UNIVERSITAS JEMBER KODE

DOKUMEN
FAKULTAS KEPERAWATAN
PRODI S-1 KEPERAWATAN
FORM PP-05
LEMBAR KERJA
MAHASISWA
Dosen Pengampu Mata kuliah : Ns. Yeni Fitria, M.Kep.
Pokok Bahasan : Model Adaptasi Stres
Stuart
Model Pembelajaran : Case Method

IDENTITAS MAHASISWA

Nama/NIM/Kelas
Nama
Anggota
kelompok
Pertemuan Ke
Hari/Tanggal

BAHAN DISKUSI
1. Bacalah Buku text Book Prinsip dan praktik keperawatan Kesehatan jiwa stuart (2013)
atau Buku Ajar Keperawatan Kesehatan Jiwa (Wuri, EW dkk, 2019) dan petunjuk teknis
pengkajian keperawatan kesehatan jiwa sebagai panduan dalam melakukan pengkajian
Kesehatan Jiwa
2. Lihat film ”A Beautiful mind”
3. Obervasi dan Tuliskan hasil analisis pada tokoh utama film tersebut berdasarkan model
adaptasi stress stuart pada form yang telah disiapkan (terlampir)
4. Analisis film keperawatan kesehatan jiwa dilakukan sesuai jadwal topik tersebut
5. Laporan pengkajian diupload di MMP
HASIL DISKUSI
Tuliskan hasil analisis pada format yang telah disediakan!
1. Faktor Predisposisi
2. Faktor Presipitasi

3. Penilaian terhadap stressor

Kognitif:

Afektif:

Fisiologis:

Perilaku:

Sosial:

4. Sumber koping

5. Mekanisme koping
 UNIVERSITAS JEMBER KODE
DOKUMEN
FAKULTAS KEPERAWATAN
PRODI S-1 KEPERAWATAN
FORM PP-05
LEMBAR KERJA
MAHASISWA
Dosen Pengampu Mata kuliah : Ns. Yen i Fitria, M.Kep.
Pokok Bahasan : Pengkajian Keperawatan Jiwa
Model Pembelajaran : Case Method

IDENTITAS MAHASISWA

Nama/NIM/Kelas
Nama
Anggota
kelompok
Pertemuan Ke
Hari/Tanggal

BAHAN DISKUSI
1. Bacalah Buku text Book Prinsip dan praktik keperawatan Kesehatan jiwa stuart (2013)
atau Buku Ajar Keperawatan Kesehatan Jiwa (Wuri, EW dkk, 2019) dan petunjuk teknis
pengkajian keperawatan kesehatan jiwa sebagai panduan dalam melakukan pengkajian
Kesehatan Jiwa
2. Siapkan form pengkajian kesehatan jiwa
3. Lihat film ”A Beautiful mind”
4. Obervasi dan Tuliskan hasil pengkajian pada tokoh utama film tersebut pada form yang
telah disiapkan (terlampir)
5. Praktikum pengkajian keperawatan kesehatan jiwa dilakukan sesuai jadwal topik tersebut
6. Laporan pengkajian diupload di MMP
HASIL DISKUSI
Tuliskan hasil pengkajian pada format yang telah disediakan!
 PENGKAJIAN KEPERAWATAN
KESEHATAN JIWA

Tanggal MRS : ………………..

Tanggal Dirawat di Ruangan : ………………..
Tanggal Pengkajian : ……………........
Ruang Rawat : …………………

I. IDENTITAS KLIEN
Nama................................................(L/P)
Umur : …………….. ………
Alamat : ………………………
Pendidikan : .....................................
Agama : ....................................
Status : ....................................
Pekerjaan : ………………………
JenisKel. : ………………………
No CM : ………………………

II. ALASAN MASUK

a. DataPrimer
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
b. DataSekunder
.........................................................................................................................................
.........................................................................................................................................
c. Keluhan Utama Saat Pengkajian
.........................................................................................................................................

