FORMAT ASUHAN KEPERAWATAN PADA KELUARGA

PENGKAJIAN (Tanggal:...............................................)

I. Data Umum :
1. Nama Kepala Keluarga
: ........................................................................
2. Umur : ..................................................................
......
3. Alamat
: ........................................................................
Telepon : ........................................................................
4. Pekerjaan Kepala Keluarga
: ........................................................................
5. Pendidikan Kepala Keluarga
: ........................................................................
6. Komposisi Keluarga
: ........................................................................

Status Imunisasi
Hub.
Pend.
No Nama L/P Keluarga Umur Polio DPT Hepatitis Ket.
Terakhir
dgn KK BCG Campak
1 2 3 4 1 2 3 1 2 3

Genogram :

7. Tipe keluarga
: .............................................................................
8. Suku bangsa
: .............................................................................
9. Agama
: .............................................................................
10. Status sosial ekonomi keluarga
: .............................................................................
11. Aktifitas rekreasi keluarga
: ........................................................................................

II. Riwayat Tahap Perkembangan Keluarga :

1. Tahap perkembangan keluarga saat
ini : ....................................................................
......................................................................................................................................
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 2. Tahap perkembangan keluarga keluarga yang belum
terpenuhi : ..............................
......................................................................................................................................
3. Riwayat keluarga
inti : .................................................................................................
......................................................................................................................................
4. Riwayat keluarga sebelumnya
: .............................................................................
.....................................................................................................................................

III. Lingkungan :
1. Karakteristik rumah :
a. Luas bangunan dan bagian-
bagiannya : ...........................................................
b. Tipe
bangunan : ...................................................................................................
c. Ventilasi
rumah : ..................................................................................................
d. Kebersihan
ruang : ............................................................................................
e. Sumber
air : .........................................................................................................
2. Denah rumah :
3. Karakteristik tetangga dan
komunitasnya : ..................................................................
......................................................................................................................................
4. Mobilitas geografis
keluarga : ....................................................................................
......................................................................................................................................
5. Perkumpulan keluarga dan interaksi dengan
masyarakat : ........................................
......................................................................................................................................
6. Sistem pendukung
keluarga : ....................................................................................
......................................................................................................................................

IV. Struktur Keluarga :

1. Pola komunikasi
keluarga : .......................................................................................
......................................................................................................................................
2. Struktur kekuatan
keluarga : ......................................................................................
......................................................................................................................................
3. Struktur peran ( formal dan
informal ) : ......................................................................
......................................................................................................................................

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 4. Nilai dan normal
keluarga : ........................................................................................
.....................................................................................................................................

V. Fungsi Keluarga :
1. Fungsi
ekonomi : .......................................................................................................
......................................................................................................................................
2. Fungsi mendapatkan status
sosial :..............................................................................
......................................................................................................................................
3. Fungsi
pendidikan: ......................................................................................................
......................................................................................................................................
4. Fungsi
sosialisasi : .......................................................................................................
......................................................................................................................................
5. Fungsi perawatan kesehatan :
f. Mengenal masalah
kesehatan : .............................................................................
................................................................................................................................
g. Mengambil keputusan mengenai tindakan
kesehatan : .........................................
................................................................................................................................
h. Kemampuan merawat anggota keluarga yg
sakit : ................................................
................................................................................................................................
i. Kemampuan memelihara/ memodifikasi lingkungan (rumah) yg
sehat : ...............
................................................................................................................................
j. Kemampuan memanfaatkan fasilitas
kesehatan : .................................................
................................................................................................................................
6. Fungsi
religius : ...........................................................................................................
......................................................................................................................................
7. Fungsi
rekreasi : .........................................................................................................
......................................................................................................................................
8. Fungsi
Reproduksi : ...................................................................................................
......................................................................................................................................
9. Fungsi
afektif : ............................................................................................................
.....................................................................................................................................

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VI. Stres Dan Koping Keluarga :
1. Stressor jangka pendek dan
panjang : ......................................................................
......................................................................................................................................
2. Kemampuan keluarga berespon terhadap situasi /
stressor : ....................................
......................................................................................................................................
3. Strategi koping yang
digunakan : ...............................................................................
......................................................................................................................................
4. Srategi adaptasi
disfungsional : .................................................................................
.....................................................................................................................................

VII. Pemeriksaan Fisik :

Nama Anggota Keluarga
No. Aspek yang Dikaji
Bpk. A Ibu. B An. C ..........
1. FISIK:
a. Kondisi umum .................... .................... .................... ....................
b. TTV .................... .................... .................... ....................
c. Kepala & leher .................... .................... .................... ....................
d. Thoraks .................... .................... .................... ....................
e. Abdomen .................... .................... .................... ....................
f. Ekstremitas .................... .................... .................... ....................
g. Genetalia .................... .................... .................... ....................
h. Dll. .................... .................... .................... ....................
2. Mental
3. Emosional
4. Sosial
5. Spiritual

VIII. Harapan keluarga :

.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

ANALISIS DATA

No. Data Masalah Penyebab

1. DS:

STIKES KEPANJEN 4
 DO:
2. DS:
DO:
3. DS:
DO:

PERUMUSAN DIAGNOSIS KEPERAWATAN

No. Diagnosis Keperawatan (PES)

1.
2.
3.

PENILAIAN (SKORING) DIAGNOSIS KEPERAWATAN

No. Kriteria Skor Pembenaran

Dx.

1. a. Sifat masalah...... ..... x 1= ...... ............................................

3
b. Kemungkinan masalah dapat ...... x 2= ...... ............................................
diubah........... 2
c. Potensi masalah untuk ...... x 1= ...... ...........................................
dicegah....... 3
d. Menonjolnnya masalah ........ ....... x 1= ...... ...........................................
2
TOTAL SKOR .................

2.

3.

PRIORITAS DIAGNOSIS KEPERAWATAN

Prioritas Diagnosis Keperawatan Skor

1.
2.
3.

PERENCANAAN

No. Tujuan Kriteria Evaluasi Rencana Intervensi

Dx. Kriteria Standar
1. UMUM: ................. Kognitif 1. ............
.............................. 2. ............
Afektif 1. ............
KHUSUS: ............. 2. ............

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 ............................. Psikomotor 1. ............
2. ............
2.

IMPLEMENTASI

Tgl. &
Waktu No. Dx Implementasi TTD
1.

2.

3.

EVALUASI

Tgl. & No. Dx. Evaluasi

Waktu
1. S : .........................................
O : .........................................
A : .........................................
P : .........................................
2. S : .........................................
O : .........................................
A : .........................................
P : .........................................

Kepanjen,............................................................

Mahasiswa

( ................................................ )

STIKES KEPANJEN 6
STIKES KEPANJEN 7