FORMAT PENGKAJIAN

KEPERAWATAN KELUARGA
PROGRAM STUDI PROFESI NERS
FAKULTAS ILMU-ILMU KESEHATAN
UNIVERSITAS NUSA NIPA
INDONESIA
2022

A. PENGKAJIAN
Pengkajian dilakukan pada : hari/tanggal/tahun/jam :
Identitas Umum Keluarga
a. Identitas Kepala Keluarga
Nama kepala keluarga : ........................................................................................
Umur : ........................................................................................
Agama : ........................................................................................
Pendidikan : ........................................................................................
Pekerjaan : ........................................................................................
Suku / Bangsa : ........................................................................................
Alamat : ........................................................................................

b. Komposisi keluarga :
No. Nama L/P Umur Hubungan keluarga Pendidikan Pekerjaan

1.

2.

3.

4.

Asuhan Keperawatan Keluarga |1

 7

10

Genogram :

Keterangan :
: Laki-laki
: perempuan
X : meninggal
: memiliki hubungan keluarga
: tinggal serumah
: klien

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 c. Tipe Keluarga :
1). Jenis tipe keluarga :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................

2). Masalah yang terjadi dengan tipe tersebut :

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
..............................................................................................................
d. Suku Bangsa :
1). Asal suku bangsa :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................

2). Budaya yang berhubungan dengan kesehatan :

...............................................................................................................................
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...............................................................................................................................
...............................................................................................................
e. Agama dan Kepercayaan yang mempengaruhi Kesehatan :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................
f. Status social ekonomi keluarga :
1). Anggota keluarga yang mencari nafkah :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................

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 2). Penghasilan :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................
3). Upaya lain :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................

4). Harta benda yang dimiliki (perabot, transportasi,dll) :

...............................................................................................................................
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...............................................................................................................................
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5). Kebutuhan yang dikeluarkan tiap bulan :

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

g. Aktivitas Rekreasi Keluarga :

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...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
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 II. RIWAYAT DAN TAHAP PERKEMBANGAN KELUARGA
1. Tahap perkembangan keluarga saat ini (ditentukan dengan anak tertua) :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
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2. Tahap perkembangan keluarga yang belum terpenuhi dan kendalanya :
.........................................................................................................................................
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.........................................................................................................................................
.........................................................................................................................................
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3. Riwayat kesehatan keluarga inti :
1). Riwayat kesehatan keluarga saat ini
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
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2). Riwayat penyakit keturunan
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3). Riwayat kesehatan masing-masing anggota keluarga

Tindakan
Keadaan Imunisasi yang
No. Nama Umur BB Masalah kesehatan
kesehatan (BCG/polio/DPT/HB/campak) telah
dilakukan

1.

Asuhan Keperawatan Keluarga |5

2.

3.

4.

5.

4). Sumber pelayanan kesehatan yang dimanfaatkan

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
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............................................................................................................
4. Riwayat kesehatan keluarga sebelumnya :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
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Asuhan Keperawatan Keluarga |6

III. PENGKAJIAN LINGKUNGAN
1. Karakteristik rumah
a. Luas rumah : ................................................................................................................
.....................................................................................................................
b. Tipe rumah : ................................................................................................................
.....................................................................................................................
c. Kepemilikan : ..............................................................................................................
.....................................................................................................................
d. Jumlah dan ratio kamar/ruangan : ...............................................................................
.....................................................................................................................
e. Ventilasi/jendela : ........................................................................................................
.....................................................................................................................
f. Pemanfaatan ruangan : ...........................................................................................
.....................................................................................................................
g. Septic tank : ada/tidak, letak............................................................................
h. Sumber air minum : .....................................................................................................
.....................................................................................................................
i. Kamar mandi/WC : ...............................................................................................
.....................................................................................................................
j. Sampah : ................................................................................................................
.....................................................................................................................
k. Kebersihan lingkungan : ...............................................................................................
.....................................................................................................................
2. Karakteristik tetangga dan komunitas RW
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3. Mobilitas geografis keluarga
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.......................................................................................................

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 4. Perkumpulan keluarga dan interaksi dengan masyarakat
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5. Sistem pendukung keluarga
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........................................................................................................

