FORMAT PENGKAJIAN KELUARGA

A. Data umum

1. Nama KK :……………………………………
2. Umur KK : ……………………………………
3. Alamat : ……………………………………
4. No. Telephon : ……………………………………
5. Pekerjaan : ……………………………………
6. Pendidikan: ……………………………………
7. Susunan Anggota Keluarga :

Sex Tgl Lahir Gol

No Nama Pendidikan Pekerjaan Hubungan
(L/P) (umur) Darah

Genogram ( dibuat 3 generasi )

8. Tipe Keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
................

9. Latar belakang kebudayaan (etnik)

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

10. Identifikasi religius

..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
........................
11. Status kelas sosial
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
........................
12. Mobilitas kelas sosial
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
........................
B. Riwayat Keluarga dan Tahap Perkembangan

13. Tahap perkembangan keluarga saat ini

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

14. Tahap perkembangan keluarga yang belum terpenuhi

..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
........................
 15. Riwayat keluarga inti
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
........................

16. Riwayat keluarga asal

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

C. Data Lingkungan

17. Karakteristik rumah

Denah rumah

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

18. Karakteristik lingkungan tempat tinggal dan masyarakat

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

19. Mobilitas geografis keluarga

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

20. Hubungan sosial keluarga dengan masyarakat

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

D. Struktur Keluarga

21. Pola dan Komunikasi Keluarga

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

22. Struktur Kekuatan

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

23. Struktur Peran

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

24. Nilai-Nilai Keluarga

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

E. Fungsi Keluarga

25. Fungsi Afektif

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

26. Fungsi Sosialisasi

..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
............................
27. Fungsi Perawatan Kesehatan

a. Kemampuan keluarga mengenal masalah

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

b. Kemampuan keluarga mengambil keputusan mengenai tindakan yang tepat

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

c. Kemampuan keluarga merawat anggota keluarga yang sakit

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

d. Kemampuan keluarga memelihara lingkungan rumah yang sehat

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

e. Kemampuan keluarga menggunakan fasilitas/pelayanan kesehatan yang ada di

masyarakat
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
........................

28. Terapi Komplementer dan Alternatif

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

29. Sumber Pembiayaan

..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
........................
F. Stress dan Koping Keluarga

30. Stressor jangka pendek

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

31. Stressor jangka panjang

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

32. Strategi koping keluarga

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

33. Adaptasi keluarga

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

G. Pemeriksaan Fisik

N Jenis pemeriksaan ayah ibu Anak 1 Anak 2 Anak 3

o
1. TTV :
Tensi :
Suhu :
Nadi :
Nafas :

2. Kulit, rambut dan

kuku.
I :
 P:
P:
A:
3. Kepala, leher
I :
P:
P:
A:
4. Thoraks dan paru
I :
P:
P:
A:
3. Abdomen
I :
P:
P:
A:
4. Genitalia
I :
P:
P:
A:
5. Ekstremitas atas +
refleks fisiologis
I :
P:
P:
A:
6. Ekstremitas bawah +
refleks fisiologis
I :
P:
P:
A:

