ASUHAN KEPERAWATAN KELUARGA PADA ………

I. PENGKAJIAN

A. DATA UMUM1. Nama KK (inisial) : ………………………2. Umur : ………………………3. Pendidikan : ………………………4. Pekerjaan : ………………………5. Alamat : ………………………6. Komposisi Keluarga

NO NAMA (INISIAL)

UMUR JENISKELAMIN

HUB DGN KK

PENDD PEKERJAAN

7. Genogram

8. Tipe Keluarga : ..............................................................

9. Budaya : .......................................................................................................

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10. Agama : .......................................................................................................

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11. Status Sosial ekonomi Klg : ...........................................................................................

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12. Aktivitas Rekreasi atau Waktu Luang : ............................................................................

B. RIWAYAT DAN TAHAP PERKEMBANGAN KELUARGA

13. Tahap Perkembangan Keluarga Saat Ini : .................................................................

14. Tugas Perkembangan Keluarga Yang Belum Terpenuhi : ...............................................

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15. Riwayat kesehatan Keluarga Inti

a. Riwayat Penyakit Keturunan : .................................................................................................................................

b. Riwayat kesehatan Masing-masing Anggota Keluarga :

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16. Riwayat Keluarga Sebelumnya :

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C. LINGKUNGAN17. Karakteristik Rumah

- Denah Rumah

- Status Rumah : ......................................................................................................

- Tipe Rumah : ......................................................................................................

- Luas Rumah/ : .....................................................................................................

Keadaan ......................................................................................................

- Kebersihan& pencahayaan : .........................................................................................

18. Karakteristik Tetangga dan Komunitas : ..........................................................................

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19..Mobilitas Geografis Keluarga : .......................................................................................

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20. Perkumpulan Keluarga dan Interaksi dengan Masyarakat : .............................................

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21. Sistem Pendukung Keluarga : ..........................................................................................

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D. STRUKTUR KELUARGA

22. Pola Komunikasi Keluarga : …………………………………………………………….

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23. Struktur Kekuatan Kelurga : …………………………………………............................

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24. Struktur Peran : ............................................................................................

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25. Nilai dan Norma Keluarga : ..............................................................................................

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E. FUNGSI KELUARGA

26. Fungsi Afektif : ................................................................................................................

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27. Fungsi Sosialisasi : ............................................................................................................

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28. Fungsi Perawatan Kesehatan (Data Spesifik)

a. Kemampuan Mengenal Masalah Kesehatan :

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b. Kemampuan Mengambil Keputusan Untuk Melakukan Tindakan :

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b. Kemampuan Melakukan Pearawatan Terhadap Anggota Keluarga Yang Sakit :

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d. Kemampuan Menciptakan Lingkungan Yang Dapat Meningkatkan Kesehatan :

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e. Kemampuan Keluaraga Memanfaatkan Fasilitas Kesehatan Yang Ada :

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F. STRES DAN KOPING KELUARGA :.................................................................................................................................................

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G. HARAPAN KELUARGA TERHADAP PERAWAT BERHUBUNGAN DENGAN MASALAH YANG DIHADAPI...................................................................................................................................................

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H. PEMERIKSAAN FISIK (HEAD TO TOES)

ANGGOTA KLGKEPALA

LEHER

DADA

ABDOMEN

EXTRENITAS

DATA TAMBAHAN

1. Tanda-tanda vital :

ANALISA DATA

NO HARI/TGL DATA DIAGNOSA KEP

II. DIAGNOSA KEPERAWATAN

1. ……………………………………………………………………………………………..

2. ………………………………………………………………………………………………

III. RENCANA KEPERAWATAN

Diagnosa Keperawatan

Tujuan Evaluasi Rencana TindakanUmum Khusus Kriteria Standar

IV. IMPLEMENTASI DAN EVALUASI FORMATIF

NO TGL DX KEPERAWATAN IMPLEMENTASI EVALUASI FORMATIF TTD

V. EVALUASI SUMATIF

NO TGL DX KEP EVALUASI SUMATIF