PENGKAJIAN KEPERAWATAN KELUARGA

Fasilitas Yankes No. Register

Nama Perawat Yang Tanggal

Mengkaji Pengkajian
1. Data Keluarga
Nama Kepala Keluarga Bahasa Sehari-
Hari
Alamat Rumah & Telp Jarak Yankes
Terdekat
Agama & Suku Alat Transportasi

DATA ANGGOTA KELUARGA

N Nama Hub dgn Umur JK Suku Pendidikan Pekerjaan Status TTV (TD, Status Alat
o KK Terakhir Saat Ini Gizi (TB, N, S, P) Imunisasi Bantu/
BB, BMI) Dasar Protesa

LANJUTAN
N Nama Penampilan Status Kesehatan Riwayat Penyakit/ Analisis Masalah
o Umum Saat ini Alergi Kesehatan INDIVIDU

2. DATA PENGKAJIAN INDIVIDU YANG SAKIT (terlampir)

3. DATA PENUNJANG KELUARGA

Rumah dan Sanitasi Lingkungan PHBS Di Rumah Tangga
Kondisi Rumah : Jika ada Bunifas, Persalinan ditolong oleh tenaga kesehatan :
............................................................................................... Ya/
............................................................................................... Tidak* ................................................................................................
............................................................................................... ............
............................................................................................... ............................................................................................................
............................................................................................... Jika ada bayi, Memberi ASI ekslusif :
............................................................................................... Ya/
............................................................................................... Tidak* ................................................................................................
............
 Ventilasi : ............................................................................................................
Cukup/Kurang*...................................................................... jika ada balita, Menimbang balita tiap bln :
............................................................................................... Ya/
............................................................................................... Tidak* ................................................................................................
............................................................................................... ............
............................................................................................... Menggunakan air bersih untuk makan & minum:
Pencahayaan Rumah : Ya/
Baik/ Tidak* ................................................................................................
Tidak* ................................................................................... ............
............................................................................................................
...........
...............................................................................................
Menggunakan air bersih untuk kebersihan diri:
...............................................................................................
Ya/
...............................................................................................
Tidak* ................................................................................................
...............................................................................................
............
Saluran Buang Limbah : ............................................................................................................
Baik Mencuci tangan dengan air bersih & sabun :
/Cukup/Kurang*.................................................................... Ya/
............................................................................................... Tidak* ................................................................................................
............................................................................................... ............
............................................................................................... ............................................................................................................
............................................................................................... Melakukan pembuangan sampah pada tempatnya :
Sumber Air Bersih : Ya/
Sehat/Tidak Tidak* ................................................................................................
Sehat*.................................................................................... ............
............................................................................................... ............................................................................................................
Menjaga lingkungan rumah tampak bersih :
...............................................................................................
Ya/
...............................................................................................
Tidak* ................................................................................................
...............................................................................................
............
Jamban Memenuhi Syarat : ............................................................................................................
Ya/Tidak* Mengkonsumsi lauk dan pauk tiap hari :
............................................................................ Ya/
............................................................................................... Tidak* ................................................................................................
............................................................................................... ............
............................................................................................... ............................................................................................................
