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FORMAT PENGUMPULAN DATA

ASUHAN KEPERAWATAN KOMUNITAS


PROGRAM STUDI NERS
STIKES BETHESDA YAKKUM YOGYAKARTA

Nomor :
Tanggal :
Nama Petugas :

I. IDENTITAS UMUM KELUARGA


Inisial Kepala Keluarga :

Umur KK :

Jenis Kelamin : 1. Laki-laki 2. Perempuan

Suku : 1. Jawa 2.Sunda. 3.betawi


4.lainnya...............

Status Perkawinan : 1. Kawin


2. Tidak kawin
3. Janda/duda
Agama : 1. Islam
2. Katolik
3. Kristen Protestan
4. Hindu
5. Budha
6. Kepercayaan
Pendidikan : 1. Tidak sekolah
2. SD
3. SMP
4. SMA
5. PT(perguruan tinggi)

Pekerjaan Kepala Keluarga : 1. Buruh


2. Pedagang
3. Pegawai swasta
4. PNS/TNI?Polri
5. Lainnya:
Penghasilan perbulan (sesuai UMR :
daerah masing-masing)

Jaminan Kesehatan yang dimiliki : 1. BPJS


2. Asuransi swasta
3. Pribadi :............
Alamat Rumah :

Keluhan Kesehatan KK dalam 3 bulan : 1. TB Paru/ batuk berdarah/batuk


berdahak / batuk pilek
terakhir 2. Hipertensi/ darah tinggi
3. Stroke
4. DM/ kencing manis
5. Asam Urat
6. Gastritis
7. Sebutkan penyakit
lainnya.................

1. Data Anggota Keluarga yang Tinggal Serumah

No Inisial L/P Umur BB/TB Pendidika Pekerjaan TTV Hub. Dg KK


Nama (IMT) n (N,TD,S)
terakhir
1.
2.
3.
4.
5.
6.
7.

2. Data Kesehatan
Riwayat kesehatan ............................................................................................................
Keluhan yang
dirasakan 3 bulan ............................................................................................................
terakhir
Apa jenis pelayanan 1. Puskesmas 5. Pengobatan alternatif
kesehatan yang 2. RSU/ RS swasta 6. Posbindu
digunakan keluarga 3. Klinik 7. Lain-lain,
saat mengalami 4. Dokter / bidan praktik sebutkan…………………………
masalah kesehatan?
Trasnportasi apa yang 1. Jalan kaki 3. Kendaraan umum
digunakan ke 2. Kendaraan pribadi 4. Lainnya, sebutkan……………………………
pelayanan kesehatan?
Jarak ke pelayanan 1. < 1 km
kesehatan yang sering 2. ≥ 1 km
dikunjungi?
Apa jenis jaminan 1. KIS
kesehatan yang 2. BPJS
digunakan / dimiliki 3. Jamkesda
keluarga ? 4. Asuransi swasta
5. Lain-lain, sebutkan......
3. DATA PENUNJANG KELUARGA
A. Rumah dan Sanitasi Lingkungan
Keterangan: Gambaran Kondisi
1. Kondisi Rumah : ............................................................................................................................................................
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2. Ventilasi : Cukup/kurang ............................................................................................................................................................


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3. Pencahayaan Rumah : Baik/Tidak ............................................................................................................................................................


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4. Saluran pembuangan Limbah: Baik/Cukup/Kurang ............................................................................................................................................................


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5. Sumber air bersih : sehat/tidak sehat ............................................................................................................................................................
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6. Jamban Memenuhi Syarat : Ya/Tidak* ............................................................................................................................................................


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7. Tempat sampah : Ya/Tidak* ............................................................................................................................................................


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8. Rasio Luas Bangunan Rumah dengan Jumlah Anggota Keluarga 8m2/orang : ............................................................................................................................................................
Ya/Tidak* ............................................................................................................................................................
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B. PHBS di Rumah Tangga
Keterangan Ya Tidak Data Kualitatif (gambaran kondisi)
1. Jika ada ibu nifas, Persalinan ditolong ............................................................................................................................................................
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oleh tenaga kesehatan
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2. Jika ada bayi, Memberi ASI ekslusif ............................................................................................................................................................


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3. Jika ada balita, Menimbang balita tiap ............................................................................................................................................................


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bulan
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4. Menggunakan air bersih untuk makan ............................................................................................................................................................


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& minum
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5. Menggunakan air bersih untuk ............................................................................................................................................................
............................................................................................................................................................
kebersihan diri
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6. Mencuci tangan dengan air bersih & ............................................................................................................................................................


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sabun
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7. Melakukan pembuangan sampah ............................................................................................................................................................


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pada tempatnya
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8. Menjaga lingkungan rumah tampak ............................................................................................................................................................


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bersih
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9. Mengkonsumsi lauk dan pauk tiap hari


10. Menggunakan jamban sehat ............................................................................................................................................................
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11. Memberantas jentik di rumah sekali ............................................................................................................................................................