III. RIWAYAT PENYAKIT SEKARANG (FAKTOR PRESIPITASI)

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

1
 ...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

IV. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)

1. Pernah mengalami gangguan jiwa di masa lalu ?
 Ya
 Tidak
JikaYa,Jelaskan kapan, tanda gejala/keluhan :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
2. Faktor Penyebab/Pendukung :
a. Riwayat Trauma
Usia Pelaku Korban Saksi
1. Aniayafisik ………… ………… ………… …………
2. Aniayaseksual ………… ………… ………… …………
3. Penolakan ………… ………… ………… …………
4. Kekerasan dalam keluarga ………… ………… ………… …………
5. Tindakan kriminal ………… ………… ………… …………
Jelaskan:
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
DiagnosaKeperawatan :
b. Pernah melakukan upaya / percobaan / bunuh diri
Jelaskan:
.....................................................................................................................................
.....................................................................................................................................
................................................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
DiagnosaKeperawatan :

2
 c. Pengalaman masalalu yang tidak menyenangkan (peristiwa kegagalan, kematian,
perpisahan )
Jika ada jelaskan :
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
DiagnosaKeperawatan :
d. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
 Ya
 Tidak
Jika yaJelaskan
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Diagnosa Keperawatan :
e. Riwayat Penggunaan NAPZA
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Diagnosa Keperawatan :
3. Upaya yang telah dilakukan terkait kondisi di atas dan hasilnya :
Jelaskan :
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
Diagnosa Keperawatan :
4. Riwayat Penyakit Keluarga
Anggotakeluarga yang gangguanjiwa
?
 Ada
 Tidak
Jika ada :

3
Hubungankeluarga :

4
 ..........................................................................................................................................
Gejala :
..........................................................................................................................................
Riwayat pengobatan :
..........................................................................................................................................
Diagnosa Keperawatan :

V. PENGKAJIAN PSIKOSOSIAL (Sebelum dan sesudah sakit)

1. Genogram:

Jelaskan:
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Diagnosa Keperawatan :
2. Konsep Diri
a. Citra tubuh :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

5
 b. Identitas :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

c. Peran :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
d. Ideal diri :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
e. Hargadiri :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Diagnosa Keperawatan :
3. Hubungan Sosial
a. Orang yang berarti/terdekat
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
b. Peran serta dalam kegiatan kelompok/masyarakat dan hubungan sosial
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................

6
 ...................................................................................................................................
c. Hambatan dalam berhubungan dengan orang lain
Pasien merupakan pribadi yang tidak mudah beradaptasi dan tidak mudah
berteman. Hal ini menyebabkan pasien dianggap aneh.
Diagnosa Keperawatan :

4. Spiritual
a. Agama
Pasien terkadang beribadah namun waktunya lebih dihabiskan untuk meneliti teori.
b. Pandangan terhadap gangguan jiwa
Pasien tidak mengetahui apabila dirinya mengidap gangguan jiwa karena tidak bisa
membedakan dunia nyata dan khayalan.
Diagnosa Keperawatan:

VI. PEMERIKSAAAN FISIK

1. Keadaan umum
Pasien nampak seperti orang sehat dan penampilan yang rapi, namun hanya lebih
penyendiri dan tidak banyak berinteraksi.
2. Kesadaran (Kuantitas)
Compos mentis adalah kondisi sadar sepenuhnya. Pada kondisi ini, respon
pasien terhadap diri sendiri dan lingkungan sangat baik. Pasien juga dapat
menjawab pertanyaan penanya dengan baik. Nilai GCS untuk compos mentis
adalah 15-14.
3. Tanda vital: tidak terkaji
TD : ……. mm/Hg
N :….........x/menit
S...................CO
P...................x/menit
4. Ukur: tidak terkaji
BB.............Kg

7
 TB : ……. Cm
5. Keluhan fisik:
tidak terkaji
Diagnosa Keperawatan :
VII.STATUS MENTAL
1. Penampilan (Penanpilan usia, cara perpakaian, kebersihan)
Jelaskan:

Pasien berpenampilan dengan rapi serta mengikuti tren yang ada di tempatnya, pasien
juga selalu menjaga kebersihan namun ketika sedang meneliti pasien tidak
memperhatikan kebersihannya.
Diagnosa Keperawatan:
2. Pembicaraan (Frekuensi, Volume, Jumlah, Karakter) :
Jelaskan:
Pasien hanya berbicara kepada orang yang ia butuhkan atau ia kenali.
Diagnosa Keperawatan:
3. Aktifitasmotorik/Psikomotor
Kelambatan :
 Hipokinesia,hipoaktifitas
 Katalepsi
 Sub stupor katatonik
 Fleksibilitas serea
Jelaskan:

