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LAPORAN ASUHAN KEPERAWATAN KELUARGA ..........
DISUSUN OLEH : Nama : ............................ NIM : ..............................
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA POLITEKNIK KESEHATAN PALANGKARAYA KELAS ... 2019
FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KELUARGA I.
DATA UMUM KELUARGA A. Kepala Keluarga Nama Kepala Keluarga
: ...............................................................
Jenis Kelamin
: ...............................................................
Umur
: ...............................................................
Alamat
: ...............................................................
Pekerjaan
: ...............................................................
Pendidikan
: ...............................................................
Agama
: ...............................................................
Suku/Bangsa
: ...............................................................
B. Daftar Anggota Keluarga No.
Nama
Jenis Hub. dg kelamin KK
TTL/Umur
Pendidikan
Pekerjaan
C. Genogram 3 (tiga) Generasi
D. Tipe Keluarga ........................................ ........................................ ........................................ ........................................ ........................................ ........................................
.................................... .................................... .................................... .................................... .................................... ....................................
............ ............ ............ ............ ............ ............
........................................ .................................... ............
E. Latar Belakang Keluarga 1. Latar Belakang Budaya Keluarga Dan Anggota Keluarga ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... .......
2. Bahasa Yang Digunakan ........................................ ........................................ ........................................ ........................................
.................................... .................................... .................................... ....................................
......... ......... ......... .........
3. Pengaruh Budaya Terhadap Kesehatan Keluarga ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... .......
B. Identifikasi Agama ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ...........
C. Status Kelas Sosial ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ...........
........................................ .................................... ........... ........................................ .................................... ...........
D. Pola Pemenuhan Kebutuhan Nutrisi Keluarga ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ........... ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ .
E. Rekreasi Keluarga dan Pemanfaatan Waktu Luang ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
II.
TAHAP PERKEMBANGAN DAN SEJARAH KELUARGA 1. Tahap Perkembangan dan Tugas Perkembangan Keluarga Saat Ini ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
2. Tugas Perkembangan yang Belum Terpenuhi ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
3. Riwayat Kesehatan Keluarga Inti ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ............................................ .................................... ........ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
4. Riwayat Kesehatan Keluarga Sebelumnya ........................................ .................................... ............
........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ............................................ .................................... ........ ........................................ .................................... ............
II.
DATA LINGKUNGAN 1. Karakteristik Rumah ( Disertai Denah Rumah dan Lingkungan Sekitar Rumah ) ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ............................................ .................................... ........ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
Denah Rumah dan Lingkungan Sekitar Rumah U B
T S
2. Karakteristik Tetangga Dan Komunitas ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
3. Mobilitas Geografis Keluarga . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....................................... .................................... ............. ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
Perkumpulan Keluarga Dan Interaksi Dengan Masyarakat ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
Sistem Pendukung Keluarga ........................................ .................................... ............ ........................................ .................................... ............
........................................ .................................... ............ ........................................ .................................... ............
III. STRUKTUR KELUARGA 1. Pola Komunikasi Keluarga ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
2. Struktur Kekuatan Keluarga ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
3. Struktur Peran ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
4. Nilai-Nilai Keluarga ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
IV. FUNGSI KELUARGA 1. Fungsi Afektif ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
2. Fungsi Sosialisasi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....................................... .................................... ............. ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
3. Fungsi Perawatan Kesehatan ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ............................................ .................................... ........ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ............................................ .................................... ........
4. Fungsi Reproduksi ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
V.
PEMERIKSAAN FISIK A.
....................................................................
Penampilan Umum
:
........................................ .................................... .............. ........................................ .................................... .............. ........................................ .................................... ..............
Pemeriksaan Tanda-Tanda Vital
:
........................................ .................................... .............. ........................................ .................................... .............. ........................................ .................................... ..............
Keluhan Yang Dirasakan Saat Ini ........................................ ........................................ ........................................ ........................................
Pemeriksaan Fisik ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................
: .................................... .................................... .................................... ....................................
.............. .............. .............. ..............
: .................................... .................................... .................................... .................................... .................................... .................................... .................................... .................................... .................................... .................................... .................................... ....................................