............................................................................................... Menggunakan jamban sehat :
Tempat Sampah: Ya/
Ya/Tidak*......................................................... Tidak* ................................................................................................
............................................................................................... ............
............................................................................................................
...............................................................................................
...............................................................................................
Memberantas jentik di rumah sekali seminggu :
...............................................................................................
Ya/
Rasio Luas Bangunan Rumah dengan Jumlah Anggota
Tidak* ................................................................................................
Keluarga 8m2/orang :
............
Ya/Tidak*........................................................... ............................................................................................................
............................................................................................... Makan buah dan sayur setiap hari : Ya/
............................................................................................... Tidak* ................................................................................................
............
............................................................................................................
Melakukan aktivitas fisik setiap hari : Ya/
Tidak* ................................................................................................
............
............................................................................................................
Tidak merokok di dalam rumah : Ya/
Tidak* ................................................................................................
............
............................................................................................................
4. KEMAMPUAN KELUARGA MELAKUKAN TUGAS PEMELIHARAAN KESEHATAN ANGGOTA KELUARGA
1) Adakah perhatian keluarga kepada anggotanya yang menderita sakit: Ada Tidak karena ........................................................
2) Apakah keluarga mengetahui masalah kesehatan yang dialami anggota dalam keluarganya : Ya Tidak
3) Apakah keluarga mengetahui penyebab masalah kesehatan yang dialami anggota dalam keluarganya: Ya Tidak
4) Apakah keluarga mengetahui tanda dan gejala masalah kesehatan yang dialami anggota dalam keluarganya : Ya Tidak
5) Apakah keluarga mengetahui akibat masalah kesehatan yang dialami anggota dalam keluarganya bila tidak diobati/dirawat :
Ya Tidak ......................................................................................................................................................................................
6) Pada siapa keluarga biasa menggali informasi tentang masalah kesehatan yang dialami anggota keluarganya: Keluarga
Tetangga Kader Tenaga kesehatan, yaitu.................................................................................................................................
7) Keyakinan keluarga tentang masalah kesehatan yang dialami anggota keluarganya: Tidak perlu ditangani karena akan sembuh
sendiri biasanya Perlu berobat ke fasilitas yankes Tidak terpikir
8) Apakah keluarga melakukan upaya peningkatan kesehatan yang dialami anggota keluarganya secara aktif :
Ya Tidak,
Jelaskan ................................................................................................................................................................................................
.............
9) Apakah keluarga mengetahui kebutuhan pengobatan masalah kesehatan yang dialami yang dialami anggota keluarganya :
Ya Tidak , Jelaskan........................................................................................................................................................................
10) Apakah keluarga dapat melakukan cara merawat anggota keluarga dengan masalah kesehatan yang dialaminya:
Ya Tidak,
Jelaskan.................................................................................................................................................................................................
11) Apakah keluarga dapat melakukan pencegahan masalah kesehatan yang dialami anggota keluarganya:
Ya Tidak, Jelaskan.........................................................................................................................................................................
12) Apakah keluarga mampu memelihara atau memodifikasi lingkungan yang mendukung kesehatan anggota keluarga yang
mengalami masalah kesehatan : Ya Tidak,
Jelaskan.................................................................................................................................................................................................
13) Apakah keluarga mampu menggali dan memanfaatkan sumber di masyarakat untuk mengatasi masalah kesehatan anggota
keluarganya :
Ya Tidak,
Jelaskan.................................................................................................................................................................................................
KRITERIA KEMANDIRIAN KELUARGA : Kesimpulan:
1. Menerima petugas puskesmas - Kemandirian I : Jika memenuhi kriteria 1& 2
2. Menerima yankes sesuai rencana - Kemandirian II; jika memenuhi kriteria 1 s.d 5
3. Menyatakan masalah kesehatan secara benar - Kemandirian III: Jika memenuhi kriteria 1 s.d 6
4. Memanfaatkan faskes sesuai anjuran - Kemandirian IV: Jika memenuhi kriteria 1 s.d 7
5. Melaksanakan perawatan sederhana sesuai anjuran
6. Melaksanakan tindakan pencegahan secara aktif
7. Melaksanakan tindakan promotif secara aktif