Pasien tidak memperhatikan lingkungannya dan hanya berfokus pada dirinya sendiri.
Peningkatan :

8
  Hiperkinesia,hiperaktifitas  Grimace
 Stereotipi  Otomatisma
 Gaduh Gelisah Katatonik  Negativisme
 Mannarism  Reaksikonversi
 Katapleksi  Tremor
 Tik  Verbigerasi
 Ekhopraxia  Berjalankaku/rigid
 Command automatism  Kompulsif :sebutkan …………
Jelaskan:
Pasien selalu merasa cemas bahkan depresi Ketika apa yang dia inginkan tidak tercapai
(seperti penelitiannya)
Diagnosa Keperawatan :
4. Mood dan Afek
a. Mood
 Depresi  Khawatir
 Ketakutan  Anhedonia
 Euforia  Kesepian
 Lain
lain
Jelaskan

Pasien selalu merasa cemas bahkan depresi Ketika apa yang dia inginkan tidak
tercapai (seperti penelitiannya)
b. Afek
 Sesuai *Tidak sesuai
 Tumpul/dangkal/datar  Labil

Jelaskan:

Pasien terkadang merespon secara terpaksa bahkan tidak merespon Ketika diajak
berinteraksi.
Diagnosa Keperawatan

9
5. Interaksi Selama Wawancara
 Bermusuhan  Kontak mata kurang
 Tidak kooperatif  Defensif
 Mudah tersinggung *Curiga
Jelaskan:

Pasien menganggap bahwa orang lain hanya ingin tahu dirinya sehingga pasien seperti
menjaga dirinya.
Diagnosa Keperawatan
6. Persepsi Sensorik
a. Halusinasi
 Pendengaran
 Penglihatan
 Perabaan
 Pengecapan
 Penciuman
b. Ilusi
 Ada
 Tidakada
Jelaskan:

Pasien mengalami ilusi seperti adanya teman khayalan bahkan bisa menyentuh,
berkomunikasi dengan khayalannya.
Diagnosa Keperawatan
7. Proses Pikir
a. ArusPikir:
 Koheren  Inkoheren
 Sirkumtansial  Asosiai longgar
 Tangensial *Flight of Idea
 Blocking  Perseverasi
 Logorhoe  Neologisme
 Clang Association  Main kata kata
 Afasia  Lain lain…
Jelaskan:
Pasien sangat cerdas dan gaya bicara nya sangat rumit.

1
0
 .....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
b. Isi Pikir
 Obsesif  Fobia,sebutkan…………..
 Ekstasi  Waham:
 Fantasi o Agama
 Alienasi o Somatik/hipokondria
 Pikiran bunuh diri o Kebesaran
 Preokupasi o Kejar / curiga
 Pikiran isolasisosial o Nihilistik
 Ide yang terkait o Dosa
 PikiranRendahdiri o Sisip pikir
 Pesimisme o Siar piker
 Pikiran magis o Kontrol pikir
 Pikiran curiga  Lain lain :
Jelaskan:
Pasien sangat terobsesi dengan matematika dan penelitian tentang teori teori baru
yang ia ciptakan.
c. Bentuk pikir :
 Realistik
 Non realistik
 Dereistik
 Otistik
Jelaskan:

Pasien berpikiran realistis namun sebenarnya dia berbicara dengan ilusi nya
Diagnosa Keperawatan:

8. Kesadaran
 Orientasi (waktu, tempat, orang)
Jelaskan:
Pasien bisa mengerti waktu dan tempat, namun pasien bisa menghadirkan ilusinya.

