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Format Pengkajian Keperawatan Keluarga

Format Pengkajian Keperawatan Keluarga

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06/27/2013

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FORMAT PENGKAJIAN

ASUHAN KEPERAWATAN KELUARGA
STIKES HANG TUAH SURABAYA
A. PENGKAJIAN (TANGGAL : ..................................)
I. Data Umum
1. Nama kepala keluarga : ......................................................................................................
2. Alamat dan telepn : ......................................................................................................
!. Peker"aan KK : ......................................................................................................
#. Pend$d$kan KK : ......................................................................................................
%. Kmp&$&$ keluarga : ......................................................................................................
N. Nama
Jen$&
kel
'u(
kel )
KK
Umur D$k
*tatu& $mun$&a&$
Ket
Pl$ DPT 'epat$t$& +ampak
Gengram :
1. T$pe keluarga : ......................................................................................................
2. *uku (ang&a : ......................................................................................................
!. Agama : ......................................................................................................
#. *tatu& &&$al eknm$ : ......................................................................................................
%. Akt$,$ta& rekrea&$ keluarga
.............................................................................................................................................
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II. -$.a/at Dan Ta0ap Perkem(angan Keluarga
1. Ta0ap perkem(angan keluarga &aat $n$
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................................................................................................................................................
2. Tuga& perkem(angan keluarga /ang (elum terpenu0$
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!. -$.a/at ke&e0atan keluarga $nt$
................................................................................................................................................
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................................................................................................................................................
#. -$.a/at ke&e0atan keluarga &e(elumn/a
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
III. Data L$ngkungan
1. Karakter$&t$k ruma0
Dena0 ruma0
2. Karakter$&t$k tetangga dan kmun$ta&n/a
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
!. 1($l$ta& gegra2$& keluarga
................................................................................................................................................
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#. Perkumpulan keluarga dan $nterak&$ dengan ma&/arakat
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%. *$&tem pendukung keluarga
................................................................................................................................................
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................................................................................................................................................
I3. *truktur Keluarga
1. *truktur peran
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2. Pla kmun$ka&$ keluarga
................................................................................................................................................
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................................................................................................................................................
!. *truktur kekuatan keluarga
................................................................................................................................................
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................................................................................................................................................
3. 4ung&$ Keluarga
1. 4ung&$ eknm$
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2. 4ung&$ mendapatkan &tatu& &&$al
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
!. 4ung&$ pend$d$kan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
#. 4ung&$ &&$al$&a&$
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
%. 4ung&$ pemenu0an (pera.atan5pemel$0araan) ke&e0atan
