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FORMAT DOKUMENTASI ASUHAN KEPERAWATAN KELUARGA

ASUHAN KEPERAWATAN PADA KELUARGA Tn./Ny...DENGAN ...................................


Nama Mahasiswa
NIM
Tanggal Pengkajian
I.

:
:
:

PENGKAJIAN
A. Data Umum
1. Nama Kepala Keluarga
2. Alamat kepala Keluarga
3. Komposisi keluarga
No.

Nama

Jenis
Kelamin

: ...........................................................................................
: ...........................................................................................
:
Hubungan
Umur
Pendidikan
Pekerjaan
dengan KK

Genogram :
Keterangan:
4. Tipe Keluarga
: ...........................................................................................
5. Budaya
a. Suku :
b. Bahasa
: ...........................................................................................
6. Agama
: ...........................................................................................
7. Status sosial ekonomi keluarga
: ...........................................................................................
a. Pendapatan keluarga satu bulan : ...........................................................................................
b. Pengelola keuangan keluarga
: ...........................................................................................
c. Bagaimana pandangan keluarga terhadap pendidikan anggota keluarga
........................................................................................................................................................
d. Adakah nilai/keyakinan/agama yang bertentangan dengan kesehatan
........................................................................................................................................................
8. Aktivitas rekreasi keluarga
a. Kebiasaan rekreasi dalam keluarga
........................................................................................................................................................
b. Bagaimana keluargamenggunakan waktu senggangnya
........................................................................................................................................................
B. Riwayat Perkembangan
1. Tahap perkembangan keluarga saat ini
..........................................................................................................................................................
2. Tahap perkembangan keluarga yang belum terpenuhi
..........................................................................................................................................................
3. Riwayat keluarga inti
..........................................................................................................................................................
4. Riwayat keluarga sebelumnya

..........................................................................................................................................................
C. Lingkungan
1. Karakteristik rumah
a. Jenis rumah
: ...........................................................................................
b. Jenis bangunan
: ...........................................................................................
c. Luas bangunan
: ...........................................................................................
d. Luas pekarangan
: ...........................................................................................
e. Status kepemilikan rumah
: ...........................................................................................
f. Kondisi ventilasi rumah
: ...........................................................................................
g. Kondisi penerangan rumah
: ...........................................................................................
h. Kondisi pencahayaan rumah
: ...........................................................................................
i. Kondisi lantai
: ...........................................................................................
j. Kebersihan rumah secara keseluruhan :....................................................................................
k. Bagaiman pembagian ruangan-ruangan di rumah :...................................................................
l. Pengelolaan sampah keluarga :
m. Sumber air bersih dalam keluarga :
n. Kondisi jamban keluarga
: ...........................................................................................
o. Pembuangan limbah
: ...........................................................................................
2. Karakteristik tetangga dan komunitas RW
............................................................................................................................................................
3. Mobilisasi geografi keluarga
............................................................................................................................................................
4. Perkumpulan keluarga dan interaksi dengan masyarakat
............................................................................................................................................................
5. Sistem pendukung keluarga
Formal
:.......................................................................................................................................
Informal :.......................................................................................................................................
D. Struktur Keluarga
1. Struktur komunikasi keluarga
............................................................................................................................................................
2. Struktur kekuatan keluarga
............................................................................................................................................................
3. Struktur peran
............................................................................................................................................................
4. Struktur nilai dan norma budaya
............................................................................................................................................................
E. Fungsi Keluarga
1. Fungsi afektif
............................................................................................................................................................
............................................................................................................................................................
2. Fungsi sosialisasi
............................................................................................................................................................
............................................................................................................................................................
3. Fungsi perawatan kesehatan
a. Kemampuan keluarga mengenal masalah kesehatan
........................................................................................................................................................

F.

G.

H.

I.
J.

II.

b. Kemampuan keluarga mengambil keputusan mengenai tindakan kesehatan yang tepat.


........................................................................................................................................................
c. Kemampuan keluarga merawat anggota keluarga yang sakit
........................................................................................................................................................
d. Kemampuan keluarga memodifikasi lingkungan
........................................................................................................................................................
e. Kemampuan keluarga menggunakan fasilitas/pelayanan kesehatan di masyarakat.
........................................................................................................................................................
4. Fungsi reproduksi
............................................................................................................................................................
5. Fungsi ekonomi
............................................................................................................................................................
Stress dan koping keluarga
1. Stressor yang dihadapi keluarga (jangka pendek dan jangka panjang)
............................................................................................................................................................
2. Kemampuan keluarga berespon terhadap situasi/ stressor
............................................................................................................................................................
3. Strategi koping yang digunakan
............................................................................................................................................................
4. Strategi adaptasi disfungsional
............................................................................................................................................................
Pemenuhan Kebutuhan Dasar Manusia
1. Praktik diet keluarga (nutrisi dan cairan):............................................................................................
2. Pola tidur
: ...........................................................................................................
3. Olah raga/mobilisasi
: ...........................................................................................................
4. Pola eliminasi
: ...........................................................................................................
5. Personal higiene
: ...........................................................................................................
Pengkajian Psikiatrik
1. Konsep diri
a. Gambaran diri
: ...........................................................................................................
b. Peran diri
: ...........................................................................................................
c. Ideal diri
: ...........................................................................................................
d. Identitas diri
: ...........................................................................................................
e. Harga diri
: ...........................................................................................................
2. Status kesehatan mental
............................................................................................................................................................
3. Pengkajian resiko
............................................................................................................................................................
Harapan Keluarga
..................................................................................................................................................................
Pemeriksaan Fisik (pendekatan head to toe)
..................................................................................................................................................................

ANALISA DATA
No

Tanggal

Data Fokus

Masalah

Etiologi

Data subyektif:
.....................................................
Data Obyektif
.....................................................
Rumusan Masalah
1. ...
2. ...
3. ...
III.

PRIORITAS DIAGNOSA KEPERAWATAN


No.

Kriteria

S
k
a
l
a

B
o
b
o
t

Skoring

Pembenaran

1.
2.
3.
Urutan Prioritas Diagnosa Keperawatan
1. ...
2. ...
3. ...
IV.

RENCANA ASUHAN KEPERAWATAN KELUARGA/INTERVENSI


No.

Diagnosa
Keperawatan

Tujuan
Umum

Evaluasi
Kriteria
Standar

Khusus

Intervensi

1.
2.
3.
V.

IMPLEMENTASI ASUHAN KEPERAWATAN KELUARGA


No
Diagnosa

Tanggal
/jam

Implementasi

Evaluasi Formatif
Do:
Ds:

Ttd

VI. EVALUASI SUMATIF DAN RENCANA TINDAK LANJUT


EVALUASI SUMATIF
Tanggal

Diagnosa Keperawatan

Evaluasi Sumatif
S
O
A
P

Ttd

:
:
:
:

RENCANA TINDAK LANJUT


Anggota
KK

Masalah
Kesehatan

Intervensi yang telah


dilakukan

RTL

Para
f

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