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Lampiran 1 Format Pengkajian Asuhan Keperawatan Keluarga

ASUHAN KEPERAWATAN KELUARGA DENGAN SALAH SATU ANGGOTA KELUARGA


MENDERITA..................DI LINGKUNGAN.............. KELURAHAN........

A. PENGKAJIAN (tanggal :__________________________)


I. Data Umum
1. Kepala Keluarga KK :_____________________________________
2. Alamat dan Telepon :_____________________________________
3. Pekerjaan KK :_____________________________________
4. Pendidikan KK :_____________________________________
5. Komposisi Keluarga :_____________________________________

Status Imunisasi
Pendidikan
Hub Kel. KK
Jenis Kel.

Ket.
Umur

No Nama Polio DPT Hepatitis

Campak
BCG
1 2 3 4 1 2 3 1 2 3

Genogram :
6. Tipe Keluarga :_______________________________________
7. Suku Bangsa : ______________________________________
8. Agama :_______________________________________
9. Status sosial ekonomi keluarga :_______________________________________
10. Aktivitas rekreasi keluarga
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II. Riwayat dan tahap perkembangan keluarga
1. Tahap perkembangan keluarga saat ini
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2. Tugas perkembangan keluarga yang belum terpenuhi
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3. Riwayat kesehatan keluarga inti
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4. Riwayat kesehatan keluarga sebelumnya
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III. Data lingkungan
1. Karakteristik rumah
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Denah rumah

2. Karakteristik tetangga dan komunitasnya


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3. Mobilitas geografis keluarga (lama keluarga tinggal di dusun atau pindahan)
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4. Perkumpulan keluarga dan interaksi dengan masyarakat
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5. Sistem pendukung keluarga
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IV. Struktur keluarga
1. Struktur peran
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2. Nilai dan norma kleuarga
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3. Pola komunikasi keluarga
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4. Struktur kekuasaan keluarga (siapa pengambil keputusan)
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V. Fungsi keluarga
1. Fungsi afektif
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2. Fungsi sosialisasil
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3. Fungsi pemenuhan (perawatan/pemeliharaan) kesehatan
a. Mengenal masalah kesehatan
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b. Mengambil keputusan mengenai tindakan kesehatan
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c. Kemampuan merawat anggota keluarga yang sakit
d. Kemampuan keluarga memelihara/memodifikasi lingkungan rumah yang kuat
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e. Kemampuan menggunakan fasilitas pelayanan kesehat
4. Fungsi reproduksi
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5. Fungsi ekonomi
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VI. Stres dan koping keluarga
1. Stresor jangka pendek dan panjang
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2. Kemampuan keluarga berespons terhadap stresor
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3. Strategi koping yang digunakan
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4. Strategi adaptasi disfungsional (pengambinghitaman,penggunaan ancaman,dll)
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VII. Pemeriksaan kesehatan tiap individu anggota keluarga (menggunakan table)
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VIII. Harapan keluarga
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B. DIAGNOSIS KEPERAWATAN KELUARGA

I. Analisis dan sintesis data

No Data Masalah Penyebab


1 Subjektif :
Objektif :
2 Subjektif :
Objektif :
3 Subjektif :
Objektif :

II. Perumusan diagnosis keperawatan


No Diagnosa Keperawatan (PES)
1
2
3

III. Penilaian (Skoring) diagnosis keperawatan


No Kriteria Skor Pembenaran
Diag.
Kep.
1 a. Sifat masalah :............. .....x1 = 3
b. Kemungkinan masalah dapat diubah:.......... .....x2 = 2
c. Potensial masalah untuk dicegah:......... .....x1 = 3
d. Menonjolnya masala:................... .....x1 = 2
2
3

IV. Prioritas diagnosis keperawatan


Prioritas Diagnosis Keperawatan Skor
1
2

C. RENCANA ASUHAN KEPERAWATAN KELUARGA


Diagnosa Keperawatan : ...........................................................................................................
............................................................................................................

Tujuan Kriteria Evaluasi Kriteria Evaluasi Rencana


Kriteria / Standar Kriteria/Standar Intervensi
Umum/Khusus

D. IMPLEMENTASI

No. Tanggal & waktu Diagnosa Keperawatan Implementasi


1
2

E. EVALUASI

No. Tanggal Diagnosa


Implementasi
& waktu Keperawatan
1 S:
O:
A:
P:

2 S:
O:
A:
P:

Catatan :

Pada setiap tahap perlu dituliskan dengan jelas dan benar tentang tempat, tanggal, nama perawat
sebagai bukti identifikasi