FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KELUARGA

STIKES SARI MULIA BANJARMASIN

T.A 20/2012

Identitas Umum Keluarga

Identitas Kepala Keluarga

Nama :..................... Pendidikan :........................

Umur :..................... Pekerjaan :........................

Agama :..................... Alamat :.........................

Suku :..................... Nomor Telpon :........................

Komposis keluarga

No Nama L/P Umur Hubungan Keluarga Pekerjaan Pendidikan

1 Tn. jarman L 23 anak Buruh -

2 -
3 -
4 -
5 -
6
7
8
9

Genogram : buatlah genogram 3 generasi

Tipe Keluarga :

1. Jenis tipe keluarga :.....................................................................

2. Maslah yang terjadi dengan tipe tersebut :.....................................................................

Suku Bangsa

1. Asal suku bangsa :....................................................................

2. Budaya yang berhubungan dengan kesehatan :....................................................................

Agama dan kepercayaan yang memengaruhi kesehatan:

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

Status Sosial Ekonomi Keluarga :

1. Anggota keluarga yang mencari nafkah :................................

 2. Penghasilan :................................
3. Upaya lain :................................
4. Harta benda yang dimiliki (perabot, transportasi, dan lain-lain :................................
5. Kebutuhan yang dikelurkan setiap bulan :.................................
Aktivitas Rekreasi Keluarga :
.............................................................................................................................................
.............................................................................................................................................
................

Riwayat dan tahap perkembangan keluarga

Tahap perkembangan keluarga saat ini (ditentukan dengan anak tertua)

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

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

Tahap perkembangan keluarga yang belum terpenuhi dan kendalannya

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

.........................................................................................................................................................
Riwayat kesehatan keluarga inti :

1. Riwayat kesehatan keluarga saat ini

..................................................................................................................................................
2. Riwayat penyakit keturunan
...................................................................................................................................................
3. Riwayat kesehatan masing – masing anggota keluarga

No Nama Umur BB Keadaan Imunisasi Masalah Tindakan

kesehatan BCG/Polio/DPT/HB/campak kesehatan yang telah
dilakukan

4. Sumber pelayanan kesehatan yang dimanfaatkan

....................................................................................................................................................
5. Riwayat kesehatan keluarga sebelumnya
....................................................................................................................................................

Pengkajian Lingkungan
Karakteristik Rumah
1. Luas rumah .........................................................................................................................................
2. Tipe rumah...........................................................................................................................................
3. Kepemilikan ........................................................................................................................................
4. Jumlah dan rasio kamar/ ruangan ......................................................................................................
5. Ventilasi/ jendela.................................................................................................................................
6. Pemanfaatan ruangan ........................................................................................................................
7. Septik tank: ada/tidak....................................................Letak:............................................................
8. Sumber air minum...............................................................................................................................
9. Kamar mandi/ WC:..............................................................................................................................
10.Sampah :...................................................Limbah RT:.........................................................................
11.Kebersihan lingkungan:......................................................................................................................

Karakteristik tetangga dan komunitas

1. Kebiasaan :...........................................................................................................
2. Aturan/kesepakatan :...........................................................................................................
3. Budaya :...........................................................................................................

Mobilitas Geografi Keluarga :.........................................................................................................

Perkumpulan Keluarga Dan Integraksi Dengan Masyarakat :..........................................................

Sistem pendukung keluarga :.........................................................................................................

Struktur Keluarga
Pola/Cara Komunkasi Keluarga :............................................................................................................

Struktur Kekuatan Keluarga :............................................................................................................

Struktur Peran (Peran Masing-Masing Anggota Keluarga) :

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

Nilai Dan Norma

Keluarga: ..................................................................................................................................................
..............................................................................................................................

Fungsi Keluarga
Fungsi Afektif...................................................................................................................................

Fungsi sosialisasi

1. Kerukunan hidup dalam keluarga :

.....................................................................................................................................................
.....................................................................................................................................................
2. Interaksi dan hubungan dalam keluarga :
.....................................................................................................................................................
.....................................................................................................................................................
3. Anggota keluarga yang dominan dalam pengambilan keputusan :
.....................................................................................................................................................
.....................................................................................................................................................
 4. Kegiatan keluarga waktu senggang:
....................................................................................................................................................
5. Partisipasi dalam kegiatan sosial :
.....................................................................................................................................................
.....................................................................................................................................................
6. Fungsi perawatan kesehatan :
.....................................................................................................................................................
.....................................................................................................................................................

Fungsi Reproduksi
1. Perencanaan jumlah anak
2. Akseptor : ya ........................yang digunakan....................................lamanya............................
3. Akseptor : Belum/tidak..........., alasannya :
4. Keterangan lain:..........................................................................................................................

Fungsi Ekonomi

1. Upaya pemenuhan sandang pangan :.........................................................................................

.....................................................................................................................................................
2. Pemanfaatan sumber dimasyarakat :..........................................................................................
.....................................................................................................................................................

Stres dan Koping Keluarga

1. Stresor Jangka Pendek :..............................................................................................................

.....................................................................................................................................................
2. Stresor Jangka Panjang:...............................................................................................................
.....................................................................................................................................................
3. Respon Keluarga Terhadap Stresor :...........................................................................................
.....................................................................................................................................................
4. Strategi Koping :..........................................................................................................................
....................................................................................................................................................
5. Strategi Adaptasi Disfungsional :.................................................................................................
....................................................................................................................................................

Keadaaan Gizi Keluarga

1. Pemenuhan gizi :.........................................................................................................................

....................................................................................................................................................
2. Upaya lain :..................................................................................................................................
....................................................................................................................................................

Harapan keluarga

1. Terhadapa masalah kesehatannya :............................................................................................

.....................................................................................................................................................
2. Terhadap petugas kesehatan yang ada :......................................................................................
.....................................................................................................................................................

Pemeriksaaan Fisik
No Variabel Nama Anggota Keluarga
Tn. Ny. An. An.
1 Riwayat Penyakit saat ini
2 Keluhan yang dirasakan
3 Tanda dan gejala
4 Riwayat penyakit sebelumnya
5 Tanda-tanda vital
6 Sistem kardiovaskuler
7 Sistem respirasi
8 Sistem saluran pencernaan
9 Sistem persarafan
10 Sistem muskuloskeletal
11 Sistem genitalia

Tipologi masalah kesehatan

No Daftar masalah Kesehatan

1 Ancaman
................................................................................................................................................
................................................................................................................................................
..........................................................................................................................

2 Kurang/tidak sehat
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
...........

3 Defisit
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
............

Pengkajian Khusus Berdasarkan 5 Tugas Keluarga

No Kriteria Pengkajian
1 Mengenal masalah
2 Mengambil keputusan yang tepat
3 Merawat anggota keluarga yang sakit atau punya masalah
4 Momidifikasi lingkungan
5 Memanfaatkan sarana kesehatan
Daftra Masalah
No Data Problem Etiologi
Skoring

Kriteria bobot Pembenaran

SIFAT MASALAH
 Ancaman
 Kurang/tidak sehat
 Krisis
KEMUNGKINAN MASALAH DAPAT DIUBAH
 Mudah
 Sebagian
 Tidak dapat
POTENSIAL MASALAH DAPAT DICEGAH
 Tinggi
 Cukup
 Rendah
MENONJOLNYA MASALAH
 Segera ditangani
 Tak perlu segera ditangani
 Tak dirasakan

Rencana tindakan keperawatan

No Diagnosa keperawatan Tujuan Kriteria hasil Interfensi

Implementasi

No. No. Diagnosis Keperawatan Pukul Tindakan keperawatan Paraf

Evaluasi

No No. Diagnosa Keperawatan Evaluasi paraf