FORMAT PENGKAJIAN KEPERAWATAN KELUARGA

A. DATA DASAR KELUARGA

1. Nama Kepala keluarga : ............................................................................................................................
2. Umur :
3. Jenis kelamin : ............................................................................................................................
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat Rumah : ............................................................................................................................
8. Komposisi keluarga :
N Nama Umur JK Hub. dg
Agama Pendidikan Pekerjaan Imunisasi
o (inisial) (thn) (L/P) KK

9. Tipe keluarga : ............................................................................................................................

10. Genogram keluarga : 3 generasi

11. Suku bangsa : .......................................................................................................................

12. Bahasa yang digunakan : .......................................................................................................................

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 13. Praktik keagamaan keluarga : .......................................................................................................................
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14. Status sosial ekonomi
a. Pencari nafkah keluarga :
b. Pendapatan perbulan :
c. Pengeluaran perbulan : .......................................................................................................................
d. Barang-barang yang :
dimiliki keluarga .......................................................................................................................
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e. Tabungan keluarga :
f. Biaya kesehatan :
(asuransi kesehatan) .......................................................................................................................

B. TAHAP PERKEMBANGAN DAN RIWAYAT KELUARGA

15. Tahap perkembangan keluarga saat ini (dilihat dari anak tertua)
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16. Tahap perkembangan keluarga yang belum terpenuhi

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Kendala :
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17. Riwayat keluarga inti dan riwayat kesehatan

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N Nama Penyakit Keadaan 6 bln terakhir Pelayanan kesehatan yg

o (inisial) Keturunan Sehat Sakit digunakan

Masalah kesehatan keluarga yang menonjol saat ini:

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18. Riwayat keluarga asal kedua orangtua dan riwayat kesehatan

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C. PENGKAJIAN LINGKUNGAN
19. Karakteristik rumah
a. Kepemilikan rumah : [ ] Milik sendiri [ ] Menyewa [ ] Menumpang
b. Jenis bangunan : [ ] Permanen [ ] Semi Permanen [ ] Non Permanen
c. Jenis lantai : [ ] Keramik/ Semen [ ] Papan [ ] Tanah
d. Jumlah ruangan : .................... ruangan
[ ] Ruang tamu [ ] Ruang keluarga [ ] Dapur
[ ] Kamar tidur [ ] Kamar mandi/ toilet [ ] Lain-lain
e. Ventilasi ruangan : [ ] Ada, ≥ 20% dari luas lantai
[ ] Ada, ˂ 20% dari luas lantai
[ ] Tidak ada
f. Jendela rumah: [ ] Dibuka siang hari
[ ] Tertutup siang hari
g. Kondisi rumah : [ ] Bersih, tertata rapi dan cukup penerangan
[ ] Bersih, tertata rapi dan tidak cukup penerangan
[ ] Bersih, tidak tertata rapi dan cukup penerangan
[ ] Bersih, tidak tertata rapi dan tidak cukup penerangan
[ ] Tidak bersih dan cukup penerangan
[ ] Tidak bersih dan tidak cukup penerangan
h. Denah rumah :

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 20. Sarana air bersih
a. Sumber air bersih : [ ] Sumurgali/bor [ ] PDAM [ ] Sungai
[ ] Air isi ulang [ ] Beli [ ] Lain-lain
b. Jarak sumber air : [ ] ≥ 10 meter
dengan septiktank [ ] ˂ 10 meter
c. Keadaan fisik air : [ ] Berwarna [ ] Tidak berwarna
[ ] Berbau [ ] Tidak berbau
[ ] Berasa [ ] Tidak berasa
[ ] Bersih [ ] Tidak bersih
d. Tempatpenampungan air : [ ] Ada, kondisi terbuka, terdapat jentik nyamuk
[ ] Ada, kondisi terbuka, tidak terdapat jentik nyamuk
[ ] Ada, kondisi tertutup, terdapat jentik nyamuk
[ ] Ada, kondisi tertutup, tidak terdapat jentik nyamuk
[ ] Tidak ada

21. Air limbah dan Sampah keluarga

a. Tempat pebuangan limbah : [ ] Ada
[ ] Tidak ada
b. Tempat pembuanan sampah : [ ] Ada, kondisi terbuka
[ ] Ada, kondisi tertutup
[ ] Tidak ada
c. Pengelolaan sampah keluarga : [ ] Dibakar [ ] Ditimbun
[ ] Dibuang ke TPSA [ ] Lain-lain

