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 : ......................................................................................................

Hub Status imunisasi

Jenis
No. Nama kel – Umur Dik Ket
kel Polio DPT Hepatitis Campak
KK

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
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2. Tugas perkembangan keluarga yang belum terpenuhi
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3. Riwayat kesehatan keluarga inti
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4. Riwayat kesehatan keluarga sebelumnya
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III. Data Lingkungan

1. Karakteristik rumah

Denah rumah

2. Karakteristik tetangga dan komunitasnya

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3. Mobilitas geografis keluarga
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4. Perkumpulan keluarga dan interaksi dengan masyarakat
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5. Sistem pendukung keluarga
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IV. Struktur Keluarga
1. Struktur peran
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2. Pola komunikasi keluarga
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3. Struktur kekuatan keluarga
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V. Fungsi Keluarga
1. 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
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b. Mengambil keputusan mengenai tindakan kesehatan
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c. Kemampuan merawat anggota keluarga yang sakit
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d. Kemampuan keluarga memelihara/memodifikasi lingkungan rumah yang sehat
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e. Kemampuan menggunakan fasilitas pelayanan kesehatan
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6. Fungsi religius
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 7. Fungsi rekreasi
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8. Fungsi reproduksi
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9. Fungsi afeksi
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VI. Stress Dan Koping Keluarga

1. 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

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VIII. Harapan Keluarga
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Surabaya, .....................
Mahasiswa

(...............................)
 B. DIAGNOSIS KEPERAWATAN KELUARGA
I. Analisis Dan Sintesis Data
No. Data Masalah Penyebab
 III. Daftar Diagnosis Keperawatan Yang Muncul
No. Diagnosa Keperawatan (PES)

IV. Penilaian (Skoring) Diagnosis Keperawatan

Dx. kep : ......................................................................................................................................
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No. Kriteria Skor Bobot Nilai Pembenaran

Sifat masalah
- Tidak/kurang sehat 3
1 1
- Ancaman kesehatan 2
- Keadaan sejahtera 1
Kemungkinan masalah dapat diubah
- Mudah 2
2 2
- Sebagian 1
- Tidak dapat 0
Potensial masalah untuk dicegah
- Tinggi 3
3 1
- Cukup 2
- Rendah 1
Menonjolnya masalah
- Masalah berat harus segera ditangani 2
4 1
- Ada masalah, tetapi tidak perlu segera ditangani 1
- Masalah tidak dirasakan 0
Total skor

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

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No. Kriteria Skor Bobot Nilai Pembenaran

Sifat masalah
- Tidak/kurang sehat 3
1 1
- Ancaman kesehatan 2
- Keadaan sejahtera 1
Kemungkinan masalah dapat diubah
- Mudah 2
2 2
- Sebagian 1
- Tidak dapat 0
Potensial masalah untuk dicegah
- Tinggi 3
3 1
- Cukup 2
- Rendah 1
Menonjolnya masalah
- Masalah berat harus segera ditangani 2
4 1
- Ada masalah, tetapi tidak perlu segera ditangani 1
- Masalah tidak dirasakan 0
Total skor
 Dx. kep : ......................................................................................................................................
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No. Kriteria Skor Bobot Nilai Pembenaran

Sifat masalah
- Tidak/kurang sehat 3
1 1
- Ancaman kesehatan 2
- Keadaan sejahtera 1
Kemungkinan masalah dapat diubah
- Mudah 2
2 2
- Sebagian 1
- Tidak dapat 0
Potensial masalah untuk dicegah
- Tinggi 3
3 1
- Cukup 2
- Rendah 1
Menonjolnya masalah
- Masalah berat harus segera ditangani 2
4 1
- Ada masalah, tetapi tidak perlu segera ditangani 1
- Masalah tidak dirasakan 0
Total skor

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

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No. Kriteria Skor Bobot Nilai Pembenaran

Sifat masalah
- Tidak/kurang sehat 3
1 1
- Ancaman kesehatan 2
- Keadaan sejahtera 1
Kemungkinan masalah dapat diubah
- Mudah 2
2 2
- Sebagian 1
- Tidak dapat 0
Potensial masalah untuk dicegah
- Tinggi 3
3 1
- Cukup 2
- Rendah 1
Menonjolnya masalah
- Masalah berat harus segera ditangani 2
4 1
- Ada masalah, tetapi tidak perlu segera ditangani 1
- Masalah tidak dirasakan 0
Total skor

V. Prioritas Diagnosis Keperawatan

Prioritas Diagnosis Keperawatan Skor
 INTERVENSI KEPERAWATAN
Diagnosa Tujuan
No. Kriteria Standar Intervensi Evaluasi
Keperawatan Umum Khusus
 IMPLEMENTASI DAN EVALUASI
Tanggal No. DP Implementasi Evaluasi Paraf