FORMAT PENGKAJIAN

PROGRAM PENDIDIKAN PROFESI NERS

KEPERAWATAN KELUARGA
FAKULTAS ILMU-ILMU KESEHATAN
UNIVERSITAS NUSA NIPA
MAUMERE
2017

A. PENGKAJIAN
Pengkajian dilakukan pada : hari/tanggal/tahun/jam :
Identitas Umum Keluarga
a. Identitas Kepala Keluarga
Nama kepala keluarga : ........................................................................................
Umur : ........................................................................................
Agama : ........................................................................................
Pendidikan : ........................................................................................
Pekerjaan : ........................................................................................
Suku / Bangsa : ........................................................................................
Alamat : ........................................................................................

b. Komposisi keluarga :
Hubungan
No Nama L/P Umur Pendidikan Pekerjaan
keluarga

1.

2.

3.

4
Genogram :

Keterangan :
: Laki-laki
: perempuan
X : meninggal
: memiliki hubungan keluarga
: tinggal serumah
: klien

c. Tipe Keluarga :
1). Jenis tipe keluarga :
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2). Masalah yang terjadi dengan tipe tersebut :
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d. Suku Bangsa :
1). Asal suku bangsa :
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 2). Budaya yang berhubungan dengan kesehatan :
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e. Agama dan Kepercayaan yang mempengaruhi Kesehatan:
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f. Status social ekonomi keluarga :
1). Anggota keluarga yang mencari nafkah :
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2). Penghasilan :
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3). Upaya lain :
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4). Harta benda yang dimiliki (perabot, transportasi,dll) :
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5). Kebutuhan yang dikeluarkan tiap bulan :
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g. Aktivitas Rekreasi Keluarga :
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II. RIWAYAT DAN TAHAP PERKEMBANGAN KELUARGA
1. Tahap perkembangan keluarga saat ini (ditentukan dengan anak tertua) :
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2. Tahap perkembangan keluarga yang belum terpenuhi dan kendalanya :
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3. Riwayat kesehatan keluarga inti :
1). Riwayat kesehatan keluarga saat ini
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2). Riwayat penyakit keturunan
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3). Riwayat kesehatan masing-masing anggota keluarga
Imunisasi Tindakan
Keadaan Masalah
No. Nama Umur BB (BCG/polio/DPT/HB/c yang telah
kesehatan kesehatan
ampak) dilakukan

1.

2.

3.
 4.

4). Sumber pelayanan kesehatan yang dimanfaatkan

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4. Riwayat kesehatan keluarga sebelumnya :
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III. PENGKAJIAN LINGKUNGAN
1. Karakteristik rumah
a. Luas rumah : .................................................................................................
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b. Tipe rumah : ..................................................................................................
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c. Kepemilikan : ................................................................................................
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d. Jumlah dan ratio kamar/ruangan : .................................................................
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e. Ventilasi/jendela : ........................................................................................
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f. Pemanfaatan ruangan : ................................................................................
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g. Septic tank : ada/tidak, letak............................................................................
h. Sumber air minum : ......................................................................................
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i. Kamar mandi/WC : .......................................................................................
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j. Sampah : ......................................................................................................
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k. Kebersihan lingkungan : ................................................................................
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2. Karakteristik tetangga dan komunitas RW
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3. Mobilitas geografis keluarga
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4. Perkumpulan keluarga dan interaksi dengan masyarakat
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5. Sistem pendukung keluarga
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6. Gambar Denah Rumah :

Keterangan ;
IV. STRUKTUR KELUARGA
1. Pola Komunikasi Keluarga
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2. Struktur Kekuatan Keluarga
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3. Struktur Peran (peran masing-masing anggota keluarga)
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4. Nilai dan Norma Keluarga
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V. FUNGSI KELUARGA
1. Fungsi afektif
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2. Fungsi sosialisasi
a. Kerukunan hidup dalam keluarga
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b. Interaksi dan hubungan dalam keluarga
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c. Anggota keluarga yang dominan dalam pengambilan keputusan
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 d. Kegiatan keluarga waktu senggang
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e. Partisipasi dalam kegiatan social
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3. Fungsi perawatan kesehatan
a. Pengetahuan dan persepsi keluarga tentang penyakit/masalah kesehatan keluarganya
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b. Kemampuan keluarga mengambil keputusan tindakan kesehatan yang tepat
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c. Kemampuan keluarga merawat anggota keluarga yang sakit
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d. Kemampuan keluarga memelihara lingkungan rumah yang sehat
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e. Kemampuan keluarga menggunakan fasilitas kesehatan di masyarakat
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4. Fungsi reproduksi
a. Perencanaan jumlah anak
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 b. Akseptor KB
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5. Fungsi ekonomi
a. Upaya pemenuhan sandang pangan
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b. Pemanfaatan sumber di masyarakat
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VI. STRESS DAN KOPING KELUARGA
a. Stressor jangka pendek dan jangka panjang
1). Stresor jangka pendek
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2). Stresor jangka panjang
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b. Kemampuan keluarga berespon terhadap situasi atau stressor
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c. Strategi koping yang digunakan
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d. Strategi adaptasi disfungsional
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VII. RIWAYAT KESEHATAN KELUARGA
Riwayat kesehatan masing-masing anggota keluarga
1. Tn. ..............
a. Riwayat kesehatan saat ini :
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b. Riwayat kesehatan sebelumnya :
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2. Ny. .............
a. Riwayat kesehatan saat ini :
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b. Riwayat kesehatan sebelumnya :
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3. An................
a. Riwayat kesehatan saat ini :
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b. Riwayat kesehatan sebelumnya :
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4. An. ..................
a. Riwayat kesehatan saat ini :
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 b. Riwayat kesehatan sebelumnya :
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VIII. KEADAAN GIZI KELUARGA
Pemenuhan Gizi
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Upaya Lain
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IX. PEMERIKSAAN FISIK KELUARGA

