KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGI

FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA

PROGRAM STUDI ILMU KEPERAWATAN
Jalan PB Sudirman 80232 Denpasar Tlp (0361) 222510 Fax. (0361) 246656

FORMAT PENGKAJIAN KEPERAWATAN KELUARGA

I. DATA UMUM KELUARGA

1. Identitas Kepala keluaga

Nama :
Umur :
Agama :
Suku :
Pendidikan :
Alamat :
No. Telepon :
 2. Komposisi keluarga

Hub dgn
No Nama L/P Umur
KK
Pendidikan Pekerjaan Keterangan
1
2
3
4
5
6
7
8
9
10

3. Genogram

4. Tipe keluarga
1) Jenis tipe keluarga.
2) Masalah yang terjadi dengan tipe tersebut
..
..
5. Suku Bangsa
1) Asal suku bangsa......
2) Budaya yang berhubungan dengan kesehatan..
..
6. Agama
Kepercayaan yang mempengaruhi kesehatan.

7. Status sosial ekonomi keluarga
1). Anggota keluarga yang mencari nafkah...
2). Penghasilan...
..
 3). Upaya lain untuk menambah penghasilan
..
4). Kebutuhan yang dikeluarkan setiap bulan
..
5). Harta benda yang dimiliki (perabot, transportasi dll)...
..
6). Tabungan khusus kesehatan.........................................................................................
......................................................................................................................................
8. Aktifitas rekreasi keluarga..................................................................................................
............................................................................................................................................

II. RIWAYAT DAN TAHAP PERKEMBANGAN KELUARGA

1. Tahap perkembangan keluarga saat ini (ditentukan dengan anak tertua):..........................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
2. Tahap perkembangan keluarga yang belum terpenuhi dan kendalanya.............................
............................................................................................................................................
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............................................................................................................................................
............................................................................................................................................
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3. Riwayat keluarga inti:
1). Riwayat terbentuknya keluarga inti.............................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
2). Riwayat kesehatan keluarga saat ini............................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 3). Riwayat kesehatan masing-masing anggota keluarga
Imunisasi
Keadaan Masalah Tindakan yang
No Nama Umur BB/TB
(BCG/Polio/DPT/HB/
kesehatan kesehatan telah dilakukan
Campak)

4). Sumber pelayanan kesehatan yang dimanfaatkan........................................................

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

III. DATA LINGKUNGAN

1. Karakteristik rumah
1). Luas rumah...................................................................................................................
2). Tipe rumah....................................................................................................................
3). Kepemilikan..................................................................................................................
4). Jumlah dan rasio kamar/ruangan..................................................................................
5). Ventilasi dan jendela.....................................................................................................
6). Pemanfaatan ruangan....................................................................................................
7). Septic tank: ada/tidak..............letak..............................................................................
8). Sumber air minum........................................................................................................
9). Kamar mandi/WC.........................................................................................................
10).Sampah............................................limbah RT............................................................
11).Kebersihan lingkungan.................................................................................................
......................................................................................................................................
 12).Denah rumah

2. Karakteristik tetangga dan komunitas tempat tinggal

1). Lingkungan fisik..........................................................................................................
......................................................................................................................................
2). Kebiasaan.....................................................................................................................
......................................................................................................................................
3). Aturan atau kesepakatan penduduk setempat...............................................................
......................................................................................................................................
4). Budaya setempat yang mempengaruhi kesehatan........................................................
......................................................................................................................................
3. Mobilitas geografis keluarga..............................................................................................
............................................................................................................................................
4. Perkumpulan keluarga dan interaksi dengan masyarakat
1). Waktu untuk berkumpul...............................................................................................
2). Perkumpulan yang ada.................................................................................................
3). Interaksi keluarga dengan masyarakat..........................................................................
5. Sistem pendukung keluarga................................................................................................
............................................................................................................................................
IV. STRUKTUR KELUARGA
1. Pola komunikasi keluarga...................................................................................................
............................................................................................................................................
............................................................................................................................................
2. Struktur kekuatan keluarga.................................................................................................
............................................................................................................................................
............................................................................................................................................
3. Struktur peran.....................................................................................................................
............................................................................................................................................
............................................................................................................................................
4. Nilai dan norma keluarga yang berkaitan dengan kesehatan.............................................
............................................................................................................................................
............................................................................................................................................

