SEKOLAH TINGGI ILMU KESEHATAN

AUFA ROYHAN
KOTA PADANGSIDIMPUAN
Berdasarkan SK Mendiknas RI No. 270/E/O/2011, 1 Desember 2011
Jl. Raja Inal Siregar Kel. Batunadua Julu, Kota Padangsidimpuan 22733. Telp.(0634) 7009557 Fax. (0634) 22684
e -mail: aufa.royhan@yahoo.com http//: stikes.aufa.ac.id

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KELUARGA

Format Pengkajian Asuhan Keperawatan Keluarga

Identitas Umum Keluarga

Identitas Kepala Keluarga:

Nama :
Umur :
Agama :
Suku :
Pendidikan :
Pekerjaan :
Alamat :

Komposisi Keluarga:

No Nama L/P Umur Hubungan Keluarga Pekerjaan Pendidikan

1
2
3
4
5
6
7
8
9
10

Genogran (buat 3 generasi)

Tipe Keluarga

1. Jenis tipe keluarga:...................................................................................................................................

2. Masalah yang terjadi dengan tipe keluarga tersebut:
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Suku Bangsa

1. Asal suku bangsa:......................................................................................................................................

2. Budaya yang berhubungan dengan kesehatan:
..................................................................................................................................................................
..................................................................................................................................................................

Agama dan keperacayaan yang mempengaruhi kesehatan

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

Status Sosial Ekonomi Keluarga:

1. Anggota keluarga yang mencari nafkah....................................................................................................

2. Penghasilan................................................................................................................................................
3. Upaya lain:.................................................................................................................................................
4. Harta benda yang dimiliki (perabot, transportasi, dll)...............................................................................
5. Kebutuhan yang dikeluarkan setiap bulan.................................................................................................

Aktivitas Rekreasi Keluarga:

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

Riwayat dan Tahap Perkembangan Keluarga

Tahap perkembangan keluarga saat ini (ditetukan dengan anak tertua):

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

Tahap perkembangan keluarga yang belum terpenuhi dan kendalanya:

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

Riwayat keehatan keluarga inti

1. Riwayat kesehatan keluarga saat ini:
.......................................................................................................................................................................
......................................................................................................................................................................

2. Riwayat penyakit keturrunan:

.......................................................................................................................................................................
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3. Riwayat Kesehatan Masing-Masing Anggota Keluarga:

N Nama Umur B Keadaan Imunisasi Masalah Kesehatan Tindakan yang telah

o B kesehatan dilakukan
4. Sumber pelayanan kesehatan yang dimanfaatkan:
.......................................................................................................................................................................
.......................................................................................................................................................................

5. Riwayat kesehatan keluarga sebelumnya:

.......................................................................................................................................................................
.......................................................................................................................................................................
Pengkajian Lingkungan

Karakteristik Rumah
1. Luas rumah:...................................................................................................................................................
2. Tipe rumah:...................................................................................................................................................
3. Kepemilikian:................................................................................................................................................
4. Jumlah kamar................................................................................................................................................
5. Ventilasi/jendela:...........................................................................................................................................
6. Pemanfaatan ruangan:...................................................................................................................................
7. Septi tank: ada/tidak ada:.................................................Letak:...................................................................
8. Sumber air minum:.......................................................................................................................................
9. Kamar mandi/wc:..........................................................................................................................................
10. Sampah:.........................................................Limbah RT:..........................................................................
11. Kebersihan Lingkungan:...............................................................................................................................

Karakteristik Teangga dan Komunitas RW

1. Kebiasaan:
.......................................................................................................................................................................
.......................................................................................................................................................................

2. Aturan/kesepakatan:
.......................................................................................................................................................................
.......................................................................................................................................................................

3. Budaya:
.......................................................................................................................................................................
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Mobilitas Geografis Kluarga:

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Perkumpulan Keluarga dan Interaksi dengan Masyarakat

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Sistem pendukung Keluarga

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Struktur Keluarga
1. Pola/cara komunikasi keluarga
.......................................................................................................................................................................
.......................................................................................................................................................................

2. Truktur kekuatan keluarga

.......................................................................................................................................................................
.......................................................................................................................................................................
3. Struktur peran (peran masing-masing anggota keluarga)
.......................................................................................................................................................................
.......................................................................................................................................................................

4. Nilai dan norma Keluarga

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

Fungsi Keluarga

Fungsi Afektif:
..............................................................................................................................................................................
..............................................................................................................................................................................

Fungsi sosisalisasi

1. Kerukunan hidup dalam keluarga:

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

2. Interaksi dan hubungan dalam keluarga:

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

3. Anggota keluarga yang dominan dalam pengambilan keputusan:

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

4. Kegiatan keluarga waktu senggang

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

5. Partisipasi dalam kegiatan sosisal:

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

6. Fungsi perawatan kesehatan:

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

Fungsi Reproduksi

1. Perencanaan jumlah anak:...........................................................................................................................

