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JURUSAN KEPERAWATANFAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA

LAPORAN PENDAHULUAN

STRATEGI PELAKSANAAN

TINDAKAN KEPERAWATAN HARI KE..................

A. PROSES KEPERAWATAN1. Kondisi klien:

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2. Diagnosa keperawatan:....................................................................................................................................................................................................................................................................................................

3. Tujuan khusus:......................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Tindakan keperawatan:..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN KEPERAWATANORIENTASI

1. Salam Terapeutik:..................................................................................................................................................

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2. Evaluasi/ Validasi:......................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Kontrak: Topik, waktu, dan tempat..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................


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KERJA: Langkah-Langkah Tindakan keperawatan..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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TERMINASI:1. Evaluasi respon klien terhadap tindakan keperawatan:

Subyektif:......................................................................................................................................................................................................................................................................................................................................................................................................................................................

Obyektif:

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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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RENCANA ASUHAN KEPERAWATAN

Nama Klien :

No. Reg. :

TanggalNo

DxDiagnosa Keperawatan Tujuan Kriteria Standart Intervensi Rasional TT


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IMPLEMENTASI DAN EVALUASI

KEPERAWATAN KESEHATAN JIWA

Nama : _________________ Ruangan : _____________________ RM No. : _________________

NODx

Tanggal& Jam

IMPLEMENTASI KEPERAWATAN EVALUASI


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ANALISA PROSES INTERAKSI

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

Status interaksi perawat-klien : .......................... ............................... .......... Tanggal : .............................. ............................... ......

Lingkungan : .......................... ............................... .......... Jam : .............................. ............................... ......

Deskripsi klien : .......................... ............................... .......... Bangsal : .............................. ............................... ......Tujuan (berorientasi pada klien : .......................... ............................... ..........

KOMUNIKASI VERBAL KOMUNIKASI NONVERBAL

ANALISA BERPUSATPADA PERAWAT

ANALISA BERPUSATPADA KLIEN

RASIONAL

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Rekomendasi :.............................................................................................................................................................................................................


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PENILAIAN KEMAMPUAN PERAWAT DALAM MERAWAT PASIEN DENGAN

PERILAKU KEKERASAN

No Kemampuan

Bobot nilai Dilakukan

Ya Tidak

A Pasien

SP Ip

Fase orientasi25

Fase kerja50

1 Mengidentifikasi penyebab PK

2 Mengidentifikasi tanda dan gejala PK

3 Mengidentifikasi PK yang dilakukan

4 Mengidentifikasi akibat PK

5 Menyebutkan cara mengontrol PK

6 Membantu pasien mempraktekkan latihan cara mengontrol fisik I

7 Menganjurkan pasien memasukkan dalam kegiatan harian

Fase terminasi 25

Nil ai SP Ip

SP IIp

Fase orientasi 25

Fase kerja 50

1 Mengevaluasi jadwal kegiatan harian pasien

2 Melatih pasien mengontrol PK dengan cara fisik II

3 Menganjurkan pasien memasukkan dalam jadwal kegiatan harian

Fase terminasi 25

Nilai SP I I p

SP IIIp

Fase orientasi 25

Fase kerja 50


2 Melatih pasien mengontrol PK dengan cara verbal


Fase terminasi 50

Nilai SP IIIpSP IVp

Fase orientasi 25

Fase kerja 501 Mengevaluasi jadwal kegiatan harian pasien

2 Melatih pasien mengontrol PK dengan cara spiritual


Fase terminasi 50

Nilai SP IVpSP Vp

Fase orientasi 25

Fase kerja 50


2 Menjelaskan cara mengontrol PK dengan minum obat


Fase terminasi 50


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Nil ai SP Vp

B Keluarga

SP I k

Fase orientasi 25

Fase kerja 50

1 Mendiskusikan masalah yang dirasakan keluarga dalam merawat

pasien

2 Menjelaskan pengertian PK, tanda dan gejala, serta proses

terjadinya PK

3 Menjelaskan cara merawat pasien dengan PK

Fase terminasi 25

Nilai SP Ik

SP II k

Fase orientasi 25

Fase kerja 50

1 Melatih keluarga mempraktekkan cara merawat pasien dengan PK

2 Melatih keluarga melakukan cara merawat langsung kepada pasien

PKFase terminasi 25

Nilai SP IIk

SP III k

Fase orientasi 25

Fase kerja 50

1 Membantu keluarga membuat jadual aktivitas di rumah termasuk

minum obat (discharge planning)

2 Menjelaskan follow up pasien setelah pulang

Fase terminasi 25

Nilai SP III k

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