10
 ...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
 Meninggi
 Menurun:
 Kesadaran berubah
 Hipnosa
 Confusion
 Sedasi
 Stupor
Jelaskan:
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Diagnosa Keperawatan:
9. Memori
 Gangguan daya ingat jangka panjang ( > 1 bulan)
 Gangguan dayaingat jangka menengah ( 24 jam - ≤ 1 bulan)
 Gangguan daya ingat pendek (kurun waktu 10 detik sampai 15 menit)
Jelaskan:
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Diagnosa Keperawatan:
10. Tingkat Konsentrasi dan Berhitung
a. Konsentrasi
 Mudah beralih
 Tidak mampu
berkonsentrasi Jelaskan:
...................................................................................................................................
...................................................................................................................................
b. Berhitung
Jelaskan:
...................................................................................................................................
...................................................................................................................................

11
 Diagnosa Keperawatan:
11. Kemampuan Penilaian
 Gangguan ringan
 Gangguan
bermakna Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Diagnosa Keperawatan:
12. Daya Tilik Diri
 Mengingkari penyakit yang diderita
 Menyalah kanhal-hal diluar dirinya
Jelaskan:
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Diagnosa Keperawatan:

VIII. KEBUTUHAN PERSIAPAN PULANG

1. Kemampuan klien memenuhi kebutuhan
 perawatan kesehatan,

 transportasi,
 tempat tinggal.
 Keuangan dan kebutuhan
lainnya. Jelaskan:
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
2. Kegiatan Hidup Sehari hari
a. Perawatan diri
1) Mandi
Jelaskan :
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

12
 2) Berpakaian, berhias dan
berdandan Jelaskan :
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3) Makan
Jelaskan :
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
4) Toileting (BAK, BAB)
Jelaskan :
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
Diagnosa Keperawatan:
b. Nutrisi
Berapa frekwensi makan dan frekwensi kudapan dalam sehari.
............................................................................................................................
............................................................................................................................
Bagaimana nafsu makannya
............................................................................................................................
............................................................................................................................
Bagaimana berat badannya.
............................................................................................................................
............................................................................................................................
Diagnosa Keperawatan:
c. Tidur
1) Istirahat dan tidur
Tidur siang, lama : s/d
Tidur malam, lama : s/d
Aktifitas sebelum/sesudah tidur : ,
Jelaskan
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................

13
 2) Gangguan tidur
 Insomnia
 Hipersomnia
 Parasomnia

 Lain
lain
Jelaskan
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
Diagnosa Keperawatan:

3. Kemampuan lain lain

 Mengantisipasi kebutuhan hidup

...................................................................................................................................
...................................................................................................................................
 Membuat keputusan berdasarkan keinginannya,
...................................................................................................................................
...................................................................................................................................
 Mengatur penggunaan obat dan melakukan pemeriksaan kesehatannya sendiri.
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Diagnosa Keperawatan:
4. Sistem Pendukung Ya Tidak
Keluarga
Terapis
Teman sejawat
Kelompok sosial
Jelaskan :
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Diagnosa Keperawatan:

14
IX. MEKANISME KOPING
Jelaskan :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
Diagnosa Keperawatan:

X. MASALAH PSIKOSOSIALDAN LINGKUNGAN

 Masalah dengan dukungan kelompok, spesifiknya
Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 Masalah berhubungan dengan lingkungan,
spesifiknya Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 Masalah dengan pendidikan, spesifiknya
Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 Masalah dengan pekerjaan,
spesifiknya Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 Masalah dengan perumahan, spesifiknya
Jelaskan :
..........................................................................................................................................
..........................................................................................................................................

15
 ..........................................................................................................................................
..........................................................................................................................................
 Masalah dengan ekonomi, spesifiknya
Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 Masalah dengan pelayanan kesehatan, spesifiknya
Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 Masalah lainnya,
spesifiknya Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Diagnosa Keperawatan:

XI. ASPEK PENGETAHUAN

Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang kurang
tentang suatu hal?
Bagaimana pengetahuan klien/keluarga saat ini tentang penyakit / gangguan jiwa,
perawatan dan penatalaksanaanya faktor yang memperberat masalah (presipitasi), obat-
obatan atau lainnya. Apakah perlu diberikan tambahan pengetahuan yang berkaitan
dengan spesifiknya masalah tsb
 Penyakit/gangguan jiwa  Penatalaksanaan
 Sistem pendukung  Lain-lain, jelaskan
 Faktor presipitasi
Jelaskan :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

16
 Diagnosa Keperawatan:

XII. ASPEK MEDIS

1. Diagnosis Multi Axis
Axis I : .........................................................................................................................
Axis II : ........................................................................................................................
Axis III : .........................................................................................................................
Axis IV :.........................................................................................................................
Axis V : ........................................................................................................................
2. Terapi Medis
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

17
XIII. ANALISA DATA

DIAGNOSA
NO DATA
KEPERAWATAN
1. DS:
.....................................................................
.....................................................................
DO:
.....................................................................
.....................................................................

