Format Pengkajian Keluarga Fix

PRODI NERS TAHAP AKADEMIK STIKes SANTA ELISABETH FORM 8
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 :
Nama Jenis Hub dgn TTL / Status
No Pendidikan Pekerjaan
(Inisial) Kelamin Kk Umur Imunisasi
Genogram :
Keterangan :
7. Tipe keluarga
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8. Suku
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Buku Panduan Praktek Belajar Lapangan Prodi Ners Tahap Akademik STIKes Santa Elisabeth Medan
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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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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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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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32. Pemeriksaan fisik head to toe secara inspeksi. Palpasi, auskultasi, dan perkusi dan tanda-tanda vital
termasuk tinggi badan dan berat badan (lampirkan)
VII. Harapan keluarga terhadap ASKEP keluarga

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FORM 9
PRODI NERS TAHAP AKADEMIK STIKes SANTA ELISABETH
MEDAN-0618214020-0618225509
B. DIAGNOSA KEPERAWATAN KELUARGA

ANALISA DATA
NO DATA MASALAH KEPERAWATAN
1 Data Subjektif :
Data Objektif :
2 Data Subjektif :
Data Objektif :
MEDAN-0618214020-0618225509
PERUMUSAN DIAGNOSA KEPERAWATAN
NO DIAGNOSA KEPERAWATAN (PES)

1
dst
MEDAN-0618214020-0618225509
Penilaian (Skoring) Diagnosa Keperawatan

NO BOBOT SKORE PEMBENARAN
1 Sifat masalah :...... ...., / 3 X 1=
2 Kemungkinan masalah ...., / 2 X 2=

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

dicegah : ....
4 Menonjolnya masalah ....., / 2X1=

:.....
Total
MEDAN-0618214020-0618225509
Penilaian (Skoring) Diagnosa Keperawatan

NO BOBOT SKORE PEMBENARAN
1 Sifat masalah :...... ...., / 3 X 1=
2 Kemungkinan masalah ...., / 2 X 2=

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

dicegah : ....
4 Menonjolnya masalah ....., / 2X1=

:.....
Total
Jln. Bunga Terompet No. 118, Kel. Sempakata Kec. Medan Selayang FORM 12
MEDAN-0618214020-0618225509
PRIORITAS DIAGNOSA KEPERAWATAN

PRIORITAS DIAGNOSA KEPERAWATAN SKOR
1
MEDAN-0618214020-0618225509
C. RENCANA ASUHAN KEPERAWATAN KELUARGA/ KOMUNITAS

Diagnosa Tujuan /NOC Rencana Tindakan Evaluasi
Keperawatan /NIC Kriteria Standard
MEDAN-0618214020-0618225509
D. IMPLEMENTASI
NO TTD /
DP ke: IMPLEMENTASI
TGL & WAKTU PARAF
1
MEDAN-0618214020-0618225509
E. EVALUASI
TANGGAL NO. EVALUASI TTD / PARAF
& WAKTU DP
1 S:
O:
A:
P:
2 S:
O:
A:
P:
3 S:
O:
A:
P:
FORM 16
MEDAN-0618214020-0618225509
PEMERIKSAAN FISIK KHUSUS UNTUK KELUARGA BINAAN

Nama Anggota Keluarga
Pemeriksaan Fisik
Kepala Keluarga Istri Anak 1 Anak 2 Anak 3
Umum
1. Penampilan
Umum
• Kesadaran
• Cara berpakaian
• Kebersihan
personal
• Postur dan cara

berjalan
• Bentuk dan ukuran Proporsional sesuai Proporsional sesuai Proporsional Proporsional sesuai Proporsional
tubuh BB dengan TB BB dengan TB sesuai BB dengan BB dengan TB sesuai BB dengan
TB TB
TB: TB: TB: TB: TB:
BB: BB: BB: BB: BB:
Tanda-tanda vital Tgl : Tgl : Tgl : Tgl : Tgl :
TD : TD : TD : TD : TD :
Nadi : Nadi : Nadi : Nadi : Nadi :
Suhu : Suhu : Suhu : Suhu : Suhu :
RR : 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:
Auskultasi: Auskultasi: Auskultasi: Auskultasi:
Perkusi: Perkusi: Perkusi: Perkusi:
Ekstremitas
Ektremitas Atas
Ektremitas Bawah
Kesimpulan
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PRODI NERS TAHAP AKADEMIK STIKes SANTA ELISABETH FORM 8

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KELUARGA

10. Status sosial ekonomi keluarga

II. Riwayat dan tahap perkembangan keluarga

20. Sistem pendukung keluarga

IV. Struktur keluarga

VI. Stress dan koping keluarga

VII. Harapan keluarga terhadap ASKEP keluarga

B. DIAGNOSA KEPERAWATAN KELUARGA

PERUMUSAN DIAGNOSA KEPERAWATAN

NO DIAGNOSA KEPERAWATAN (PES)

Penilaian (Skoring) Diagnosa Keperawatan

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

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

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

Penilaian (Skoring) Diagnosa Keperawatan

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

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

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

PRIORITAS DIAGNOSA KEPERAWATAN

C. RENCANA ASUHAN KEPERAWATAN KELUARGA/ KOMUNITAS

PEMERIKSAAN FISIK KHUSUS UNTUK KELUARGA BINAAN

• Postur dan cara

Abdomen Inspeksi: Inspeksi: Inspeksi: Inspeksi:

Auskultasi: Auskultasi: Auskultasi: Auskultasi:

Perkusi: Perkusi: Perkusi: Perkusi:

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