FORMAT PENGUMPULAN DATA KESEHATAN KELUARGA STIKES

SANTA ELISABETH MEDAN

1.1. Pengkajian
1.1.1. Pengumpulan data
1. Data umum
a. Identitas kepala keluarga
- Nama :
- Alamat :
b. Komposisi keluarga

No Nama JK Umur Hub. Kelg. Pendidikan Pekerjaan Status

Kesehatan/
Imunisasi
KK

c. Genogram
Buat gambaran garis keturunan keluarga 3 generasi (pihak kepala
keluarga/suami dan dari pihak istri). Lengkapi dengan usia dan
penyakit yang ada pada anggota keluarga dan yang meninggal
tuliskan usia meninggal dan penyebabnya.
d. Tipe keluarga:

e. Suku/bangsa...
f. Agama: ..
g. Status ekonomi keluarga:...
.
h. Aktivitas rekreasi keluarga:



......
2. Riwayat tahap perkembangan keluarga
a. Tahap perkembangan keluarga saat ini
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b. Tugas perkembangan keluarga masih banyak yang belum dapat
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3. Riwayat kesehatan keluarga inti.
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4. Keadaan lingkungan
a. Tinggal di rumah , luas .., komposisi
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keadaan, ventilasi.
Lantai.., sumber air minum., pembuangan
air limbah..jamban keluarga..
, pekarangan , kandang ternak
, dan lain-lain
yang dianggap perlu.
b. Karakteristik tetangga dan komunitas
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c. Mobilitas keluarga
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d. Perkumpulan keluarga dan interaksi dengan masyarakat
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f. Sistem pendukung keluarga
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5. Struktur keluarga
a. Pola komunikasi digunakan dalam keluarga
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b. Kekuatan keluarga
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6. Struktur peran
a. Peran
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b. Nilai atau norma agama
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7. Fungsi keluarga
a. Fungsi afektif




...
b. Fungsi sosialisasi
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c. Fungsi reproduksi
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d. Fungsi perawatan kesehatan
1) Kepala keluarga
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2) Istri.....................................................................................................
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3) Anak I
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4) Anak II, dst.
e. Fungsi ekonomi
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8. Stress dan koping keluarga
a. Stressor jangka panjang dan pendek
1) Stressor jangka panjang..
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2) Stressor jangka pendek
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3) Kemampuan keluarga berespon terhadap masalah
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b. Strategi koping
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9. Strategi adaptasi disfungsional
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10. Harapan keluarga





11. Data tambahan
a. Nutrisi
...
...
..
..
..
 b. Eliminasi ..
..
c. Istirahat Tidur, .
......................................................................................................
...
d. Aktivitas sehari-hari .

...
12. Kebiasaan buruk/perilaku yang merugikan kesehatan




..
13. Pengetahuan terhadap penyakit menular dan penyakit khronis









..
14. Pemeriksaan fisik dari anggota keluarga, dilakukan pada semua anggota
keluarga yang berada di rumah pada saat kunjungan rumah.
 Tabel Pemeriksaan Fisik Anggota Keluarga

Pemeriksaan Fisik Nama Anggota Keluarga

Kepala Keluarga Istri Anak I Anak II, dst
Kepala
Tanda-tanda vital
BB/TB
Mata
Hidung
Mulut
Leher
Dada
Abdomen
Tangan
Kaki
Keadaan umum

Medan,
Pengkajian,

( )
1.1.2. Analisa Data:

Data Etiologi Problem

1.2. Rumusan Diagnosa Keperawatan Keluarga

Nama KK :
Alamat :
Kelurahan :
Puskesmas :

NO DIAGNOSA KEPERAWATAN TANGGAL NAMA &

DITEMUKAN TERATASI TANDA
TANGAN
1.3. Perencanaan Keperawatan Keluarga

1. Penentuan prioritas diagnose keperawatan keluarga

a. Diagnosa keperawatan
.
.

No Kriteria Perhitungan Skor Pembenaran

1 Sifat masalah /3x3

2 Kemungkinan /2x2
masalah dapat
diubah
3 Potensi /3x3
masalah untuk
dicegah.
4 Menonjolnya /2x1
masalah

Total Score

b. Diagnosa keperawatan keluarga.

No Kriteria Perhitungan Skor Pembenaran

1 Sifat masalah /3x3

2 Kemungkinan /2x2
masalah dapat
diubah
3 Potensi /3x3
masalah untuk
dicegah.
4 Menonjolnya /2x2
masalah

Total Score
c. Diagnosa keperawatan keluarga.

.

No Kriteria Perhitungan Skor Pembenaran

1 Sifat masalah /3x3

2 Kemungkinan /2x2
masalah dapat
diubah
3 Potensi /3x3
masalah untuk
dicegah.
4 Menonjolnya /2x2
masalah

Total Score
 FORMAT RENCANA RENCANA ASUHAN KEPERAWATAN KELUARGA STIKES SANTA ELISABETH MEDAN

Nama KK :
Alamat :
Puskesmas :

DIAGNOSA NOC NIC NAMA &

KEPERAWATAN TANDA
TANGAN
 FORMAT IMPLEMENTASI DAN EVALUASI KEPERAWATAN KELUARGA STIKES SANTA ELISABETH MEDAN

Nama KK :
Alamat :
Puskesmas :

NO. TANGGAL/ IMPLEMENTASI EVALUASI NAMA &

DX PUKUL TANDA TANGAN