FORMAT PENGKAJIAN

ASUHAN KEPERAWATAN KELUARGA

A. PENGKAJIAN (TANGGAL : ..................................)

I. Data Umum
1. Nama kepala keluarga : ......................................................................................................
2. Alamat dan telepon : ......................................................................................................
3. Pekerjaan KK : ......................................................................................................
4. Pendidikan KK : ......................................................................................................
5. Komposisi keluarga : ......................................................................................................

Hub Status imunisasi

Jenis
No. Nama kel – Umur Dik Ket
kel Polio DPT Hepatitis Campak
KK

Genogram :

1. Tipe keluarga : ......................................................................................................

2. Suku bangsa : ......................................................................................................
3. Agama : ......................................................................................................
4. Status sosial ekonomi : ......................................................................................................
5. Aktivitas rekreasi keluarga
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II. Riwayat Dan Tahap Perkembangan Keluarga
1. Tahap perkembangan keluarga saat ini
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2. Tugas perkembangan keluarga yang belum terpenuhi
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3. Riwayat kesehatan keluarga inti
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4. Riwayat kesehatan keluarga sebelumnya
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III. Data Lingkungan
1. Karakteristik rumah

Denah rumah

2. Karakteristik tetangga dan komunitasnya

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3. Mobilitas geografis keluarga
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4. Perkumpulan keluarga dan interaksi dengan masyarakat
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5. Sistem pendukung keluarga
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IV. Struktur Keluarga
1. Struktur peran
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2. Pola komunikasi keluarga
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3. Struktur kekuatan keluarga
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V. Fungsi Keluarga
1. Fungsi ekonomi
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2. Fungsi mendapatkan status sosial
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3. Fungsi pendidikan
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4. Fungsi sosialisasi
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5. Fungsi pemenuhan (perawatan/pemeliharaan) kesehatan
a. Mengenal masalah keluarga
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b. Mengambil keputusan mengenai tindakan kesehatan
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c. Kemampuan merawat anggota keluarga yang sakit
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d. Kemampuan keluarga memelihara/memodifikasi lingkungan rumah yang sehat
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e. Kemampuan menggunakan fasilitas pelayanan kesehatan
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6. Fungsi religius
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 7. Fungsi rekreasi
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8. Fungsi reproduksi
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9. Fungsi afeksi
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VI. Stress Dan Koping Keluarga

1. Stressor jangka pendek dan panjang
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2. Kemampuan keluarga berespon terhadap stressor
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3. Strategi koping yang digunakan
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4. Strategi adaptasi disfungsional
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VII. Pemeriksaan Kesehatan Tiap Individu Anggota Keluarga

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VIII. Harapan Keluarga
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Mahasiswa

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B. DIAGNOSIS KEPERAWATAN KELUARGA
I. Analisis Dan Sintesis Data
No. Data Masalah Penyebab
 II. Daftar Diagnosis Keperawatan Yang Muncul
No
Diagnosa Keperawatan (PES)
.

III. Penilaian (Skoring) Diagnosis Keperawatan

Dx. kep : ......................................................................................................................................
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No
Kriteria Skor Bobot Nilai Pembenaran
.
Sifat masalah
- Tidak/kurang sehat 3
1 1
- Ancaman kesehatan 2
- Keadaan sejahtera 1
Kemungkinan masalah dapat diubah
- Mudah 2
2 2
- Sebagian 1
- Tidak dapat 0
Potensial masalah untuk dicegah
- Tinggi 3
3 1
- Cukup 2
- Rendah 1
Menonjolnya masalah
- Masalah berat harus segera ditangani 2
4 1
- Ada masalah, tetapi tidak perlu segera ditangani 1
- Masalah tidak dirasakan 0
Total skor

Dx. kep : ......................................................................................................................................

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No
Kriteria Skor Bobot Nilai Pembenaran
.
Sifat masalah
- Tidak/kurang sehat 3
1 1
- Ancaman kesehatan 2
- Keadaan sejahtera 1
Kemungkinan masalah dapat diubah
- Mudah 2
2 2
- Sebagian 1
- Tidak dapat 0
Potensial masalah untuk dicegah
- Tinggi 3
3 1
- Cukup 2
- Rendah 1
4 Menonjolnya masalah 1
- Masalah berat harus segera ditangani 2
- Ada masalah, tetapi tidak perlu segera ditangani 1
- Masalah tidak dirasakan 0
Total skor
 Dx. kep : ......................................................................................................................................
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No
Kriteria Skor Bobot Nilai Pembenaran
.
Sifat masalah
- Tidak/kurang sehat 3
1 1
- Ancaman kesehatan 2
- Keadaan sejahtera 1
Kemungkinan masalah dapat diubah
- Mudah 2
2 2
- Sebagian 1
- Tidak dapat 0
Potensial masalah untuk dicegah
- Tinggi 3
3 1
- Cukup 2
- Rendah 1
Menonjolnya masalah
- Masalah berat harus segera ditangani 2
4 1
- Ada masalah, tetapi tidak perlu segera ditangani 1
- Masalah tidak dirasakan 0
Total skor

Dx. kep : ......................................................................................................................................

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No
Kriteria Skor Bobot Nilai Pembenaran
.
Sifat masalah
- Tidak/kurang sehat 3
1 1
- Ancaman kesehatan 2
- Keadaan sejahtera 1
Kemungkinan masalah dapat diubah
- Mudah 2
2 2
- Sebagian 1
- Tidak dapat 0
Potensial masalah untuk dicegah
- Tinggi 3
3 1
- Cukup 2
- Rendah 1
Menonjolnya masalah
- Masalah berat harus segera ditangani 2
4 1
- Ada masalah, tetapi tidak perlu segera ditangani 1
- Masalah tidak dirasakan 0
Total skor

IV. Prioritas Diagnosis Keperawatan

Prioritas Diagnosis Keperawatan Skor
 INTERVENSI KEPERAWATAN
No Diagnosa Tujuan
Kriteria Standar Intervensi Evaluasi
. Keperawatan Umum Khusus
 IMPLEMENTASI DAN EVALUASI
Tanggal No. DP Implementasi Evaluasi Paraf