ASUHAN KEPERAWATAN KELUARGA PADA

I. PENGKAJIAN
A.

DATA UMUM
1. Nama KK (inisial)
2. Umur
3. Pendidikan
4. Pekerjaan
5. Alamat
6. Komposisi Keluarga
NO NAMA
UMUR
(INISIAL)

:
:
:
:
:
JENIS
HUB
KELAMIN DGN KK

PENDD

PEKERJAAN

7. Genogram

8. Tipe Keluarga

: ..............................................................

9. Budaya

: .......................................................................................................
.......................................................................................................

10. Agama

: .......................................................................................................
.......................................................................................................

11. Status Sosial ekonomi Klg : ...........................................................................................

...........................................................................................
12. Aktivitas Rekreasi atau Waktu Luang : ............................................................................

B.

RIWAYAT DAN TAHAP PERKEMBANGAN KELUARGA

13.

Tahap Perkembangan Keluarga Saat

Ini : .................................................................

14.

Tugas Perkembangan Keluarga Yang Belum

Terpenuhi : ...............................................
............................................................................................................................................

15.

Riwayat kesehatan Keluarga Inti

a.

Riwayat Penyakit
Keturunan : ...............................................................................................................
..................

b.

Riwayat kesehatan Masing-masing Anggota Keluarga :

...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
....................................................................................................................................

16.

Riwayat Keluarga Sebelumnya :

............................................................................................................................................
............................................................................................................................................

C.

LINGKUNGAN
17. Karakteristik Rumah
- Denah Rumah

- Status Rumah

: ......................................................................................................

- Tipe Rumah

: ......................................................................................................

- Luas Rumah/

: .....................................................................................................

Keadaan

......................................................................................................

- Kebersihan& pencahayaan : .........................................................................................

18. Karakteristik Tetangga dan Komunitas : ..........................................................................
..........................................................................................................................................
19..Mobilitas Geografis Keluarga : .......................................................................................
...........................................................................................................................................
20. Perkumpulan Keluarga dan Interaksi dengan Masyarakat : .............................................
..........................................................................................................................................
21. Sistem Pendukung Keluarga : ..........................................................................................
..........................................................................................................................................

D.

STRUKTUR KELUARGA
22. Pola Komunikasi Keluarga : .

23. Struktur Kekuatan Kelurga : ............................

............................................................................................................................................
24. Struktur Peran

: ............................................................................................

............................................................................................................................................
............................................................................................................................................
25. Nilai dan Norma Keluarga : ..............................................................................................
...........................................................................................................................................
E.

FUNGSI KELUARGA
26. Fungsi Afektif : ................................................................................................................
.................................................................................................................
27. Fungsi Sosialisasi : ............................................................................................................
...........................................................................................................

28. Fungsi Perawatan Kesehatan (Data Spesifik)

a. Kemampuan Mengenal Masalah Kesehatan :
........................................................................................................................................
........................................................................................................................................
b. Kemampuan Mengambil Keputusan Untuk Melakukan Tindakan :
.......................................................................................................................................
......................................................................................................................................
b. Kemampuan Melakukan Pearawatan Terhadap Anggota Keluarga Yang Sakit :
......................................................................................................................................
......................................................................................................................................
d. Kemampuan Menciptakan Lingkungan Yang Dapat Meningkatkan Kesehatan :
......................................................................................................................................
......................................................................................................................................
e. Kemampuan Keluaraga Memanfaatkan Fasilitas Kesehatan Yang Ada :
.....................................................................................................................................
.........................................................................................................................................

F.

STRES DAN KOPING KELUARGA :

.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

G.

HARAPAN KELUARGA TERHADAP PERAWAT BERHUBUNGAN DENGAN

MASALAH YANG DIHADAPI
...................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................

H. PEMERIKSAAN FISIK (HEAD TO TOES)

ANGGOTA KLG
KEPALA

LEHER

DADA

ABDOMEN

EXTRENITAS

DATA TAMBAHAN
1. Tanda-tanda vital :

ANALISA DATA
NO

HARI/TGL

DATA

DIAGNOSA KEP

II. DIAGNOSA KEPERAWATAN

1. ..

2.

V. EVALUASI SUMATIF
NO

TGL

DX KEP

EVALUASI SUMATIF

III. RENCANA KEPERAWATAN

NO TANGGAL DX KEPERAWATAN

TUJUAN
TUM

TUK

RENCANA
KEPERAWATAN

IV. IMPLEMENTASI DAN EVALUASI FORMATIF

NO TGL

DX KEPERAWATAN

IMPLEMENTASI

EVALUASI FORMATIF

TTD