Tempat, Tanggal

Nama jelas dan TTD

Lampiran 2

Penulisan Askep Keluarga Binaan

a. Data Fokus

Data Subjektif Data Objektif

b. Skoring

No Kriteria Bobot Perhitungan Pembenaran

1 Sifat Masalah Masalah yang sedang
Skala : 1 Skor/angka terjadi, menunjukkan
Potensial (skor 1) tertinggi X tanda dan gejala, atau
Risiko (skor 2) bobot dalam kondisi sehat
Aktual (skor 3)
2 Kemungkinan  Pengetahuan
masalah untuk 2 Skor/angka yang ada sekarag,
dirubah : tertinggi X teknologi, dan
Skala: bobot tindakan untuk
mudah =2 menangani
sebagian =1 masalah
tidak dapat = 0  Sumber daya
keluarga dalam
bentuk fisik,
keuangan dan
tenaga
 Sumber daya
perawat dalam
bentuk
pengetahuan,
keterampilan dan
waktu
 Sumber daya
masyarakat
dalam bentuk
fasilitas,
organisasi dalam
masyarakat dan
sokongan
masyarakat
3 Potensial masalah  Kepelikan dari
untuk di cegah 1 Skor/angka masalah, yang
Skala: tertinggi X berhubungan
 Tinggi =3 bobot dengan penyakit
Cukup =2 atau masalah
Rendah =1  Lamanya
masalah, yang
berhubungan
dengan penyakit
atau masalah
 Tindakan yang
sdang dijalankan
adalah tindakan-
tindakan yang
tepat dalam
memperbaiki
masalah
 Adanya
kelompok high
risk atau
kelompok yang
sangat peka
menambah
potensi untuk
mencegah
masalah
4 Menonjolnya Persepsi keluarga
masalah: 1 Skor/angka melihat masalah
Skala : tertinggi X
Segera ditangani = bobot
2
Mslh ada tapi tdk
perlu segera
ditangani = 1
Masalah tidak
dirasakan = 0

c. Diagnosa keperawatan setelah dilakukan prioritas

d. Intervensi Keperawatan (contoh)

No Diagnosa NOC NIC

1 Ketidakefektifan Keluarga mampu Pendidikan kesehatan :
pemeliharaan…. mengenal masalah pengajaran proses
kesehatan tentang HT penyakit (5510)
Pengetahuan : a. Kaji tingkat
manajemen HT pengetahuan pasien
a. ……………. terkait proses penyakit
b. …………….. b. …..
Pengetahuan Anjuran
diet (1802) Pengajaran proses
a. ……………. penyakit (5602)
 b. ……………… a. ……
Pengetahuan : regimen b. ….
pengobatan (1813: Pengajaran : diet yang
a. …… tepat/dianjurkan
b. ……….
Keluarga mampu Dukungan membuat
memutuskan untuk keputusan
merawat, meningkatkan Dukungan emosional
atau memperbaiki Dukungan caregiver
kesehatan Membangun harapan
Berpartisipasi dalam
memutuskan
perawatan kesehatan
Kesiapan caregiver
dalam perawatan
rumah
Keluarga mampu Manajemen nutrisi yang
merawat anggota tepat
keluarga untuk Konseling nutrisi
memperbaiki kesehatan Tambahkan terapi
Perilaku kepatuhan : komplementer/modalitas
menyiapkan diet
Dst…. Sesuaikan dengan
kondisi kasus
Keluarga mampu Pencegahan jatuh
memodifikasi Manajemen lingkungan :
lingkungan : control rumah yang aman
resiko dan keamanan Manajemen lingkungan
Deteksi risiko
Pengetahuan
pencegahan jatuh
Perilaku pencegahan
jatuh
Keluarga mampu Panduan pelayanan
memanfaatkan fasilitas kesehatan
kesehatan Mengunjungi fasilitas
Pengetahuan tentang kesehatan
sumber kesehatan Bantuan system kesehatan
Perilaku mencari
pelayanan kesehatan
Partisipasi keluarga
dalam perawatan
keluarga

e. Implementasi dan Evaluasi

No Diagnosa Implementasi Evaluasi Nama

dan TTD
1 Ketidakefektifan Hari/Tanggal… S
… Pukul ….. O
TUK 1 : A
1. Melakukan…. P
2. Dst….
Hari/Tanggal… S
Pukul ….. O
TUK 2 : A
1. Melakukan…. P
Dst….
Dst (sampai dengan
TUK 5)
 FORMAT PENULISAN
LAPORAN PENDAHULUAN

Kunjungan ke : …………..

A. Latar Belakang
B. Proses Keperawatan
1. Diagnosa keperawatan
2. Tujuan umum
3. Tujuan khusus
C. Implementasi Tindakan Keperawatan
1. Metode
2. Media dan alat
3. Waktu dan tempat
D. Kriteria Evaluasi
1. Kriteria Struktur
2. Kriteria Proses
3. Kriteria hasil