Format Asuhan Kep Jiwa
Format Asuhan Kep Jiwa
............................................................
ANALISA DATA
DO :
DS :
DO :
RENCANA TINDAKAN KEPERAWATAN
KLIEN DENGAN ...................................................................
Nama klien : Diagnosis Medis :
No. CM : Ruangan :
TUK
DOKUMENTASI HASIL ASUHAN KEPERAWATAN
TINDAKAN KEPERAWATAN EVALUASI
FORMAT
ANALISA PROSES INTERAKSI
. .
P: ............................................ P: ............................................ ................................................ ................................................ ...............................
K: .......................................... K: .......................................... ................................................. ................................................. ...............................
. .
P: ............................................ P: ............................................ ................................................ ................................................ ...............................
Kesan
Perawat : .....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................
FORMAT
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
(Dibuat setiap kali sebelum interaksi / pertemuan dengan klien)
A. PROSES KEPERAWATAN.
1. Kondisi Klien:
.......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
2. Diagnosa Keperawatan.
..........................................................................................................................................
a. FASE ORIENTASI
1. Salam Terapeutik
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
2. Evaluasi / validasi
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
3. Kontrak
Topik : ............................................................................................................
Waktu : ...........................................................................................................
Tempat : ...........................................................................................................
b. FASE KERJA
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
.................................................................................................................................................. .....
................................................................................................................................................. ......
................................................................................................................................................ .......
............................................................................................................................................... ........
..............................................................................................................................................
......................................................................................................................................................
c. FASE TERMINASI
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi Subyektif (Klien)
...................................................................................................................................................
................................................................................................................................................. .
...................................................................................................................................................
................................................................................................................................................
Evaluasi Obyekti (Perawat)
...................................................................................................................................................
...................................................................................................................................................
................................................................................................................................................ ..
...................................................................................................................................................
...............................................................................................................................................
2. Rencana Tindak Lanjut
...................................................................................................................................................
...................................................................................................................................................
................................................................................................................................................ ..
................................................................................................................................................
3. Kontrak yang akan datang
Topik : ............................................................................................................
............................................................................................................
Waktu : ...........................................................................................................
Tempat : ...........................................................................................................
IMPLEMENTASI DAN EVALUASI
Nama : Ruang :