UNIVERSITAS NAHDLATUL ULAMA SURABAYA

FAKULTAS KEPERAWATAN DAN KEBIDANAN

PROGRAM STUDI PROFESI NERS
KAMPUS A JL. SMEA NO. 57 SURABAYA (031) 8291920, 8284508, FAX (031) 8298582
KAMPUS B RS. ISLAM JEMURSARI JL. JEMURSARI NO. 51-57 SURABAYA
Website : www.unusa.ac.id Email : info@unusa.ac.id

ASUHAN KEPERAWATAN KELUARGA

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

I. Data Umum
1. Nama kepala keluarga : ..............................................................................................
2. Alamat dan telepon : ..............................................................................................
3. Komposisi keluarga :

Hub Pek Pend Status Imunisasi

Jenis kel –
No. Nama Umur Hepatiti Cam Ket
kel KK Polio DPT
s pak

Genogram :
Penjelasan Genogram :

1. Tipe Keluarga : ..................................................................................

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2. Latar Belakang Budaya : ..................................................................................
Keluarga ………………………………………………………
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3. Agama : ..................................................................................
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4. Status Kelas Sosial Ekonomi : ..................................................................................

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 5. Aktivitas Rekreasi Keluarga
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II. Riwayat Dan Tahap Perkembangan Keluarga

1. Tahap Perkembangan Keluarga Saat Ini
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2. Tugas Perkembangan Keluarga Yang Belum Terpenuhi
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3. Riwayat Kesehatan Keluarga Inti
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4. Riwayat Kesehatan Keluarga Sebelumnya
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III. Data Lingkungan
1. Karakteristik Rumah

Denah Rumah

2. Karakteristik Tetangga Dan Komunitasnya

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3. Mobilitas Geografis Keluarga
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4. Perkumpulan Keluarga Dan Interaksi Dengan Masyarakat
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IV. Struktur Keluarga

1. Struktur Peran
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2. Pola Komunikasi Keluarga
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3. Struktur Kekuasaan Keluarga
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 4. Nilai Keluarga
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V. Fungsi Keluarga
1. Fungsi Afektif
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2. Fungsi Status Sosialisasi
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3. Fungsi Pemenuhan (Perawatan/Pemeliharaan) Kesehatan
a. Mengenal Masalah Keluarga
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b. Mengambil Keputusan Mengenai Tindakan Kesehatan
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c. Kemampuan Merawat Anggota Keluarga Yang Sakit
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d. Kemampuan Keluarga Memelihara/Memodifikasi Lingkungan Rumah Yang
Sehat
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e. Kemampuan Menggunakan Fasilitas Pelayanan Kesehatan
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4. Fungsi Reproduksi
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5. Fungsi Ekonomi
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VI. Stress Dan Koping Keluarga

1. Stressor Jangka Pendek Dan Panjang
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2. Kemampuan Keluarga Berespon Terhadap Stressor
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3. Strategi Koping Yang Digunakan
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4. Strategi Adaptasi Disfungsional
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VII. Pemeriksaan Kesehatan Tiap Individu Anggota Keluarga
Anggota Keluarga
Sistem Tubuh

Tanda vital

Kepala/Rambut

Mata

Telinga
 Hidung

Mulut

Leher

Dada/Thoraks
 Abdomen

Ektremitas bawah

Ekstremitas atas

Kulit

Riwayat Alergi
Riwayat Pemakaian
Obat

Kesimpulan
VIII. Harapan Keluarga
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Surabaya, .....................
Mahasiswa

