ASUHAN KEPERAWATAN KELUARGA

PADA KELUARGA ................ DENGAN .......................................................

A. PENGKAJIAN
1. Data Umum
a. Kepala Keluarga (KK) : ..........................................................................
b. Alamat : ..........................................................................
c. Pekerjaan KK : ..........................................................................
d. Pendidikan KK : ..........................................................................
e. Komposisi Keluarga:
Status Imunisasi
Hubungan Umur Hepa Camp Ket
No Nama JK Pendidikan Polio BCG DPT
dengan KK (tahun) titis ak
1 2 3 4 1 2 3 1 2 3

Genogram:

Keterangan :
 : Laki – laki : Laki-laki meninggal
: Perempuan : Perempuan meninggal
: Pasien : Tinggal serumah

2. Tipe Keluarga : .....................................................................................

3. Suku Bangsa : .....................................................................................
4. Agama : .....................................................................................
5. Status Sosial Ekonomi :
a. Anggota keluarga yang mencari nafkah : ......................................................
b. Penghasilan : ..................................................................................................
c. Upaya lain : ...................................................................................................
d. Harta benda yang dimiliki (perabot, transportasi, dll):
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e. Kebutuhan yang dikeluarkan tiap bulan:
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6. Aktivitas Rekreasi Keluarga
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7. Riwayat dan Tahap Perkembangan Keluarga
a. Riwayat Perkembangan Keluarga Saat Ini
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b. Tugas Perkembangan Keluarga yang Belum Terpenuhi
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c. Riwayat Kesehatan Keluarga Inti
Anggota Riwayat Kesehatan Riwayat Kesehatan Saat Ini
Keluarga Dahulu
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d. Riwayat Kesehatan Keluarga Sebelumnya

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8. Data Lingkungan
a. Karakteristik Rumah:
a) Luas rumah : ...........................................................................................
b) Tipe rumah : ...........................................................................................
c) Kepemilikan : ...........................................................................................
d) Jumlah dan rasio ruangan :
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 e) Pemanfaatan
ruangan : ..................................................................
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f) Pembuangan
kotoran : ...................................................................
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g) Sumber air
minum : ....................................................................
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h)Pengelolaan sampah dilakukan dengan cara dikumpulkan dan dibuang
oleh petugas sampah ke TPS : .....................................................................
i) Lingkungan di dalam
rumah : .....................................................................
j) Lingkungan luar
rumah : ............................................................................
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Denah:
 b. Karakteristik Tetangga dan Komunitas
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c. Mobilitas Geografis Keluarga
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d. Perkumpulan Keluarga dan Interaksi dengan Masyarakat
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e. Sistem Pendukung Keluarga
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9. Struktur Keluarga
a. Struktur Peran
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b. Nilai atau Norma Keluarga
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c. Pola Komunikasi Keluarga
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 d. Struktur Kekuatan Keluarga
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10. Fungsi Keluarga
a. Fungsi Keluarga
Asah : ......................................................................................................................
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Asih : .......................................................................................................................
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Asuh : ......................................................................................................................
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b. Fungsi Ekonomi
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c. Fungsi Mendapatkan Status Sosial
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d. Fungsi Pendidikan
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e. Fungsi Sosialisasi
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f. Fungsi Pemenuhan (Perawatan/ Pemeliharaan Kesehatan)
1) Mengenal masalah
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2) Mengambil keputusan mengenai tindakan kesehatan

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3) Kemampuan Merawat Anggota Keluarga yang Sakit

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4) Kemampuan Keluarga Memelihara/Memodifikasi Lingkungan Rumah

yang Sehat
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5) Kemampuan Menggunakan Fasilitas Pelayanan yang Sehat
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f. Fungsi Religius
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g. Fungsi Rekreasi
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 h. Fungsi Reproduksi
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i. Fungsi Afeksi
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11. Stress dan Koping Keluarga
a. Stressor Jangka Pendek dan Panjang
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b. Kemampuan Keluarga Berespon terhadap Stressor
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c. Strategi Koping yang Digunakan
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d. Strategi Adaptasi Disfungsional
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12. Pemeriksaan Kesehatan Tiap Individu Anggota Keluarga
Pemeriksaa
Ayah Ibu Anak ke-1 Anak ke-2 Anak ke-3
n Fisik
Keluhan
Umum

Kepala

BB, TB, IMT

 TTV

Mata

Hidung

Telinga

Mulut

Leher &
Tenggorokan

Dada

Abdomen

Tangan

Kaki

Kulit dan
kuku
Keadaan
Umum
GDS
Kolesterol
Asam Urat
Lainnya
13. Harapan Keluarga
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 ANALISA DATA
Masalah Kesehatan
No. Data Subyektif Data Obyektif
Kode Diagnosis
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 SKORING PRIORITAS DIAGNOSA

Perhitungan : skor/angka tertinggi x bobot.

 PRIOROTAS DIAGNOSIS KEPERAWATAN
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DIAGNOSIS
KEPERAWATAN
Kode
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RENCANA KEPERAWATAN
RENCANA KEPERAWATAN
NOC
Hasil
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CATATAN PERKEMBANGAN
NIC
Kode Intervensi
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 HARI/ EVALUASI
NO. IMPLEMENTASI
TANGGAL/
DX
JAM Kode Implementasi
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