KEMENTERIAN KESEHATAN R.

I
POLITEKNIK KEMENKES MATARAM

LAPORAN
ASUHAN KEPERAWATAN KELUARGA

Oleh :
Nama :
NIM :

DISUSUN DALAM RANGKA KEGIATAN

PRAKTEK KERJA LAPANGAN ( PKL )
PROGRAM STUDI D.IV KEPERAWATAN BIMA
26 Peb. s/d. 17 Maret 2018
 FORMAT PENGKAJIAN
ASUHAN KEPERAWATAN KELUARGA

A. Pengkajian
1. Data umum
a. Identitas Kepala Keluarga
 Nama :______________________________________
 Umur :______________________________________
 Alamat dan No. Tlp :______________________________________
 Pendidikan :______________________________________
 Pekerjaan :______________________________________
 Suku / Bangsa :______________________________________

b. Komposisi Keluarga

HUB DGN STATUS IMUNISASI

NO NAMA JK UMUR PENDD. Ket.
KK HB POLIO DPT CAMPAK

c. Genogram
Keterangan :
= meninggal
= laki-laki masih hidup
= perempuan masih hidup
= hubungan perkawinan
= klien
= tinggal serumah

d. Tipe keluarga :____________________________________________

e. Suku / Bangsa :____________________________________________
f. Agama :____________________________________________
g. Status Sosek :____________________________________________
__________________________________________________________________
h. Penghasilan keluarga :____________________________________________
__________________________________________________________________
i. Aktivitas rekreasi keluarga :______________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

2. Riwayat dan Tahap Perkembangan Keluarga

a. Tahap perkembangan keluarga saat ini : ___________________________________
____________________________________________________________________
b. Tahap perkembangan keluarga yang belum terpenuhi : ________________________
____________________________________________________________________
c. Riwayat keluarga inti : _________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
d. Riwayat keluarga sebelumnya : __________________________________________
____________________________________________________________________
____________________________________________________________________
3. Pengkajian Lingkungan
a. Karakteristik Rumah :
1) Status rumah : ____________________________________________
2) Luas rumah yang ditempati : _____________________________________
________________________________________________________________
3) Keadaan rumah secara umum : ____________________________________
________________________________________________________________
4) Sumber air minum : _____________________________________________
________________________________________________________________

5) Denah rumah :

b. Karakteristik tetangga dan komunitas RW : _________________________________

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
c. Mobilitas geografis :___________________________________________________
____________________________________________________________________
____________________________________________________________________
d. Perkumpulan keluarga dan Interaksi dengan masyarakat :_____________________
____________________________________________________________________
____________________________________________________________________
 e. Sistem pendukung dan jaringan sosial keluarga :_____________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

4. Struktur keluarga
a. Pola komunikasi keluarga :______________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
b. Struktur kekuatan keluarga :_____________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
c. Struktur peran
 Ayah :___________________________________________________________
________________________________________________________________
 Ibu :___________________________________________________________
________________________________________________________________
 Anak :___________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
d. Nilai keluarga :________________________________________________________
____________________________________________________________________
____________________________________________________________________

5. Fungsi keluarga
a. Fungsi afektif :________________________________________________________
____________________________________________________________________
____________________________________________________________________
 b. Fungsi social :________________________________________________________
____________________________________________________________________
____________________________________________________________________
c. Fungsi perawatan kesehatan :____________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
d. Fungsi reproduksi :____________________________________________________
____________________________________________________________________
____________________________________________________________________
e. Fungsi ekonomi :______________________________________________________
____________________________________________________________________
____________________________________________________________________

6. Stress dan koping keluarga

a. Stressor jangka pendek :________________________________________________
____________________________________________________________________
____________________________________________________________________
b. Stressor jangka panjang :________________________________________________
____________________________________________________________________
____________________________________________________________________
c. Kemampuan keluarga berespon terhadap stressor : ___________________________
____________________________________________________________________
____________________________________________________________________
d. Kekuatan yang mengimbangi stressor :_____________________________________
____________________________________________________________________
____________________________________________________________________
e. Strategi adaptasi disfungsional : __________________________________________
____________________________________________________________________
____________________________________________________________________
7. Pemeriksaan Fisik

Ayah Ibu Anak 1 Anak 2 Anak 3

Keadaan
umum
Penampilan
TD
Nadi
Temperatur
Pernafasan
Kepala
Mata
Hidung
Mulut
Telinga
Leher
Thorax
Abdomen
Genetalia
Ekstremitas

8. Harapan keluarga :
B. Rumusan Masalah Kesehatan dan Masalah Keperawatan
1. Masalah kesehatan :
a. Masalah Keperawatan :
1)

2. Masalah kesehatan :
a. Masalah Keperawatan :
1) Masalah kesehatan :
C. Analisa Data

Masalah Kes./ Masalah

Etiologi Pengelompokan Data
Keperawatan
(E) (S)
(P)
D. Diagnosa Keperawatan Keluarga

E. Typologi Masalah Kesehatan/ Keperawatan Keluarga

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