FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KELUARGA
Pengkajian tanggal ..............................
Nama
Mahasiswa :
NIM :
Format Pengkajian Keperawatan Keluarga
Identitas Umum Keluarga
Identitas Kepala Keluarga
1. Nama :
2. Umur/ tanggal lahir :
3. Agama :
4. Suku :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :
8. Nomor Telpon :
Komposisi Keluarga
N0
|
Nama
|
L/P
|
Umur
|
Hub. Keluarga
|
Pekerjaan
|
Pendidikan
|
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1.
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2.
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3.
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4.
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5.
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6.
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7.
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8.
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9.
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10.
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Genogram : buatlah genogram 3 generasi
Tipe Keluarga :
1. Jenis tipe keluarga :
.........................................................................................................
2.
Masalah yang terjadi dengan tipe
tersebut :
....................................................................................................................................................................................................................................................................................
Suku Bangsa :
1. Asal suku bangsa :
...........................................................................................................
2.
Budaya yang berhubungan dengan kesehatan
: ..............................................................................................................................................................................................................................................................................................................................................................................................................................
Agama dan kepercayaan yang memengaruhi kesehatan :
......................................................................................................................................................
Status Sosial Ekonomi Keluarga :
1.
Anggota keluarga yang mencari nafkah ..........................................................................................................................................
2.
Penghasilan :
....................................................................................................................................................................................................................................................................................
3.
Upah lain :
....................................................................................................................................................................................................................................................................................
4.
Harta benda yang dimiliki (perabot,
transportasi, dan lain-lain)
....................................................................................................................................................................................................................................................................................
5.
Kebutuhan yang dikeluarkan setiap bulan
:
..............................................................................................................................................................................................................................................................................................................................................................................................................................
Aktivitas Rekreasi Keluarga :
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Riwayat dan Tahap Perkembangan Keluarga
Tahap Perkembangan Keluarga saat ini
(ditentukan dengan anak tertua) : ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Tahap Perkembangan Keluarga yang belum
terpenuhi dan kendalanya : ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Riwayat kesehatan keluarga inti :
1.
Riwayat kesehatan keluarga saat ini :
..............................................................................................................................................................................................................................................................................................................................................................................................................................
2.
Riwayat penyakit keturunan :
....................................................................................................................................................................................................................................................................................
3.
Riwayat kesehatan masing-masing anggota
keluarga :
N0
|
Nama
|
Umur
|
BB
|
Keadaan kesehatan
|
Imunisasi (BCG/Polio/DPI/HB/Campak)
|
Masalah kesehatan
|
Tindakan Yang Telah Dilakukan
|
1.
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2.
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3.
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4.
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5.
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6.
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7.
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8.
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9.
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10.
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4.
Sumber pelayanan kesehatan yang
dimanfaatkan :
..............................................................................................................................................................................................................................................................................................................................................................................................................................
5.
Riwayat kesehatan keluarga sebelumnya :
....................................................................................................................................................................................................................................................................................
Pengkajian Lingkungan
Karakteristik Rumah
1.
Luas rumah :
..........................................................................................................................................
2.
Tipe rumah :
..........................................................................................................................................
3.
Kepemiliksn :
..........................................................................................................................................
4.
Jumlah dan rasio kamar/ruangan : ..........................................................................................................................................
5.
Ventilasi/jendela :
..........................................................................................................................................
6.
Pemanfaatan ruangan :
..........................................................................................................................................
7.
Septik tank : ada/tidak
................................. letak :
..........................................................................................................................................
8.
Sumber air minum: ..........................................................................................................................................
9.
Kamar mandi/WC:
..........................................................................................................................................
10.
Sampah
........................................................limbah RT
..........................................................................................................................................
11.
Kebersihan lingkungan:
..............................................................................................................................................................................................................................................................................................................................................................................................................................
Karakteristik Tetangga dan Komunitas RW
1.
Kebiasaan: ..........................................................................................................................................
2.
Aturan/kesepakatan:
..........................................................................................................................................
3.
Budaya:
..........................................................................................................................................
Mobilisasi Geografis Keluarga: ................................................................................................
Perkumpulan Keluarga dan Interaksi
dengan Masyarakat:
............................................................................................................................................................................................................................................................................................................
Sistem Pendukung Keluarga:
............................................................................................................................................................................................................................................................................................................
Struktur Keluarga
Pola/cara Komunikasi Keluarga: ......................................................................................................................................................
Struktur Kekuatan Keluarga:
............................................................................................................................................................................................................................................................................................................
