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

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

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

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

Pengkajian Dilakukan

Nama :

Hari :

Tanggal :

Waktu :

Metode :

A. PENGKAJIAN

I. Data Umum

Nama KK :

Jenis Kelamin :

Umur :

Agama :

Pendidikan :

Pekerjaan :

Alamat :

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 Komposisi keluarga

Hubungan Status Status

No Nama Umur JK Pendidikan Pekerjaan
Dengan Kk Imunisasi Kesehatan

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 Genogram :

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 Tipe Keluarga :.............................................................................................
Suku :.............................................................................................
Agama :.............................................................................................
Status sosial :.............................................................................................
Rekreasi :.............................................................................................
Struktur peran : .............................................................................................
...............................................................................................
..............................................................................................
...............................................................................................
...............................................................................................
...............................................................................................
...............................................................................................
..............................................................................................

II. Riwayat Tahap Perkembangan Keluarga

1. Tahap perkembangan keluarga saat ini
......................................................................................................................
.....................................................................................................................
.....................................................................................................................
2. Tahap perkembangan keluarga yang belum terpenuhi
....................................................................................................................
....................................................................................................................
....................................................................................................................
3. Riwayat kesehatan keluarga
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 Riwayat kesehatan keluarga sebelumnya
....................................................................................................................
....................................................................................................................
....................................................................................................................
....................................................................................................................
III. Riwayat kesehatan

a. Kebutuhan Nutrisi

Kebiasaan makan :..................................................................................

Kebiasaan minum :...................................................................................

b. Kebutuhan Eliminasi

Pola BAK :..................................................................................

Pola BAB :..................................................................................

c. Istirahat Tidur

Waktu tidur :..................................................................................

Waktu bangun :..................................................................................

d. Kebersihan Diri

Mandi :..................................................................................

gosok gigi :..................................................................................

keramas :..................................................................................

potong kuku :..................................................................................

e. Rekreasi/Waktu Senggang

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

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

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

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 IV. Fungsi Keluarga

1. Fungsi Afektif

....................................................................................................................
....................................................................................................................
....................................................................................................................
2. Fungsi Sosial
......................................................................................................................
......................................................................................................................
.....................................................................................................................
3. Fungsi Perawatan Kesehatan
a. Kemampuan keluarga mengenal masalah
.................................................................................................................
.................................................................................................................
.................................................................................................................
b. Kemampuan keluarga merawat anggota yang sakit
.................................................................................................................
.................................................................................................................
.................................................................................................................
c. Kemampuan keluarga menjaga lingkungan rumah
.................................................................................................................
.................................................................................................................
.................................................................................................................
d. Kemampuan keluarga memanfaatkan faasilitas kesehatan
.................................................................................................................
.................................................................................................................
.................................................................................................................
4. Fungsi Reproduksi
......................................................................................................................
......................................................................................................................
...................................................................................................................

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 V. Fasilitas sosial budaya dan ekonomi

1. Pekerjaan
.................................................................................................................
.................................................................................................................
.................................................................................................................
2. Penghasilan dan pengeluaran
.................................................................................................................
.................................................................................................................
.................................................................................................................
3. Simpanan/uang keluarga
.................................................................................................................
.................................................................................................................
4. Sistem nilai
.................................................................................................................
.................................................................................................................
5. Hubungan dengan masyarakat
.................................................................................................................
.................................................................................................................
6. Mobilitas geografis keluarga
.................................................................................................................
.................................................................................................................
.................................................................................................................
VI. Faktor Lingkungan
1. Karasteristik rumah
Luas :......................................................................
Jenis : ......................................................................
Sirkulasi udara : ......................................................................
Pemanfaatan ruangan : ......................................................................
Kebersihan ruangan : ......................................................................
Lantai : ......................................................................
Jarak kakus dng sumber air minum :

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 Persediaan air bersih : ......................................................................
........................................................................
........................................................................
Pembuangan air limbah :....................................................................
.......................................................................
Jamban keluarga : .....................................................................
.......................................................................
2. Karasteristik tetangga dan komunitas

...............................................................................................................
..............................................................................................................
...............................................................................................................
3. Dena rumah

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 VII. Psikologis
1. Status emosi
a. Stressor jangka panjang dan jangka pendek
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
b. Kemampuan keluarga berespon terhadap stressor
.................................................................................................................
.................................................................................................................
c. Stressor koping yang digunakan
.................................................................................................................
.................................................................................................................
d. Strategi adaptasi fungsional
.................................................................................................................
.................................................................................................................
2. Konsep diri
a. Body image : .................................................................................
b. Personal identity : .................................................................................
c. Peran : .................................................................................
d. Ideal diri : .................................................................................
e. Harga diri : .................................................................................
VIII. Derajat Kesehatan
1. Kejadian kesehatan
.................................................................................................................
.................................................................................................................
2. Kejadian cacat
.................................................................................................................
.................................................................................................................