6. Gambar Denah Rumah :

IV. STRUKTUR KELUARGA

1. Pola Komunikasi Keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
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 2. Struktur Kekuatan Keluarga
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3. Struktur Peran (peran masing-masing anggota keluarga)
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4. Nilai dan Norma Keluarga
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V. FUNGSI KELUARGA
1. Fungsi afektif
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2. Fungsi sosialisasi
a. Kerukunan hidup dalam keluarga
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b. Interaksi dan hubungan dalam keluarga
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 ................................................................................................................................................
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c. Anggota keluarga yang dominan dalam pengambilan keputusan
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d. Kegiatan keluarga waktu senggang
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e. Partisipasi dalam kegiatan social

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3. Fungsi perawatan kesehatan
a. Pengetahuan dan persepsi keluarga tentang penyakit/masalah kesehatan keluarganya
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................................................................................................................................................
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................................................................................................................................................
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b. Kemampuan keluarga mengambil keputusan tindakan kesehatan yang tepat
................................................................................................................................................
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................................................................................................................................................
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.........................................................................................................
c. Kemampuan keluarga merawat anggota keluarga yang sakit
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 ................................................................................................................................................
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d. Kemampuan keluarga memelihara lingkungan rumah yang sehat
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e. Kemampuan keluarga menggunakan fasilitas kesehatan di masyarakat
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4. Fungsi reproduksi
a. Perencanaan jumlah anak
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b. Akseptor KB
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5. Fungsi ekonomi
a. Upaya pemenuhan sandang pangan
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b. Pemanfaatan sumber di masyarakat
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Asuhan Keperawatan Keluarga | 11

VI. STRESS DAN KOPING KELUARGA
a. Stressor jangka pendek dan jangka panjang
1). Stresor jangka pendek
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2). Stresor jangka panjang
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b. Kemampuan keluarga berespon terhadap situasi atau stressor
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c. Strategi koping yang digunakan
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d. Strategi adaptasi disfungsional
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VII. RIWAYAT KESEHATAN KELUARGA

Riwayat kesehatan masing-masing anggota keluarga
1. Tn. ..............
a. Riwayat kesehatan saat ini :
....................................................................................................................................
....................................................................................................................................

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 ....................................................................................................................................
....................................................................................................................................
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b. Riwayat kesehatan sebelumnya :
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2. Ny. .............
a. Riwayat kesehatan saat ini :
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b. Riwayat kesehatan sebelumnya :
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3. An................
a. Riwayat kesehatan saat ini :
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b. Riwayat kesehatan sebelumnya :
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4. An. ..................
a. Riwayat kesehatan saat ini :

Asuhan Keperawatan Keluarga | 13

 ....................................................................................................................................
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b. Riwayat kesehatan sebelumnya :
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VIII. KEADAAN GIZI KELUARGA

Pemenuhan Gizi
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................................................................................................................................
Upaya Lain
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IX. PEMERIKSAAN FISIK KELUARGA

Pemeriksaan KK ......... ......... ......... ......... .........

Tanda-Tanda
Vital

Kepala :
Rambut
Kulit Kepala
Pina
Pemeriksaan KK ......... ......... ......... ......... .........

Canalis Telinga

Asuhan Keperawatan Keluarga | 14

Gendang Telinga

Sclera Mata

Konjungtiva

Hidung

Gigi

Gusi/ Lidah

Tonsil / pharing

Kel. Getah
Bening
Kel. Thyroid

Thorax :
Palpasi Paru
Auskultasi Paru

Perkusi Paru

Auskultasi
Jantung
Perkusi Jantung

Ictus Cordis

Abdomen :
Bentuk
Auskultasi

Perkusi

Kandung
Kemih
Perkusi Ginjal

Masa Abdomen

Nyeri Tekan

Ekstremitas:
Edema
Reflek Fisiologis

Capillary Refill

Asuhan Keperawatan Keluarga | 15

J. HARAPAN KELUARGA
1. Terhadap masalah kesehatan :……………………….......................................
.............................................................................................................................................
.............................................................................................................................................
...............................................................................................................
2. Terhadap petugas kesehatan yang ada : …………………….......................................
.............................................................................................................................................
.............................................................................................................................................
...............................................................................................................

Maumere, ………………………………….2022

Mengetahui,

Mengkaji, Clinical Teacher

(……………………………………) (………………………………………………..)

Asuhan Keperawatan Keluarga | 16

 B. KLASIFIKASI DATA :

Hari / Tanggal : …………………………….......................................................................

Nama Klien/ Usia : …………………………....... / ..................................................................
Diagnosa Medis : …………………………….......................................................................

