7/18/2019 Format Dokumentasi Asuhan Keperawatan Keluarga

FORMAT DOKUMENTASI ASUHAN KEPERAWATAN KELUARGA

ASUHAN KEPERAWATAN PADA KELUARGA Tn./Ny...DENGAN ...................................

Nama Mahasiswa :
NIM :
Tanggal Pengkajian :

I. PENGKAJIAN
A. Data Umum
1. Nama Kepala Keluarga : ...........................................................................................
2. Alamat kepala Keluarga : ...........................................................................................
3. Kmpsisi keluarga :
  !enis   "u#ungan
N. Nama   Umur   Pen$i$ikan Pekerjaan
Kelamin $engan KK

%engram :

Keterangan:

&. Tipe Keluarga : ...........................................................................................

'. (u$a)a
a. *uku :
#. (ahasa : ...........................................................................................
+. Agama : ...........................................................................................
,. *tatus ssial eknmi keluarga : ...........................................................................................
a. Pen$apatan keluarga satu #ulan : ...........................................................................................
#. Pengella keuangan keluarga : ...........................................................................................
-. (agaimana pan$angan keluarga terha$ap pen$i$ikan anggta keluarga
........................................................................................................................................................
$. A$akah nilaike)akinanagama )ang #ertentangan $engan kesehatan
........................................................................................................................................................
/. Akti0itas rekreasi keluarga
a. Ke#iasaan rekreasi $alam keluarga
........................................................................................................................................................
#. (agaimana keluargamenggunakan waktu senggangn)a
........................................................................................................................................................
(. iwa)at Perkem#angan
1. Tahap perkem#angan keluarga saat ini
..........................................................................................................................................................
2. Tahap perkem#angan keluarga )ang #elum terpenuhi
..........................................................................................................................................................
3. iwa)at keluarga inti
..........................................................................................................................................................
&. iwa)at keluarga se#elumn)a

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7/18/2019 Format Dokumentasi Asuhan Keperawatan Keluarga

..........................................................................................................................................................
. ingkungan
1. Karakteristik rumah
a. !enis rumah : ...........................................................................................
#. !enis #angunan : ...........................................................................................

-.
$. uas
uas #angunan
pekarangan :: ...........................................................................................
...........................................................................................
e. *tatus kepemilikan rumah : ...........................................................................................
4. Kn$isi 0entilasi rumah : ...........................................................................................
g. Kn$isi penerangan rumah : ...........................................................................................
h. Kn$isi pen-aha)aan rumah : ...........................................................................................
i. Kn$isi lantai : ...........................................................................................
 j. Ke#ersihan rumah se-ara keseluruhan :....................................................................................
k. (agaiman pem#agian ruangan5ruangan $i rumah :...................................................................
l. Pengellaan sampah keluarga :
m. *um#er air #ersih $alam keluarga :

n.
. Kn$isi
Pem#uangan jam#an keluarga
lim#ah :: ...........................................................................................
...........................................................................................
2. Karakteristik tetangga $an kmunitas 6
............................................................................................................................................................
3. M#ilisasi gegra4i keluarga
............................................................................................................................................................
&. Perkumpulan keluarga $an interaksi $engan mas)arakat
............................................................................................................................................................
'. *istem pen$ukung keluarga
7rmal :.......................................................................................................................................
In4rmal :.......................................................................................................................................
D. *truktur Keluarga
1. *truktur kmunikasi keluarga
............................................................................................................................................................
2. *truktur kekuatan keluarga
............................................................................................................................................................
3. *truktur peran
............................................................................................................................................................
&. *truktur nilai $an nrma #u$a)a
............................................................................................................................................................
8. 7ungsi Keluarga
1. 7ungsi a4ekti4
............................................................................................................................................................
............................................................................................................................................................
2. 7ungsi ssialisasi
............................................................................................................................................................
............................................................................................................................................................
3. 7ungsi perawatan kesehatan
a. Kemampuan keluarga mengenal masalah kesehatan
........................................................................................................................................................

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7/18/2019 Format Dokumentasi Asuhan Keperawatan Keluarga

#. Kemampuan keluarga mengam#il keputusan mengenai tin$akan kesehatan )ang tepat.

........................................................................................................................................................
-. Kemampuan keluarga merawat anggta keluarga )ang sakit
........................................................................................................................................................
$. Kemampuan keluarga mem$i4ikasi lingkungan

e. ........................................................................................................................................................
Kemampuan keluarga menggunakan 4asilitaspela)anan kesehatan $i mas)arakat.
........................................................................................................................................................
&. 7ungsi repr$uksi
............................................................................................................................................................
'. 7ungsi eknmi
............................................................................................................................................................
7. *tress $an kping keluarga
1. *tressr )ang $iha$api keluarga 9jangka pen$ek $an jangka panjang
............................................................................................................................................................
2. Kemampuan keluarga #erespn terha$ap situasi stressr

............................................................................................................................................................
3. *trategi kping )ang $igunakan
............................................................................................................................................................
&. *trategi a$aptasi $is4ungsinal
............................................................................................................................................................
%. Pemenuhan Ke#utuhan Dasar Manusia
1. Praktik $iet keluarga 9nutrisi $an -airan:............................................................................................
2. Pla ti$ur : ...........................................................................................................
3. ;lah ragam#ilisasi : ...........................................................................................................
&. Pla eliminasi : ...........................................................................................................
'. Persnal higiene : ...........................................................................................................
". Pengkajian Psikiatrik
1. Knsep $iri
a. %am#aran $iri : ...........................................................................................................
#. Peran $iri : ...........................................................................................................
-. I$eal $iri : ...........................................................................................................
$. I$entitas $iri : ...........................................................................................................
e. "arga $iri : ...........................................................................................................
2. *tatus kesehatan mental
............................................................................................................................................................
3. Pengkajian resik
............................................................................................................................................................
I. "arapan Keluarga
..................................................................................................................................................................
!. Pemeriksaan 7isik 9pen$ekatan hea$ t te
..................................................................................................................................................................

II. ANALISA DATA

No Tanggal Data Foku Maala! Et"olog"

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7/18/2019 Format Dokumentasi Asuhan Keperawatan Keluarga

Data su#)ekti4:
.....................................................

Data ;#)ekti4
.....................................................

umusan Masalah
1. ...
2. ...
3. ...

III. PRIORITAS DIAGNOSA KEPERAWATAN

S %
k o
No. K#"t$#"a   a  & Sko#"ng P$'&$na#an
l o
a  t
(.

).

*.
Urutan Priritas Diagnsa Keperawatan
1. ...
2. ...
3. ...

I+. REN,ANA ASUHAN KEPERAWATAN KELUARGA/INTER+ENSI

D"agnoa  Tuuan E0alua"
No. Int$#0$n"
K$-$#aatan U'u' K!uu K#"t$#"a Stan1a#
1.
2.
3.

+. IMPLEMENTASI ASUHAN KEPERAWATAN KELUARGA

No Tanggal I'-l$'$nta" E0alua" Fo#'at"2 Tt1

D"agnoa  /a'
Do3

D3

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7/18/2019 Format Dokumentasi Asuhan Keperawatan Keluarga

+I. E+ALUASI SUMATIF DAN REN,ANA TINDAK LANJUT

E+ALUASI SUMATIF
Tanggal D"agnoa K$-$#aatan E0alua" Su'at"2 Tt1
S 3
O 3
A 3
P 3

REN,ANA TINDAK LANJUT

Anggota  Maala! Int$#0$n" yang t$la! Pa#a 
RTL
KK K$$!atan 1"lakukan 2

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