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 3. Kejadian kematian dalam satu tahun terakhir
.................................................................................................................
.................................................................................................................
4. Perilaku keluarga dalam penanggulangan sakit
.................................................................................................................
.................................................................................................................
IX. Pemeriksaan Fisik Keluarga
Dilakukan pada tanggal/ jam :
Anggota keluarga
NO Pemeriksaan fisik

1. Pemeriksaan TTV
 Tekanan darah
 Nadi
 Suhu
 Pernafasan

Head To Toe
2
 Kepala &
rambut
Inspeksi
Palpasi

 Mata
Inspeksi
Palpasi

 hidung
inspeksi
palpasi

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
  telinga
inspeksi
palpasi

 mulut
inspeksi
palpasi

 leher
inspeksi
palpasi

 integumen
inspeksi
palpasi

 pemeriksaan
thoraks
inspeksi
palpasi
perkusi
auskultasi
 abdomen
inspeksi
auskultasi
palpasi
perkusi
 eksttemitas
atas
bawah

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 Anggota keluarga
Pemeriksaan fisik
NO

2. Pemeriksaan TTV
 Tekanan darah
 Nadi
 Suhu
 Pernafasan

Head To Toe
2
 Kepala &
rambut
Inspeksi
Palpasi

 Mata
Inspeksi
Palpasi

 hidung
inspeksi
palpasi

 telinga
inspeksi
palpasi

 mulut
inspeksi
palpasi

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
  leher
inspeksi
palpasi

 integumen
inspeksi
palpasi

 pemeriksaan
thoraks
inspeksi
palpasi
perkusi
auskultasi

 abdomen
inspeksi
auskultasi
palpasi
perkusi

 eksttemitas
atas
bawah

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 X. Harapan keluarga terhadap petugas kesehatan
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
............................................................................................. ............................

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
B. KLASIFIKASI DATA
DATA SUBJEKTIF DATA OBJEKTIF

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

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
C. ANALISA DATA
DATA
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
PROGRAM STUDI NERS JENJANG PROFESI
STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
ETIOLOGI
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
MASALAH
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
D. DIAGNOSA KEPERAWATAN
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
E. PRIORITAS MASALAH (SKORING)
...............................................................................................................................
...............................................................................................................................
KRITERIA SKALA BOBOT SKORING PEMBERNARAN

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

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

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

................................
................................
.................................
...................................
.................................
...................................
.................................
.................................
.................................
...................................
TOTAL SKOR

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

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 ...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
NO KRITERIA PERHITUNGAN SKOR PEMBERNARAN

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

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

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

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

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

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

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

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

TOTAL SKOR

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

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 ...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
NO KRITERIA PERHITUNGAN SKOR PEMBERNARAN

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

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

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

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

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

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

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

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

TOTAL SKOR

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
F. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
......................................................................................................................

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
G. RENCANA ASUHAN KEPERAWATAN
..................................................................................................................................................................................................................
..................................................................................................................................................................................................................
TUJUAN
JANGKA
PANJANG
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
PROGRAM STUDI NERS JENJANG PROFESI
STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
EVALUASI
JANGKA PENDEK KRITERIA
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
INTERVENSI RASIONAL
STANDAR
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... ............................................. ....................................
.................................... .............................................. ....................................
.................................... ............................................. ....................................
.................................... ............................................. ....................................
.................................... ............................................. ....................................
..................................................................................................................................................................................................................
..................................................................................................................................................................................................................
TUJUAN
JANGKA
PANJANG
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
PROGRAM STUDI NERS JENJANG PROFESI
STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
EVALUASI
JANGKA PENDEK KRITERIA
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
INTERVENSI RASIONAL
STANDAR
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... ............................................. ....................................
.................................... .............................................. ....................................
.................................... ............................................. ....................................
.................................... ............................................. ....................................
.................................... ............................................. ....................................
..................................................................................................................................................................................................................
..................................................................................................................................................................................................................
TUJUAN
JANGKA
PANJANG
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
PROGRAM STUDI NERS JENJANG PROFESI
STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
EVALUASI
JANGKA PENDEK KRITERIA
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
..................................... ..................
INTERVENSI RASIONAL
STANDAR
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... .............................................. ....................................
.................................... ............................................. ....................................
.................................... .............................................. ....................................
.................................... ............................................. ....................................
.................................... ............................................. ....................................
.................................... ............................................. ....................................
H. IMPLEMENTASI DAN EVALUASI

NO.DX WAKTU TUK IMPLEMENTASI EVALUASI

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

PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 NO.DX WAKTU TUK IMPLEMENTASI EVALUASI

...................................................................... ......................................................................
...................................................................... ......................................................................
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PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019
 NO.DX WAKTU TUK IMPLEMENTASI EVALUASI

...................................................................... ......................................................................
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PROGRAM STUDI NERS JENJANG PROFESI

STIKES MUHAMMADIYAH SIDRAP
TAHUN AKADEMIK 2018/2019