FORMAT STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

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Nama Pasien :
No Medrek :
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I. PROSES KEPERAWATAN
1. Kondisi klien ( gambarkan kondisi klien pada saat terkahir bertemu)
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2. Diagnosa Keperawatan
(tuliskan diagnosa keperawatan yang akan diatasi pada pertemuan ini sesuai dengan
data diatas, tulis diagnosa keberapa)
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3. Tujuan Keperawatan
(tuliskan tujuan yang akan dicapai pada pertemuan ini)
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4. Tindakan Keperawatan
(tuliskan tindakan keperawatan secara teoritis dari tujuan keperawatan yang akan
diselesaikan pada pertemuan ini)
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II. STRATEGI KOMUNIKASI TERAPEUTIK
1. Orientasi
 Salam terapeutik
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 Evaluasi/validasi
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 Kontrak (topik, waktu, tempat)
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2. Kerja
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3. Terminasi
 Evaluasi subyektif (perasaan klien setelah berbincang-bincang)
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 Evaluasi obyektif (isi materi yang sudah dibicarakan)
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 Rencana tindak langsung (PR untuk klien)
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Kontrak pertemuan yang akan datang (waktu, tempat,
topik) .................................................................................................................................
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