FORMAT ASUHAN KEPERAWATAN KELUARGA

1.

PENGKAJIAN
Pengumpulan data dilaksanakan pada hari ...........................................................................................
Data diperoleh dengan cara wawancara, observasi, pemeriksaan fisik dan dokumentasi.
a.

Data Umum Keluarga

1) Kepala Keluarga
a.

Nama

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

b.

Umur

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

c.

Jenis Kelamin : ...................................

d.

Agama

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

e.

Pendidikan

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

f.

Pekerjaan

g.

Suku / Bangsa : .................................

h.

Alamat

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

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

2) Komposisi keluarga
Tabel ........
Komposisi Keluarga ..............
No
1
2
3
4
5
6
7
8
9
10

Nama

L/P

Umur

Hub. dgn KK

Pendidikan

Pekerjaan

Keterangan

3) Genogram

Gambar 1 : Genogram Keluarga ............................. dengan ...................................................................

Keterangan :
: Laki-laki

: Anak kandung

: Perempuan
: Laki-laki meninggal

: Anak angkat

: Perempuan meninggal
: Tinggal serumah

: Abortus

: Menikah
: Pisah
: Cerai

: Kembar

Penjelasan: ....................................................................................................................................................
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4) Tipe Keluarga :
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5) Latar Belakang Budaya (Etnis) :
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6) Agama : ..........................................................................................................................................
7) Status Sosial Ekonomi Keluarga
Tabel ........
Rata-rata dan Pengeluaran Keluarga ...................................
NO
NAMA
PEKERJAAN PENDAPATAN PENGELUARAN KETERANGAN

Penjelasan :
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8) Aktivitas Rekreasi Keluarga atau waktu luang
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b. Tahap dan Riwayat Perkembangan Keluarga
a.
Tahap perkembangan keluarga saat ini
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b.
Tahap perkembangan keluarga yang belum terpenuhi
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c.
Riwayat keluarga sebelumnya

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c. Data Lingkungan
1) Karakteristik rumah (tipe, ukuran, jumlah ruangan)

Keterangan :

2) Karakteristik lingkungan dan komunitas

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3) Mobilitas geografi keluarga

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4) Perkumpulan keluarga dan interaksi dengan masyarakat
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5) Sistem keluarga dan interaksi dengan masyarakat
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d. Struktur Keluaga
1) Pola Komunikasi
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2) Struktur Kekuasaan
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3) Struktur Peran
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4) Nilai dan Norma Keluarga
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e. Fungsi Keluarga

1) Fungsi Afektif
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2) Fungsi Sosialisasi
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3) Fungsi Perawatan Kesehatan
a) Keyakinan, nilai dan perilaku keluarga
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b) Definisi keluarga tentang sehat dan sakit
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c) Status kesehatan dan kerentanan sakit yang dirasakan oleh keluarga
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d) Praktek diet keluarga
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e) Kebiasaan tidur dan istirahat
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f) Latihan dan rekreasi

g)

h)

i)

j)

k)

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Kebiasaan pengguaan obat-obatan dalam keluarga
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Perawatan diri
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Praktek lingkungan
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Pemeriksaan kesehatan secara teratur
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Kesehatan gigi
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l) Riwayat kesehatan keluarga

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m) Pelayanan perawatan kesehatan yang diterima

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n) Pesanan atau persepsi terhadap pelayanan kesehatan
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o) Sumber pembiayaan pelayaan kesehatan
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p) Logistik untuk mendapatkan perawatan
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f. Pemeriksaan Fisik Keluarga
Pemeriksaan
Fisik
Kepala

TTV

BB/TB

Mata

Hidung

Mulut

Leher

Dada

Abdomen

Tangan

Kaki

g. Koping Keluarga
1) Stressor jangka pendek dan panjang
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2) Kemampuan keluarga untuk berespon terhadap situasi/stressor
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3) Penggunaan strategi koping
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4) Strategi adaptasi disfungsional

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ANALISA DATA
TGL

DATA

SKALA PRIORITAS MASALAH

MASALAH

Masalah 1: .
KRITERIA

BOBOT

PERHITUNGAN

PEMBENARAN

1. Sifat masalah
Aktual: 3
Resiko: 2
Potensial: 1
1

2. Kemungkinan
masalah dapat diubah
Mudah: 2
Sebagian: 1
Tidak dapat: 0
2

3. Kemungkinan
masalah
dapat
dicegah
Tinggi: 3
Cukup: 2
Rendah: 1

4. Menonjolnya
masalah
Segera: 2
Tidak segera: 1
Tidak dirasakan: 0

Skor

Masalah 2: .

KRITERIA
1.

BOBOT

Sifat masalah
Aktual: 3
Resiko: 2
Potensial: 1
1

2. Kemungkinan
masalah dapat diubah
Mudah: 2
Sebagian: 1
Tidak dapat: 0
2

3. Kemungkinan
masalah
dicegah
Tinggi: 3
Cukup: 2
Rendah: 1

dapat

4. Menonjolnya
masalah
Segera: 2
Tidak segera: 1
Tidak dirasakan: 0
1

Skor

PERHITUNGAN

PEMBENARAN

Masalah 3: .
KRITERIA

BOBOT

1.

Sifat
masalah
Aktual: 3
Resiko: 2
Potensial: 1
1

2.

Kemungkin
an masalah dapat
diubah
Mudah: 2
Sebagian: 1
Tidak dapat: 0
2

3.

Kemungkin
an masalah dapat
dicegah
Tinggi: 3
Cukup: 2
Rendah: 1

Menonjolny
a masalah
Segera: 2
Tidak segera: 1
Tidak dirasakan: 0

4.

PERHITUNGAN

PEMBENARAN

Skor

Diagnosa Masalah
1.

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2.

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3.

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