FORMAT LAPORAN PENDAHULUAN KEPERAWATAN KELUARGA

Laporan pendahuluan kunjungan ke.........

Tanggal:
1. LATAR BELAKANG
a) Karakteristik keluarga
Tuliskan data keluarga, baik yang adaptif maupun yang maladaptif, yang menjadi
justifikasi laporan yang dibuat. Sertakan pula analisis konsep yang terkait dengan data
b) Data yang perlu dikaji lebih lanjut
Tuliskan data-data yang menurut mahasiswa perlu ditambah untuk menegakkan diagnosa
keperawatan
c) Masalah keperawatan keluarga
2. TINJAUAN TEORI
a. Konsep dasar keluarga
b. Konsep dasar masalah
1) Pengertian
2) Etiologi
3) Patofisiologi
4) Manifestasi Klinis
5) Pemeriksaan Penunjang/Diagnostik
6) Penatalaksanaan Medis
3. TINJAUAN ASKEP
a. Pengkajian
1) Data Subjektif
2) Data Objektif
3) Diagnosa Keperawatan
b. Perencanaan
1) Prioritas Masalah
2) Tujuan dan Kriteria Evaluasi
3) Intervensi
4) Rasional Tindakan
c. Implementasi (pengertian)
d. Evaluasi (sesuaikan dengan permasalahan yang muncul)
4. WOC
(Mulai etiologi-proses-manifestasi klinis-masalah keperawatan dan komplikasi)
5. DAFTAR PUSTAKA
 FORMAT ASUHAN KEPERAWATAN KELUARGA

1. Pengkajian
Pengumpulan data dilaksanakan pada hari ……. ….......... pukul …...... wita. Data diperoleh
dengan cara wawancara, observasi, pemeriksaan fisik dan dokumentasi.
a. Data umum
1) Kepala Keluarga
a. Nama :
b. Umur :
c. Jenis kelamin :
d. Pendidikan :
e. Pekerjaan :
f. Agama :
g. Suku / Bangsa :
h. Alamat :
i. Tanggal pengkajian :

2) Komposisi Keluarga
Tabel …..
Komposisi Keluarga …………………
Umur Hub. Pendi Peker Imun Kon
No. Nama L/P Ket
(th) dg KK dikan jaan isasi disi
1
2

3) Genogram

Gambar 1 : Genogram Keluarga Bapak...... dengan……………………………………...

 Keterangan :

Penjelasan : ......................................................................................................................
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4) Tipe Keluarga
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5) Latar Belakang Budaya (Etnis)
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6) Agama
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7) Status Sosial Ekonomi Keluarga
Tabel ….
Rata-Rata Pendapatan dan Pengeluaran Keluarga
Bapak....................
No. Nama Pekerjaan Pendapatan Pengeluaran Saldo Keterangan
1
2
Jumlah
Penjelasan : ...........................................................................................................
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8) Aktivitas rekreasi keluarga atau waktu luang
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b. Tahap dan Riwayat Perkembangan Keluarga

1) Tahap perkembangan keluarga saat ini
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2) Tahap perkembangan keluarga yang belum terpenuhi
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3) Riwayat keluarga sebelumnya
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c. Data Lingkungan
1) Karakteristik rumah
a. Luas rumah..................................
b. Tipe rumah......................................
c. Kepemilikan.......................................
d. Pemanfaatan
ruangan...............................................................................................
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e. Septic
tank.....................................................................................................
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f. Sumber air minum
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g. Kamar
mandi/WC..........................................................................................
 h. Sampah...............................................................................................
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i. Kebersihan
lingkungan..........................................................................................
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Gambar 2 Denah Rumah Keluarga :

Keterangan : .....................................................................................................................
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2) Karakteristik lingkungan dan komunitas
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3) Mobilitas geografi keluarga
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4) Perkumpulan keluarga dan interaksi dengan masyarakat.
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5) Sistem pendukung atau jaringan sosial keluarga
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d. Struktur Keluarga
1) Pola komunikasi
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2) Struktur Kekuasaan
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3) Struktur Peran
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4) Nilai dan Norma Keluarga
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e. Fungsi Keluarga
1) Fungsi Afektif
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2) Fungsi sosialisasi
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3) Fungsi Perawatan Kesehatan
a) Keyakinan, nilai dan prilaku keluarga
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b) Definisi keluarga tentang sehat dan sakit
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c) Status kesehatan dan kerentanan sakit yang dirasakan oleh keluarga.
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d) Praktek diet keluarga
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e) Kebiasaan tidur dan istirahat
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f) Latihan dan rekreasi
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g) Kebiasaan penggunaan obat-obatan dalam keluarga
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h) Perawatan diri
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 i) Praktek lingkungan
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j) Pemeriksaan kesehatan secara teratur
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k) Kesehatan gigi
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l) Riwayat kesehatan keluarga
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m) Pelayanan perawatan kesehatan yang diterima
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n) Perasaan atau persepsi terhadap pelayanan kesehatan
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o) Sumber pembiayaan pelayanan kesehatan
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p) Logistik untuk mendapatkan perawatan
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f. Pemeriksaan Fisik
 Anggota keluarga Keadaan Umum Gejala kardinal Keadaan Fisik

Pengkajian Head to Toe

Kepala dan wajah

Leher

Thorak

Abdomen dan pinggang

Genetalia

Ekstremitas

Integumen

g. Koping Keluarga
1) Stresor jangka pendek dan panjang
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2) Kemampuan keluarga untuk berespon terhadap
situasi/stressor
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3) Penggunaan strategi koping
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4) Strategi adaptasi disfungsional
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h. Analisa Data
Tabel ….
Analisa Data Asuhan ……………………..
No. Data Subjektif Data Objektif Masalah Keperawatan

i. Rumusan Masalah
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j. Skoring
Tabel ….
Skoring Masalah …………………………..
No Kriteria Perhitungan Score Pembinaan
1 Sifat masalah (actual, resiko,
potensial)

2 Kemungkinan masalah dapat diubah

(mudah, hanya sebagian, tidak dapat)

3 Potensi masalah untuk dicegah (tinggi,

cukup, rendah)

4 Menonjolkan masalah (segera diatasi,

masalah yang tidak perlu segera
ditangani, masalah tidak dirasakan)
 Jumlah

Diagnosa Keperawatan
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Kriteria Perhitungan Score Pembinaan
Sifat masalah (actual, resiko, potensial)

Kemungkinan masalah dapat diubah

(mudah, hanya sebagian, tidak dapat)

Potensi masalah untuk dicegah (tinggi,

cukup, rendah)
 Menonjolkan masalah (segera diatasi,
masalah yang tidak perlu segera
ditangani, masalah tidak dirasakan)

Jumlah

k.Diagnosa Keperawatan
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2. Perencanaan
a. Prioritas Diagnosa Keperawatan
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b. Rencana Perawatan
Tabel ….
Perencanaan Perawatan Pada ……………
Evaluasi
No Dx Tujuan Intervensi
Kriteria Standar
1 Tupan :
Tupen :
3. Implementasi dan Evaluasi
 Tabel …
Implementasi Keperawatan …………
No.
No Hari/Tgl/Jam Implementasi Evaluasi Paraf
Dx
1
 Tabel …
Evaluasi Asuhan Keperawatan ………………………..
Hari/Tgl/Jam Dx Kep Evaluasi Paraf