Sturktur Peran (peran masing-masing
anggota keluarga) ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Nilai dan Norma Keluarga ............................................................................................................................................................................................................................................................................................................
Fungsi Keluarga
Fungsi Afektif ............................................................................................................................................................................................................................................................................................................
Fungsi Sosialisasi
1.
Kerukunan hidup dalam keluarga:
....................................................................................................................................................................................................................................................................................
2.
Interaksi dan hubungan dalam keluarga:
....................................................................................................................................................................................................................................................................................
3.
Anggota keluarga yang dominan dalam pengambilan
keputusan:
....................................................................................................................................................................................................................................................................................
4.
Kegiatan keluarga waktu senggang:
....................................................................................................................................................................................................................................................................................
5.
Partisipasi dalam kegiatan sosial:
....................................................................................................................................................................................................................................................................................
6.
Fungsi perawatan kesehatan:
..............................................................................................................................................................................................................................................................................................................................................................................................................................
Fungsi Reproduksi
1.
Perencanaan jumlah anak: ..........................................................................................................................................
2.
Akseptor: Ya
........................yang digunakan.....................lamanya
...............................
3.
Aspektor: Belum/tidak
........................., alasannya:
........................................................
4.
Keterangan lain:
....................................................................................................................................................................................................................................................................................
Fungsi Ekonomi
1. Upaya pemenuhan sandang pangan: ....................................................................................................................................................................................................................................................................................
2. Pemanfaatan sumber di masyarakat:
..........................................................................................................................................
Stres dan Koping
Keluarga
1. Stres jangka pendek: ..........................................................................................................................................
2. Stresor jangka panjang:
...................................................................................................
3. Respons keluargaterhadap stresor:
..........................................................................................................................................
4. Strategi koping:
.........................................................................................................................................
5. Strategi adaptasi disfungsional:
..........................................................................................................................................
Keadaan Gizi Keluarga
1. Pemenuhan gizi:
..........................................................................................................................................
2. Upaya lain: ..........................................................................................................................................
Harapan Keluarga
1. Terhadap masalah kesehatannya:
....................................................................................................................................................................................................................................................................................
2. Terhadap petugas kesehatan yang ada: ....................................................................................................................................................................................................................................................................................
Pemeriksaan Fisik
No.
|
Variabel
|
Nama Anggota Keluarga
|
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Tn.
|
Ny.
|
An.
|
An.
|
||
1.
|
Riwayat penyakit saat ini
|
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2.
|
Keluhan yang dirasakan
|
||||
3.
|
Tanda dan gejala
|
||||
4.
|
Riwayat penyakit sebelumnya
|
||||
5.
|
Tanda-tanda vital
|
||||
6.
|
Sistem kardiovaskular
|
||||
7.
|
Sistem respirasi
|
||||
8.
|
Sistem saluran pencernaan
|
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9.
|
Sistem persarafan
|
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10.
|
Sistem muskuloskeletat
|
||||
11.
|
Sistem genetalia
|
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Tipologi Masalah
Kesehatan
No.
|
Daftar Masalah Kesehatan
|
1.
|
Ancaman
|
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. .
|
|
2.
|
Kurang/Tidak Sehat
|
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. .
|
|
3.
|
Defisit
|
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. .
|
|
Pengkajian Khusus
Berdasarkan 5 Tugas Keluarga
No.
|
Kriteria
|
Pengkajian
|
1.
|
Mengenal masalah
|
|
2.
|
Mengambil keputusan
|
|
3.
|
Merawat anggota keluarga yang sakit
atau punya masalah
|
|
4.
|
Memodifikasi lingkungan
|
|
5.
|
Memanfaatkan sarana kesehatan
|
Daftar Masalah
No.
|
Data
|
Problem
|
Etiolog
|
Skoring
Kriteria
|
Bobot
|
Pembenaran
|
SIFAT MASALAH
· Ancaman
· Kurang/tidak sehat
· Krisis
|
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KEMUNGKINAN MASALAH DAPAT DIUBAH
· Mudah
· Sebagian
· Tidak dapat
|
||
POTENSIAL MASALAH DAPAT DICEGAH
· Tinggi
· Cukup
· Rendah
|
||
MENONJOLNYA MASALAH
· Segera ditangani
· Tak perlu segera ditangani
· Tak dirasakan
|
Rencana Tindakan
Keperawatan
No.
|
Diagnosis Keperawatan
|
Tujuan
|
Kriteria Hasil
|
Interfensi
|
implementasi
No.
|
No. Diagnosis Keperawatan
|
Pukul
|
Tindakan Keperawatan
|
Parah
|
Tanda tangan
mahasiswa
(.....................................................)
|
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