AKPER YPIB MAJALENGKA

STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Nama Mahasiswa :......................................................................................... .................

Nama Pasien :..........................................................................................................
Hari/ Tanggal :..........................................................................................................
Hari Ke/Pertemuan ke :...........................................................................................................
Fase :...........................................................................................................

A. PROSES KEPERAWATAN
1. Kondisi Klien (Gambarkan kondisi klien pada saat terakhir ketemu )
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2. Diagnosa Keperawatan (Tulislah diagnosa keperawatan yang akan diatasi pada

pertemuan ini sesuai dengan data diatas)
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3. Tujuan Khusus (tulislah tujuan khusus keperawatan yang akan dicapai pada
pertemuan ini, sesuai dengan diagnosa diatas, tulis tujuan khusus keberapa)

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4. Tindakan Keperawatan (tulis tindakan keperawatan secara teoritis dan tujuan
keperawatan diatas yang akan diselesaikan pada pertemuan ini)
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B. STRATEGI KOMUNIKASI TERAPEUTIK
(penjabaran dari semua tindakan keperawatan, buat semua dalam kalimat langsung)
1. Orientasi
a. Salam terapeutik :
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b. Memperkenalkan diri/mengingatkan nama:
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c. Membuka pembicaraan dengan topik umum
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d. Evaluasi/validasi tindak lanjut pada pertemuan sebelumnya :
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e. Membuat/ validasi Kontrak (Topik, Waktu dan Tempat)
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2. Kerja (penjabaran Langkah-langkah Tindakan Keperawatan)
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3. Terminasi
a. Evaluasi respon klien terhadap tindakan keperawatan
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Evaluasi kemampuan klien setelah intervensi (obyektif)
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b. Tindak lanjut klien (latihan apa yang harus dilakukan oleh klien, berapa kali
sehari, jam berapa saja)
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c. Kontrak yang akan datang
Topik :........................................................................................................................
Waktu :.......................................................................................................................
 Tempat :......................................................................................................................

d. Salam terapeutik
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