padang Luwih, Tegal Jaya Dalung - Badung
Telp. (0361) 9072036,Email: binausada@yahoo.com Web: binausadabali.ac.id

FORMAT STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Nama : ................................. No. RM : .................................

Umur : ................................. Tgl. MRS : .................................
Jenis Kelamin : ................................. Dx. Medis : .................................
Ruang : .................................

Kondisi Klien:
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Alasan Masuk Rumah Sakit:

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Data Fokus:
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Diagnosa Keperawatan (masalah):

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Tujuan Khusus: tujuan yang akan dicapai, kriteria hasil

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Tindakan keperawatan: tindakan apa yang akan dilakukan, SOP tindakan tersebut

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 STRATEGI KOMUNIKASI

DALAM PELAKSANAAN TINDAKAN KEPERAWATAN

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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KERJA (langkah-langkah tindakan keperawatan): komunikasi saat melakukan tindakan

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TERMINASI

Evaluasi respon klien terhadap tindakan keperawatan

Evaluasi:
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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Kontrak yang akan datang

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Waktu : ...................................................................................................................................
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Tempat : .................................................................................................................................
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