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seminggu
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12. Makan buah dan sayur setiap hari ............................................................................................................................................................


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13. Melakukan aktivitas fisik setiap hari ............................................................................................................................................................


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14. Tidak merokok di dalam rumah ............................................................................................................................................................


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4. Upaya Peningkatan Kesehatan (Winshield Survei dan Wawancara)

No Uraian Pengkajian Penilaian Gambaran Kondisi No Uraian Pengkajian Penilaian Gambaran Kondisi
Ada Tidak Ada Tidak
A Fasilitas layanan E. Status Ekonomi
Keehatan yang tersedia
1. Posyandu balita 1. Sumbangan (asal
sumber
pendanaan)
2. Posyandu lansia 2. Jenis pekerjaan

3. Puskesmas dan 3. Rata-rata


Jaringannya pendapatan per
bulan
4. Klinik 4. lainnya
5. Rumah sakit
6. Sebutkan lainnya F Status Sosiall
Budaya Spritual
B Pelayanan 1. Sarana Ibadah
kesehatan yang
dimanfaatkan
1. Imunisasi dasar 2. Kegiatan
lengkap Keagamaan
3. Imunisasi ibu hamil 4. Keprcayaan
yang
bertentangan
dengan
penanggulangan
masalah
kesehatan
5. Makanan tambahan 4. Kegiatan sosial
(kerja bakti,
arisan ,dll)
6. Vitamin tambahan
C Fasilitas Pendidikan G Komunikasi
Uraian Pengkajian Penilaian Gambaran Kondisi Uraian Pengkajian Penilaian Gambaran Kondisi
Ada Tidak Ada Tidak
1. Fasilitas Pendidikan 1. Alat komunikasi
Yang tersedia yang digunakan
dalam kelompok
sehari-hari:
a. Telepon
b. Hp
c. Faximie
d. lainnya
a. TK 2. Efektivitas
proses
komunikasi
antar anggota
keluarga
b. SD

c. SMP H Fasilitas Rekreasi


yang tersedia

d. SMA 1. taman

e. Universitas 2. pantai
f. lainnya 3. sarana olah raga

2. Fasilitas pendidikan 4. Lainnya


yang digunakan
untuk kegiatan
penyuluhan
kesehatan,
pembelajaran dll
D Lingkungan sekitar I Kebiasaan/perilaku
tempat tinggal
Uraian Pengkajian Penilaian Gambaran Kondisi Uraian Pengkajian Penilaian Gambaran Kondisi
Ada Tidak Ada Tidak
1. Sumber air bersih 1. Pemeliharaan
kebersihan diri
2. Dapur umum 2. Pengelolaan
makanan bersih
dan sehat
3. Tenpat pembuangan
sampah
4. Sarana MCK
5. Saluran
pembuangan limbah
6. lainnya
3. Pengkajian Agregate

A. Balita

Usia Balita: ...............

Keterangan Ya Tidak Keterangan


1. Balita rutin posyandu 1 bulan sekali
2. Riwayat penyakit 3 bulan terakhir:
a. Diare
b. Influenza
c. Kejang Demam
d. Lainnya..............
3. Melakukan Imunisasi:
a. BCG
b. Polio
c. DPT
d. Hepatitis
e. Campak
f. Lainnya......

B. Ibu Hamil

Usia Kehamilan:........................

Keterangan Ya Tidak Keterangan


4. Pemeriksaan ibu hamil secara
teratur minimal 1 bulan sekali
5. Memeriksakan kehamilan ke
Puskesmas/RS/klinik/Bidan
6. Ibu hamil minum suplemen /zat
besi/asam folat
7. Melakukan imunisasi selama masa
kehamilan
8. Keluhan kehamilan yang dirasakan:
Pusing,cepat lelah,mual dan muntah

C. Remaja

Keterangan Ya Tidak Keterangan


1. Anggota keluarga usia Remaja
(uisa 13-20 tahun)
2. Mengkonsumsi Rokok/Minuman
Keras
3. Mengikuti penyuluhan
rokok/miras/narkoba
4. Mengikuti penyuluhan tentang
reproduksi
5. Pernah mendapatkan suplemen zat
besi
6. Riwayat Penyakit yang dialami
remaja 3 bulan terakhir:
a. Gastritis
b. Diare
c. Thypoid
d. Lainnya........

D. Lansia

Keterangan Ya Tidak Keterangan


1. Anggota keluarga Lansia usia ≥ 60
tahun
2. Lansia tinggal bersama anggota
keluarga
3. Kemampuan aktivitas lansia mandiri
4. Kemampuan aktivitas lansia dibantu
5. Lansia rutin mengunjungi
Puskesmas/RS/klinik (1 bulan
minimal 1 kali)
6. Riwayat penyakit lansia 3 bulan
terakhir:
a. Hipertensi (Ukur TD : ≥140/90
mmHg))
b. Diabetes Melitus (hasil cek GDS)
c. Nyeri sendi
d. Asam urat
e. Gangguan tidur
f. Gastritis
g. Lainnya : ................