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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