Keluarga Binaan (ASKEP LENGKAP)

FORMAT ASUHAN KEPERAWATAN KELUARGA

I. FORMAT PENGKAJIAN KELUARGA

A. Data umum

1. Nama KK :……………………………………
2. Umur KK : ……………………………………
3. Alamat : ……………………………………
4. No. Telephon : ……………………………………
5. Pekerjaan : ……………………………………
6. Pendidikan: ……………………………………
7. Susunan Anggota Keluarga :
Sex Hub Gol Masalah
No Nama Umur Pendidikan Pekerjaan
(L/P) Dg KK Darah Kesehatan

Genogram ( dibuat 3 generasi )

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

9. Latar belakang kebudayaan (etnik)

..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
 10. Identifikasi religius
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
11. Status kelas sosial
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
12. Mobilitas kelas sosial
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
13. Aktivitas Rekreasi Keluarga
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
B. Riwayat Keluarga dan Tahap Perkembangan

14. Tahap perkembangan keluarga saat ini

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

15. Tahap perkembangan keluarga yang belum terpenuhi

..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
 16. Riwayat keluarga inti
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................

17. Riwayat keluarga asal

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

C. Data Lingkungan

18. Karakteristik rumah

Denah rumah

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

19. Karakteristik lingkungan tempat tinggal dan masyarakat

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

20. Mobilitas geografis keluarga

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

21. Hubungan sosial keluarga dengan masyarakat

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

D. Struktur Keluarga

22. Pola dan Komunikasi Keluarga

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

23. Struktur Kekuatan

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

24. Struktur Peran

..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
 25. Nilai-Nilai Keluarga
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................

E. Fungsi Keluarga

26. Fungsi Afektif

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

27. Fungsi Sosialisasi

..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
28. Fungsi Perawatan Kesehatan
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................

29. Terapi Komplementer dan Alternatif

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

30. Sumber Pembiayaan

..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
F. Stress dan Koping Keluarga

31. Stressor jangka pendek

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

32. Stressor jangka panjang

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

33. Strategi koping keluarga

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

34. Adaptasi keluarga

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

G. Harapan Keluarga
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
................................................................................................................
H. Pemeriksaan Fisik

No Jenis pemeriksaan ayah ibu Anak 1 Anak 2 Anak 3

1. TTV :
Tensi :
Suhu :
Nadi :
Nafas :
2. Kulit, rambut dan
kuku.
I :
P:
P:
A:
3. Kepala, leher
I :
P:
P:
A:
4. Thoraks dan paru
I :
P:
P:
A:
5. Abdomen
I :
P:
P:
A:
6. Genitalia
I :
P:
P:
A:
7. Ekstremitas atas +
refleks fisiologis
I :
P:
P:
A:
8. Ekstremitas bawah
+
refleks fisiologis
I :
P:
P:
A:
 II. ANALISA DATA

Data Masalah Keperawatan

Data Subyektif: …………………………………
 ........................................
 ........................................

Data Obyektif:
 ........................................
 ........................................

III. DIAGNOSA KEPERAWATAN

a. Prioritas Masalah
Kriteria Perhitungan Skor Pembenaran
Sifat Masalah :

Kemungkinan masalah
dapat diubah :

Potensial masalah
dapat dicegah :

Menonjolnya masalah :
Total

b. Daftar Diagnosa berdasarkan prioritas

IV. RENCANA INTERVENSI KEPERAWATAN KELUARGA

No Diagnosa Tujuan Tujuan Kriteria Evaluasi Rencana Tindakan
Keperawatan Umum Khusus Kriteria Standar
Keluarga
1
 V. CATATAN PERKEMBANGAN
No Diagnosa Implementasi Evaluasi Tgl/ TT
Keperawatan
TUK 1 : S:
............................................ O:
A:
TUK 2 : P:
............................................