Lampiran
2. DATA PENGKAJIAN INDIVIDU YANG SAKIT
Nama Individu yang sakit : Diagnosa Medik :

Sumber Dana Kesehatan : Rujukan Dokter/ Rumah Sakit :

Keadaan Umum Sirkulasi/ Cairan Perkemihan Pernapasan

Kesadaran : ............................... Edema Bunyi Pola BAK ........ x/hr, Sianosis
GCS : ......................................... jantung: ................................. vol ........... ml/hr Sekret / Slym
TD : ............... mm/Hg Hematuri Poliuria
.............. Irama ireguler
Oliguria Disuria
P : ................ x/ menit Asites Akral dingin Wheezing
Inkontinensia Retensi
S : ...................... 0C Tanda Perdarahan:
Nyeri saat BAK
N : ............... x/ menit purpura/ hematom/ Ronki ......................................
KemampuanBAK :
Takikardia petekie/ hematemesis/ ..........
Mandiri/ Bantu
Bradikardia melena/ epistaksis* sebagian/tergantung* Otot bantu
Tubuh teraba hangat Tanda Anemia : Pucat/ ............................................. napas .....................................
Menggigil Konjungtiva pucat/ Lidah Alat bantu: .........
pucat/ Bibir pucat/ Tidak/Ya*..................... Alat bantu
Akral pucat* Gunakan Obat : nafas ......................................
Tanda Dehidrasi: Tidak/Ya*.............................. .........
mata cekung/ turgor kulit Dispnea
 berkurang/ bibir kering * Kemampuan BAB : Sesak
Pusing Kesemutan Mandiri/ Bantu Stridor
Berkeringat Rasa Haus sebagian/tergantung* Krepirasi
Pengisian kapiler 3 detik Alat bantu: ..............................................
............................................. Tidak/Ya*............................. ..............................................
............................................. ..............................................
..............................................
..............................................
Pencernaan Muskuloskeletal Neurosensori
Mual Muntah Kembung Tonus otot Fungsi Penglihatan : Fungsi perabaan :
Nafsu Makan : Kontraktur Buram Kesemutan pada ...............
Berkurang/Tidak* Fraktur Tak bisa melihat Kebas pada ..........................
Sulit Menelan Nyeri otot/tulang* Alat bantu ........ Disorientasi Parese
Visus ........... Halusinasi Disartria
Disphagia Drop Foot Lokasi
Fungsi pendengaran : Amnesia Paralisis
Bau Nafas ....................................
Kurang jelas Refleks patologis .................
Kerusakan gigi/gusi/ lidah/ Tremor Jenis ............ Tuli Kejang : sifat ...... lama ..
geraham/rahang/palatum* ...................... Alat bantu frekuensi ....................................
Distensi Abdomen Malaise / fatique Tinnitus Fungsi Penciuman
Bising Atropi Fungsi Perasa Mampu
Usus: ......................................... Kekuatan otot ................. Mampu Terganggu
.......... Terganggu
.......................
Konstipasi Postur tidak
Kulit
Diare ............. x/hr normal ..................................
Jaringan parut Memar Laserasi Ulserasi Pus
Hemoroid, ...........
...................................................................................................
grade ........................................ RPS Atas : bebas/ terbatas/
Bulae/lepuh Perdarahan bawah
........... kelemahan/ kelumpuhan
Krustae ......................................................................................
Teraba Masa (kanan / kiri)*
............
abdomen ................................. RPS Bawah :
Luka bakar Kulit ...... Derajat ...... Perubahan warna.
................. bebas/terbatas/
Decubitus: grade ...... Lokasi ..................................
Stomatitis kelemahan/kelumpuhan Tidur dan Istirahat
Warna ....................................... (kanan / kiri)*
Susah tidur
.......... Berdiri : Mandiri/ Bantu
Waktu tidur ..........
Riwayat obat sebagian/tergantung*
Bantuan obat, ..
pencahar ................................... Berjalan : Mandiri/ Bantu
.....................................
.............. sebagian/tergantung*
...................................................................................................
Maag Alat Bantu : ...................................................................................................
Konsistensi ........................... Tidak/Ya*............................ ...................................................................................................
Diet Khusus: Nyeri :
Tidak/Ya*................................. Tidak/Ya*............................
Kebiasaan makan-minum :
Mandiri/ Bantu sebagian/
Tergantung*
Alergi makanan/minuman :
Tidak/Ya*..................................
Alat bantu :
Tidak/Ya*..................................
Mental Komunikasi dan Budaya Kebersihan Diri Perawatan Diri Sehari-hari
Cemas Denial Marah Interaksi dengan Keluarga : Gigi-Mulut kotor Mandi : Mandiri/ Bantu
Takut Putus asa Depresi Baik/ tehambat* Mata kotor Kulit kotor sebagian/tergantung*
Rendah diri Menarik diri .............................................. Perineal/genital kotor Berpakaian : Mandiri/ Bantu
Agresif Perilaku kekerasan Berkomunikasi : Hidung koto Kuku kotor sebagian/tergantung*
Respon pasca trauma .......... Lancar/ Telinga kotor Menyisir Rambut : Mandiri/
Tidak mau melihat bagian terhambat* ........................... Rambut-Kepala kotor Bantu
tubuh yang rusak ................... .... sebagian/tergantung*
.... Kegiatan sosial sehari-hari : ........................................... ....
 ........................................... .... ..... ...........................................
...........................................

Keterangan Tambahan Terkait Individu

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DATA PENUNJANG MEDIS INDIVIDU YANG SAKIT

Laboratorium Radiologi EKG USG

DIAGNOSA KEPERAWATAN
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MENGETAHUI :
Nama Koordinator
Fasilitas Yankes
Nama Perawat yang mengkaji
Nama Individu/ Keluarga/
Kelompok
Penyakit/ Masalah Kesehatan
Tgl/
Diagnosa Keperawatan
No.
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PERENCANAAN KEPERAWATAN
No. Register
Nama
Penanggungjawab/ KK
Alamat
Tujuan
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Tanggal/ Tanda
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 IMPLEMENTASI DAN EVALUASI KEPERAWATAN
Fasilitas Yankes
Nama Perawat yang mengkaji
Nama Individu/ Keluarga/
Kelompok
Penyakit/ Masalah Kesehatan
Tgl/
Diagnosa Keperawatan
No.
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No. Register
Nama
Penanggungjawab/ KK
Alamat
Implementasi
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 TINDAKAN TIM PENYEDIA PELAYANAN KEPERAWATAN KELUARGA DI RUMAH

