FORMAT PENGKAJIAN

ASUHAN KEPERAWATAN KELUARGA
STIKES HANG TUAH SURABAYA

A. PENGKAJIAN (TANGGAL : ..................................)
I.
Data Umum
1. Nama kepala keluarga : ......................................................................................................
2. Alamat dan telepon
: ......................................................................................................
3. Pekerjaan KK
: ......................................................................................................
4. Pendidikan KK
: ......................................................................................................
5. Komposisi keluarga
: ......................................................................................................
No.

Jenis
Nama
kel

Hub
kel –
KK

Status imunisasi
Umur

Dik

Polio

DPT

Hepatitis

Campak

Ket

Genogram :

1.
2.
3.
4.
5.

Tipe keluarga
: ......................................................................................................
Suku bangsa
: ......................................................................................................
Agama
: ......................................................................................................
Status sosial ekonomi : ......................................................................................................
Aktivitas rekreasi keluarga

II.

III.

.............................................................................................................................................
.............................................................................................................................................
Riwayat Dan Tahap Perkembangan Keluarga
1.
Tahap perkembangan keluarga saat ini
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2.
Tugas perkembangan keluarga yang belum terpenuhi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3.
Riwayat kesehatan keluarga inti
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4.
Riwayat kesehatan keluarga sebelumnya
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Data Lingkungan
1.
Karakteristik rumah

Denah rumah

2.
Karakteristik tetangga dan komunitasnya
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3.
Mobilitas geografis keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4.
Perkumpulan keluarga dan interaksi dengan masyarakat
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
5.
Sistem pendukung keluarga

................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
IV. Struktur Keluarga
1.
Struktur peran
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2.
Pola komunikasi keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3.
Struktur kekuatan keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
V.

Fungsi Keluarga
1.
Fungsi ekonomi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2.
Fungsi mendapatkan status sosial
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3.
Fungsi pendidikan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4.
Fungsi sosialisasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
5.
Fungsi pemenuhan (perawatan/pemeliharaan) kesehatan
a. Mengenal masalah keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
b. Mengambil keputusan mengenai tindakan kesehatan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
c. Kemampuan merawat anggota keluarga yang sakit
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
d. Kemampuan keluarga memelihara/memodifikasi lingkungan rumah yang sehat
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
e. Kemampuan menggunakan fasilitas pelayanan kesehatan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
6.
Fungsi religius
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

7.
Fungsi rekreasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
8.
Fungsi reproduksi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
9.
Fungsi afeksi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
VI. Stress Dan Koping Keluarga
1.
Stressor jangka pendek dan panjang
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2.
Kemampuan keluarga berespon terhadap stressor
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3.
Strategi koping yang digunakan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4.
Strategi adaptasi disfungsional
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
VII. Pemeriksaan Kesehatan Tiap Individu Anggota Keluarga
......................................................................................................................................................
......................................................................................................................................................
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VIII. Harapan Keluarga
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

Surabaya, .....................
Mahasiswa

(...............................)

B. DIAGNOSIS KEPERAWATAN KELUARGA
I.
Analisis Dan Sintesis Data
No.

Data

Masalah

Penyebab

III.
No.

Daftar Diagnosis Keperawatan Yang Muncul
Diagnosa Keperawatan (PES)

IV. Penilaian (Skoring) Diagnosis Keperawatan
Dx. kep : ......................................................................................................................................
.......................................................................................................................................
No.
1

2

3

4

Kriteria
Sifat masalah
- Tidak/kurang sehat
- Ancaman kesehatan
- Keadaan sejahtera
Kemungkinan masalah dapat diubah
- Mudah
- Sebagian
- Tidak dapat
Potensial masalah untuk dicegah
- Tinggi
- Cukup
- Rendah
Menonjolnya masalah
- Masalah berat harus segera ditangani
- Ada masalah, tetapi tidak perlu segera ditangani
- Masalah tidak dirasakan
Total skor

Skor Bobot Nilai
3
2
1
2
1
0
3
2
1
2
1
0

Pembenaran

1

2

1

1

Dx. kep : ......................................................................................................................................
.......................................................................................................................................
No.
1

2

3

4

Kriteria
Skor Bobot Nilai
Sifat masalah
- Tidak/kurang sehat
3
1
- Ancaman kesehatan
2
- Keadaan sejahtera
1
Kemungkinan masalah dapat diubah
- Mudah
2
2
- Sebagian
1
- Tidak dapat
0
Potensial masalah untuk dicegah
- Tinggi
3
1
- Cukup
2
- Rendah
1
Menonjolnya masalah
- Masalah berat harus segera ditangani
2
1
1
- Ada masalah, tetapi tidak perlu segera ditangani
0
- Masalah tidak dirasakan
Total skor

Pembenaran

Dx. kep : ......................................................................................................................................
.......................................................................................................................................
No.
1

2

3

4

Kriteria
Sifat masalah
- Tidak/kurang sehat
- Ancaman kesehatan
- Keadaan sejahtera
Kemungkinan masalah dapat diubah
- Mudah
- Sebagian
- Tidak dapat
Potensial masalah untuk dicegah
- Tinggi
- Cukup
- Rendah
Menonjolnya masalah
- Masalah berat harus segera ditangani
- Ada masalah, tetapi tidak perlu segera ditangani
- Masalah tidak dirasakan
Total skor

Skor Bobot Nilai
3
2
1
2
1
0
3
2
1
2
1
0

Pembenaran

1

2

1

1

Dx. kep : ......................................................................................................................................
.......................................................................................................................................
No.
1

2

3

4

Kriteria
Skor Bobot Nilai
Sifat masalah
- Tidak/kurang sehat
3
1
- Ancaman kesehatan
2
- Keadaan sejahtera
1
Kemungkinan masalah dapat diubah
- Mudah
2
2
- Sebagian
1
- Tidak dapat
0
Potensial masalah untuk dicegah
- Tinggi
3
1
- Cukup
2
- Rendah
1
Menonjolnya masalah
- Masalah berat harus segera ditangani
2
1
1
- Ada masalah, tetapi tidak perlu segera ditangani
0
- Masalah tidak dirasakan
Total skor
V. Prioritas Diagnosis Keperawatan
Prioritas
Diagnosis Keperawatan

Pembenaran

Skor

INTERVENSI KEPERAWATAN
No.

Diagnosa
Keperawatan

Tujuan
Umum

Khusus

Kriteria

Standar

Intervensi

Evaluasi

Tanggal

No. DP

IMPLEMENTASI DAN EVALUASI
Implementasi

Evaluasi

Paraf

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