Format Pengkajian Keperawatan Keluarga [PDF]

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FORMAT PENGKAJIAN KEPERAWATAN KELUARGA



A. DATA UMUM 1. Nama Kepala keluarga :



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



2. Umur : 3. Pendidikan



:



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



4. Jenis kelamin



:



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



5. Pekerjaan



:



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



6. Alamat Rumah



:



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



7. Komposisi keluarga



:



No



Nama



Umur



JK



Pendidikan



8. Riwayat kesehatan keluarga Susunan anggota keluarga Genogram : ( 3 generasi)



Pekerjaan



Hub. dg KK



9. Tipe keluarga :



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



10. Suku bangsa :



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



11. Agama



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



:



12. Status sosial ekonomi a. Pendapatan KK perbulan : ..................................................................... b. Pendapatan tambahan



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



c. Biaya yang dikeluarkan keluarga perbulan : ........................................... d. Barang-barang yang dimiliki keluarga : ................................................... e. Tabungan dan biaya kesehatan keluarga : ............................................. 13. Aktivitas rekreasi keluarga a. Tempat :



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



b. Jenis



:



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



c. Waktu



:



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



B. RIWAYAT DAN TAHAP PERKEMBANGAN KELUARGA 14. Tahap perkembangan keluarga saat ini (dilihat dari anak tertua) ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... 15. Tahap perkembangan keluarga yang belum terpenuhi ....................................................................................................................... .......................................................................................................................



....................................................................................................................... Kendala : ....................................................................................................................... ....................................................................................................................... .......................................................................................................................



16. Riwayat kesehatan keluarga inti



No



Penyakit Keturunan



Nama



Keadaan 6 bln terakhir Sehat



Sakit



Pelayanan kesehatan yg digunakan



Masalah kesehatan keluarga yang menonjol saat ini : ....................................................................................................................... ....................................................................................................................... .......................................................................................................................



C. KEBIASAAN ANGGOTA KELUARGA SEHARI-HARI 17. Nutrisi a. Frekwensi makan : .................................................................................. b. Jenis makanan-makanan pokok : 1) Lauk pauk



:



2) Sayur-mayur : 3) Buah-buahan : 4) Lain-lain



:



c. Makanan selingan : .................................................................................. d. Makanan pantangan : .............................................................................. e. Cara mengelola makanan : ......................................................................



f.



Cara menyajikan makanan : ....................................................................



g. Masalah dalam pemenuhan kebutuhan nutrisi keluarga : ................................................................................................................. ................................................................................................................. ................................................................................................................. 18. Pola istirahat : a. Waktu istirahat/tidur : .............................................................................. b. Lama istirahat atau tidur : ........................................................................ c. Masalah dalam pemenuhan kubutuhan istirahat dan tidur : ..................... ................................................................................................................. ................................................................................................................. ................................................................................................................. 19. Pola eliminasi a. BAB : b. BAK : c. Masalah-masalah dalam pemenuhan kebutuhan eliminasi : .................... ................................................................................................................. ................................................................................................................. ................................................................................................................. 20. Aktivitas olah raga a. Apakah keluarga senang olah raga : ....................................................... b. Jenis olah raga : ...................................................................................... c. Kapan olah raga biasa dilakukan : ...........................................................



21. Hygiene keluarga : a. Kebiasaan mandi : ................................................................................... b. Menggosok gigi : .....................................................................................



c. Kebiasaan mencuci rambut : ................................................................... d. Kebiasaan mengganti pakaian : .............................................................. e. Masalah higiene keluarga : ..................................................................... ................................................................................................................. .................................................................................................................



D. PENGKAJIAN LINGKUNGAN 22. Perumahan a. Jenis bangunan : ..................................................................................... b. Jenis lantai : ............................................................................................. c. Jumlah ruangan : .................................................................... (Jelaskan) d. Ventilasi ruangan : ................................................................................... e. Denah rumah : .........................................................................................



23. Sarana air bersih a. Sumber air minum keluarga : ................................................................... b. Jarak sumber air minim denan septiktank : .............................................. c. Keadaan fisik air yang digunakan : .......................................................... d. Lain-lain : ................................................................................................. .................................................................................................................



