STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Masalah utama : Hari/tanggal

Pertemuan Ke :

A. PROSES KEPERAWATAN
1. Kondisi klien
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Data Obyektif : ...................................................................................................................
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2. Tindakan keperawatan
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B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
Orientasi
1. Salam terapeutik
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2. Evaluasi/validasi
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3. Kontrak
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Kerja (langkah-langkah tindakan keperawatan)
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Terminasi
1. Evaluasi Respon Klien terhadap tindakan keperawatan
 Evaluasi Subyektif
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 Evaluasi obyektif

Diklat rsjk
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2. Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil yang tindakan yang
telah dilakukan)
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3. Kontrak yang akan datang
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Kendari, Juli 2015

Mahasiswa,

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Diklat rsjk
 STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Hari/Tanggal: Senin, ........................

Pertemuan: Pertama

A. PROSES KEPERAWATAN
1. Kondisi klien
Tn. C, 28 tahun, sejak 2 minggu yang lalu tampak selalu menyendiri, tidak mau bicara,
tidur menghadap tembok dengan posisi seperti janin, tidak mau ikut kegiatan diruangan,
kontak mata tidak ada, klien mempunyai riwayat suka bicara sendiri, dan tertawa sendiri.

2. Diagnosa keperawatan
Risiko gangguan sensori persepsi

3. Tujuan khusus
a. Klien dapat membina hubungan saling percaya
b. Klien dapat menyebutkan penyebab tentang menarik diri

4. Tindakan keperawatan
- Membina hubungan saling percaya dengan klien
- Mendiskusikan dengan klien tentang penyebab menarik diri

B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN

Orientasi

 Salam terapeutik
Selamat pagi pak, saya mahasiswa ......... yang dinas diruang ini, nama saya ........... ,
biasa teman-teman saya memanggi dengan ........, nama bapak siapa? Bapak suka disebut
siapa? Bapak ....., nama yang bagus. Pak saya akan merawat bapak selama 2 minggu dari
hari senin sampai sabtu, dan dari jam 07.30-14.00 WIB.

 Evaluasi/validasi
Bagaiamana perasaan bapak hari ini?

 Kontrak

Diklat rsjk
 Baik pak (...), bagaimana kalau kita bercakap-cakap sebentar, kurang lebih 15 menit, kita
akan membicarakan tentang alasan bapak sampai dibawa ke RS ini, bagaimana pak?
Baik kita bicara dimana ?Baik kalau begitu disini saja ya

Kerja (langkah-langkah tindakan keperawatan)

Bapak ....., apa yang membuat bapak sampai di bawa ke RS. Bapak tadi melihat saya, mata
bapak bagus ya? Apa bapak punya orang yang dekat dengan bapak. Kalau boleh saya tahu
mengapa dekat dengan bapak, jadi bapak dekat dengan ......... karena bisa membagi cerita.
Lalu apa ada orang yang tidak dekat dengan bapak? Mengapa bapak tidak dekat. Baik pak
tadi bapak sudah cerita siapa yang dekat dan siapa yang tidak dekat dengan bapak, dan apa
yang membuat bapak dekat dan tidak dekat.

Terminasi
1. Evaluasi Respon Klien terhadap tindakan keperawatan
 Evaluasi Subyektif
Bagaimana perasaan bapak setelah bercakap-cakap dengan saya saait ini?

 Evaluasi obyektif
Baik pak, coba sebutkan kembali apa yang menyebabkan bapak dekat dengan orang
lain dan apa yang menyebabkan bapak tidak dekat dengan orang lain.

2. Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil yang tindakan
yang telah dilakukan)
Bapak tadi sudah cerita kepada saya alasan bapak tidak mau bergaul dengan orang lain,
coba bapak ingat-ingat kembali alasan bapak tidak mau dekat dengan orang lain selain
yang bapak sebutkan tadi
3. Kontrak yang akan datang
Baik pak pertemuan kita sekarang cukup sekian dulu, karena sesuai dengan janji kita tadi
bahwa kita bercakap-cakap hanya 15 menit dan sekarang sudah cukup 15 menit,
bagaimana kalau kita bercakap-cakap lagi sebentar jam 10.00 WIB seperti sekarang
waktunya 15 menit, disini atau di ruang lain yang lebih nyaman, bagaimana pak. Baik
kalau begitu kita bicarakan apa manfaatnya kalau kita bergaul dengan orang lain.
Selamat pagi,

Kendari, ..................

Mahasiswa,

Diklat rsjk
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Diklat rsjk