PRODI NERS TAHAP AKADEMIK STIKes SANTA ELISABETH

Jln. Bunga Terompet No. 118, Kel. Sempakata Kec. Medan Selayang
MEDAN-0618214020-0618225509
http://stikeselisabethmedan.ac.id/, email: stikes_elisabeth@yahoo.co.id

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KELUARGA

A. PENGKAJIAN (tanggal)
I. Data Umum
1. Nama KK (Inisial) :
2. Usia :
3. Pendidikan :
4. Pekerjaan :
5. Alamat :
6. Komposisi anggota keluarga :
Status
N Nama Jenis Hub TTL /
Pendidikan Pekerjaan Imunisa
o (Inisial) Kelamin dgn Kk Umur
si
1
2
3
4
5
6

Genogram :

Keterangan :

7. Tipe keluarga
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8. Suku
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Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 1

9. Agama
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10. Status sosial ekonomi keluarga

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11. Aktivitas rekreasi keluarga

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II. Riwayat dan tahap perkembangan keluarga

12. Tahap perkembangan keluarga saat ini
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13. Tahap perkembangan keluarga yang belum terpenuhi

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14. Riwayat keluarga inti

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15. Riwayat keluarga sebelumnya

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III. Lingkungan
16. Karakteristik rumah (termasuk denah rumah)
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Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 2

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17. Karakteristik tetangga dan komunitas

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18. Mobilitas geografis keluarga

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19. Perkumpulan keluarga dan interaksi dengan masyarakat

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20. Sistem pendukung keluarga

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IV. Struktur keluarga

21. Pola komunikasi keluarga
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22. Struktur kekuatan keluarga

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23. Struktur peran

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Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 3

24. Nilai dan norma budaya
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V. Fungsi keluarga
25. Fungsi afektif
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26. Fungsi sosialisasi

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27. Fungsi perawatan kesehatan

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VI. Stress dan koping keluarga

28. Stressor jangka pendek
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29. Kemampuan keluarga berespon terhadap masalah

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30. Strategi koping yang digunakan

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31. Strategi adaptasi disfungsional

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Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 4

 32. Pemeriksaan fisik head to toe secara inspeksi. Palpasi, auskultasi, dan perkusi dan tanda-
tanda vital termasuk tinggi badan dan berat badan (lampirkan)
Nama Anggota Keluarga
Pemeriksaan Fisik
Kepala
Istri Anak-anak
Umum Keluarga
1. Penampilan
Umum
 Kesadaran
 Cara berpakaian
 Kebersihan
personal
 Postur dan cara
berjalan
 Bentuk dan Proporsional Proporsional Proporsional Proporsional
ukuran tubuh sesuai BB sesuai BB sesuai BB sesuai BB
dengan TB dengan TB dengan TB dengan TB
TB: TB: TB: TB:
BB: BB: BB: BB:
Tanda-tanda vital Tgl : Tgl : Tgl : Tgl :
TD : TD : TD : TD :
Nadi : Nadi : Nadi : Nadi :
Suhu : Suhu : Suhu : Suhu :
RR : RR : RR : RR :
2. Status mental dan
cara berbicara:
Status emosi
Orientasi
Proses berfikir
Gaya bicara
Pemeriksaan Kulit
Kuku
Pemeriksaan
Kepala
Bentuk & Sensori
Rambut
Mata
Hidung
Telinga
Mulut
Leher
Dada (Pernafasan)
Dada
(Cardiovaskuler)
Abdomen Inspeksi: Inspeksi: Inspeksi: Inspeksi:
Palpasi: Palpasi: Palpasi: Palpasi:

Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 5

 Auskultasi: Auskultasi: Auskultasi: Auskultasi:
Perkusi: Perkusi: Perkusi: Perkusi:
Ekstremitas
Ektremitas Atas
Ektremitas Bawah
Kesimpulan