22. Jamban/ WC keluarga

a. Jenis jambanyang digunakan : [ ] WC duduk [ ] WC jongkok
[ ] WC cemplung [ ] BAB/ BAK di sungai
b. Status jamban yang digunakan : [ ] Milik sendiri [ ] Milik umum
c. Kondisi jamban : [ ] Bersih [ ] Tidak bersih
d. Kebersihan jamban : [ ] Dibersihkan setiap hari
[ ] Dibersihkan satu kali seminggu
[ ] Lain-lain, sebutkan .......................................................................

23. Kandang ternak

a. Mempunyai kandang ternak : [ ] Ya [ ] Tidak
b. Jarak kandang ternak dg rumah: .......................................... meter
c. Kondisi kandang ternak : [ ] Bersih [ ] Kotor
[ ] Basah/ Lembab [ ] Kering

Jurusan Keperawatan Poltekkes Jambi

 24. Pekarangan rumah
a. Pemanfaatan pekarangan : ...........................................................................................................
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b. Kondisi pekarangan : [ ] Bersih dan tertata rapi
[ ] Bersih, tidak tertata rapi
[ ] Kotor

25. Karakteristik tetangga dan komunitas

a. Karakteristik fisik lingkungan : ...........................................................................................................
b. Tipe komunitas : [ ] Desa [ ] Kota
c. Tipe lingkungan : [ ] Perumahan [ ] Non perumahan
d. Kondisi jalan : [ ] Baik dan terpelihara [ ] Rusak, tidak terpelihara
e. Industri/ home industry : [ ] Ada [ ] Tidak ada
f. Fasilitas pelayanan kesehatan : [ ] Ada, ............... meter [ ] Tidak ada
g. Fasiltas pelayanan sosial : [ ] Ada, ............... meter [ ] Tidak ada
h. Fasilitas pendidikan : [ ] Ada, ............... meter [ ] Tidak ada
i. Faslitas rekreasi : [ ] Ada, ............... meter [ ] Tidak ada
j. Fasilitas/ tempat ibadah: [ ] Ada, ............... meter [ ] Tidak ada
k. Transportasi umum : [ ] Ada, ............... meter [ ] Tidak ada
l. Insidens kriminalitas : [ ] Ada, ............... kali [ ] Tidak ada
m. Lain-lain :
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26. Mobilitas geografis keluarga
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27. Transaksi keluarga dengan komunitas
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Jurusan Keperawatan Poltekkes Jambi

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D. STRUKTUR KELUARGA
28. Pola komunikasi keluarga: ..............................................................................................................................
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29. Struktur kekuasan keluarga:.............................................................................................................................
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30. Struktur peran keluarga:...................................................................................................................................
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31. Nilai keluarga:...................................................................................................................................................
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E. FUNGSI KELUARGA
32. Fungsi afektif:...................................................................................................................................................
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33. Fungsi reproduksi:............................................................................................................................................

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34. Fungsi sosialisasi : ..........................................................................................................................................

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35. Fungsi perawatan kesehatan

a. Persepsi dan keyakinan keluarga tentang kesehatan
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b. Praktik Diet (Nutrisi) Keluarga
1) Pengetahuan keluarga tentang nutrisi
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2) Frekwensi makan: ..............................................................................................................
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3) Jenis makanan sehari-hari
a) Lauk-pauk: ...................................................................................................................
b) Sayur-mayur: ...................................................................................................................
c) Buah-buahan:
d) Lain-lain: ...................................................................................................................
4) Makanan selingan: ..............................................................................................................

Jurusan Keperawatan Poltekkes Jambi

 5) Makanan pantangan: ..........................................................................................................
6) Cara mengelola makanan:...................................................................................................
7) Cara menyajikan makanan: ................................................................................................
8) Masalah dalam pemenuhan kebutuhan nutrisi keluarga:
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c. Kebiasaan tidur dan istirahat keluarga

1) Kebiasaan sebelum tidur keluarga: .....................................................................................................
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2) Jam berapa keluarga mulai tidur : ........................................................................................................
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3) Berapa lama tidur keluarga: .................................................................................................................
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4) Dimana keluarga tidur: .........................................................................................................................
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5) Kebiasaan istirahat (tidur) siang keluarga: ..........................................................................................
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6) Masalah dalam pemenuhan kubutuhan istirahat dan tidur: .................................................................
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d. Praktik aktifitas fisik dan rekreaasi

1) Pengetahuan keluarga tentang aktifitas fisik dan rekreasi: .................................................................
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2) Aktifitas fisik sehari-hari keluarga: .......................................................................................................