24. Air limbah



a. Tempat pebuangan limbah keluarga : ...................................................... b. Apakah pembuangan air limbah sesuai dengan syarat kesehatan : ................................................................................................................. c. Lain – lain : .............................................................................................. ................................................................................................................. 25. Pengelolaan sampah a. Tempat pembuanan sampah keluarga : ................................................... b. Kondisi sampah (TERBUKA / TERTUTUP) : ........................................... c. Pengelolaan sampah rumah tangga : ...................................................... 26. Jamban/ WC keluarga yang digunakan a. Jenis WC keluarga yang digunakan : ....................................................... b. Status jamban/ WC yang digunakan : ...................................................... c. Apakah jamban/ WC yang digunakan sesuai dengan syarat kesehatan : ................................................................................................................. d. Lain – lain : .............................................................................................. ................................................................................................................. 27. Kandang ternak a. Apakah keluarga mempunyai kandang ternak : ....................................... b. Jarak kandang ternak dengan rumah : ..................................................... c. Kebersihan kandang ternak : ................................................................... d. Lain – lain : .............................................................................................. 28. Karakteristik tetangga dan komunitas RW a. Lingkungan fisik sekitar : .......................................................................... b. Apakah ada aturan/kesepakatan penduduk setempat : .......................... ................................................................................................................. c.



Budaya setempat yang mempengaruhi kesehatan : ............................... .................................................................................................................



E. STRUKTUR KELUARGA 29. Pola komunikasi keluarga : ............................................................................ ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... 30. Struktur kekuatan keluarga : .......................................................................... ....................................................................................................................... ....................................................................................................................... 31. Pembagian peran dalam keluarga : ............................................................... ....................................................................................................................... ....................................................................................................................... 32. Nilai / Norma yang dianut keluarga : .............................................................. ....................................................................................................................... .......................................................................................................................



F. FUNGSI KELUARGA 33. Fungsi afektif : ............................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... 34. Fungsi reproduksi : ........................................................................................ ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... 35. Fungsi sosialisasi : ......................................................................................... ....................................................................................................................... .......................................................................................................................



....................................................................................................................... 36. Fungsi ekonomi : .......................................................................................... ....................................................................................................................... ....................................................................................................................... .......................................................................................................................



37. Fungsi perawatan kesehatan (termasuk pengkajian lima tugas kesehatan keluarga: Kemampuan keluarga mengenal masalah: ...................................................................................................................... ....................................................................................................................... ....................................................................................................................... Kemampuan keluarga mengambil keputusan: ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... Kemampuan keluarga merawat anggota keluarga yang sakit: ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... Kemampuan keluarga memodifikasi lingkungan rumah: ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... Kemampuan keluarga memanfaatkan fasilitas yankes: ....................................................................................................................... .......................................................................................................................



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



G. STRES DAN KOPING KELUARGA 38. Stressor jangka panjang dan jangka pendek : ............................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... 39. Strategi koping yang digunakan : ................................................................... ....................................................................................................................... ....................................................................................................................... .......................................................................................................................



H. PENGKAJIAN FISIK SETIAP ANGGOTA KELUARGA N O 1



ASPEK PENGKAJIAN Penampilan umum (tingkat kesadaran, BB, TB, IMT, TD, Nadi, Suhu,



2



Frekuensi Napas) Kepala dan Wajah



3



Leher



4



Dada



5



Abdomen



HASIL PENGKAJIAN



N O



ASPEK PENGKAJIAN



6



Genitalia



7



Punggung



8



Ekstremitas atas dan bawah



HASIL PENGKAJIAN



40. Harapan keluarga ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... 41. Catatan tambahan ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... .......................................................................................................................



Yang Melakukan Pengkajian



(



)



NIM.



ANALISIS DATA NAMA KK : ....................................................................... ALAMAT : ....................................................................... HARI/ TGL : ....................................................................... NO



DATA



DIAGNOSIS KEPERAWATAN



PRIORITAS MASALAH NAMA KK ALAMAT HARI/ TGL DIAGNOSIS KEPERAWATAN



1.



2.



3.



4.



: : : :



Kriteria Ada/ tidaknya masalah Skala: Defisit (aktual) Ancaman (risiko) Krisis yang akan datang Kondisi masalah untuk diubah Skala: Mudah untuk diubah Sebagian mudah untuk diubah Tidak dapat diubah Potensial masalah untuk dicegah Skala: Tinggi Sedang Rendah Menonjolnya masalah Skala: Masalah butuh perhatian segera Masalah tidak butuh perhatian segera Tidak dianggap sebagai masalah yang membutuhkan perubahan



Total skor



....................................................................... ....................................................................... ....................................................................... ....................................................................... Skor



Bobot



3 2 1



1



2 1 0



2



3 2 1



1



2



1



 



 



1 0



3



Pembenaran



DIAGNOSIS KEPERAWATAN NAMA KK ALAMAT HARI/ TGL NO



DIAGNOSIS KEPERAWATAN



: ....................................................................... : ....................................................................... : ....................................................................... TUJUAN (NOC)



INTERVENSI (NIC)



IMPLEMENTASI DAN EVALUASI NAMA KK ALAMAT HARI/TGL /JAM



: ....................................................................... : ....................................................................... DIAGNOSIS KEPERAWATAN



IMPLEMENTASI



EVALUASI