(...............................)
B. DIAGNOSIS KEPERAWATAN KELUARGA
1. ANALISIS DATA
No. Data Masalah
No. Data Masalah
2. PENILAIAN (SKORING) PRIORITAS MASALAH
Dx. Kep : ........................................................................................................................................................................................................
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No Kriteria Skor Bobot Hasil Pembenaran
1. Sifat masalah
Skala : Wellness 3
Tidak/kurang sehat 3 1
Ancaman kesehatan 2
Krisis 1
2. Kemungkinan masalah dapat diubah
Skala : Mudah
Sebagian 2 2
Tidak dapat 1
0
3. Potensial masalah untuk dicegah
Skala : Tinggi
Cukup 3 1
Rendah 2
1
4. Menonjolnya masalah
Skala :
Segera 2
Tidak perlu 1 1
Tidak dirasakan 0
Total
Dx. Kep : ........................................................................................................................................................................................................
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No Kriteria Skor Bobot Hasil Pembenaran
1. Sifat masalah ……………………………………………………………
Skala : Wellness 3 ……………………………………………………………
Tidak/kurang sehat 3 1 ……………………………………………………………
Ancaman kesehatan 2 ……………………………………………………………
Krisis 1 ……………………………………………………………

2. Kemungkinan masalah dapat diubah ……………………………………………………………

Skala : Mudah ……………………………………………………………
Sebagian 2 2 ……………………………………………………………
Tidak dapat 1 ……………………………………………………………
0 ……………………………………………………………

3. Potensial masalah untuk dicegah ……………………………………………………………

Skala : Tinggi 3 ……………………………………………………………
Cukup 2 1 ……………………………………………………………
Rendah 1 ……………………………………………………………
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4. Menonjolnya masalah ……………………………………………………………
Skala : ……………………………………………………………
Segera 2 ……………………………………………………………
Tidak perlu 1 1 ……………………………………………………………
Tidak dirasakan 0 ……………………………………………………………
Total
Dx. Kep : ........................................................................................................................................................................................................
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No Kriteria Skor Bobot Hasil Pembenaran
1. Sifat masalah ……………………………………………………………
Skala : Wellness 3 ……………………………………………………………
Tidak/kurang sehat 3 1 ……………………………………………………………
Ancaman kesehatan 2 ……………………………………………………………
Krisis 1 ……………………………………………………………
2. Kemungkinan masalah dapat diubah ……………………………………………………………
Skala : Mudah 2 ……………………………………………………………
Sebagian 1 2 ……………………………………………………………
Tidak dapat 0 ……………………………………………………………
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3. Potensial masalah untuk dicegah ……………………………………………………………
Skala : Tinggi 3 ……………………………………………………………
Cukup 2 1 ……………………………………………………………
Rendah 1 ……………………………………………………………
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4. Menonjolnya masalah ……………………………………………………………
Skala : ……………………………………………………………
Segera 2 ……………………………………………………………
Tidak perlu 1 1 ……………………………………………………………
Tidak dirasakan 0 ……………………………………………………………

Total
Prioritas Diagnosis Keperawatan
No. Prioritas Diagnosis Keperawatan Skor
3. INTERVENSI KEPERAWATAN
No. Data / Karakteristik Diagnosis Nursing Outcome Criteria Nursing Intervention Criteria
(NANDA) (NOC) (NIC)
No. Data / Karakteristik Diagnosis Nursing Outcome Criteria Nursing Intervention Criteria
(NANDA) (NOC) (NIC)
No. Data / Karakteristik Diagnosis Nursing Outcome Criteria Nursing Intervention Criteria
(NANDA) (NOC) (NIC)
No. Data / Karakteristik Diagnosis Nursing Outcome Criteria Nursing Intervention Criteria
(NANDA) (NOC) (NIC)
4. IMPLEMENTASI DAN EVALUASI KEPERAWATAN
TTD
No. DIAGNOSA IMPLEMENTASI EVALUASI
PERAWAT
 TTD
No. DIAGNOSA IMPLEMENTASI EVALUASI
PERAWAT
 TTD
No. DIAGNOSA IMPLEMENTASI EVALUASI
PERAWAT
 TTD
No. DIAGNOSA IMPLEMENTASI EVALUASI
PERAWAT
No. DIAGNOSA IMPLEMENTASI EVALUASI TTD
PERAWAT
No. DIAGNOSA IMPLEMENTASI EVALUASI TTD
PERAWAT
No. DIAGNOSA IMPLEMENTASI EVALUASI TTD
PERAWAT