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STRATEGI PELAKSANAAN DAN STRATEGI KOMUNIKASI DALAM
PELAKSANAAN TINDAKAN KEPERAWATAN
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I. FORMAT STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN (SP)
A. Identitas Pasien
Nama Pasien :………………………………………………………………….
Dx medis : …………………………………………………………………
Kamar : …………………………………………………………………
B. Kondisi klien :
1. Alasan masuk RS :
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2. Data fokus
DS :
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DO :
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C. Tanda-Tanda Vital
TD :……….. mmHg
Suhu :…………oC
Nadi :………….x/menit
RR :…………x/menit
D. Diagnosa Keperawatan :
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E. Tujuan khusus (Tujuan yang akan dicapai & kriteria hasil
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F. Tindakan Keperawatan : tindakan apa yang akan dilakukan
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II. FORMAT STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN
KEPERAWATAN
A. Orientasi
1. Salam teurapeutik
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2. Evaluasi/validasi
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3. Kontrak (tujuan, waktu, dan tempat)
a. Tujuan:
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b. Waktu :
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c. Tempat :
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B. Kerja (langkah – langkah tindakan keperawatan) : komunikasi saat melakukan
tindakan
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C. Terminasi
1. Evaluasi respon klien terhadap tindakan keperawatan
a. Subjektif
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b. Objektif
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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)
a. Topik:
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b. Waktu:
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c. Tempat
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