FORMAT

STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN (SPTK)

a. PROSES KEPERAWATAN
1. Kondisi Klien :
DO…………………………………………………………………………………
DS…………………………………………………………………………………
2. Diagnosa Keperawatan :
……………………………………………………………………………………
……………………………………………………………………………………
Tujuan Khusus :
……………………………………………………………………………………
……………………………………………………………………………………
Tindakan Keperawatan :
……………………………………………………………………………………
……………………………………………………………………………………

b. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN

KEPERAWATAN
1. Fase Orientasi
a. Salam Terapeutik
…………………………………………………………………………………
…………………………………………………………………………….........
b. Perkenalan/Validasi identitas perawat
…………………………………………………………………………………
…………………………………………………………………………………
c. Pembicaraan dengan topic netral
…………………………………………………………………………………
…………………………………………………………………………….........
 d. Evaluasi/validasi
…………………………………………………………………………………
…………………………………………………………………………….........
e. Kontrak :
Topik ………………………………………………………………………......
Waktu ……………………………………………………………………….....
Tempat ………………………………………………………………………...

2. Fase Kerja (Langkah-langkah tindakan keperawatan)

……………………………………………………………………………………
……………………………………………………………………………………
…………………………………………………………………………………...

3. Fase Terminasi
a. Evaluasi Respon klien terhadap tindakan keperawatan
Evaluasi klien (Subjektif)
…………………………………………………………………………………
…………………………………………………………………………….
Evaluasi perawat (objek setelah reinforcement)
…………………………………………………………………………………
…………………………………………………………………………….
b. Rencana Tindak lanjut
…………………………………………………………………………………
…………………………………………………………………………………
c. Kontrak yang akan datang
Topik ………………………………………………………………………..
Waktu ……………………………………………………………………….
Tempat ……………………………………………………………………
 FORMAT
LAPORAN PENDAHULUAN (LP)

I. KONSEP TEORI
A. Pengertian
..............................................................................................................................
..............................................................................................................................
.............................................................................................................................
B. Etiologi
..............................................................................................................................
..............................................................................................................................
.........................................................................................................................
C. Tanda dan Gejala
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
D. Patofisiologi
..............................................................................................................................
..............................................................................................................................
.........................................................................................................................
E. Penatalaksanaan
1 Penatalaksanaan non-medis
2 Penatalaksanaan medis

II. KONSEP ASUHAN KEPERAWATAN

A. Pengkajian
..............................................................................................................................
..............................................................................................................................
.................................................................................................................
B. Diagnosa Keperawatan
..............................................................................................................................
..............................................................................................................................
.............................................................................................................................
C. Intervensi/Rencana Keperawatan
..............................................................................................................................
..............................................................................................................................
............................................................................................................................
D. Evaluasi
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
 Format Laporan Pendahuluan Asuhan Keperawatan Jiwa

LAPORAN PENDAHULUAN

I. KASUS (MASALAH UTAMA)

A. Definisi
..............................................................................................................................
..............................................................................................................................
................................................................................................................
B. Tanda dan Gejala
..............................................................................................................................
..............................................................................................................................
.................................................................................................................
C. Tingkatan
..............................................................................................................................
..............................................................................................................................
................................................................................................................
D. Klasifikasi
..............................................................................................................................
..............................................................................................................................
................................................................................................................
E. Rentang Respon
..............................................................................................................................
..............................................................................................................................
................................................................................................................
F. Faktor Predisposisi
..............................................................................................................................
..............................................................................................................................
................................................................................................................
G. Faktor Presipitasi
..............................................................................................................................
..............................................................................................................................
................................................................................................................
H. Mekanisme Koping
..............................................................................................................................
..............................................................................................................................
................................................................................................................
II. PROSES TERJADINYA MASALAH
....................................................................................................................................
....................................................................................................................................
.....................................................................................................................
III. DATA FOKUS PENGKAJIAN
....................................................................................................................................
....................................................................................................................................
.....................................................................................................................
IV. MASALAH KEPERAWATAN
1. .............................................................................................................................
2. ................................................................................................................................
3. .....................................................................................................................
V. ANALISA DATA
No Masalah Keperawatan Data Yang Dikaji
Data Subjektif (DO) : ................

Data Objektif (DS) : ......................

Data Subjektif (DO) : ................

Data Objektif (DS) : ......................

VI. DIAGNOSA KEPERAWATAN

....................................................................................................................................
.....................................................................................................................
Diagnosa keperawatan berisi satu masalah keperawatan yang menjadi prioritas.
Ditulis hanya problemnya saja tanpa penyebab (tidak menggunakan
“berhubungan dengan”)
VII. RENCANA TINDAKAN KEPERAWATAN
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
Rencana tindakan keperawatan berisi rencana tindakan dari diagnosis
keperawatan yang diangkat.