PROGRAM PROFESI NERS

FAKULTAS ILMU KEPERAWATAN

UNIVERSITAS MUHAMMADIYAH JAKARTA
Jl. Cempaka Putih Tengah I/I Jakarta, Telp/Fax : 021-42802202

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KELUARGA

PENGKAJIAN
Data Umum
1. Nama KK :
2. Usia :
3. Pendidikan :
4. Pekerjaan :
5. Alamat :
6. Komposisi Anggota Keluarga

Jenis Hub.dgn Status

NO Nama (Inisial) TTL/Umur Pendidikan Pekerjaan
Kelamin KK Imunisasi

Genogram :

Keterangan Genogram :
: Perempuan: Laki-Laki

: Meninggal : Cerai/ putus Hubungan

: Tinggal satu rumah : Garis Pernikahan

: Klien
: Garis Keturunan
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 7. Tipe Keluarga
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8. Suku :
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9. Agama :
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10. Status Sosial Ekonomi Keluarga

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11. Aktivitas dan Rekreasi Keluarga

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Riwayat & Tahap Perkembangan Keluarga

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 12. Tahap Perkembangan Keluarga Saat ini
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13. Tahap Perkembangan Keluarga yang Belum Terpenuhi

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14. Riwayat Keluarga Inti

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 15. Riwayat Keluarga Sebelumnya
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III. Lingkungan
16. Karakteristik Rumah (Termasuk Denah Rumah )
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17. Karakteristik Tetangga dan Komunitas
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 18. Mobilitas Geografis Keluarga
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19. Perkumpulan keluarga dan interaksi dengan masyarakat
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20. Sistem Pendukung Keluarga
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IV. Struktur Keluarga

21. Pola Komunikasi Keluarga
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 22. Struktur Kekuatan Keluarga
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23. Struktur Peran
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24. Nilai dan Norma Budaya
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V. Fungsi Keluarga
25. Fungsi Afektif
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 26. Fungsi Sosialisasi
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27. Fungsi Perawatan Kesehatan
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 VI. Stresor dan Koping Keluarga
28. Stresor Jangka Pendek
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29. Kemampuan Keluarga Berespon Terhadap Masalah
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30. Strategi Koping yang digunakan
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31. Strategi Adaptasi Disfungsional
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32. Pemeriksaan Head To Toe (Terlampir )

VII. Harapan Keluarga Terhadap Asuhan Keperawatan Keluarga

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 ANALISA DATA

No Data Masalah Keperawatan

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 SKORING

Masalah Keperawatan
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No Skor Bobot Nilai Pembenaran
1. Sifat Masalah
Tidak/Kurang Sehat 3
1
Ancaman Kesehatan 2
Krisis dan Keadaan Sejahtera 1
2. Kemungkinan Masalah Dapat Di
Ubah :
2 2
Mudah
1
Hanya Sebagian
0
Tidak Dapat
3. Potensi Masalah Dapat Dicegah:
Tinggi 3
1
Cukup 2
Rendah 1
4. Menonjolnya Masalah :
Harus segera ditangani 2
1
Tidak perlu segera ditangani 1
Masalah tidak dirasakan 0
Jumlah
Masalah Keperawatan
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No Skor Bobot Nilai Pembenaran
1. Sifat Masalah
Tidak/Kurang Sehat 3
1
Ancaman Kesehatan 2
Krisis dan Keadaan Sejahtera 1
2. Kemungkinan Masalah Dapat Di
Ubah :
2 2
Mudah
1
Hanya Sebagian
0
Tidak Dapat
3. Potensi Masalah Dapat Dicegah:
Tinggi 3
1
Cukup 2
Rendah 1
4. Menonjolnya Masalah : 1

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 Harus segera ditangani 2
Tidak perlu segera ditangani 1
Masalah tidak dirasakan 0
Jumlah

Masalah Keperawatan
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No Skor Bobot Nilai Pembenaran
1. Sifat Masalah
Tidak/Kurang Sehat 3
1
Ancaman Kesehatan 2
Krisis dan Keadaan Sejahtera 1
2. Kemungkinan Masalah Dapat Di
Ubah :
2 2
Mudah
1
Hanya Sebagian
0
Tidak Dapat
3. Potensi Masalah Dapat Dicegah:
Tinggi 3
1
Cukup 2
Rendah 1
4. Menonjolnya Masalah :
Harus segera ditangani 2
1
Tidak perlu segera ditangani 1
Masalah tidak dirasakan 0
Jumlah

Daftar Prioritas Diagnosa Keperawatan (Sesuai dengan Hasil Skoring)

1.
2.
3.
4.
5.

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NO Diagnosa Keperawatan Tujuan Umum Tujuan Khusus Kriteria

Diagnosa Tanda
No Implementasi Evaluasi (SOAP)
Kep Tangan

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 NO JENIS PEMERIKSAAN NAMA ANGGOTA KELUARGA

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1. TB/ BB TB : BB : TB : BB : TB : BB
2. Tanda-tanda Vital TD : mmhg TD : mmhg TD :
HR : x/menit HR : x/menit HR :
RR : x/menit RR : x/menit RR :
0 0
S: C S: C S:
3. Rambut

4. Kepala

5. Mata

6. Hidung

7. Telinga

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8. Mulut

9. Leher

10. Dada, Jantung, Paru-

Paru

11. Abdomen

12. Ekstremitas

13. Integumen

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