Lampiran 3: Lembar Format Pengajian Asuhan Keperawatan Keluarga

ASUHAN KEPERAWATAN KELUARGA

A. PENGKAJIAN (tanggal : .................................... )

I. Data umum

1. Kepala Keluarga (KK) : ................................................................

2. Alamat dan telepon : ................................................................
3. Pekerjaan KK : ................................................................
4. Pendidikan KK : ................................................................
5. Komposisi keluarga :.................................................................

No. Nama Jenis Hub. Umur Pen- Status Imunisasi Ket.

Kel. Dg. didikan
BCG Polio DPT Hepatitis Campak
KK
1 2 3 4 1 2 3 1 2 3

1.

2.

3.

4.

5.

6.

7.

8.

9.

Genogram:

6. Tipe keluarga : ................................................................

7. Suku bangsa : ................................................................
Lampiran 3: Lembar Format Pengajian Asuhan Keperawatan Keluarga

8. Agama : ................................................................
9. Status sosial ekonomi keluarga

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10. Aktivitas rekreasi keluarga

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II. Riwayat dan tahap perkembangan keluarga

11. Tahap perkembangan keluarga saat ini :

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12. Tugas perkembangan keluarga yang belum terpenuhi

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13. Riwayat kesehatan keluarga inti

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14. Riwayat kesehatan keluarga sebelumnya

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III. Data lingkungan

15. a. Karakteristik rumah

b. Denah rumah

c. penggelolaan sampah :

d. Sumber air

e. Jamban Keluarga

f. Pembuangan air limbah

g. Fasilitas sosial dengan dan fasilitas kesehatan

Lampiran 3: Lembar Format Pengajian Asuhan Keperawatan Keluarga

16. Karakteristik tetangga dan komunitasnya

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17. Mobilitas geografis keluarga

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18. Perkumpulan keluarga dan interaksi dengan masyarakat

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19. Sistem pendukung keluarga

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IV. Struktur keluarga

20. Pola Komunikasi keluarga

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21. Struktur Kekuatan keluarga

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22. Struktur Peran

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23. Nilai dan norma keluarga

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Lampiran 3: Lembar Format Pengajian Asuhan Keperawatan Keluarga

V. Fungsi keluarga
24. Fungsi ekonomi

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25. Fungsi mendapatkan status sosial

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26. Fungsi pendidikan

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27. Fungsi pemenuhan (perawatan/pemeliharaan) kesehatan

a. Mengenal masalah kesehatan

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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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Lampiran 3: Lembar Format Pengajian Asuhan Keperawatan Keluarga

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e. Kemampuan menggunakan fasilitas pelayanan kesehatan

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28. Fungsi religius

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29. Fungsi rekreasi

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30. Fungsi reproduksi

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31. Fungsi afeksi

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VI. Stres dan koping keluarga

32. Stresor jangka pendek dan panjang
a. Stressor jangka pendek

b. Stressor jangka panjang

Lampiran 3: Lembar Format Pengajian Asuhan Keperawatan Keluarga

33. Kemampuan keluarga berespons terhadap stresor

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34. Strategi koping yang digunakan

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35. Strategi adaptasi disfungsional

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VII. Pemeriksaan kesehatan tiap individu anggota keluarga

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VIII. Harapan keluarga

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B. DIAGNOSIS KEPERAWATAN KELUARGA

I. Analisis dan sintesis data

No. Data Masalah Penyebab

1. Subjektif:

Objektif:
Lampiran 3: Lembar Format Pengajian Asuhan Keperawatan Keluarga

2. Subjektif:

Objektif:

3. Subjektif:

Objektif:

II. Perumusan diagnosis keperawatan

No. Diagnosis Keperawatan (PES)

1.

2.

3.

III. Penilaian (skoring) diagnosis keperawatan

No.
Diag.
Kep. Kriteria Skor Pembenaran

1. a. Sifat masalah: ×1=

3

b. Kemungkinan masalah
×2=
2
dapat diubah:

c. Potensial masalah untuk ×1=

3
dicegah:

×1=
d. Menonjolnya masalah: 2
Lampiran 3: Lembar Format Pengajian Asuhan Keperawatan Keluarga

Total skor

2.

3.

IV. Prioritas diagnosis keperawatan

Prioritas Diagnosis Keperawatan Skor

1.

2.

3.

C. RENCANA ASUHAN KEPERAWATAN KELUARGA

Diag. Keperawatan:

Tujuan Kriteria Hasil/standar Intervensi

D. IMPLEMENTASI

No.
Tanggal & Diag. Implementasi
Lampiran 3: Lembar Format Pengajian Asuhan Keperawatan Keluarga

waktu Kep.

1.

2.

E. EVALUASI

No.
Diag.
Tanggal &
waktu Kep. Evaluasi

1. S:

O:

A:

P:

2. S:

O:
A:
P:

Catatan:
Pada setiap tahap perlu dituliskan dengan jelas dan benar tentang tempat, tanggal,
nama perawat sebagai bukti identifikasi.