FORMAT PENGKAJIAN

ASUHAN KEPERAWATAN KELUARGA

STIKES HANG TUAH SURABAYA

A. PENGKAJIAN (TANGGAL : ..................................)I. Data Umum

1. Nama kepala keluarga : ......................................................................................................2. Alamat dan telepon : ......................................................................................................3. Pekerjaan KK : ......................................................................................................4. Pendidikan KK : ......................................................................................................5. Komposisi keluarga : ......................................................................................................

No. NamaJenis kel

Hub kel – KK

Umur DikStatus imunisasi

KetPolio DPT Hepatitis Campak

Genogram :

1. Tipe keluarga : ......................................................................................................2. Suku bangsa : ......................................................................................................3. Agama : ......................................................................................................4. Status sosial ekonomi : ......................................................................................................5. Aktivitas rekreasi keluarga

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.............................................................................................................................................II. Riwayat Dan Tahap Perkembangan Keluarga

1. Tahap perkembangan keluarga saat ini................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

2. Tugas perkembangan keluarga yang belum terpenuhi................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

3. Riwayat kesehatan keluarga inti................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

4. Riwayat kesehatan keluarga sebelumnya................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

III. Data Lingkungan1. Karakteristik rumah

Denah rumah

2. Karakteristik tetangga dan komunitasnya................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

3. Mobilitas geografis keluarga................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

4. Perkumpulan keluarga dan interaksi dengan masyarakat................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

5. Sistem pendukung keluarga

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................................................................................................................................................IV. Struktur Keluarga

1. Struktur peran................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

2. Pola komunikasi keluarga................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

3. Struktur kekuatan keluarga................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

V. Fungsi Keluarga1. Fungsi ekonomi

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................................................................................................................................................2. Fungsi mendapatkan status sosial

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................................................................................................................................................3. Fungsi pendidikan

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................................................................................................................................................4. Fungsi sosialisasi

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................................................................................................................................................5. Fungsi pemenuhan (perawatan/pemeliharaan) kesehatan

a. Mengenal masalah keluarga.................................................................................................................................................................................................................................................................................... ..........................................................................................................................................

b. Mengambil keputusan mengenai tindakan kesehatan.................................................................................................................................................................................................................................................................................... ..........................................................................................................................................

c. Kemampuan merawat anggota keluarga yang sakit.................................................................................................................................................................................................................................................................................... ..........................................................................................................................................

d. Kemampuan keluarga memelihara/memodifikasi lingkungan rumah yang sehat.................................................................................................................................................................................................................................................................................... ..........................................................................................................................................

e. Kemampuan menggunakan fasilitas pelayanan kesehatan.................................................................................................................................................................................................................................................................................... ..........................................................................................................................................

6. Fungsi religius................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

7. Fungsi rekreasi................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

8. Fungsi reproduksi................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

9. Fungsi afeksi................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

VI. Stress Dan Koping Keluarga1. Stressor jangka pendek dan panjang

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................................................................................................................................................2. Kemampuan keluarga berespon terhadap stressor

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................................................................................................................................................3. Strategi koping yang digunakan

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................................................................................................................................................4. Strategi adaptasi disfungsional

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VII. Pemeriksaan Kesehatan Tiap Individu Anggota Keluarga...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................

VIII. Harapan Keluarga...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................

Surabaya, .....................Mahasiswa

(...............................)

B. DIAGNOSIS KEPERAWATAN KELUARGAI. Analisis Dan Sintesis Data

No. Data Masalah Penyebab

II. Daftar Diagnosis Keperawatan Yang MunculNo.

Diagnosa Keperawatan (PES)

III. Penilaian (Skoring) Diagnosis KeperawatanDx. kep : ......................................................................................................................................

.......................................................................................................................................

No.

Kriteria Skor Bobot Nilai Pembenaran

1

Sifat masalah- Tidak/kurang sehat- Ancaman kesehatan- Keadaan sejahtera

321

1

2

Kemungkinan masalah dapat diubah- Mudah- Sebagian- Tidak dapat

210

2

3

Potensial masalah untuk dicegah- Tinggi- Cukup- Rendah

321

1

4

Menonjolnya masalah- Masalah berat harus segera ditangani- Ada masalah, tetapi tidak perlu segera ditangani- Masalah tidak dirasakan

210

1

Total skor

Dx. kep : .............................................................................................................................................................................................................................................................................

No.

Kriteria Skor Bobot Nilai Pembenaran

1

Sifat masalah- Tidak/kurang sehat- Ancaman kesehatan- Keadaan sejahtera

321

1

2

Kemungkinan masalah dapat diubah- Mudah- Sebagian- Tidak dapat

210

2

3

Potensial masalah untuk dicegah- Tinggi- Cukup- Rendah

321

1

4 Menonjolnya masalah- Masalah berat harus segera ditangani- Ada masalah, tetapi tidak perlu segera ditangani

21

1

- Masalah tidak dirasakan 0Total skor

Dx. kep : .............................................................................................................................................................................................................................................................................

No.

Kriteria Skor Bobot Nilai Pembenaran

1

Sifat masalah- Tidak/kurang sehat- Ancaman kesehatan- Keadaan sejahtera

321

1

2

Kemungkinan masalah dapat diubah- Mudah- Sebagian- Tidak dapat

210

2

3

Potensial masalah untuk dicegah- Tinggi- Cukup- Rendah

321

1

4

Menonjolnya masalah- Masalah berat harus segera ditangani- Ada masalah, tetapi tidak perlu segera ditangani- Masalah tidak dirasakan

210

1

Total skor

Dx. kep : .............................................................................................................................................................................................................................................................................

No.

Kriteria Skor Bobot Nilai Pembenaran

1

Sifat masalah- Tidak/kurang sehat- Ancaman kesehatan- Keadaan sejahtera

321

1

2

Kemungkinan masalah dapat diubah- Mudah- Sebagian- Tidak dapat

210

2

3

Potensial masalah untuk dicegah- Tinggi- Cukup- Rendah

321

1

4

Menonjolnya masalah- Masalah berat harus segera ditangani- Ada masalah, tetapi tidak perlu segera ditangani- Masalah tidak dirasakan

210

1

Total skor

IV. Prioritas Diagnosis KeperawatanPrioritas Diagnosis Keperawatan Skor

INTERVENSI KEPERAWATANNo.

Diagnosa Keperawatan

TujuanKriteria Standar Intervensi Evaluasi

Umum Khusus

IMPLEMENTASI DAN EVALUASITanggal No. DP Implementasi Evaluasi Paraf