Data Subyektif :
............................................................................................................................................................
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............................................................................................................................................................
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............................................................................................................................................................
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Data Obyektif :
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Asuhan Keperawatan Keluarga | 17

 C. ANALISA DATA :

Hari / Tanggal : ……………………………....................................................................

Nama Klien/ Usia : …………………………....... / .................................................................
Diagnosa Medis : …………………………….......................................................................
(minimal 3 diagnosa)
No Data Etiologi Problem

Asuhan Keperawatan Keluarga | 18

 FORMAT SKORING/PRIORITAS MASALAH
DIAGNOSA KEPERAWATAN KELUARGA

Masalah Keperawatan 1 : ………………………………………………………………..........

Kriteria Bobot Perhitungan Pembenaran

1. Sifat masalah
 Aktual: 3 ..../3 x 1 = ....
1
 Resiko tinggi: 2
 Potensial: 1

2. Kemungkinan
masalah dapat diubah ....../2 x 2 = ....
 Tinggi: 2 2
 Sedang: 1
 Rendah : 0

3. Potensial untuk
dicegah
 Mudah : 3 1 ...../3 x 1 = ....
 Cukup: 2
 Tidak dapat : 1

4. Menonjolnya masalah
 Masalah dirasakan
dan perlu
penanganan segera:
2
 Masalah dirasakan, 1 ...../2 x 1 =.....
tidak perlu
ditangani segera: 1
 Masalah tidak
dirasakan: 0

Skor

Asuhan Keperawatan Keluarga | 19

Masalah Keperawatan 2: …………………………………………………………............….

Kriteria Bobot Perhitungan Pembenaran

1. Sifat masalah
 Aktual: 3 ..../3 x 1 = ....
1
 Resiko tinggi: 2
 Potensial: 1

2. Kemungkinan masalah
dapat diubah ....../2 x 2 = ....
 Tinggi: 2 2
 Sedang: 1
 Rendah : 0

3. Potensial untuk
dicegah
 Mudah : 3 1 ...../3 x 1 = ....
 Cukup: 2
 Tidak dapat : 1

4. Menonjolnya masalah
 Masalah dirasakan
dan perlu
penanganan segera:
2
 Masalah dirasakan, 1 ...../2 x 1 =.....
tidak perlu
ditangani segera: 1
 Masalah tidak
dirasakan: 0

Skor

Asuhan Keperawatan Keluarga | 20

 D. DIAGNOSA KEPERAWATAN :

Hari / Tanggal : …………………………….......................................................................

PRIORITAS MASALAH KEPERAWATAN :

Berdasarkan rumusan prioritas diatas, maka dapat diketahui prioritas permasalahan keluarga
Tn./Ny……….............. adalah sebagai berikut ;

1. .................................................................................................................................

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

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

2. .................................................................................................................................

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

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

3. .................................................................................................................................

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

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

4. .................................................................................................................................

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

5. .................................................................................................................................

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Asuhan Keperawatan Keluarga | 21

 Contoh Format
SALIN di lembar bagian tengah
Double Folio Bergaris
F. RENCANA KEPERAWATAN
DEPARTEMEN KEPERAWATAN KELUARGA

NAMA KLIEN : .................................................... NAMA MAHASISWA : ..........................................................................................

NIRM : .................................................... PROGRAM : .........................................................................................
DIAGNOSA MEDIS : .................................................... INSITITUSI : .........................................................................................
LOKASI : ....................................................

TUJUAN EVALUASI IMPLEMENTASI EVALUASI PARAF

DIAGNOSA RENCANA KEPERAWATAN
No TGL JANGKA JANGKA Tgl / CI /
KEPERAWATAN
Kriteria Standar PELAKSANAAN Mhsswa
PANJANG PENDEK Jam CT
1 ....
Pemeriksaan DS : R/ .... S:
Penunjang: 2. ... O:
 Lab, Rontgen, Ct R/ .... A:
Scan, MRI, dsb. DO : Dst.. P:
 Obser-vasi
Monitoring  Pem-Fis

(Berdasarkan ONEC, yaitu :

 Observation (Observasi)
 Nursing (Tindakan Mandiri
Perawat)
 Education (Pendidikan
Kesehatan)
 Collaboration (Kolaborasi
Medis, Paramedis, dan
Keluarga)

Asuhan Keperawatan Keluarga |1