UNIVERSITAS AUFA ROYHAN

DI KOTA PADANGSIDIMPUAN
Berdasarkan SK Mendiknas RI No. 270/E/O/2011, 1 Desember 2011
Jl. Raja Inal Siregar Kel. Batunadua Julu, Kota Padangsidimpuan 22733. Telp.(0634) 7009557 Fax. (0634) 22684
e -mail: aufa.royhan@yahoo.com http//: stikes.aufa.ac.id

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KELUARGA

Format Pengkajian Asuhan Keperawatan Keluarga

Identitas Umum Keluarga

Identitas Kepala Keluarga:

Nama :
Umur :
Agama :
Suku :
Pendidikan :
Pekerjaan :
Alamat :

Komposisi Keluarga:

No Nama L/P Umur Hubungan Keluarga Pekerjaan Pendidikan

1
2
3
4
5
6
7
8
9
10

Genogran (buat 3 generasi)

Tipe Keluarga

1. Jenis tipe keluarga:...................................................................................................................................

2. Masalah yang terjadi dengan tipe keluarga tersebut:
..................................................................................................................................................................
..................................................................................................................................................................

Suku Bangsa

1. Asal suku bangsa:......................................................................................................................................

2. Budaya yang berhubungan dengan kesehatan:
..................................................................................................................................................................
..................................................................................................................................................................

Agama dan keperacayaan yang mempengaruhi kesehatan

..........................................................................................................................................................................

Status Sosial Ekonomi Keluarga:

1. Anggota keluarga yang mencari nafkah....................................................................................................

2. Penghasilan................................................................................................................................................
3. Upaya lain:.................................................................................................................................................
4. Harta benda yang dimiliki (perabot, transportasi, dll)...............................................................................
5. Kebutuhan yang dikeluarkan setiap bulan.................................................................................................

Aktivitas Rekreasi Keluarga:

...........................................................................................................................................................................
...........................................................................................................................................................................

Riwayat dan Tahap Perkembangan Keluarga

Tahap perkembangan keluarga saat ini (ditetukan dengan anak tertua):

...........................................................................................................................................................................
...........................................................................................................................................................................

Tahap perkembangan keluarga yang belum terpenuhi dan kendalanya:

...........................................................................................................................................................................
...........................................................................................................................................................................

Riwayat keehatan keluarga inti

1. Riwayat kesehatan keluarga saat ini:
.......................................................................................................................................................................
......................................................................................................................................................................

2. Riwayat penyakit keturrunan:

.......................................................................................................................................................................
.......................................................................................................................................................................
3. Riwayat Kesehatan Masing-Masing Anggota Keluarga:

N Nama Umur B Keadaan Imunisasi Masalah Kesehatan Tindakan yang telah

o B kesehatan dilakukan
4. Sumber pelayanan kesehatan yang dimanfaatkan:
.......................................................................................................................................................................
.......................................................................................................................................................................

5. Riwayat kesehatan keluarga sebelumnya:

.......................................................................................................................................................................
.......................................................................................................................................................................
Pengkajian Lingkungan

Karakteristik Rumah
1. Luas rumah:...................................................................................................................................................
2. Tipe rumah:...................................................................................................................................................
3. Kepemilikian:................................................................................................................................................
4. Jumlah kamar................................................................................................................................................
5. Ventilasi/jendela:...........................................................................................................................................
6. Pemanfaatan ruangan:...................................................................................................................................
7. Septi tank: ada/tidak ada:.................................................Letak:...................................................................
8. Sumber air minum:.......................................................................................................................................
9. Kamar mandi/wc:..........................................................................................................................................
10. Sampah:.........................................................Limbah RT:..........................................................................
11. Kebersihan Lingkungan:...............................................................................................................................

Karakteristik Teangga dan Komunitas RW

1. Kebiasaan:
.......................................................................................................................................................................
.......................................................................................................................................................................

2. Aturan/kesepakatan:
.......................................................................................................................................................................
.......................................................................................................................................................................

3. Budaya:
.......................................................................................................................................................................
.......................................................................................................................................................................

Mobilitas Geografis Kluarga:

..............................................................................................................................................................................
..............................................................................................................................................................................

Perkumpulan Keluarga dan Interaksi dengan Masyarakat

..............................................................................................................................................................................
..............................................................................................................................................................................

Sistem pendukung Keluarga

..............................................................................................................................................................................
..............................................................................................................................................................................
Struktur Keluarga
1. Pola/cara komunikasi keluarga
.......................................................................................................................................................................
.......................................................................................................................................................................

