ASUHAN KEPERAWATAN KELUARGA DENGAN SALAH SATU ANGGOTA KELUARGAMENDERITA..................DI LINGKUNGAN.............. KELURAHAN........

A. PENGKAJIAN (tanggal :__________________________)I. Data Umum1. Kepala Keluarga KK:_____________________________________2. Alamat dan Telepon:_____________________________________3. Pekerjaan KK:_____________________________________4. Pendidikan KK:_____________________________________5. Komposisi Keluarga:_____________________________________

NoNamaJenis Kel.Hub Kel. KKUmur PendidikanStatus ImunisasiKet.

BCGPolioDPTHepatitisCampak

1234123123

Genogram :6. Tipe Keluarga:_______________________________________7. Suku Bangsa: ______________________________________8. Agama:_______________________________________9. Status sosial ekonomi keluarga:_______________________________________10. Aktivitas rekreasi keluarga......................................................................................................................................................................................................................................................................................II. Riwayat dan tahap perkembangan keluarga1. 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 (lama keluarga tinggal di dusun atau pindahan)......................................................................................................................................................................................................................................................................................4. Perkumpulan keluarga dan interaksi dengan masyarakat.....................................................................................................................................................................................................................................................................................5. Sistem pendukung keluarga............................................................................................................................................................ .........................................................................................................................IV. Struktur keluarga1. Struktur peran........................................................................................................................................................... .........................................................................................................................2. Nilai dan norma kleuarga........................................................................................................................................................... .........................................................................................................................3. Pola komunikasi keluarga......................................................................................................................................................................................................................................................................................4. Struktur kekuasaan keluarga (siapa pengambil keputusan)......................................................................................................................................................................................................................................................................................V. Fungsi keluarga1. Fungsi afektif......................................................................................................................................................................................................................................................................................2. Fungsi sosialisasil............................................................................................................................................................................................................................................................................................................................................................................................................................3. Fungsi pemenuhan (perawatan/pemeliharaan) kesehatana. Mengenal masalah kesehatan............................................................................................................................................................................................................................................................................ b. Mengambil keputusan mengenai tindakan kesehatan............................................................................................................................................................................................................................................................................c. Kemampuan merawat anggota keluarga yang sakitd. Kemampuan keluarga memelihara/memodifikasi lingkungan rumah yang kuat............................................................................................................................................................................................................................................................................e. Kemampuan menggunakan fasilitas pelayanan kesehat4. Fungsi reproduksi............................................................................................................................................................................................................................................................................................................................................................................................................................5. Fungsi ekonomi....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................VI. Stres dan koping keluarga1. Stresor jangka pendek dan panjang......................................................................................................................................................................................................................................................................................2. Kemampuan keluarga berespons terhadap stresor......................................................................................................................................................................................................................................................................................3. Strategi koping yang digunakan......................................................................................................................................................................................................................................................................................4. Strategi adaptasi disfungsional (pengambinghitaman,penggunaan ancaman,dll)......................................................................................................................................................................................................................................................................................VII. Pemeriksaan kesehatan tiap individu anggota keluarga (menggunakan table)..................................................................................................................................................................................................................................................................................................VIII. Harapan keluarga..................................................................................................................................................................................................................................................................................................B. DIAGNOSIS KEPERAWATAN KELUARGA

I. Analisis dan sintesis data

NoDataMasalahPenyebab

1Subjektif :Objektif :

2Subjektif :Objektif :

3Subjektif :Objektif :

II. Perumusan diagnosis keperawatanNoDiagnosa Keperawatan (PES)

1

2

3

III. Penilaian (Skoring) diagnosis keperawatanNoDiag.Kep.Kriteria Skor Pembenaran

1a. Sifat masalah :.............b. Kemungkinan masalah dapat diubah:..........c. Potensial masalah untuk dicegah:.........d. Menonjolnya masala:........................x1 = 3.....x2 = 2.....x1 = 3.....x1 = 2

2

3

IV. Prioritas diagnosis keperawatanPrioritasDiagnosis KeperawatanSkor

1

2

C. RENCANA ASUHAN KEPERAWATAN KELUARGADiagnosa Keperawatan : .......................................................................................................................................................................................................................

Tujuan Umum/Khusus Kriteria Evaluasi Kriteria / StandarKriteria Evaluasi Kriteria/StandarRencana Intervensi

D. IMPLEMENTASI

No. Tanggal & waktuDiagnosa KeperawatanImplementasi

1

2

E. EVALUASI

No. Tanggal & waktuDiagnosa KeperawatanImplementasi

1S :O :A :P :

2S :O :A :P :

Catatan :

Pada setiap tahap perlu dituliskan dengan jelas dan benar tentang tempat, tanggal, nama perawat sebagai bukti identifikasi