SISTEMATIKA PENULISAN ASKEP KELUARGA

PRODI NERS STIKes MERCUBAKTIJAYA PADANG

I. KONSEP DASAR KELUARGA

a. Pengertian Keluarga
b. Struktur Keluarga
c. Tipe Keluarga
d. Tahap dan Tugas Perkembangan Keluarga (Friedman, 2010)
e. Fungsi Keluarga
f. Tugas Kesehatan Keluarga

II. KONSEP DASAR PENYAKIT

a. Pengertian
b. Etiologi/ Predisposisi
c. Manifestasi Klinik
d. Patofisiologi
e. Patways Keperawatan
Jalan munculnya masalah keperawatan dikaitkan dengan patofisiologi penyakit
Dan temuan data focus (di buat dalam bentuk bagan)
f. Manifestasi Klinik
g. Pemeriksaan Penunjang (jika ada)
h. Komplikasi
i. Penatalaksanaan
j. Pengkajian Fokus ( Termasuk pemeriksaan penunjang )
k. Diagnosa Keperawatan
l. Intervensi (NOC-NIC)

III. TINJAUAN KASUS

a. Pengkajian
b. Diagnosa Keperawatan
c. Perencanaan
d. Implementasi
e. Evaluasi

I. DAFTAR PUSTAKA
a. Literatur minimal 5 buku relevan dan 5 jurnal relevan
b. Literatur terbitan maksimal 10 tahun terakhir
 FORMAT ASUHAN KEPERAWATAN PADA LANSIA DI KELUARGA

A. PENGKAJIAN
Hari/ Tanggal :
Jam :
I. Identitas Pasien
a. Nama kepala keluarga :
b. Umur kepala keluarga :
c. Alamat :
d. Pendidikan kepala keluarga :
e. Pekerjaan :
f. Komposisi keluarga

No. Nama Jenis Kelamin Hubungan Usia Pendidikan Pekerjaan Ket.

dengan KK
1.
2.
3.
Genogram :

g. Tipe keluarga :
h. Agama :
i. Suku :
j. Status sosial ekonomi keluarga :
II. Riwayat dan Tahapan Perkembangan Keluarga
1. Tahap perkembangan keluarga saat ini
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2. Tahap perkembangan keluarga yang belum terpenuhi
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3. Riwayat keluarga inti
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 4. Riwayat keluarga sebelumnya
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III. Lingkungan
1. Krakteristik rumah
→ Denah rumah
2. Karakteristik tetangga dan komunitas
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3. Mobilitas grafis keluarga
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4. Perkumpulan keluarga dan interaksi komunitas
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5. Sistem pendukung keluarga
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IV. Struktur keluarga
1. Struktur peran
a) Peran formal .......................................................................................................................
b) Peran informal ....................................................................................................................

2. Pola komunikasi
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3. Struktur kekuatan keluarga
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4. Nilai dan norma keluarga
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V. Fungsi Keluarga
1. Fungsi Afektif
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2. Fungsi sosialisasi
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3. Fungsi perawatan
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VI. Stres dan Koping Keluarga
1. Stresor yang dimiliki
a) Stresor jangka pendek..........................................................................................................
b) Stresor jangka panjang.........................................................................................................
2. Kemampuan keluarga berespon terhadap situasi/stresor
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3. Strategi koping yang digunakan
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4. Strategi adaptasi keluarga
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5. Harapan keluarga
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VII. Pemeriksaan Fisik
Tabel pemeriksaan fisik

Pemeriksaan Nama pasien (inisial)

Kepala
Leher
Telinga
 Mata
Mulut dan hidung
Dada dan paru-paru
Abdomen
Reproduksi
Eliminasi
Sistem Integumen
Sistem
muskuloskeletal
BB dan TB
Tanda- tanda vital
Pemeriksaan lain
Ekstremitas
Keluhan Utama

B. ANALISA DATA

No Data Diagnosa Keperawatan

1 DS :

DO :

2 DS :
 DO :

SKORING
Kriteria Bobot Total Pembenaran
Sifat masalah:
Defisit kesehatan (3)
Ancaman kesehatan
(2)
Faktor risiko (1)
Kemungkinan diubah:
Mudah (2)
Sebagian (1)
Tidak dapat (0)
Kemungkinan
dicegah:
Tinggi (3)
Cukup (2)
Rendah (1)
Menonjolnya masalah: .
Membutuhkan
perhatian segera (2)
Tidak membutuhkan
perhatian segera (1)
Tidak dirasakan
sebagai masalah atau
kondisi yang
membutuhkan
perubahan (0)
Total
C. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS

No Diagnosa Keperawatan Skor

1
2
3

D. PERENCANAAN

No Dx. Kep NOC NIC

1

3
E. PELAKSANAAN DAN EVALUASI
CATATAN PERKEMBANGAN
No Diagnosa Tanggal/Jam Implementasi Evaluasi Tanda
Keperawatan tangan
1 - Subyektif :
- Objektif :
- Analisis :
- Perencanaan :

2 -