, SST.

MPH
 LAMPIRAN

Lampiran 1 Pengkajian Keperawatan Keluarga

1. Data Umum
Jenis Hubungan Um
No Nama Pekerjaan Pendidikan
Kelamin dg KK ur
1.
2.
3.
4.
5.

Genogram :
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------

Tipe Keluarga :
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

2
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------

Latar Belakang Budaya (Etnis)

-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
Identifikasi Religius
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
Status Ekonomi
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
Aktivitas rekreasi atau waktu luang
-------------------------------------------------------------------------------------------

3
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

Riwayat Dan Tahap Perkembangan Keluarga

-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

2. Data Lingkungan

Karakteristik Rumah
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

4
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

Karakteristik lingkungan dan komunitas tempat tinggal yang lebih

luas.
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

Mobilitas Geografis Keluarga

-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

5
Hubungan Keluarga dengan Fasilitas-Fasilitas Kesehatan dalam
Komunitas
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
Sistem Pendukung Keluarga:
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------

3. Struktur Keluarga
Pola-pola Komunikasi
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

6
Struktur Kekuasaan
Keputusan dalam Keluarga
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
Cara keluarga dalam mengambil keputusan.
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------

Model kekuasaan yang digunakan keluarga dalam membuat

keputusan.
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

Struktur Peran
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

7
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
Analisa Model Peran
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
Struktur Nilai-Nilai Keluarga
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------

Fungsi Keluarga

Fungsi Afektif
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

8
Fungsi Sosialisasi
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
Fungsi Perawatan Kesehatan
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
Fungsi Reproduksi
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

Stress Dan Koping Keluarga

-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

9
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------

Harapan Keluarga Terhadap Petugas Kesehatan

-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
Pengkajian Fisik Anggota Keluarga
Anggota Kelua ga
Pemeriksaan Fisik
1 2 3 4 5

Keluhan Utama

Nyeri :

Hal yg
mengurangi
nyeri
Hal yg
meningkatkan
nyeri
Kualitas

Kuantitas

Lokasi

Penyebaran

Waktu

Lain-lain,
sebutkan :
………………………….
Status Mental

10
 Bingung

Cemas

Takut

Marah

Sedih

Depresi

Lain-lain,
sebutkan :
………………………….
Sistem Integumen

Tekstur

Kelembaban

Cianosis

Jaundice

Luka

Bibir kering

CRT

Lain-lain,
sebutkan :
………………………….
Sistem Pernafasan

Suara nafas
normal
Suara nafas
tambahan
Penggunaan
otot bantu nafas

11
 Anggota Kelua ga
Pemeriksaan Fisik
1 2 3 4 5
Frekuensi
nafas
Irama
Kedalaman
Lain-lain,
sebutkan :
………………………….
Sistem Kardioaskuler

Palpitasi
Pembesaran
Jantung
Suara
tambahan
Lain-lain,
sebutkan :
………………………….
Sistem
Muskuloskeletal
Kekuatan otot
Kesimetrisan
otot
Tonus otot
ROM
Peradangan
sendi
Lain-lain,
sebutkan :
………………………….
Sistem Perkemihan

Disuria
Hematuria

12
 Retensi urine
Inkontinensia
Lain-lain,
sebutkan :
………………………….
Sistem Penginderaan

Gangguan
penglihatan
Gangguan
pendengaran
Lain-lain,
sebutkan :
………………………….
Sistem Pencernaan

Mual / muntah
Nyeri abdomen
Distensi
abdomen
Diare
Konstipasi
Anggota Kelua ga
Pemeriksaan Fisik
1 2 3 4 5

Lain-lain,
sebutkan :
………………………….
Sistem Persyarafan

Tingkat
kesadaran
Kesimbangan

Sensoris

Paralisis
ekstremitas

13
 Refleks
Patologis
Refleks
Fisiologis
Lain-lain,
sebutkan :
………………………….
Sistem Immunitas

Riwayat alergi

Riwayat
Autoimun
Lain-lain,
sebutkan :
………………………….
Sistem Reproduksi

Kontrasepsi

Nyeri haid

Perdarahan
pervagina
Lain-lain,
sebutkan :
………………………….
Riwayat Pengobatan

Penggunaan
obat bebas
Jenis obat yang
dikonsumsi
Lain-lain,
sebutkan :
………………………….

14
Analisa Data
Kemungkinan
No Pengelompokan Data Masalah
Penyebab

15
Diagnosa Keperawatan Keluarga

No Tanggal Dx Keperawatan TTD

16
Skala Prioritas Masalah

17
Perencanaan Keperawatan Keluarga
Dx. Kep Luaran Kriteria Evaluasi
No Intervensi
Keluarga Keperawatan Kriteria Standar

18
Pelaksanaan Tindakan Keperawatan Keluarga
Dx Tujuan
No Tanggal Implementasi TTD
Keperawatan Khusus

19
Evaluasi Asuhan Keperawatan Keluarga
Diagnosa
No Tanggal Catatan Perkembangan TTD
Keperawatan

20