Pengkajian
A. Data Umum :
1. Nama Kepala Keluarga : ......................................
2. Umur KK : ......................................
3. Pendidika KK : .......................................
4. Pekerjaan KK : ......................................
5. Alamat dan Telepon: ......................................
6. Komposisi Keluarga yang berisi mengenai riwayat anggota keluarga
7. Genogram
Symbol-simbol yang biasa digunakan :
Cerai Cerai anak angkat aborsi kembar tinggal dalam satu rumah
8. Tipe Keluarga.
.........................................................................................................
9. Suku bangsa.
............................................................................................................
10. Agama.
............................................................................................................
11. Status Sosial Ekonomi Keluarga.
................................................................................................................
12. Aktifitas Rekreasi Keluarga.
...............................................................................................................
B. Riwayat dan Tahap Perkembangan Keluarga
1. Tahap perkembangan keluarga saat ini :
.......................................................................................................
2. Tahap perkembangan keluarga yang belum terpenuhi :
.......................................................................................................
3. Riwayat keluarga inti :
........................................................................................................
4. Riwayat keluarga sebelumnya :
........................................................................................................
C. Lingkungan
1. Karakteristik rumah :
....................................................................................................................................................................
......................................................................................
Denah Rumah : (contoh)
KM KT KT
KT
D RT T KT T
RK
Bawah Atas
Keterangan :
RT = Ruang Tamu
KT = Kamar Tidur
RN = Ruang Nonton
D = Dapur
2. Karakteristik tetangga dan komunitas setempat :
....................................................................................................................................................................
...............................................................................
3. Mobilitas geografis keluarga :
....................................................................................................................................................................
................................................................................
4. Perkumpulan keluarga dan interaksi dengan masyarakat :
.........................................................................................................................
5. Sistem pendukung keluarga :
....................................................................................................................................................................
...............................................................................
D. Struktur Keluarga
1. Pola Komunikasi Keluarga :
......................................................................................................................
2. Struktur Kekuatan Keluarga :
....................................................................................................................................................................
..............................................................................
3. Struktur Peran (formal dan informal) :
....................................................................................................................................................................
................................................................................
4. Nilai dan Norma Keluarga :
....................................................................................................................................................................
...........................................................................
E. Fungsi Keluarga
1. Fungsi Afektif :
....................................................................................................................................................................
...............................................................................
2. Fungsi Sosial :
....................................................................................................................................................................
...............................................................................
3. Fungsi Perawatan Kesehatan :
a. Mengenal masalah kesehatan
....................................................................................................................
b. Mengambil keputusan tindakan kesehatan yang tepat
....................................................................................................................
c. Merawat anggota yang sakit
....................................................................................................................
d. Memelihara lingkungan yang sehat
...................................................................................................................
e. Menggunakan fasilitas kesehatan di Masyarakat
...................................................................................................................
4. Fungsi Reproduksi :
........................................................................................................................
5. Fungsi Ekonomi
.......................................................................................................................
G. Pemeriksaan Fisik
Pemeriksaan fisik dilakuakn pada semua anggota keluarga menggunakan format pengkajian head to
toe.
....................................................................................................................................................................
......................................................................................
H. Harapan Keluarga.
....................................................................................................................................................................
......................................................................................
ANALISA DATA
NATA ETIOLOGI PROBLEM
DS :
DO :
DS :
DO :
DS :
DO :
PENENTUAN PRIORITAS DIAGNOSA KESEHATAN (Scoring)
Diagnosa : .........................................................................................................
Menonjonya masalah
Skala :
a. Masalah berat, harus segerah ditangani
:2
1
b. Ada masalah tetapi tidak perlu
4 ditangani :1
c. Masalah tidak dirasakan :0
Diagnosa Keperawatan :
1. ...................................................................................
2. ...................................................................................
3. ...................................................................................
INTERVENSI/PERENCANAA
No Diagnosa Tujuan Kriteria Standar Rencana intervensi
1. I Verbal
(pengetahuan
)
Psikomotor
(perilaku)
2. II Verbal
(pengetahuan
)
Psikomotor
(perilaku)
IMPLEMENTASI
Hari/Tgl Diagnosa Implementasi Respon Paraf
I S:
O:
II S:
O:
III S:
O:
EVALUASI
No. Hari/Tgl Diagnosa Evaluasi Paraf
I S:
O:
II S:
O:
III S:
O:
P
FORMAT RESUMA KEPERAWATAN KELUARGA
Pengkajian
I. Data Umum :
1. Nama Kepala Keluarga : ......................................
2. Umur & Jenis kelamin : ......................................
3. Pendidika KK : .......................................
4. Pekerjaan KK : ......................................
5. Alamat dan Telepon : ......................................
6. Komposisi Keluarg yang berisi mengenai riwayat anggota keluarga
No Nama JK Hubungan Umur Pendidikan Pekerjaan Kondisi
KK
7. Genogram
8. Tipe Keluarga.
.......................................................................................................
9. Tahap perkembangan keluarga saat ini :
.......................................................................................................
10. Tahap perkembangan keluarga yang belum terpenuhi :
.......................................................................................................
11. Riwayat keluarga inti :
........................................................................................................
Fungsi Keluarga
1. Fungsi Afektif :
.....................................................................................................................................................
..............................................................................................
2. Fungsi Sosial :
.....................................................................................................................................................
..............................................................................................
3. Fungsi Perawatan Kesehatan :
a. Mengenal masalah keseharan
....................................................................................................................
b. Mengambil keputusan tindakan kesehatan yang tepat
....................................................................................................................
c. Merawat anggota yang sakit
....................................................................................................................
d. Memelihara lingkungan yang sehat
...................................................................................................................
e. Menggunakan fasilitas kesehatan di Masyarakat
...................................................................................................................
Harapan Keluarga.
........................................................................................................................................
..................................................................................................................
J. Pemeriksaan Fisik
Pemeriksaan fisik dilakuakn pada anggota keluarga sementara sakit
ANALISA DATA
NATA ETIOLOGI PROBLEM
DS :
DO :
DS :
DO :
DS :
DO :
PENENTUAN PRIORITAS DIAGNOSA KESEHATAN (Scoring)
Diagnosa : .........................................................................................................
Menonjonya masalah
Skala :
d. Masalah berat, harus segerah ditangani
:2
1
e. Ada masalah tetapi tidak perlu
4 ditangani :1
f. Masalah tidak dirasakan :0
Dst : .....................................................................................................................
Diagnosa Keperawatan :
4. ...................................................................................
5. ...................................................................................
6. ...................................................................................
INTERVENSI/PERENCANAA
No Diagnosa Tujuan Kriteria Standar Rencana intervensi
1. I Verbal
(pengetahuan
)
Psikomotor
(perilaku)
2. II Verbal
(pengetahuan
)
Psikomotor
(perilaku)
IMPLEMENTASI
Hari/Tgl Diagnosa Implementasi Respon Paraf
I S:
O:
II S:
O:
III S:
O:
EVALUASI
No. Hari/Tgl Diagnosa Evaluasi Paraf
I S:
O:
II S:
O:
III S:
O: