A. Data umum
1. Nama KK :……………………………………
2. Umur KK : ……………………………………
3. Alamat : ……………………………………
4. No. Telephon : ……………………………………
5. Pekerjaan : ……………………………………
6. Pendidikan: ……………………………………
7. Susunan Anggota Keluarga :
Sex Hub Gol Masalah
No Nama Umur Pendidikan Pekerjaan
(L/P) Dg KK Darah Kesehatan
8. Tipe Keluarga
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10. Identifikasi religius
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11. Status kelas sosial
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12. Mobilitas kelas sosial
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13. Aktivitas Rekreasi Keluarga
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B. Riwayat Keluarga dan Tahap Perkembangan
C. Data Lingkungan
Denah rumah
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D. Struktur Keluarga
E. Fungsi Keluarga
G. Harapan Keluarga
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H. Pemeriksaan Fisik
Data Obyektif:
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Kemungkinan masalah
dapat diubah :
Potensial masalah
dapat dicegah :
Menonjolnya masalah :
Total
1. Pengkajian
1. Nama KK :……………………………………
2. Umur KK : ……………………………………
3. Alamat : ……………………………………
4. No. Telephon : ……………………………………
5. Pekerjaan : ……………………………………
6. Pendidikan : ……………………………………
7. Susunan Anggota Keluarga :
Sex Hub Gol Masalah
No Nama Umur Pendidikan Pekerjaan
(L/P) Dg KK Darah Kesehatan
Analisa Data
Data Diagnosis Keperawatan
Data Subyektif: …………………………………
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Data Obyektif:
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Lima Tugas Kesehatan keluarga
1. ................................
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2. ................................
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Dst,.....
Tuliskan data keluarga yang teridentifikasi pada hari kunjungan (here and now) sampai
dengan menggali persepsi keluarga tentang lima tugas kesehatan keluarga terkait masalah
yang teridentifikasi. Apala tidak ditemukan data here and now, maka lakukan pengkajian
sesuai dengan fungsi-fungsi keluarga dan struktur keluarga.
2. Diagnosis Keperawatan
Tuliskan diagnosis keperawatan yang muncul dari analisa data (here and now)
3. Rencana Intervensi
Sebutkan rencana intervensi untuk menyelesaikan masalah (Sesuai NANDA NIC-NOC)
Tujuan Khusus ditulis secara detail sesuai prinsip SMART. Misal : keluarga dapat
menjelaskan kembali manfaat dari teknik relaksasi otot progresif yaitu ……..
4. Implementasi
Sebutkan secara detail kegiatan yang akan dilakukan mahasiswa bersama keluarga untuk
menyelesaikan masalah keperawatan yang muncul sesuai dengan tujuan khusus yang sudah
direncanakan
5. Evaluasi
S : ……………..
O : ……………..
A : ……………..
P : ……………..
I : ……………..
E : …………….
R : ……………..
Format Laporan Pendahuluan (Untuk Ujian Keluarga)
LAPORAN PENDAHULUAN
ASUHAN KEPERAWATAN KELUARGA …………
1. Latar Belakang
Tuliskan secara deskriptif gambaran mengenai keluarga yang akan diberikan intervensi
melipti point-point sebagai berikut :
a. Karakteristik keluarga tuliskan data keluarga, baik yang adaptif maupun
maladaptive, yang menjadi dasar/justifikasi kenapa harus dilakukan kunjungan
tersebut.
b. Data yang perlu dikaji lebih lanjut tuliskan data-data yang mungkin perlu dikaji
lebih lanjut/ ditambahkan untuk menegakkan diagnosis tersebut
c. Masalah keperawatan keluarga
2. Proses keperawatan
a. Diagnosis keperawatan keluarga
b. Tujuan Umum merupakan tujuan khusus dari rencana intervensi yang akan
dicapai pada saat kunjungan
c. Tujuan khusus
Sebutkan secara detail sesuai dengan prinsip SMART , missal : keluarga dapat
menjelaskan kembali 3 dari 4 manfaat makanan sehat yaitu …………..
4. Kriteria Evaluasi
a. Kriteria struktur :
b. Kriteria proses :
c. Kriteria hasil :