2. Akseptor: Ya..................................... Yang digunakan:...................................Lainnya:.............................
3. Akseptor: Belum/tidak....................... Alasan:.............................................................................................
4. Keterangan lain:...........................................................................................................................................

Fungsi Ekonomi

1. Upaya pemenuhan sandang pangan:

.......................................................................................................................................................................
.......................................................................................................................................................................
2. Pemanfaatan sumber dimasyarakat:
.......................................................................................................................................................................
.......................................................................................................................................................................

Stres dan Koping Keluarga

1. Stresor jangka pendek:..................................................................................................................................

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

2. Stresor jangka panjang:.................................................................................................................................

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

3. Respon keluarga terhadap stresor.................................................................................................................

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

4. Stratagi koping:.............................................................................................................................................
.......................................................................................................................................................................

5. Strategi adaptasi fungsional:.........................................................................................................................

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Keadaan Gizi Keluarga

1. Pemenuhan gizi:...........................................................................................................................................
.......................................................................................................................................................................

2. Uapaya Lain:................................................................................................................................................
......................................................................................................................................................................

Harapan keluarga

1. Terhadap masalah kesehatannya:

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

2. Terhadap petugas kesehatan yang ada:

.......................................................................................................................................................................
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Pemeriksaan Fisik

No Variabel Nama Anggota Keluarga

1 Riwayat penyakit saat ini

2 Keluhan yang dirasakan
3 Tanda dan gejala
4 Riwayat penyakit sebelumnya
5 Tanda-tanda vital
6 Sistem cardiovaskuler
7 Sistem respirasi
8 Sistem pencernaan
9 Sistem persarafan
10 Sistem muskuloskeletal
11 Sistem genitalia
Pengkajian Khusus Berdasarkan 5 Tugas Keluarga
No Kriteria Pengkajian
1 Mengenal Masalah
2 Mengambil Keputusan yang tepat
3 Merawat anggota keluarga yang sakit atau punya masalah
4 Memodifikasi lingkungan
5 Memanfaatkan amsalah kesehatan

Daftar Masalah
No Data Penyebab Masalah
1 Klien mengatakan kepalanya pusing Ketidakmampuan keluarga Nyeri
dan tampak klien meringis kesakitan mengenal masalah
Skala nyeri: 6, istri klien bertanya
tentang penyakit suaminya.

2 Ketika klien mengeluh sakit, istri klien Kurangnya informasi Ketidakmampuan

hanya menyuruh untuk istirahat, dan mengenai penyakit yang keluarga merawat
memberikan obat pengurang rasa sakit diderita oleh klien anggota keluarga yang
kepala yang dibeli dari warung sakit.

3 Istri klien mengatakan tidak pernah Akses fasilitas pelayanan Ketidakmampuan

membawa suami kepeleayanan kesehatan tidak bisa Keluarga
kesehatan disebabkan oleh jarak yang dijangkau memanfaatnkan
jauh, dan kurangnya kepercayaan pelayanan kesehatan
terhadap tenaga kesehatan, dan
membawa anggota keluarga ke
pengobatan kampung.

Diagnosa keperawatan Keluarga

1. Nyeri b/d Ketidakmampuan keluarga mengenal masalah

2. Ketidakmampuan keluarga merawat anggota keluarga yang sakit b/d Kurangnya informasi
mengenai penyakit yang diderita oleh klien
3. Ketidakmampuan Keluarga memanfaatnkan pelayanan kesehatanb/d Akses fasilitas
pelayanan kesehatan tidak bisa dijangkau

Skoring
No. Kriteria Nilai Bobot
1. Sifat Masalah : 1

Skala : 3

– Tidak/kurang sehat 2

– Ancaman Kesehatan 1

– Krisis
2. Kemungkinan masalah dapat diubah : 2

Skala : 2

– Dengan mudah 1
 – Hanya sebagian 0

– Tidak dapat
3. Potensi masalah untuk dicegah : 1

Skala : 3

– Tinggi 2

– Cukup 1

– Rendah
4. Menonjolnya masalah : 1

Skala : 2

– Masalah berat, harus ditangani 1

– Masalah tidak perlu segera ditangani 0

– Masalah tidak dirasakan

Rencana Tindakan Keperawatan

No Diagnosa Keperawatan Tujuan Kriteria Hasil Intervensi

Implementasi
No No Diagnosa Hari/tangal/jam Implementasi Paraf
Keperawatan

Evaluasi
No No Diangosa Keperawatan Evaluasi Paraf