NAMA KLIEN
UMUR
ALAMAT/ TELP
NAMA PENANGGUNG JAWAB KELUARGA
ALAMAT/ TELP
DIAGNOSA MEDIK

TGL DATA PENUNJANG TINDAKAN TINDAK LANJUT DISIPLIN PROFESI NAMA/ TTD
 PENJAJAKAN TAHAP I
PENGKAJIAN KEPERAWATAN KELOMPOK
Fasilitas Yankes No. Register
Nama Perawat yang Mengkaji Tanggal Pengkajian
Nama Kelompok Alamat
1. DATA DASAR ANGGOTA KELOMPOK 2. STATUS KESEHATAN ANGGOTA KELOMPOK
No. Nama J Tgl Lahir Pendidikan Pekerjaan Agama Suku Keadaan Umum TTV Status Gizi Riwayat Penyakit Alat Bantu/ Pola Ket. Lain Analisis
K TD N P S TB BB Konjungtiva Protesa Olahraga Tidur Masalah
Kesehatan

LANJUTAN .
3. UPAYA PENINGKATAN KESEHATAN
No Uraian Pengkajian Penilaian Gambaran Kondisi No Uraian Pengkajian Penilaian Gambaran Kondisi
Ada Tidak Ada Tidak
A Fasilitas pelayanan kesehatanyang tersedia untuk E Status ekonomi
kelompok
1. Posyandu 1. Sumbangan (asal sumber pendanaan)
2. Tenaga kesehatan yang berpraktik 2. Jenis pekerjaan
3. Puskesmas dan jaringannya 3. Rata-rata pendapatan perbulan
4. Klinik 4. Lainnya
1. Rumah Sakit
2. Lainnya
 B Pelayanan kesehatan yang dimanfaatkan oleh F Status sosial budaya spiritual
kelompok
1. Imunisasi dasar lengkap 1. Sarana ibadah
2. Imunisasi ibu hamil 2. Kegiatan keagamaan

3. Makanan tambahan 3. Kepercayaan yang bertentangan dengan

penanggulangan masalah kesehatan
4. Vitamin tambahan 4. Kegiatan sosial (kerjabakti, arisan, dll)
5. Pelayanan kesehatan
6. Lainnya

C Fasilitas pendidikan G Komunikasi

1. Fasilitas pendidikan yang tersedia untuk 1. Alat komunikasi yang digunakan dalam
kelompok kelompok sehari-hari
a. Playgroup a. Telepon
b. TK b. Handphone
c. SD c. Faximile
d. SMP/ MTs d. Lainnya
e. SMA/ MA
f. Universitas/ Sekolah Tinggi
g. Lainnya

2. Fasilitas pendidikan yang dimanfaatkan untuk 2. Efektivitas proses komunikasi antar

kelompok untuk kegiatan penyuluhan anggota dalam kelompok
kesehatan, pembelajaran di kelompok, dll

D Lingkungan sekitar tempat tinggal anggota H Fasilitas rekreasi yang tersedia untuk
kelompok kelompok
1. Sumber air bersih 1. Taman
2. Dapur umum 2. Pantai
3. Tempat pembuangan sampah 3. Sarana olahraga
4. Sarana MCK (berapa jumlahnya) 4. Lainnya
5. Saluran pembuangan limbah
6. Lainnya
J Kebiasaan / Perilaku dalam kelompok
1. Pemeliharaan kebersihan diri

2. Pengelolaan makanan bersih dan sehat

MENGETAHUI :
Nama Koordinator Tanggal/ Tandatangan
 LAPORAN BULANAN KEGIATAN PUSKESMAS (LB 4)

UPAYA KEPERAWATAN KESEHATAN MASYARAKAT

NO VARIABEL L P JUMLAH KETERANGAN

1. Keluarga dengan lansia Risti di bina

2. Keluarga dengan Bayi dan Balita Risti di bina
3. Keluarga dengan bumil risti di bina
4. Keluarga dengan bufas risti di bina
5. Keluarga dengan penyakit menular dibina (..................................)
6. Keluarga dengan penyakit Tidak Menular di bina (....................)
7. Keluarga dengan kasus psichiatry di bina
8. Keluarga dengan kasus Gizi buruk di bina
9. Kelompok balita di bina
10. Kelompok Lansia di bina
11. Kelompok UKS di bina
15. Kelompok khusus ( ............................................................) dibina
16. Panti werdha di bina
17. Panti asuhan di bina
18. Jumlah Keluarga di bina
19. Kemandirian Keluarga sebelum dibina
a. Keluarga Mandiri 1
b. Keluarga Mandiri 2
c. Keluarga Mandiri 3
d. Keluarga Mandiri 4
20. Peningkatan Kemandirian Keluarga setelah dibina
a.. Keluarga Mandiri 2
b. Keluarga Mandiri 3
c. Keluarga Mandiri 4
21 Kasus tersangka penyakit/ masalah Kesehatan dirujuk
22 Kasus DO dari intervensi/ Pemantauan program Kesehatan

................................., 20.........

MENGETAHUI
KEPALA PUSKESMAS KOORDINATOR PERKESMAS

....................................................... .................................................
NIP : NIP :