Student’s Name :

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ASUHAN KEPERAWATAN KELUARGA

A.PENGKAJIAN

I.Data Umum

1. Kepala keluarga (KK) : ........................................................................

2. Alamat dan telpon : ........................................................................
3. Pekerjaan KK : ........................................................................
4. Pendidikan KK : ........................................................................
5. Komposisi keluarga : ......................................................................
Pendidikan Pekerjaan Ket./Suku
No Nama Umur Sex Hubungan
TS BS MS TT L

6. Tipe keluarga : .....................................................................

7. Suku bangsa : .....................................................................
8. Agama : .....................................................................
9. Status sosial ekonomi keluarga : .......................................................................

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10. Aktifitas rekreasi keluarga

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II.Riwayat dan tahap perkembangan keluarga

11.Tahap perkembangan keluarga saat ini

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12.Tugas perkembangan keluarga yang belum terpenuhi

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13.Riwayat kesehatan keluarga inti

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14.Riwayat kesehatan keluarga sebelumnya

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III.Data Lingkungan

15.Karakteristik rumah

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Denah rumah
 16.Karakteristik tetangga dan komunitasnya

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17.Mobilitas geografis keluarga

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18.Perkumpulan keluarga dan interaksi dengan masyarakat

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19.Sistem pendukung keluarga

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IV.Struktur keluarga

20.Stuktur peran

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21.Nilai atau norma

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22.Pola komunikasi

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23.Struktur kekuatan keluarga

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V.Fungsi keluarga

24.Fungsi ekonomi

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25.Fungsi mendapatkan status sosial

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26.Fungsi pendidikan

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27.Fungsi sosialisasi

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28.Fungsi pemenuhan (perawatan/pemeliharaan) kesehatan

a.Mengenal masalah kesehatan

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 b.Mengambil keputusan

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c.Kemampuan merawat anggota keluarga yang sakit

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d.Kemampuan keluarga memelihara/memodifikasi lingkungan rumah yang sehat

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e.Kemampuan keluarga menggunakan fasilitas kesehatan

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29.Fungsi religius

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30.Fungsi rekreasi

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 31.Fungsi afektif

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32.Fungsi reproduksi

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VI.Stres dan koping keluarga

33.Stresor jangka pendek dan panjang

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34.Kemampuan keluarga berespon terhadap stresor

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35.Strategi koping yang digunakan

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36.Strategi adaptasi disfungsional

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VII.Pemeriksaan kesehatan tiap anggota keluarga

Variabel Nama anggota keluarga

Keluhan

Riwayat
penyakit saat
ini

Tanda dan
gejala

Vital signs

Sis respirasi

Sis kardio-
vascular

Sis GI

Sis neurologi

Sis muskulo-
skeletal

Sis reproduksi

VIII.Harapan keluarga

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Tabel analisa data

No S & O Data Etiologi Masalah keperawatan

Tabel prioritas Masalah

Masalah 1

No Kriteria skor bobot pembenaran

1 Sifat masalah
- Tidak/kurang sehat 3
- Ancaman kesehatan 2 1
- Keadaan sejahtera 1
2 Kemungkinan masalah dapat diubah
- Mudah 2
- Sebagian 1 2
- Tidak dapat 0
3 Potensial masalah untuk dicegah
- Tinggi 3
- Cukup 2 1
- Rendah 1
4 Menonjolnya masalah
- Masalah berat harus segera ditangani 2 1
- Ada masalah tetapi tidak perlu ditangani 1
- Masalah tidak dirasakan 0
Jumlah skor

Masalah 2

No Kriteria skor bobot pembenaran

1 Sifat masalah
- Tidak/kurang sehat 3
- Ancaman kesehatan 2 1
- Keadaan sejahtera 1
2 Kemungkinan masalah dapat diubah
- Mudah 2
- Sebagian 1 2
- Tidak dapat 0
3 Potensial masalah untuk dicegah
- Tinggi 3
- Cukup 2 1
- Rendah 1
4 Menonjolnya masalah
- Masalah berat harus segera ditangani 2 1
- Ada masalah tetapi tidak perlu ditangani 1
- Masalah tidak dirasakan 0
Jumlah skor
Masalah 3

No Kriteria skor bobot pembenaran

1 Sifat masalah
- Tidak/kurang sehat 3
- Ancaman kesehatan 2 1
- Keadaan sejahtera 1
2 Kemungkinan masalah dapat diubah
- Mudah 2
- Sebagian 1 2
- Tidak dapat 0
3 Potensial masalah untuk dicegah
- Tinggi 3
- Cukup 2 1
- Rendah 1
4 Menonjolnya masalah
- Masalah berat harus segera ditangani 2 1
- Ada masalah tetapi tidak perlu ditangani 1
- Masalah tidak dirasakan 0
Jumlah skor

Masalah 4
No Kriteria skor bobot pembenaran
1 Sifat masalah
- Tidak/kurang sehat 3
- Ancaman kesehatan 2 1
- Keadaan sejahtera 1
2 Kemungkinan masalah dapat diubah
- Mudah 2
- Sebagian 1 2
- Tidak dapat 0
3 Potensial masalah untuk dicegah
- Tinggi 3
- Cukup 2 1
- Rendah 1
4 Menonjolnya masalah
- Masalah berat harus segera ditangani 2 1
- Ada masalah tetapi tidak perlu ditangani 1
- Masalah tidak dirasakan 0
Jumlah skor

B. Diagnosa Keperawatan
1.
2.
3.
4.
 Student’s Name :
____________________

C. Perencanaan

Diagnosa kep Tujuan kriteria evaluasi Rencana tindakan

Jangka panjang Jangka pendek kriteria standar
Diagnosa kep Tujuan kriteria evaluasi Rencana tindakan
Jangka panjang Jangka pendek kriteria standar
Diagnosa kep Tujuan kriteria evaluasi Rencana tindakan
Jangka panjang Jangka pendek kriteria standar
D. Tindakan keperawatan dan evaluasi

Diagnosa kep Tujuan jangka pendek Hari/tgl/jam Tindakan keperawatan Evaluasi Paraf keluarga
Diagnosa kep Tujuan jangka pendek Hari/tgl/jam Tindakan keperawatan Evaluasi Paraf keluarga
Diagnosa kep Tujuan jangka pendek Hari/tgl/jam Tindakan keperawatan Evaluasi Paraf keluarga
Diagnosa kep Tujuan jangka pendek Hari/tgl/jam Tindakan keperawatan Evaluasi Paraf keluarga

Dosen Mata Kuliah/Preceptor Kepala Keluarga

(………………………………) (………………………………)