Format Keluarga
Format Keluarga
KEPERAWATAN KELUARGA
PROGRAM PENDIDIKAN PROFESI NERS
FAKULTAS ILMU-ILMU KESEHATAN
UNIVERSITAS NUSA NIPA
MAUMERE
2018
A. PENGKAJIAN
Pengkajian dilakukan pada : hari/tanggal/tahun/jam :
Identitas Umum Keluarga
a. Identitas Kepala Keluarga
Nama kepala keluarga : ........................................................................................
Umur : ........................................................................................
Agama : ........................................................................................
Pendidikan : ........................................................................................
Pekerjaan : ........................................................................................
Suku / Bangsa : ........................................................................................
Alamat : ........................................................................................
b. Komposisi keluarga :
No. Nama L/P Umur Hubungan keluarga Pendidikan Pekerjaan
1.
2.
3.
4.
10
Genogram :
Keterangan :
: Laki-laki
: perempuan
X : meninggal
: memiliki hubungan keluarga
: tinggal serumah
: klien
c. Tipe Keluarga :
1). Jenis tipe keluarga :
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2). Penghasilan :
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1.
2.
4.
5.
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4. Riwayat kesehatan keluarga sebelumnya :
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III.PENGKAJIAN LINGKUNGAN
1. Karakteristik rumah
V. FUNGSI KELUARGA
1. Fungsi afektif
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2. Fungsi sosialisasi
a. Kerukunan hidup dalam keluarga
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b. Interaksi dan hubungan dalam keluarga
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b. Akseptor KB
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5. Fungsi ekonomi
a. Upaya pemenuhan sandang pangan
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b. Pemanfaatan sumber di masyarakat
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Tanda-Tanda
Vital
Kepala :
Rambut
Kulit Kepala
Pina
Pemeriksaan KK ......... ......... ......... ......... .........
Gendang
Telinga
Sclera Mata
Konjungtiva
Hidung
Gigi
Gusi/ Lidah
Tonsil / pharing
Kel. Getah
Bening
Kel. Thyroid
Thorax :
Palpasi Paru
Auskultasi Paru
Perkusi Paru
Auskultasi
Jantung
Perkusi Jantung
Ictus Cordis
Abdomen :
Bentuk
Auskultasi
Perkusi
Kandung
Kemih
Perkusi Ginjal
Masa Abdomen
Nyeri Tekan
Ekstremitas:
Edema
Reflek
Fisiologis
Capillary Refill
Maumere, ………………………………….2018
Mengetahui,
(……………………………………) (………………………………………………..)
Data Subyektif :
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Data Obyektif :
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C. ANALISA DATA :
Hari / Tanggal : ……………………………....................................................................
Nama Klien/ Usia : …………………………....... / .................................................................
Diagnosa Medis : …………………………….......................................................................
(minimal 3 diagnosa)
No Data Etiologi Problem
2. Kemungkinan
masalah dapat diubah ....../2 x 2 = ....
Tinggi: 2
Sedang: 1
Rendah : 0
3. Potensial untuk
dicegah
Mudah : 3 ...../3 x 1 = ....
Cukup: 2
Tidak dapat : 1
4. Menonjolnya
masalah
Masalah dirasakan
dan perlu
penanganan
segera: 2
Masalah ..... x 1 =.....
dirasakan, tidak
perlu ditangani
segera: 1
Masalah tidak
dirasakan: 0
Skor
3. Kemungkinan
masalah dapat diubah ....../2 x 2 = ....
Tinggi: 2
Sedang: 1
Rendah : 0
4. Potensial untuk
dicegah
Mudah : 3 ...../3 x 1 = ....
Cukup: 2
Tidak dapat : 1
5. Menonjolnya
masalah
Masalah dirasakan
dan perlu
penanganan
segera: 2
Masalah ..... x 1 =.....
dirasakan, tidak
perlu ditangani
segera: 1
Masalah tidak
dirasakan: 0
Skor
D. DIAGNOSA KEPERAWATAN :
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