FORMAT

ASUHAN KEPERAWATAN JIWA

XIV. POHON MASALAH

PALANGKA RAYA, ............................

MAHASISWA,

...................................................................
ANALISA DATA

NO DATA DIAGNOSA KEPERAWATAN

DS :

DO :

DS :

DO :

DS :

DO :

DS :

DO :
 RENCANA TINDAKAN KEPERAWATAN
KLIEN DENGAN ...................................................................
Nama klien : Diagnosis Medis :
No. CM : Ruangan :

No Diagnosa keperawatan Perencanaan

Tujuan Kriteria hasil Intervensi
TUM

TUK
DOKUMENTASI HASIL ASUHAN KEPERAWATAN
TINDAKAN KEPERAWATAN EVALUASI
 90

FORMAT
ANALISA PROSES INTERAKSI

Inisial klien : ........................................................ Nama Mahasiswa : ......................................................

Status interaksi perawat – kien : ........................................................ Tanggal : ......................................................
Lingkungan : ........................................................ Jam : ......................................................
Deskripsi Klien : ........................................................ Bangsal : ......................................................

Tujuan (Berorientasi pada klien): .......................................................

ANALISA BERPUSAT PADA ANALISA BERPUSAT PADA

KOMUNIKASI VERBAL KAMUNIKASI NON VERBAL RASIONAL
PERAWAT KLIEN
.
P: ............................................ P: ........................................... ................................................ ................................................ ...............................

K: .......................................... K: .......................................... ................................................. ................................................. ...............................

P: ............................................ P: ............................................ ................................................. ................................................. ...............................

K: .......................................... K: .......................................... ................................................. ................................................ ...............................

. .
P: ............................................ P: ............................................ ................................................ ................................................ ...............................
 91

K: .......................................... K: .......................................... ................................................. ................................................. ...............................

. .
P: ............................................ P: ............................................ ................................................ ................................................ ...............................

K: .......................................... K: .......................................... ................................................. ................................................. ...............................

Kesan Perawat :

..................................................................................................................................................................................................................................................................................................... .......
.................................................................................................................................................................................................................................................... ........................................................
............................................................................................................................................................................................................................................................................................................
 19

FORMAT
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
(Dibuat setiap kali sebelum interaksi / pertemuan dengan klien)

A. PROSES KEPERAWATAN.

1. Kondisi Klien:
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
2. Diagnosa Keperawatan.
....................................................................................................................................................

3. Tujuan Khusus (TUK)

....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
4. Tindakan Keperawatan
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN KEPERAWATAN

a. FASE ORIENTASI

1. Salam Terapeutik
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

2. Evaluasi / validasi
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
3. Kontrak
Topik : ............................................................................................................
Waktu : ...........................................................................................................
Tempat : ...........................................................................................................

b. FASE KERJA
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
 20

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 : ...........................................................................................................
 19

IMPLEMENTASI DAN EVALUASI

Nama : Ruang :
No Tanggal & jam Implementasi keperawatan Evaluasi