.............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. ..............
........................................ .................................... ..............
VI. HARAPAN KELUARGA ........................................ .................................... ................ ........................................ .................................... ................ ........................................ .................................... ................ ........................................ .................................... ................ ........................................ .................................... ................
......................................, ..................2019
Mahasiswa (.........................................................................) NIM
VII. ANALISA DATA No.
DATA SUBJEKTIF DAN OBJEKTIF
MASALAH KEPERAWATAN
VIII. PRIORITAS MASALAH 1. Diagnosa Keperawatan Keluarga : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................................................................................................................................... ...........................................................................................................................................
No. Kriteria 1. Sifat Masalah : 2.
Kemungkinan masalah Untuk Dirubah :
3.
Potensial Masalah Untuk Dicegah :
4.
Menonjolnya Masalah :
Perhitungan
Pembenaran
Skor Total B. Diagnosa
Keperawatan
Keluarga : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................................................ ............................................................................ ............................................................................ ..................................................................
No. Kriteria 1. Sifat Masalah : 2.
Kemungkinan masalah Untuk Dirubah :
3.
Potensial Masalah Untuk Dicegah :
Perhitungan
Pembenaran
4.
Menonjolnya Masalah :
Skor Total
IX. DAFTAR DIAGNOSA KEPERAWATAN KELUARGA SESUAI PRIORITAS 1.
........................................................................................................................................ . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................................................................................................................................ . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
2.
........................................................................................................................................ . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................................................................................................................................ . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
3.
........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ..
4.
........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ..
5.
........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ..
X. No.
RENCANA ASUHAN KEPERAWATAN KELUARGA Diagnosa Keperawatan Keluarga
Tujuan Umum
Format Asuhan Keperawata Keluarga
Tujuan Khusus
Evaluasi Kriteria
Standar
Intervensi
Hal. 16
XI. IMPLEMENTASI DAN EVALUASI KEPERAWATAN No.
Hari/Tanggal/Jam
Format Asuhan Keperawata Keluarga
Implementasi
Evaluasi
Hal. 17
DISUSUN OLEH : Nama : ............................ NIM : ..............................
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA POLITEKNIK KESEHATAN PALANGKARAYA KELAS ... 2019
FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KELUARGA I.
DATA UMUM KELUARGA A. Kepala Keluarga Nama Kepala Keluarga
: ...............................................................
Jenis Kelamin
: ...............................................................
Umur
: ...............................................................
Alamat
: ...............................................................
Pekerjaan
: ...............................................................
Pendidikan
: ...............................................................
Agama
: ...............................................................
Suku/Bangsa
: ...............................................................
B. Daftar Anggota Keluarga No.
Nama
Jenis Hub. dg kelamin KK
TTL/Umur
Pendidikan
Pekerjaan
C. Genogram 3 (tiga) Generasi
D. Tipe Keluarga ........................................ ........................................ ........................................ ........................................ ........................................ ........................................
.................................... .................................... .................................... .................................... .................................... ....................................
............ ............ ............ ............ ............ ............
........................................ .................................... ............
E. Latar Belakang Keluarga 1. Latar Belakang Budaya Keluarga Dan Anggota Keluarga ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... .......
2. Bahasa Yang Digunakan ........................................ ........................................ ........................................ ........................................
.................................... .................................... .................................... ....................................
......... ......... ......... .........
3. Pengaruh Budaya Terhadap Kesehatan Keluarga ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... ........ ........................................ .................................... .......
B. Identifikasi Agama ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ...........
C. Status Kelas Sosial ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ...........
........................................ .................................... ........... ........................................ .................................... ...........
D. Pola Pemenuhan Kebutuhan Nutrisi Keluarga ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ........... ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ .
E. Rekreasi Keluarga dan Pemanfaatan Waktu Luang ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
II.
TAHAP PERKEMBANGAN DAN SEJARAH KELUARGA 1. Tahap Perkembangan dan Tugas Perkembangan Keluarga Saat Ini ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
2. Tugas Perkembangan yang Belum Terpenuhi ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
3. Riwayat Kesehatan Keluarga Inti ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ............................................ .................................... ........ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
4. Riwayat Kesehatan Keluarga Sebelumnya ........................................ .................................... ............
