Lampiran 1. Format Pengkajian Asuhan Keperawatan Keluarga.doc

Lampiran 1

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KELUARGA

Pengkajian (angga!"

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%aa Um&m 1. Nama Kepala Keluarga Keluarga : .......... ............... .......... .......... .......... .......... .......... .......... .......... .......... .......... ..... 2. Usia : ........................................... ............................................................ ................. 3. Pend Pendid idik ikan an : .... ...... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .. 4. Peker ekerja jaan an : ..... ...... ........ ...... .... .... .... .... .... .... .... .... ........ ...... .... .... .... .... .... .... .... .... .... .... ...... 5. Alamat : ............................................................ 6. Komposisi Komposisi Anggota Anggota Keluarga Keluarga :

N'$

Nama

Jeni Ke!amin

H&) *gn KK 

Um&r

Pen*i*ikan

Pekerjaan + ke$

%. Agama : .............................................................................................. 1&. #tatus #osial 'konomi Klg : ........................................................... ............................................................................................................ ............................................................................................................ 11. Akti(itas )ekreasi Keluarga : ........................................................... ............................................................................................................ ............................................................................................................ II$ Ri,a-a *an Ta.ap Perkem)angan Ke!&arga 1. !a*ap perkem+angan keluarga saat ini : ........................................... .......................................................................................................... .......................................................................................................... .......................................................................................................... 2. !a*ap perkem+angan keluarga ,ang +elum terpenu*i : .................... .......................................................................................................... .......................................................................................................... .......................................................................................................... 3. )i-a,at Kese*atan keluarga inti : .................................................... .......................................................................................................... .......................................................................................................... .......................................................................................................... 4. )i-a,at keluarga se+elumn,a : ....................................................... ..........................................................................................................

2.

#truktur kekuatan keluarga : ............................................................. .......................................................................................................... .......................................................................................................... 3. #truktur peran keluarga : .................................................................. a. Peran ormal : ....................................................................... .......................................................................................................... ..........................................................................................................  +. Peran inormal : ....................................................................... .......................................................................................................... .......................................................................................................... 4. Nilai dan norma +uda,a : ................................................................. .......................................................................................................... ..........................................................................................................

/$

F&ngi Ke!&arga 1. ungsi aekti : ................................................................................. .......................................................................................................... .......................................................................................................... 2. ungsi sosialisasi : ............................................................................ ..........................................................................................................

Pemeriksaan isik  Keadaan Umum !inggi $adan : $erat $adan : !! : !ekanan /ara* :  Nadi : Pernaasan : #u*u : Kepala : a. $entuk   +. Ukuran 7. ke+ersi*an d. Keadaan )am+ut e. 8arna )am+ut 0ata : a. #imetris9asimetris  +. Konjungti(a anemis9!idak anemis

Kepala Keluarga

Anggota

Anggota

Anggota

Keluarga

Keluarga

Keluarga

 1

2

3

a. #imetris9asimetris  +. $un,i Paru antung A+domen: =nspeksi Auskultasi Perkusi Palpasi 'ktremitas atas : tangan 'ktremitas +a-a* : Kaki a. Ga,a +erjalan  +. Keseim+angan Genetalia Postur +adan

/II$ Harapan Ke!&arga Ter.a*ap A&.an Kepera,aan Ke!&arga 1. !er*adap masala* kese*atan : ...........................................................

ANALISA %ATA N'

%aa

Ei'!'gi

P)=>)=!A# 0A#A
Maa!a.

MASALAH

KRITERIA

KEPERAWATAN

#iat 0asala* : Kemungkinan 0asala* dapat diu+a*: 1.

Kemungkinan 0asala* dapat di7ega* : 0enonjoln,a 0asala* : J&m!a. #iat 0asala* :

2.

3.

Kemungkinan 0asala* dapat diu+a*: Kemungkinan 0asala* dapat di7ega* : 0enonjoln,a 0asala* : J&m!a. #iat 0asala* : Kemungkinan 0asala* dapat diu+a*: Kemungkinan 0asala* dapat di7ega* : 0enonjoln,a 0asala* : J&m!a.

Pri'ria Maa!a. Kepera,aan 1$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ 2$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

PERHITUNGAN

SKOR

PEM0ENARAN

)'N;ANA K'P')A8A!AN K'
T&j&an T&j&an Um&m T&j&an K.&&

E3a!&ai Krieria

San*ar

Iner3eni

'A
Imp!emenai

E3a!&ai