2. DS:
.....................................................................
.....................................................................
DO:
.....................................................................
.....................................................................

3. DS:
.....................................................................
.....................................................................
DO:
.....................................................................
.....................................................................

4. DS:
.....................................................................
.....................................................................
DO:
.....................................................................
.....................................................................

dst DS:
.....................................................................
.....................................................................
DO:
.....................................................................
.....................................................................

18
XIV. DAFTAR DIAGNOSA KEPERAWATAN
1. ………………………………………
2. ………………………………………
3. ………………………………………
4. ………………………………………
5. ………………………………………
6. ………………………………………
7. ………………………………………
8. dst

XV. POHON MASALAH

XVI. PRIORITAS DIAGNOSA KEPERAWATAN

1. ……………………………………………….
2. ………………………………………………
3. ………………………………………………
4. .………………………………………………

Lawang, ……………………….
Perawat yang mengkaji

NIM/NIRM: ..………….

19
 TINDAKAN KEPERAWATAN JIWA
Nama : Ruang :
No CM : Unit :
Tanggal Diagnosa
No Tindakan Keperawatan Evaluasi Ttd
Jam Keperawatan

1
 UNIVERSITAS JEMBER KODE
DOKUMEN
FAKULTAS KEPERAWATAN
PRODI S-1 KEPERAWATAN
FORM PP-05
LEMBAR KERJA
MAHASISWA
Dosen Pengampu Mata kuliah : Ns. Yeni Fitria, M.Kep.
Pokok Bahasan : Komunikasi Terapeutik dalam asuhan keperawatan
kesehatan jiwa (SPTK dan API)
Model Pembelajaran : Case Method

IDENTITAS MAHASISWA

Nama/NIM/Kelas
Pertemuan Ke

Hari/Tanggal

BAHAN DISKUSI
1. Bacalah Buku text Book Prinsip dan praktik keperawatan Kesehatan jiwa stuart (2013)
atau Buku Ajar Keperawatan Kesehatan Jiwa (Wuri, EW dkk, 2019) sebagai panduan
dalam menyusun strategi pelaksanaan Tindakan keperawatan (SPTK) dan melakukan
Analisis Proses Interaksi
2. Pilihlah 1 diagnosa keperawatan jiwa dan 1 implementasi dari diagnose tersebut
3. Tuliskan SPTK Tindakan keperawatan tersebut pada form yang telah disiapkan (terlampir)
4. Lakukan Analisis Proses Interaksi
5. Laporan pengkajian diupload di MMP

HASIL
Tuliskan SPTK dan API pada format yang telah disediakan!
 FORMAT
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN
SP…./Pasien/Keluarga

A. PROSES KEPERAWATAN
1. Kondisi klien
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
2. Diagnosa keperawatan
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
3. Tujuan khusus
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
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
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
c. Fase Terminasi
1. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi subjektif
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
Evaluasi objektif
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………

2. Rencana tindak lanjut

…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………

3. Kontrak yang akan datang

Topik :
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
Waktu :
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
Tempat:
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
 FORMAT
ANALISA PROSES INTERAKSI

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

Status interaksi perawat – kien : ........................................................ Tanggal : ......................................................
Lingkungan : ........................................................ Jam : ......................................................
Deskripsi Klien : ........................................................ Bangsal : ......................................................
Tujuan (Berorientasi pada klien) : .......................................................

KAMUNIKASI NON ANALISA BERPUSAT PADA ANALISA BERPUSAT

KOMUNIKASI VERBAL RASIONAL
VERBAL PERAWAT PADA KLIEN
.
P: ............................................ P: ........................................... ................................................ ................................................ ...................................................

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

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

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

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

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

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

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

Kesan Perawat : ....................................................................

100