ASUHAN KEPERAWATAN

PADA KELUARGA Tn. ....... PADA .......

KASUS .........................................................
RT 04 RW 12 Kel. MOJOSONGO
SURAKARTA

Oleh

RAHMAWANTO

NIM. P 27220018249

PROGRAM STUDI PROFESI NERS

POLTEKKES KEMENKES SURAKARTA

TAHUN 2018/2019
 ASUHAN KEPERAWATAN PADA KELUARGA Tn. ....... PADA .......
KASUS ..................... RT 04 RW 12 Kel. MOJOSONGO
SURAKARTA

Tanggal Pengkajian : ..................................................

Waktu : ..................................................
Metode : .................................................

A. Data Umum
1. Nama KK :
2. Umur KK :
3. Alamat :
4. Pekerjaan :
5. Pendidikan :
6. Penghasilan/bulan :
7. Susunan Anggota Keluarga

No Nama Umur Sex Pendidikan Pekerjaan Hubungan

(L/P)
1
2
3
4
5

8. Genogram
 9. Tipe Keluarga
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
10. Suku Bangsa
...........................................................................................................................................
...........................................................................................................................................
11. Agama
...........................................................................................................................................
...........................................................................................................................................
12. Status Sosial Ekonomi
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
13. Aktifitas Rekreasi Keluarga
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................

B. Riwayat Tahap Perkembangan Keluarga

1. Tahap Pekerkembangan Keluarga Saat Ini
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
2. Tahap Perkembangan Keluarga Yang Belum Terpenuhi
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
3. Riwayat Keluarga Inti
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
4. Riwayat Keluarga Sebelumnya
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 ..........................................................................................................................................
C. Lingkungan
1. Karakteristik Rumah
a. Rumah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
b. Ventilasi dan Penerangan
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
c. Persediaan Air Bersih
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
d. Pembuangan Sampah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
e. Pembuangan Air Limbah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
f. Jamban /WC
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
g. Lingkungan Rumah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
2. Karakteristik Tetangga dan Komunitas RT
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
 .........................................................................................................................................
3. Mobilitas Geografis Keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
4. Perkumpulan Keluarga dan Interaksi dengan Masyarakat
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
5. Sistem Pendukung Keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................

D. Struktur Keluarga
1. Pola Komunikasi Keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
2. Struktur Kekuatan Keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
3. Struktur Peran
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
4. Nilai dan Norma Keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................

E. Fungsi Keluarga
1. Fungsi Afektif
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
 .........................................................................................................................................
2. Fungsi Sosial
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
3. Fungsi Perawatan Keluarga
a. Kemampuan Keluarga Mengenal Masalah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
b. Kemampuan Keluarga Mengambil Keputusan Mengatasi Masalah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
c. Kemampuan Keluarga Merawat Anggota yang Sakit
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
d. Kemampuan Keluarga Memelihara Lingkungan yang Sehat
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
e. Kemampuan Keluarga Menggunakan Fasilitas Kesehatan
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
4. Fungsi Reproduksi
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
5. Fungsi Ekonomi
..........................................................................................................................................
..........................................................................................................................................
 ..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................

F. Stress dan Koping Keluarga

1. Stresor
a. Jangka Panjang
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
b. Jangka Pendek
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
2. Kemampuan Keluarga Merespon Terhadap Streseor
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
3. Strategi Koping yang Digunakan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
4. Strategi Adaptasi Fungsional
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................

G. Harapan Keluraga Terhadap Petugas Kesehatan

................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
...............................................................................................................................................
H. Pemerikasaan Fisik

KU

Kepala

Mulut

Leher

Telinga

Dada

Perut

Ekstrimitas
 I. ANALISA DATA
No Data Penunjang Masalah Etiologi
No Data Penunjang Masalah Etiologi
J. PRIORITAS MASALAH
................................................................................................................................................
................................................................................................................................................
..............................................................................................................................................
Kriteria Skore Pembenaran
(skala x bobot)
Sifat masalah (bobot 1)
Skala :
3 : Aktual
2 : Risiko
1 : Sejahtera
Kemungkinan masalah dapat di
ubah (bobot 2)
Skala
2 : Mudah
1 : Sebagian
0 : Tidak di dapat
Potensial masalah untuk di
cegah (bobot 1)
Skala
3 : Tinggi
2 : Cukup
1 : Rendah
Menonjolnya masalah (bobot 1)
Skala
2 : Berat segera ditangani
1 : Tidak perlu segera ditangani
0 : Tidak dirasakan
Total

................................................................................................................................................
................................................................................................................................................
...............................................................................................................................................
Kriteria Skore Skore Pembenaran
(skala x bobot
Sifat masalah (bobot 1)
Skala :
3 : Aktual
2 : Risiko
1 : Sejahtera
Kemungkinan masalah dapat
di ubah (bobot 2)
Skala
2 : Mudah
1 : Sebagian
0 : Tidak di dapat
Potensial masalah untuk di
cegah (bobot 1)
Skala
3 : Tinggi
2 : Cukup
1 : Rendah
Menonjolnya masalah (bobot
1)
Skala
2 : Berat segera ditangani
1 : Tidak perlu segera
ditangani
0 : Tidak dirasakan
 Total
PRIORITAS MASALAH
................................................................................................................................................
................................................................................................................................................
..............................................................................................................................................
Kriteria Skore Pembenaran
(skala x bobot)
Sifat masalah (bobot 1)
Skala :
3 : Aktual
2 : Risiko
1 : Sejahtera
Kemungkinan masalah dapat di
ubah (bobot 2)
Skala
2 : Mudah
1 : Sebagian
0 : Tidak di dapat
Potensial masalah untuk di
cegah (bobot 1)
Skala
3 : Tinggi
2 : Cukup
1 : Rendah
Menonjolnya masalah (bobot 1)
Skala
2 : Berat segera ditangani
1 : Tidak perlu segera ditangani
0 : Tidak dirasakan
Total

..................................................................................................................................................
..................................................................................................................................................
.................................................................................................................................................
Kriteria Skore Skore Pembenaran
(skala x bobot
Sifat masalah (bobot 1)
Skala :
3 : Aktual
2 : Risiko
1 : Sejahtera
Kemungkinan masalah dapat
di ubah (bobot 2)
Skala
2 : Mudah
1 : Sebagian
0 : Tidak di dapat
Potensial masalah untuk di
cegah (bobot 1)
Skala
3 : Tinggi
2 : Cukup
1 : Rendah
Menonjolnya masalah (bobot
1)
Skala
2 : Berat segera ditangani
1 : Tidak perlu segera
ditangani
0 : Tidak dirasakan
 Total
I. DIAGNOSA KEPERAWATAN (Sesuai Prioritasa )
No Diagnosa Keperawatan Skore
 PERENCANAAN

No Tujuan dan Kriteria Hasil Intervensi

DX
No Tujuan dan Kriteria Hasil Intervensi
DX
 CATATAN KEPERAWATAN

No Hari/ Jam Implementasi Respon Paraf

Dx Tgl
No Hari/ Jam Implementasi Respon Paraf
Dx Tgl
 EVALUASI

No
Hari/Tgl Evaluasi (SOAP) Paraf
DX
No Hari/Tgl Evaluasi (SOAP) Paraf
DX