Pemeriksaan KK ......... ......... ......... ......... .........

Tanda-Tanda
Vital

Kepala :
Rambut
Kulit Kepala
Pina
Pemeriksaan KK ......... ......... ......... ......... .........

Canalis Telinga

Gendang Telinga

Sclera Mata

Konjungtiva

Hidung

Gigi

Gusi/ Lidah

Tonsil / pharing

Kel. Getah
Bening
Kel. Thyroid

Thorax :
 Palpasi Paru

Auskultasi Paru

Perkusi Paru

Auskultasi
Jantung
Perkusi Jantung

Ictus Cordis

Abdomen :
Bentuk
Auskultasi

Perkusi

Kandung
Kemih
Perkusi Ginjal

Masa Abdomen

Nyeri Tekan

Ekstremitas:
Edema
Reflek Fisiologis

Capillary Refill

J. HARAPAN KELUARGA
1. Terhadap masalah kesehatan :
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2. Terhadap petugas kesehatan yang ada :
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Maumere, .2017
Mengetahui,

Mengkaji Preceptor Akademik

() (..)
 B. KLASIFIKASI DATA :

Hari / Tanggal : .......................................................................

Nama Klien/ Usia : ....... / ..................................................................
Diagnosa Medis : .......................................................................

Data Subyektif :
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Data Obyektif :
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 C. ANALISA DATA :

Hari / Tanggal : ....................................................................

Nama Klien/ Usia : ....... / .................................................................
Diagnosa Medis : .......................................................................
(minimal 3 diagnosa)
No Data Etiologi Problem
 FORMAT SKORING/PRIORITAS MASALAH
DIAGNOSA KEPERAWATAN KELUARGA

Masalah Keperawatan 1 : ..........

Kriteria Bobot Perhitungan Pembenaran

1. Sifat masalah
Aktual: 3 ..../3 x 1 = ....
Resiko tinggi: 2
Potensial: 1

2. Kemungkinan
masalah dapat diubah ....../2 x 2 = ....
Tinggi: 2
Sedang: 1
Rendah : 0

3. Potensial untuk
dicegah
Mudah : 3 ...../3 x 1 = ....
Cukup: 2
Tidak dapat : 1

4. Menonjolnya masalah
Masalah dirasakan
dan perlu
penanganan segera:
2
Masalah dirasakan, ..... x 1 =.....
tidak perlu
ditangani segera: 1
Masalah tidak
dirasakan: 0

Skor
Masalah Keperawatan 2: .............

Kriteria Bobot Perhitungan Pembenaran

2. Sifat masalah
Aktual: 3 ..../3 x 1 = ....
Resiko tinggi: 2
Potensial: 1

3. Kemungkinan
masalah dapat diubah ....../2 x 2 = ....
Tinggi: 2
Sedang: 1
Rendah : 0

4. Potensial untuk
dicegah
Mudah : 3 ...../3 x 1 = ....
Cukup: 2
Tidak dapat : 1

5. Menonjolnya masalah
Masalah dirasakan
dan perlu
penanganan segera:
2
Masalah dirasakan, ..... x 1 =.....
tidak perlu
ditangani segera: 1
Masalah tidak
dirasakan: 0

Skor
 D. DIAGNOSA KEPERAWATAN :

Hari / Tanggal : .......................................................................

PRIORITAS MASALAH KEPERAWATAN :

Berdasarkan rumusan prioritas diatas, maka dapat diketahui prioritas permasalahan keluarga
Tn./Ny.............. adalah sebagai berikut ;

1. ......................................................................................................................................................
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2. ......................................................................................................................................................
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3. ......................................................................................................................................................
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4. ......................................................................................................................................................
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5. ......................................................................................................................................................
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