ASUHAN KEPERAWATAN KELUARGA

I.

DATA UMUM KELUARGA

1. Identitas Kepala keluarga

Nama :.....................................

Pendidikan :........................................

Umur :.....................................

Pekerjaan :...........................................

Agama :.....................................

Alamat :................................................

Suku :.....................................

No. Telepon

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2. Komposisi keluarga
Hub dgn

No

Nama

L/P

Umur

Pendidikan

Pekerjaan

Keterangan

KK

1
2
3
4
5

6. Status sosial ekonomi keluarga

1). Anggota keluarga yang mencari nafkah
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2). Penghasilan
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3). Upaya lain untuk menambah penghasilan

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4). Kebutuhan yang dikeluarkan setiap bulan
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6). Tabungan khusus kesehatan
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II.

RIWAYAT DAN TAHAP PERKEMBANGAN KELUARGA

1. Riwayat keluarga inti:
1). Riwayat terbentuknya keluarga inti
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2). Riwayat kesehatan keluarga saat ini
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3). Riwayat kesehatan masing-masing anggota keluarga

No

Nama

Umur

BB/TB

Keadaan
kesehatan

Imunisasi
(BCG/Polio/DPT/HB/

Masalah

Tindakan yang

kesehatan

telah dilakukan

Campak)

4). Sumber pelayanan kesehatan yang dimanfaatkan

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Riwayat kesehatan keluarga sebelumnya.
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III. DATA LINGKUNGAN

1. Karakteristik rumah
1). Luas rumah
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2). Tipe rumah
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3). Kepemilikan
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4). Jumlah dan rasio kamar/ruangan
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5). Ventilasi dan jendela

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6). Pemanfaatan ruangan
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7). Septic tank
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8). Sumber air minum
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9). Kamar mandi/WC
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10).Sampah.
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11).Kebersihan lingkungan
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2. Fungsi perawatan kesehatan
1). Pengetahuan dan persepsi keluarga tentang penyakit/masalah kesehatan keluarganya
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2). Kemampuan keluarga mengambil keputusan tindakan kesehatan yang tepat
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3). Kemampuan keluarga merawat anggota keluarga yang sakit
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4). Kemampuan keluarga memelihara lingkungan rumah yang sehat
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5). Kemampuan keluarga menggunakan fasilitas kesehatan di masyarakat
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VII. PEMERIKSAAN FISIK

Tanggal pemeriksaan:..............................................................................................................
Pemeriksaan

Vital Sign

BB, TB/PB
Kepala
Mata

Hidung

Telinga

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Nama Anggota Keluarga

Mulut

Leher

Pemeriksaan

Thorak

Abdomen

Tangan

Kaki

Genitalia

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Nama Anggota Keluarga