VI. EVALUASI AKHIR/TERMINASI

KRITERIA KEMANDIRIAN KELUARGA

Kesimpulan

1. Menerima petugas puskesmas □ Kemandirian I : Jika memenuhi

kriteria 1&2
2. Menerima yankes sesuai rencana
□ Kemandirian II : jika memenuhi
3. Menyatakan maslaah kesehatan secara benar kriteria 1 s.d 5
4. Memanfaatkan faskes sesuai anjuran □ Kemandirian III : jika
memenuhi kriteria 1 s.d 6
5. Melaksanakan perawatan sederhana sesuai anjuran
□ Kemandirian IV : Jika
6. Melaksanakan tindakan pencegahan secara aktif memenuhi kriteria 1 s.d 7
7. Melaksanakan tindakan promotif secara aktif
 Keluarga Resume

FORMAT ASUHAN KEPERAWATAN KELUARGA

1. Pengkajian

1. Nama KK :……………………………………
2. Umur KK : ……………………………………
3. Alamat : ……………………………………
4. No. Telephon : ……………………………………
5. Pekerjaan : ……………………………………
6. Pendidikan : ……………………………………
7. Susunan Anggota Keluarga :
Sex Hub Gol Masalah
No Nama Umur Pendidikan Pekerjaan
(L/P) Dg KK Darah Kesehatan

Genogram ( dibuat 3 generasi )

Analisa Data
Data Diagnosis Keperawatan
Data Subyektif: …………………………………
 ........................................
 ........................................

Data Obyektif:
 ........................................
 ........................................
Lima Tugas Kesehatan keluarga
1. ................................
 ........................................
2. ................................
 .......................................

Dst,.....
 Tuliskan data keluarga yang teridentifikasi pada hari kunjungan (here and now) sampai
dengan menggali persepsi keluarga tentang lima tugas kesehatan keluarga terkait masalah
yang teridentifikasi. Apala tidak ditemukan data here and now, maka lakukan pengkajian
sesuai dengan fungsi-fungsi keluarga dan struktur keluarga.

2. Diagnosis Keperawatan
Tuliskan diagnosis keperawatan yang muncul dari analisa data (here and now)

3. Rencana Intervensi
Sebutkan rencana intervensi untuk menyelesaikan masalah (Sesuai NANDA NIC-NOC)
Tujuan Khusus ditulis secara detail sesuai prinsip SMART. Misal : keluarga dapat
menjelaskan kembali manfaat dari teknik relaksasi otot progresif yaitu ……..

4. Implementasi
Sebutkan secara detail kegiatan yang akan dilakukan mahasiswa bersama keluarga untuk
menyelesaikan masalah keperawatan yang muncul sesuai dengan tujuan khusus yang sudah
direncanakan

5. Evaluasi
S : ……………..
O : ……………..
A : ……………..
P : ……………..
I : ……………..
E : …………….
R : ……………..
 Format Laporan Pendahuluan (Untuk Ujian Keluarga)

LAPORAN PENDAHULUAN
ASUHAN KEPERAWATAN KELUARGA …………

Kunjungan ke : ……………………………. Tanggal : ………………

1. Latar Belakang
Tuliskan secara deskriptif gambaran mengenai keluarga yang akan diberikan intervensi
melipti point-point sebagai berikut :
a. Karakteristik keluarga  tuliskan data keluarga, baik yang adaptif maupun
maladaptive, yang menjadi dasar/justifikasi kenapa harus dilakukan kunjungan
tersebut.
b. Data yang perlu dikaji lebih lanjut  tuliskan data-data yang mungkin perlu dikaji
lebih lanjut/ ditambahkan untuk menegakkan diagnosis tersebut
c. Masalah keperawatan keluarga

2. Proses keperawatan
a. Diagnosis keperawatan keluarga
b. Tujuan Umum  merupakan tujuan khusus dari rencana intervensi yang akan
dicapai pada saat kunjungan
c. Tujuan khusus
Sebutkan secara detail sesuai dengan prinsip SMART , missal : keluarga dapat
menjelaskan kembali 3 dari 4 manfaat makanan sehat yaitu …………..

3. Implementasi dan Tindakan Keperawatan

a. Metode : ……………….
b. Alat : ……………….
c. Waktu dan tempat : ……………….

4. Kriteria Evaluasi
a. Kriteria struktur :
b. Kriteria proses :
c. Kriteria hasil :