VII. Harapan keluarga terhadap ASKEP keluarga

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Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 6

 PRODI NERS TAHAP AKADEMIK STIKes SANTA ELISABETH
Jln. Bunga Terompet No. 118, Kel. Sempakata Kec. Medan Selayang
MEDAN-0618214020-0618225509
http://stikeselisabethmedan.ac.id/, email: stikes_elisabeth@yahoo.co.id

B. DIAGNOSA KEPERAWATAN KELUARGA

ANALISA DATA
NO DATA MASALAH KEPERAWATAN
1 Data Subjektif :

Data Objektif :

2 Data Subjektif :

Data Objektif :

Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 7

 PRODI NERS TAHAP AKADEMIK STIKes SANTA ELISABETH
Jln. Bunga Terompet No. 118, Kel. Sempakata Kec. Medan Selayang
MEDAN-0618214020-0618225509
http://stikeselisabethmedan.ac.id/, email: stikes_elisabeth@yahoo.co.id

PERUMUSAN DIAGNOSA KEPERAWATAN

N DIAGNOSA KEPERAWATAN (PES)

O
1

Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 8

 PRODI NERS TAHAP AKADEMIK STIKes SANTA ELISABETH
Jln. Bunga Terompet No. 118, Kel. Sempakata Kec. Medan Selayang
MEDAN-0618214020-0618225509
http://stikeselisabethmedan.ac.id/, email: stikes_elisabeth@yahoo.co.id

Penilaian (Skoring) Diagnosa Keperawatan

NO BOB SKORE PEMBENARAN
OT
1 Sifat masalah :...... ...., / 3 X 1=

2 Kemungkinan masalah ...., / 2 X 2=

dapat diubah

3 Potensial masalah untuk .....,/ 3 X 1=

dicegah : ....

4 Menonjolnya ....., / 2X1=

masalah :.....

Total

Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 9

 PRODI NERS TAHAP AKADEMIK STIKes SANTA ELISABETH
Jln. Bunga Terompet No. 118, Kel. Sempakata Kec. Medan Selayang
MEDAN-0618214020-0618225509
http://stikeselisabethmedan.ac.id/, email: stikes_elisabeth@yahoo.co.id

PRIORITAS DIAGNOSA KEPERAWATAN

PRIORITAS DIAGNOSA KEPERAWATAN SKOR
1

Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 10

 PRODI NERS TAHAP AKADEMIK STIKes SANTA ELISABETH
Jln. Bunga Terompet No. 118, Kel. Sempakata Kec. Medan Selayang
MEDAN-0618214020-0618225509
http://stikeselisabethmedan.ac.id/, email: stikes_elisabeth@yahoo.co.id

C. RENCANA ASUHAN KEPERAWATAN KELUARGA/ KOMUNITAS

Diagnosa SLKI SIKI Evaluasi
Keperawatan Kriteria Standard

Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 11

 PRODI NERS TAHAP AKADEMIK STIKes SANTA ELISABETH
Jln. Bunga Terompet No. 118, Kel. Sempakata Kec. Medan Selayang
MEDAN-0618214020-0618225509
http://stikeselisabethmedan.ac.id/, email: stikes_elisabeth@yahoo.co.id

D. IMPLEMENTASI
NO TTD /
DP ke: IMPLEMENTASI
TGL & WAKTU PARAF
1

Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 12

 PRODI NERS TAHAP AKADEMIK STIKes SANTA ELISABETH
Jln. Bunga Terompet No. 118, Kel. Sempakata Kec. Medan Selayang
MEDAN-0618214020-0618225509
http://stikeselisabethmedan.ac.id/, email: stikes_elisabeth@yahoo.co.id

E. EVALUASI

TANGGAL NO. DP EVALUASI TTD /

& WAKTU PARAF

1 S

2 S

3 S

Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 13

 A

Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 14

Pengkajian Keperawatan Keluarga STIKes Santa. Elisabeth Medan 15