V. FUNGSI KELUARGA
1. Fungsi afektif
1). Perasaan saling memiliki..............................................................................................
2). Dukungan terhadap anggota keluarga..........................................................................
3). Kehangatan...................................................................................................................
4). Saling menghargai........................................................................................................
2. 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.................................................................................
3. Fungsi perawatan kesehatan
1). Pengetahuan dan persepsi keluarga tentang penyakit/masalah kesehatan keluarganya
......................................................................................................................................
......................................................................................................................................
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......................................................................................................................................
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 ......................................................................................................................................
......................................................................................................................................
2). Kemampuan keluarga mengambil keputusan tindakan kesehatan yang tepat
......................................................................................................................................
......................................................................................................................................
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......................................................................................................................................
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......................................................................................................................................
3). Kemampuan keluarga merawat anggota keluarga yang sakit.
......................................................................................................................................
......................................................................................................................................
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4). Kemampuan keluarga memelihara lingkungan rumah yang sehat
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
5). Kemampuan keluarga menggunakan fasilitas kesehatan di masyarakat
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
4. Fungsi reproduksi
 1). Perencanaan jumlah anak..............................................................................................
2). Akseptor: Ya.......................yang digunakan.......................lamanya............................
3). Akseptor: Belum..................alasannya.........................................................................
4). Keterangan lain.............................................................................................................
5. Fungsi ekonomi
1). Upaya pemenuhan sandang pangan..............................................................................
2). Pemanfaatan sumber di masyarakat..............................................................................

VI. STRES DAN KOPING KELUARGA

1. Stresor jangka pendek.........................................................................................................
2. Stresor jangka panjang........................................................................................................
3. Respon keluarga terhadap stresor.......................................................................................
4. Strategi koping....................................................................................................................
5. Strategi adaptasi disfungsional...........................................................................................

VII. PEMERIKSAAN FISIK

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

Pemeriksaan Nama Anggota Keluarga

Vital Sign

BB, TB/PB

Kepala

Mata

Hidung

Telinga

Mulut

Leher

Pemeriksaan Nama Anggota Keluarga

Thorak

Abdomen

Tangan
Kaki

Genitalia

VIII. HARAPAN KELUARGA

1. Terhadap masalah kesehatan
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
2. Terhadap petugas kesehatan yang ada
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
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............................................................................................................................................
............................................................................................................................................

Denpasar, 17 Oktober 2017

Made Aryawa Putra

NIM. 1502116005

FORMAT ANALISA DATA

 ASUHAN KEPERAWATAN KELUARGA

Nama mahasiswa :...............................................................................

Tanggal analisa :...............................................................................

No Tanggal Data Diagnosa Keperawatan

1. Data Subjektif:

Data Objektif:

FORMAT SKORING/ PRIORITAS

 DIAGNOSIS KEPERAWATAN KELUARGA

Diagnosa Keperawatan: ...................................................................................................................

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

Kriteria Nilai Bobot Skoring Pembenaran

Sifat masalah:
Aktual 3 1
Resiko 2
Potensial 1
Kemungkinan masalah
untuk diubah
Mudah 2
Sebagian 1 2
Tidak dapat 0
Potensial masalah
untuk dicegah
Tinggi 3 1
Cukup 2
Rendah 1
Menonjolnya masalah
Segera diatasi 2
Tidak segera 1 1
diatasi
Tidak dirasakan 0
adanya masalah
TOTAL

FORMAT INTERVENSI
 ASUHAN KEPERAWATAN KELUARGA

Nama mahasiswa :.................................................................

Tanggal :.................................................................

No Diagnosa Tujuan Kriteria Evaluasi Intervensi

Keperawatan Panjang Pendek Kriteria Standar
No Diagnosa Tujuan Kriteria Evaluasi Intervensi
Keperawatan Panjang Pendek Kriteria Standar

No Tujuan Kriteria Evaluasi Intervensi

 Diagnosa Panjang Pendek Kriteria Standar
Keperawatan
 FORMAT IMPLEMENTASI
ASUHAN KEPERAWATAN KELUARGA

Nama mahasiswa :.................................................................

No Diagnosa Tanggal Implementasi Paraf

Keperawatan
No Diagnosa Tanggal Implementasi Paraf
Keperawatan
No Diagnosa Tanggal Implementasi Paraf
Keperawatan
No Diagnosa Tanggal Implementasi Paraf
Keperawatan
 FORMAT EVALUASI
ASUHAN KEPERAWATAN KELUARGA

Nama mahasiswa :.................................................................

No Diagnosa Tanggal Evaluasi Paraf

Keperawatan

S:

O:

A:

P:
No Diagnosa Tanggal Evaluasi Paraf
Keperawatan

S:

O:

A:

P: