FORMAT ASKEP KELUARGA

PRAKTEK PROFESI NERS KEPERAWATAN KELUARGA MAHASISWA

PRODI PROFESI NERS KEPERAWATAN JURUSAN KEPERAWATAN
POLTEKKES KEMENKES BENGKULU TA. 2023/2024

I. DATA UMUM
1. Nama Kepala Keluarga : …………………………………………………….
2. Alamat dan Telepon : .................................................................................
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3. Pekerjaan Kepala Keluarga : ................................................................................
4. Pendidikan Kepala Keluarga : ................................................................................
5. Komposisi Keluarga : ................................................................................

Hubungan Status Imunisasi

Dgn BCG Polio DPT Hepatitis Campak
No Nama JK Umur Pnddk KET
Kepala 1 2 3 4 1 2 3 1 2 3
Keluarga

Genogram (tiga generasi) :

6. Tipe Keluarga :..............................................................................................

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7. Suku Bangsa :.............................................................................................

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8. Agama : .............................................................................................
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 9. Status Sosial Ekonomi : .............................................................................................
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10. Aktifitas Rekreasi Keluarga : .............................................................................................

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II. RIWAYAT TAHAP PERKEMBANGAN KELUARGA

11. Tahap Perkembangan Keluarga saat ini :

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12. Tahap Perkembangan Keluarga yang belum Terpenuhi :

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13. Riwayat Keluarga Inti :

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14. Riwayat keluarga sebelumnya :

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III. LINGKUNGAN
15. Karakteristik Rumah :
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Denah Rumah :
 16. Karakteristik tetangga dan Komunitas RW :
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17. Mobilitas Geografis Keluarga :

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18. Perkumpulan Keluarga dan Interaksi dengan masyarakat :

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19. Sistem Pendukung Keluarga :

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IV. STRTUKTUR KELUARGA

20. Pola Komunikasi Keluarga :
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21. Struktur Kekuatan Keluarga :

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22. Struktur Peran Formal dan Informal :

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23. Nilai dan Norma dalam Keluarga :
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V. FUNGSI KELUARGA

24. Fungsi Afektif :

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25. Fungsi Sosial

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26. Fungsi Perawatan Keluarga :

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27. Fungsi Reproduksi :

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28. Fungsi Ekonomi :

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VI. STRES DAN KOPING KELUARGA
29. Stresor jangka pendek dan Panjang :
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30. Kemampuan keluarga Berespon terhadap situasi / stresor :

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31. Strategi Koping yang Digunakan :

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32. Strategi Adaptasi Disfungsional

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VII. PEMERIKSAAN FISIK ( HEAD TO TOE ) ( Dikaji pada setiap anggota keluarga )
NAMA ANGGOTA KELUARGA
NO VARIABEL

1 Riwayat penyakit saat ini

2 Keluhan yang dirasakan

3 Riwayat penyakit
sebelumnya

4 Tanda-tanda vital
5 Kepala

6 Leher

7 Thoraks

8 Abdomen

9 Esktremitas

10 Kulit

11 Genetalia

VIII. HARAPAN KELUARGA

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IX. ANALISIS DATA

No DATA ETIOLOGI MASALAH

Data Subjektif :

Data Objektif :
 Data Subjektif :

Data Objektif :

Data Subjektif :

Data Objektif :

X. PRIORITAS MASALAH
DX. I . …………………………………………………………………………………………….

No Kriteria Skor Bobot Pembenaran

1 Sifat Masalah
Skala : Tidak / Kurang Sehat 3
Ancaman Kesehatan 2 1
Keadaaan Sejahtera 1
2 Kemungkinan Masalah dapat diubah
Skala : Mudah 2
Sebagian 1 2
Tidak dapat 0

3 Potensial Masalah Untuk dicegah

Skala : Tinggi 3
Cukup 2 1
Rendah 1
4 Menonjolnya Masalah
 Skala : Masalah Berat harus segera di tangani 2
Adanya Masalah tetapi tidak perlu ditangani 1 1
Masalah Tidak Dirasakan : 0
Jumlah

Dx 2. . ………………………………………………………………………………………………….

No Kriteria Skor Bobot Pembenaran

1 Sifat Masalah
Skala : Tidak / Kurang Sehat 3
Ancaman Kesehatan 2 1
Keadaaan Sejahtera 1

2 Kemungkinan Masalah dapat diubah

Skala : Mudah 2
Sebagian 1 2
Tidak dapat 0

3 Potensial Masalah Untuk dicegah

Skala : Tinggi 3
Cukup 2 1
Rendah 1

4 Menonjolnya Masalah
Skala : Masalah Berat harus segera di tangani 2
Adanya Masalah tetapi tidak perlu ditangani 1 1
Masalah Tidak Dirasakan : 0

Jumlah

XI. DIAGNOSA KEPERAWATAN SESUAI PRIORITAS

1. ……………………………………………………………………………………………

2. ……………………………………………………………………………………………

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4. ……………………………………………………………………………………………
XII. RENCANA ASUHAN KEPERAWATAN KELUARGA

NO DIAGNOSA SLKI SIKI

KEPERAWATAN Kode Tujuan/Kriteria Hasil Kode Intervensi
Setelah dilakukan tindakan keperawatan
selama .....X..... jam diharapkan keluarga SIKI : ________________________________________
mampu menunjukkan :
SLKI : .............................................................................................
EKSPETASI : .............................................................................................
Dipertahankan pada Level : .............................................................................................
Ditingkatkan pada Level : .............................................................................................
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Dengan Level .............................................................................................
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Dengan Kriteria Hasil : .............................................................................................
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NB : Rencana dibuat untuk kelima tujuan sesuai tugas keluarga
XIII. IMPLEMENTASI KEPERAWATAN
NO TANGGAL/JAM IMPLEMENTASI EVALUASI