2. Truktur kekuatan keluarga

.......................................................................................................................................................................
.......................................................................................................................................................................

3. Struktur peran (peran masing-masing anggota keluarga)

.......................................................................................................................................................................
.......................................................................................................................................................................

4. Nilai dan norma Keluarga

.......................................................................................................................................................................
.......................................................................................................................................................................

Fungsi Keluarga

Fungsi Afektif:
..............................................................................................................................................................................
..............................................................................................................................................................................

Fungsi sosisalisasi

1. Kerukunan hidup dalam keluarga:

.......................................................................................................................................................................
.......................................................................................................................................................................

2. Interaksi dan hubungan dalam keluarga:

.......................................................................................................................................................................
.......................................................................................................................................................................

3. Anggota keluarga yang dominan dalam pengambilan keputusan:

.......................................................................................................................................................................
.......................................................................................................................................................................

4. Kegiatan keluarga waktu senggang

.......................................................................................................................................................................
.......................................................................................................................................................................

5. Partisipasi dalam kegiatan sosisal:

.......................................................................................................................................................................
.......................................................................................................................................................................

6. Fungsi perawatan kesehatan:

.......................................................................................................................................................................
.......................................................................................................................................................................

Fungsi Reproduksi

1. Perencanaan jumlah anak:...........................................................................................................................

2. Akseptor: Ya..................................... Yang digunakan:...................................Lainnya:.............................
3. Akseptor: Belum/tidak....................... Alasan:.............................................................................................
4. Keterangan lain:...........................................................................................................................................

Fungsi Ekonomi

1. Upaya pemenuhan sandang pangan:

.......................................................................................................................................................................
.......................................................................................................................................................................

2. Pemanfaatan sumber dimasyarakat:

.......................................................................................................................................................................
.......................................................................................................................................................................

Stres dan Koping Keluarga

1. Stresor jangka pendek:..................................................................................................................................

.......................................................................................................................................................................

2. Stresor jangka panjang:.................................................................................................................................

.......................................................................................................................................................................

3. Respon keluarga terhadap stresor.................................................................................................................

.......................................................................................................................................................................

4. Stratagi koping:.............................................................................................................................................
.......................................................................................................................................................................

5. Strategi adaptasi fungsional:.........................................................................................................................

.......................................................................................................................................................................

Keadaan Gizi Keluarga

1. Pemenuhan gizi:...........................................................................................................................................
.......................................................................................................................................................................

2. Uapaya Lain:................................................................................................................................................
......................................................................................................................................................................

Harapan keluarga

1. Terhadap masalah kesehatannya:

.......................................................................................................................................................................
.......................................................................................................................................................................

2. Terhadap petugas kesehatan yang ada:

.......................................................................................................................................................................
.......................................................................................................................................................................

Pemeriksaan Fisik

N Variabel Nama Anggota Keluarga

o
1 Riwayat penyakit saat ini
2 Keluhan yang dirasakan
3 Tanda dan gejala
4 Riwayat penyakit sebelumnya
 5 Tanda-tanda vital
6 Sistem cardiovaskuler
7 Sistem respirasi
8 Sistem pencernaan
9 Sistem persarafan
10 Sistem muskuloskeletal
11 Sistem genitalia

Pengkajian Khusus Berdasarkan 5 Tugas Keluarga

No Kriteria Pengkajian
1 Mengenal Masalah
2 Mengambil Keputusan yang tepat
3 Merawat anggota keluarga yang sakit atau punya masalah
4 Memodifikasi lingkungan
5 Memanfaatkan amsalah kesehatan

Skoring
No. Kriteria Nilai Bobot
1. Sifat Masalah : 1
Skala : 3
– Tidak/kurang sehat 2
– Ancaman Kesehatan 1
– Krisis
2. Kemungkinan masalah dapat diubah : 2
Skala : 2
– Dengan mudah 1
– Hanya sebagian 0
– Tidak dapat
3. Potensi masalah untuk dicegah : 1
Skala : 3
– Tinggi 2
– Cukup 1
– Rendah
4. Menonjolnya masalah : 1
Skala : 2
– Masalah berat, harus ditangani 1
– Masalah tidak perlu segera ditangani 0
– Masalah tidak dirasakan

Rencana Tindakan Keperawatan

No Diagnosa Keperawatan Tujuan Kriteria Hasil Intervensi
Implementasi
No No Diagnosa Hari/tangal/jam Implementasi Paraf
Keperawatan

Evaluasi
No No Diangosa Keperawatan Evaluasi Paraf