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3) Kebiasaan olahraga keluarga:
a) Jenis olahraga : ............................................................................................................................
b) Waktu : ............................................................................................................................
c) Lamanya : ............................................................................................................................
d) Tempat : ............................................................................................................................

e. Hygiene keluarga :
1) Eliminasi bab/ bak:
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2) Mandi:
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3) Mencuci rambut:
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4) Menggosok gigi:
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5) Mengganti pakaian:
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6) Memotong kuku:
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7) Masalah higiene keluarga: ..................................................................................................................
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f. Praktik merokok, minum alkohol, obat penenang, dan penggunaan narkoba

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g. Pelaksanaan lima tugas kesehatan keluarga

1) Kemampuan keluarga mengenal masalah kesehatan
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2) Kemampuan keluarga mengambil keputusan

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3) Kemampuan keluarga merawat anggota keluarga yang sakit

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4) Kemampuan keluarga memodifikasi lingkungan

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5) Kemampuan keluarga menggunakan fasilitas pelayanan kesehatan

Jurusan Keperawatan Poltekkes Jambi
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F. STRES, KOPING, DAN ADAPTASI KELUARGA

36. Stressor jangka panjang dan jangka pendek : ................................................................................................
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37. Strategi koping yang digunakan: .....................................................................................................................

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38. Adaptasi dan Harapan keluarga: .....................................................................................................................

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G. CATATAN TAMBAHAN
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Tanggal pengkajian : ............................................................................................................................

Nama Yang Melakukan Pengkajian : ............................................................................................................................
NIM : ............................................................................................................................
Tanda Tangan : ............................................................................................................................

PEMERIKSAAN FISIK ANGGOTA KELUARGA

Initial Nama:

NO ASPEK PENGKAJIAN HASIL PENGKAJIAN

1 Penampilan/ Keadaan
Umum

2 Kepala dan leher

3 Dada (Jantung dan

Paru)

4 Abdomen

Jurusan Keperawatan Poltekkes Jambi

 5 Punggung

6 Ekstremitas (Atas dan

Bawah)

7 Genetalia

ANALISIS DATA

NO DATA MASALAH KEPERAWATAN

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 DIAGNOSIS KEPERAWATAN

NO DIAGNOSIS KEPERAWATAN TANDA TANGAN

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 PRIORITAS MASALAH

Diagnosis keperawatan:
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Kriteria Skor Bobot Pembenaran

1. Ada/ tidaknya masalah 1
Skala: Defisit (aktual) 3 ........
Ancaman (risiko) 2
Krisisyang akan datang (kemungkinan) 1

2. Kondisi masalah untuk diubah 2

Skala:Mudah untuk diubah 2 ........
Sebagian mudah untuk diubah 1
Tidak dapat diubah 0

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 3. Potensial masalah untuk dicegah 1
Skala: Tinggi 3 ........
Sedang 2
Rendah 1

4. Menonjolnya masalah 1
Skala:Masalah butuh perhatian segera 2 .........
Masalah tidak butuh perhatian segera 1
Tidak dianggap sebagai masalah 0

Keterangan skoring:
1. Memutuskan skor untuk setiap kriteria.
2. Membagi skor dengan nilai tertinggi dan kali kan dengan bobot (skor/nilai tertinggi x bobot)
3. Jumlahkah nilai untuk semua kriteria. Nilai tertinggi adalah 5, setara dengan total bobot.

Jurusan Keperawatan Poltekkes Jambi

 PERENCANAAN KEPERAWATAN KELUARGA

Hari/ Tanggal : ...............................................

Inisial KK : ...............................................

Evaluasi
No Diagnosis Keperawatan Tujuan Umum Tujuan Khusus Rencana Tindakan
Kriteria Standar

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 IMPLEMENTASI DAN EVALUASI

Evaluasi TTD
No Diagnosis Keperawatan Implementasi
(SOAP) (nama)

Jurusan Keperawatan Poltekkes Jambi

Jurusan Keperawatan Poltekkes Jambi