1. Pengkajian
a. Catatan Status Kesehatan Keluarga
Puskesmas : ...............................................................
Nama Kepala Keluarga : ...............................................................
Usia : ...............................................................
Alamat : ..............................................................
Tanggal Pengkajian :................................................................
Jarak Ke Puskesmas :................................................................
Dicapai dengan : .......................................................
1) Daftar Anggota Keluarga
Nama
Hub. L/ Umur Pendi- Pekerja Imuni- Kead.Kes
No Anggota Agama KB
Keluarga P (Th) dikan an sasi ehatan
Keluarga
1 - -
2
3
4
5
2) Tipe Keluarga
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......................................................................................................................
3) Tahap Perkembangan Keluarga
.................................................................................................................................
......................................................................................................................
4) Tugas Keluarga yang Belum Terpenuhi
.................................................................................................................................
......................................................................................................................
5) Pengkajian Biologis
a) Keadaan Kesehatan
...........................................................................................................................
.................................................................................................................
b) Kebersihan Keluarga
...........................................................................................................................
...............................................................................................................
c) Penyakit yang Sering Diderita
...........................................................................................................................
................................................................................................................
d) Penyakit Kronis/Menular
...........................................................................................................................
................................................................................................................
c) Ventilasi
...........................................................................................................
d) Jamban
...................................................................................................................
e) Sumber Air Minum
...........................................................................................................
f) Pemanfaatan Halaman
...........................................................................................................
g) Pembuangan Air Kotor
...........................................................................................................
h) Pembuangan Sampah
...........................................................................................................
i) Sumber Pencemaran
...........................................................................................................
j) Type Rumah
...........................................................................................................
k) Status Kepemilikan
...........................................................................................................
b. Pengkajian Keluarga
No Data TN. Ny An
1 2 3 4 5 6 7
1 Keadaan umum:
- Penampilan
- BB
- TB
2 TTV
- Nadi
- Respirasi
- Suhu
3 Kepala:
- Bentuk
- Rambut
- Kulit Kepala
4 Mata:
- Sclera
- Kong-jungtiva
- Palpebra
- Fungsi
5 Telinga :
- Bentuk
- Keadaan
- Fungsi
6 Hidung
- Bentuk
- Keadaan
- Fungsi
7 Mulut:
- Gigi
- Fungsi Menelan
8 Leher
- Pening-katan
JVP
9 Dada:
- Bentuk
- Suara paru
- Respirasi
- Bunyi jantung
10 Abdomen:
- Bentuk
- Nyeri Tekan
11 Ekstremitas
- Oedema
- Kotrak-tur
- Gerakan
Integumen:
- Turgor
- Keadaan
- Kuku
b) Psikologis
..........................................................................................................
c) Sosial
(1) Hubungan Antar Keluarga
.....................................................................................................
(2) Hubungan dengan Orang Lain
...........................................................................................................
d) Spiritual
(1) Pelaksanaan Ibadah
.....................................................................................................
(2) Keyakinan tentang kesehatan
...................................................................................................
5) Pemeriksaan Fisik
a) Tanda-Tanda Vital
- Keadaan Umum : ..............................................
- Kesadaran : .............................................
- Tekanan darah : .............................................
- Nadi : .............................................
- Respirasi : ..............................................
- Suhu : ..........................................
- BB yang Lalu : .......Kg
- BB Sekarang : ....... Kg
- TB : ............ cm
b) Pemeriksaan Persistem
(1) Sistem Respirasi
.....................................................................................................
(2) Sistem Kardiovaskuler
....................................................................................................
(3) Sistem Pencernaan
....................................................................................................
(4) Sistem Urinaria
.....................................................................................................
(5) Sistem Persyarafan
.....................................................................................................
(6) Sistem Integumen
....................................................................................................
(7) Sistem Muskuloskeletal
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d. Genogram ( contoh )
Keterangan :
= Laki-laki
= Perempuan
= Meninggal
= Klien
= Hubungan keluarga
= Hubungan pernikahan
= Tinggal serumah
Dapur
B T
WC
Kamar
S
Kamar
Ruang Tamu
&
Ruang TV
Kamar
Keterangan:
= Pintu
= Jendela
g. Analisa Data
Masalah Kemungkinan
No Data
Keperawatan Penyebab
1 2 3 4
1 DS :
-
-
(2)
DO :
2 DS :
-
- .
DO :
-
-
3 DS : -
DO :
(3)
2) Masalah :......................................................................................
Rencana
No Tgl. Diagnosa Kep. Tujuan Rasional Implementasi Evaluasi Paraf
Perawatan
1 2 3 4 5 6 7 8 9
1 Tujuan
Umum :
Tujuan
Khusus: