RENCANA TINDAKAN KEPERAWATAN

Nama: …………… Ruang:………………. RM No:………………..

Rencana Tindakan Keperawatan Rasional

No. Dx
Tujuan dan Kriteria
Tindakan Keperawatan
Evaluasi

TUM:

TUK:

Kriteria Evaluasi:
 TINDAKAN KEPERAWATAN JIWA
Nama : Ruang :
No CM : Unit :

No Tindakan Keperawatan Evaluasi

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

Hari:……..Tanggal:…………

Interaksi ke:………………..

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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B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN KEPERAWATAN

a. ORIENTASI
1. Salam Terapeutik:
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 2. Evaluasi/ Validasi:
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3. Kontrak: (Topik, waktu, dan tempat)

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b. KERJA: Langkah-Langkah Tindakan keperawatan

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c. TERMINASI:
1. Evaluasi respon klien terhadap tindakan keperawatan:
Evaluasi Subyektif (Klien):

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Evaluasi Obyektif (Perawat):

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2. Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan yang
telah dilakukan):

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3. Kontrak yang akan datang (Topik, waktu, dan tempat):

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FORMAT ANALISIS PROSES INTERAKSI

Inisial Klien : ...................... Nama Mahasiswa .............................:
Status Interaksi : ...................... Tanggal :............................
Lingkungan : ...................... Jam :............................
Deskripsi Klien : ...................... Ruang :............................
Tujuan : ......................

Komunikasi Komunikasi Non Analisis Berpusat Analisis Berpusat

Rasional
Verbal Verbal Pada Perawat Pada Klien

P: P:

K: K:

P: P:

K: K:

P: P:

K: K:

P: P:

K: K:

P: P:

K: K:

P: P:

K: K: