FORMAT ASKEP KEPERAWATAN KELUARGA

A. Identitas Umum Keluarga

Identitas Kepala Keluarga:
Nama : Tn “J”
Umur :
Agama :
Suku : Jawa
Pendidikan : SD
Pekerjaan : Petani dan Pekerja Penambangan
Alamat :
No Tlpon :
Komposisi Keluarga :

No Nama L/P Umur Hub. Keluarga Pekerjaan Pendidikan

1 Tn “J” L Suami (Kepala Keluarga) bertani dan bekerja SD
sebagai penambang
pasir di sungai
progo.
2 Ny “S” P Istri Tn”J” Tidak Bekerja (Ibu
Rumah Tangga)
3 Sdr “W” Anak ketiga
4 Ny “D” P Ibu dari Ny”S”
5 Tn “H” L Ayah dari Ny “S”
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Genogram:
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Tipe Keluarga:
1. Jenis Tipe Keluarga:
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2. Masalah yang Terjadi dengan Tipe tersebut
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Suku Bangsa
1. Asal Suku bangsa:
Jawa
2. Budaya yang berhubungan dengan kesehatan
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Agama dan Kepercayaan yang mempengaruhi Kesehatan

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Status Sosial Ekonomi Keluarga

1. Anggota Keluarga yang mencari nafkah
Tn “J”
2. Penghasilan
Penghasilan keluarga tidak menentu ± Rp 500.000 – 700.000,- / bulan.
3. Upah Lain
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4. Harta Benda yang dimiliki
Rumah
5. Kebutuhan yang dikeluarkan
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Aktivitas Rekreasi Keluarga

Aktivitas rekreasi sesekali jalan-jalan ke pantai.

Riwayat dan Tahap perkembangan Keluarga

1. Tahap Perkembangan keluarga saat ini
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2. Tahap Perkembangan Keluarga yang belum terpenuhi kendalanya
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Riwayat Kesehatan Keluarga Inti

1. Riwayat Kesehatan keluarga saat ini
TBC
2. Riwayat penyakit keturunan
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3. Riwayat Kesehatan masing-masing anggota keluarga
Tindakan yg
Keadaan Masalah
No nama umur BB Imunisasi telah
Kesehatan Kes
dilakukan

4. Sumber pelayanan kesehatan yang dimanfaatkan

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5. Riwayat kesehatan keluarga sebelumnya
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Pengkajian Lingkungan
Karakteristik rumah
1. Luas Rumah
Luas rumah 8x7 m2
2. Tipe Rumah
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3. Kepemilikan
Sendiri
4. Jumlah dan rasio kamar/ruangan
1 ruang tamu, 1 ruang TV, 3 kamar terdapat dan ventilasi cukup
5. Ventilasi/Jendela
Keadaan ventilasi jarang di buka bila pagi hari
6. Pemanfaatan ruangan
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7. Septik tank: Septic tang kurang lebih 12 m Letak: Letak rumah yang berdekatan antara
rumah Tn “J” dengan tetangganya
8. Sumber air minum:
Air sumur yang sudah dimasak.

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9. Kamar mandi/ WC:
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10. Sampah:......................................... Limbah RT: ........................................................................
11. Kebersihan
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Karakteristik tetangga dan komunitas RW

1. Kebiasaan
Arisan RT, pengajian, dan lain-lain
2. Aturan/Kesepakatan
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3. Budaya:
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Mobilitas Geografis Keluarga

1. Perkumpulan keluarga dan interaksi dengan masyarakat
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2. Sistem penduduk keluarga
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Struktur Keluarga
1. Pola/cara komunikasi keluarga:
Berkomunikasi dengan menggunakan bahasa Jawa. Komunikasi dilakukan secara terbuka.
2. Struktur kekuatan keluarga:
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3. Struktur peran:
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4. Struktur Nilai dan norma keluarga
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Fungsi Keluarga
1. Fungsi Afektif:
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2. Fungsi Sosial:
a. Kerukunan hidup dalam keluarga
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b. Interaksi dan hubungan dalam keluarga
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c. Anggota keluarga yang dominan dalam pengambilan keputusan
Pengambilan keputusan dilakukan oleh Tn “J” sebagai kepala keluarga.
d. Kegiatan keluarga waktu senggang
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e. Partisipasi dalam kegiatan sosial
Gotong royong
f. Fungsi perawatan kesehatan
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Fungsi reproduksi
1. Perencanaan jumlah anak:
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2. Akseptor:.................................. yang di gunakan: ................... lamanya: ................................
3. Keterangan lain
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Fungsi Ekonomi
1. Upaya pemenuhan sandang pangan
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2. Pemanfaatan sumber di masyarakat
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Stres dan koping keluarga

1. Stressor jangka pendek
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2. Stressor jangka panjang
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3. Respon keluarga terhadap stressor
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4. Strategi koping:
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5. Strategi adaptasi disfungsional:
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Keadaan Gizi Keluarga

1. Pemenuhan gizi
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2. Upaya lain:
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Harapan Keluarga
1. Terhadap maslah kesehatannya
- Mencemaskan kebiasaan merokok oleh Tn “J” dan Tn “W” yang membuat rumah mereka bau
- Mencemaskan penyakit TBC yang dialaminya oleh Ny “S”, bila batuk-batuknya kambuh Ny
“S” mengatakan ingin segera sembuh dari penyakit TBC yang di alaminya
2. Terhadap petugas kesehatan yang ada
Berharap kedatangan petugas kesehatan dapat membantu Ny “S” dan dapat memberi
pengetahuan serta cara mengatasi masalahnya yaitu penyakit TBC yang dideritanya.

Pemeriksaan Fisik
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No Variabel Nama anggota Keluarga
Tn “J” Ny “S” Sdr “W” Tn “H”
1 Riwayat Penyakit saat ini TBC
2 Keluhan yang dirasakan Batuk, flu Batuk
kering
3 Tanda dan gejala
4 Riwayat penyakit sebelumnya TB Paru
5 Tanda-tanda vital
6 Sistem kardiovaskuler
7 Sistem respirasi
8 Sistem Saluran pencernaan
9 Sistem persarafan
10 Sistem muskulus skeletal
11 Sistem genetalia

Pengkajian Khusu Berdasarkan 5 Tugas Keluarga

No Kriteria Pengkajian
1 Mengenal masalah

2 Mengambil keputusan yang tepat

3 Merawat anggota keluarga yang sakit

atau punya maslah
4 Modifikasi lingkungan

5 Memanfaatkan sarana kesehatan

Daftar Masalah
No Data Problem Etiologi

Skoring
Kriteria Skor Pembenaran
Sifat Masalah
1. Kurang/tidak sehat
2. Ancaman
3. Sejahtera
Kemungkinan Masalah
dapat diubah
1. Mudah
5
2. Sebagian
3. Tidak dapat
Potensi Masalah dapat
dicegah
1. Tinggi
2. Cukup
3. Rendah
Menonjolnya maslah
1. Segera ditangani
2. Tak perlu segera ditangani
3. Tak dirasakan
Total

Kriteria Bobot Pembenaran

Sifat Masalah
1. Kurang/tidak sehat
2. Ancaman
3. Krisis
Kemungkinan Masalah
dapat diubah
1. Mudah
2. Sebagian
3. Tidak dapat
Potensi Masalah dapat
dicegah
1. Tinggi
2. Cukup
3. Rendah
Menonjolnya maslah
1. Segera ditangani
2. Tak perlu segera ditangani
3. Tak dirasakan
Total

Rencana Tindakan Keperawatan

No Diagnosis Keperawatan tujuan Kriteria Hasil Intervensi

Implementasi
6
 Tindakan
No Diagnosis Keperawatan Pukul Paraf
keperawatan

Evaluasi
No Diagnosis Keperawatan Evaluasi Paraf