RESUME ASUHAN KEPERAWATAN PADA KLIEN ………

DENGAN ………………….. DI RUANG NAKULA RUMAH SAKIT JIWA

PROVINSI BALI

I. Pengkajian
Hari/tanggal :

a. Identitas
Nama :
Umur :
Jenis kelamin :
Status :
Suku / Bangsa :
Agama :
Pendidikan :
Pekerjaan :
Hubungan :
Alamat :
No. CM :

II. Alasan Masuk :

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1) Riwayat Penyakit
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 2) Data Fokus
1. Data Subjektif
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2. Data Objektif
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III. Diagnosa Keperawatan

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IV. Rencana Keperawatan
TUM :
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TUK :
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V. Strategi Pelaksanaan
Hari/Tgl/Jam Strategi Pelaksanaan
VI. Implementasi dan Evaluasi Keperawatan

Hari / Tindakan Keperawatan Evaluasi

Tanggal
Jam
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 STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Hari/tanggal : No. RM :
Jam : Nama :
Pertemuan Ke : Asal :
Topic: JK :
Topik :

A. PROSES KEPERAWATAN
1. Kondisi Klien
Data Subjektif :
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Data Objektif :
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 2. Diagnosa Keperawatan
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3. Tujuan Khusus
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4. Tindakan
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B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN KEPERAWATAN
a) Fase Orientasi
1. Salam teraupetik
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2. Evaluasi/ validasi
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3. Kontrak
 Topik:
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 Waktu:
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 Tempat:
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b) Fase Kerja
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c) Fase Terminasi
1. Evaluasi

☯ Evaluasi Subjektif
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☯ Evaluasi objektif
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☯ Rencana tindak lanjut:-
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☯ Kontrak yang akan datang

a) Topik
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b) Waktu
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c) Tempat
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