........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ............................................ .................................... ........ ........................................ .................................... ............
II.
DATA LINGKUNGAN 1. Karakteristik Rumah ( Disertai Denah Rumah dan Lingkungan Sekitar Rumah ) ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ............................................ .................................... ........ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
Denah Rumah dan Lingkungan Sekitar Rumah U B
T S
2. Karakteristik Tetangga Dan Komunitas ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
3. Mobilitas Geografis Keluarga . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....................................... .................................... ............. ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
Perkumpulan Keluarga Dan Interaksi Dengan Masyarakat ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
Sistem Pendukung Keluarga ........................................ .................................... ............ ........................................ .................................... ............
........................................ .................................... ............ ........................................ .................................... ............
III. STRUKTUR KELUARGA 1. Pola Komunikasi Keluarga ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
2. Struktur Kekuatan Keluarga ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
3. Struktur Peran ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
4. Nilai-Nilai Keluarga ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
IV. FUNGSI KELUARGA 1. Fungsi Afektif ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
2. Fungsi Sosialisasi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....................................... .................................... ............. ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
3. Fungsi Perawatan Kesehatan ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ............................................ .................................... ........ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ............................................ .................................... ........
4. Fungsi Reproduksi ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............ ........................................ .................................... ............
V.
PEMERIKSAAN FISIK A.
....................................................................
Penampilan Umum
:
........................................ .................................... .............. ........................................ .................................... .............. ........................................ .................................... ..............
Pemeriksaan Tanda-Tanda Vital
:
........................................ .................................... .............. ........................................ .................................... .............. ........................................ .................................... ..............
Keluhan Yang Dirasakan Saat Ini ........................................ ........................................ ........................................ ........................................
Pemeriksaan Fisik ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................
: .................................... .................................... .................................... ....................................
.............. .............. .............. ..............
: .................................... .................................... .................................... .................................... .................................... .................................... .................................... .................................... .................................... .................................... .................................... ....................................
.............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. ..............
........................................ .................................... ..............
VI. HARAPAN KELUARGA ........................................ .................................... ................ ........................................ .................................... ................ ........................................ .................................... ................ ........................................ .................................... ................ ........................................ .................................... ................
......................................, ..................2019
Mahasiswa (.........................................................................) NIM
VII. ANALISA DATA No.
DATA SUBJEKTIF DAN OBJEKTIF
MASALAH KEPERAWATAN
VIII. PRIORITAS MASALAH 1. Diagnosa Keperawatan Keluarga : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................................................................................................................................... ...........................................................................................................................................
No. Kriteria 1. Sifat Masalah : 2.
Kemungkinan masalah Untuk Dirubah :
3.
Potensial Masalah Untuk Dicegah :
4.
Menonjolnya Masalah :
Perhitungan
Pembenaran
Skor Total B. Diagnosa
Keperawatan
Keluarga : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................................................ ............................................................................ ............................................................................ ..................................................................
No. Kriteria 1. Sifat Masalah : 2.
Kemungkinan masalah Untuk Dirubah :
3.
Potensial Masalah Untuk Dicegah :
Perhitungan
Pembenaran
4.
Menonjolnya Masalah :
Skor Total
IX. DAFTAR DIAGNOSA KEPERAWATAN KELUARGA SESUAI PRIORITAS 1.
........................................................................................................................................ . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................................................................................................................................ . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
2.
........................................................................................................................................ . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................................................................................................................................ . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
3.
........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ..
4.
........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ..
5.
........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ..
X. No.
RENCANA ASUHAN KEPERAWATAN KELUARGA Diagnosa Keperawatan Keluarga
Tujuan Umum
Format Asuhan Keperawata Keluarga
Tujuan Khusus
Evaluasi Kriteria
Standar
Intervensi
Hal. 16
XI. IMPLEMENTASI DAN EVALUASI KEPERAWATAN No.
Hari/Tanggal/Jam
Format Asuhan Keperawata Keluarga
Implementasi
Evaluasi
Hal. 17
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