a. 1engenal ma&ala0 keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
(. 1engam($l keputu&an mengena$ t$ndakan ke&e0atan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
6. Kemampuan mera.at anggta keluarga /ang &ak$t
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
d. Kemampuan keluarga memel$0ara5memd$2$ka&$ l$ngkungan ruma0 /ang &e0at
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
e. Kemampuan menggunakan 2a&$l$ta& pela/anan ke&e0atan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
7. 4ung&$ rel$g$u&
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
8. 4ung&$ rekrea&$
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
9. 4ung&$ reprduk&$
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
:. 4ung&$ a2ek&$
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3I. *tre&& Dan Kp$ng Keluarga
1. *tre&&r "angka pendek dan pan"ang
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2. Kemampuan keluarga (ere&pn ter0adap &tre&&r
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
!. *trateg$ kp$ng /ang d$gunakan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
#. *trateg$ adapta&$ d$&2ung&$nal
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3II. Pemer$k&aan Ke&e0atan T$ap Ind$,$du Anggta Keluarga
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
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3III. 'arapan Keluarga
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
*ura(a/a; .....................
1a0a&$&.a
(...............................)
<. DIAGN=*I* KEPE-A>ATAN KELUA-GA
I. Anal$&$& Dan *$nte&$& Data
N. Data 1a&ala0 Pen/e(a(
III. Da2tar D$agn&$& Kepera.atan ?ang 1un6ul
N. D$agn&a Kepera.atan (PE*)
I3. Pen$la$an (*kr$ng) D$agn&$& Kepera.atan
D@. kep : ......................................................................................................................................
.......................................................................................................................................
N. Kr$ter$a *kr <(t N$la$ Pem(enaran
1
*$2at ma&ala0
A T$dak5kurang &e0at
A An6aman ke&e0atan
A Keadaan &e"a0tera
!
2
1
1
2
Kemungk$nan ma&ala0 dapat d$u(a0
A 1uda0
A *e(ag$an
A T$dak dapat
2
1
B
2
!
Pten&$al ma&ala0 untuk d$6ega0
A T$ngg$
A +ukup
A -enda0
!
2
1
1
#
1enn"ln/a ma&ala0
- 1a&ala0 (erat 0aru& &egera d$tangan$
- Ada ma&ala0; tetap$ t$dak perlu &egera d$tangan$
- 1a&ala0 t$dak d$ra&akan
2
1
B
1
Ttal &kr
D@. kep : ......................................................................................................................................
.......................................................................................................................................
N. Kr$ter$a *kr <(t N$la$ Pem(enaran
1
*$2at ma&ala0
A T$dak5kurang &e0at
A An6aman ke&e0atan
A Keadaan &e"a0tera
!
2
1
1
2
Kemungk$nan ma&ala0 dapat d$u(a0
A 1uda0
A *e(ag$an
A T$dak dapat
2
1
B
2
!
Pten&$al ma&ala0 untuk d$6ega0
A T$ngg$
A +ukup
A -enda0
!
2
1
1
#
1enn"ln/a ma&ala0
- 1a&ala0 (erat 0aru& &egera d$tangan$
- Ada ma&ala0; tetap$ t$dak perlu &egera d$tangan$
- 1a&ala0 t$dak d$ra&akan
2
1
B
1
Ttal &kr
D@. kep : ......................................................................................................................................
.......................................................................................................................................
N. Kr$ter$a *kr <(t N$la$ Pem(enaran
1
*$2at ma&ala0
A T$dak5kurang &e0at
A An6aman ke&e0atan
A Keadaan &e"a0tera
!
2
1
1
2
Kemungk$nan ma&ala0 dapat d$u(a0
A 1uda0
A *e(ag$an
A T$dak dapat
2
1
B
2
!
Pten&$al ma&ala0 untuk d$6ega0
A T$ngg$
A +ukup
A -enda0
!
2
1
1
#
1enn"ln/a ma&ala0
- 1a&ala0 (erat 0aru& &egera d$tangan$
- Ada ma&ala0; tetap$ t$dak perlu &egera d$tangan$
- 1a&ala0 t$dak d$ra&akan
2
1
B
1
Ttal &kr
D@. kep : ......................................................................................................................................
.......................................................................................................................................
N. Kr$ter$a *kr <(t N$la$ Pem(enaran
1
*$2at ma&ala0
A T$dak5kurang &e0at
A An6aman ke&e0atan
A Keadaan &e"a0tera
!
2
1
1
2
Kemungk$nan ma&ala0 dapat d$u(a0
A 1uda0
A *e(ag$an
A T$dak dapat
2
1
B
2
!
Pten&$al ma&ala0 untuk d$6ega0
A T$ngg$
A +ukup
A -enda0
!
2
1
1
#
1enn"ln/a ma&ala0
- 1a&ala0 (erat 0aru& &egera d$tangan$
- Ada ma&ala0; tetap$ t$dak perlu &egera d$tangan$
- 1a&ala0 t$dak d$ra&akan
2
1
B
1
Ttal &kr
3. Pr$r$ta& D$agn&$& Kepera.atan
Pr$r$ta& D$agn&$& Kepera.atan *kr
INTERVENSI KEPERAWATAN
N.
D$agn&a
Kepera.atan
Tu"uan
Kr$ter$a *tandar Inter,en&$ E,alua&$
Umum K0u&u&
IMPLEMENTASI DAN EVALUASI
Tanggal N. DP Implementa&$ E,alua&$ Para2

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