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FORMAT PENGKAJIAN KEPERAWATAN KELUARGA PENGKAJIAN (Tanggal:...............................................) I. Data Umum : 1. Nama Kepala Keluarga : ................................................. 2. Umur : ............................. .................... 3. A l a m a t : ................................................. 4. Telepon : ............................. .................... 5. Pekerjaan Kepala Keluarga : ................................................. 6. Pendidikan Kepala Keluarga : ................................................. 7. Komposisi Keluarga : ................................................. . No Nama L/P Hub. Keluarg a dgn KK Umur Pend. Terakhi r Status Imunisasi Ket . BCG Polio DPT Hepatiti s Campak 1 2 3 4 1 2 3 1 2 3 Genogram :

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FORMAT PENGKAJIAN KEPERAWATAN KELUARGA

PENGKAJIAN (Tanggal:...............................................)

I. Data Umum :1. Nama Kepala Keluarga : .................................................2. Umur : .................................................3. A l a m a t : .................................................4. Telepon : .................................................5. Pekerjaan Kepala Keluarga : .................................................6. Pendidikan Kepala Keluarga : .................................................7. Komposisi Keluarga : ..................................................

No Nama L/PHub.

Keluarga dgn KK

Umur Pend. Terakhir

Status ImunisasiKet.

BCGPolio DPT Hepatitis

Campak1 2 3 4 1 2 3 1 2 3

Genogram :

8. Tipe keluarga : ................................................9. Suku bangsa : ................................................10.A g a m a : ................................................11.Status sosial ekonomi keluarga

: ..................................................................................................................................................................................................................................................................................................................................................................................................................................................

12.Aktifitas rekreasi keluarga : …………………………………………………………………………………………………………………………………………………..............................................................

II. Riwayat Tahap Perkembangan Keluarga :1. Tahap perkembangan keluarga saat

ini : ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2. Tahap perkembangan keluarga keluarga yang belum terpenuhi : …………………………...............................................................................................................................................................................................................................................................................................................................................................

3. Riwayat keluarga inti : ……………………………………………………….............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Riwayat keluarga sebelumnya : ...................................................................................................................................................................................................................................................................................................................................................................................................

III. Lingkungan :1. Karakteristik rumah :

a. Luas bangunan dan bagian-bagiannya :.......................................................

b. Tipe bangunan : ..............................................................................................

c. Ventilasi rumah : ...................................................................................................................................................................................

d. Kebersihan ruang : ..................................................................................................................................................................................................................

e. Sumber air : ..................................................................................................

2. Denah rumah :

3. Karakteristik tetangga dan komunitasnya :...................................................................................................................................................................................................................................................................................................................................................................................................

4. Mobilitas geografis keluarga : ..................................................................................................................................................................................................................................................................

5. Perkumpulan keluarga dan interaksi dengan masyarakat : ...................................................................................................................................................................................................................................................................................................................................................................................................

6. Sistem pendukung keluarga : ..................................................................................................................................................................................................................................................................

III. Struktur Keluarga :1. Pola komunikasi

keluarga : ..................................................................................................................................................................................................................................................................

2. Struktur kekuatan keluarga : .................................................................................................................................................................................................................................................................................................................................................................................................

3. Struktur peran ( formal dan informal ) : ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Nilai dan normal keluarga : .................................................................................................................................................................................................................................................................

IV. Fungsi Keluarga :1. Fungsi

ekonomi : ...................................................................................................................................................................................................................................................................................................................................................................................................

2. Fungsi mendapatkan status sosial :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Fungsi pendidikan: ........................................................................................................

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

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

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

.......

4. Fungsi perawatan kesehatan : a) Mengenal masalah

kesehatan : ....................................................................................................................................................................................................................................................................................................................................................................................................................................................

b) Mengambil keputusan mengenai tindakan kesehatan : ............................................................................................................................................................................................................................................................................................................................................................................................................................................

c) Kemampuan merawat anggota keluarga yg sakit :.................................................................................................................................................................................................................................................................................................................................................................................

d) Kemampuan memelihara/ memodifikasi lingkungan (rumah) yg sehat :...................................................................................................................................................................................................................................................................................................................................................................................................

e) Kemampuan memanfaatkan fasilitas kesehatan : ....................................................................................................................................................................................................................................................................................................................................................................................................................................................

5. Fungsi religius : ................................................................................................................................................................................................................................................................

6. Fungsi rekreasi : ................................................................................................................................................................................................................................................................

7. Fungsi Reproduksi : ................................................................................................................................................................................................................................................................

8. Fungsi afektif : ...............................................................................................................................................................................................................................................................

V. Stres Dan Koping Keluarga :1. Stressor jangka pendek dan

panjang : ................................................................................................................................................................................................................................................................

2. Kemampuan keluarga berespon terhadap situasi / stressor : .................................................................................................................................................................................................................................................................

3. Strategi koping yang digunakan : .................................................................................................................................................................................................................................................................

4. Srategi adaptasi disfungsional : ...........................................................................................................................................................................................................................................................

VI. PemeriksaanFisik

o Aspek yang Dikaji

Nama Anggota KeluargaBpk. Ibu. An. ..........

1. FISIK:a. Kondisi

umum

b. TTV

c. Kepala & leher

d. Thoraks

e. Abdomen

f. Ekstremitas

g. Genetalia

h. Dll.

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2. Mental

3. Emosional

4. Sosial

5. Spiritual

VII. Harapan keluarga :

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

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.......................ANALISIS DATA

No. Data Masalah Penyebab1. DS:

DO:

2. DS:

DO:

3. DS:

DO:

PERUMUSAN DIAGNOSIS KEPERAWATAN

No. Diagnosis Keperawatan (PES)1.

2.

3.

PENILAIAN (SKORING) DIAGNOSIS KEPERAWATAN

No. Dx. Kriteria Skor Pembenaran

1. a. Sifat masalah......

b. Kemungkinan masalah dapat diubah...........

c. Potensi masalah untuk dicegah.......d. Menonjolnnya masalah ........

..... x 1= ...... 3

...... x 2= ...... 2

...... x 1= ...... 3

....... x 1= ...... 2

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

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

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

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

2. Sifat masalah......

Kemungkinan masalah dapat diubah...........

Potensi masalah untuk dicegah.......Menonjolnnya masalah ........

..... x 1= ...... 3

...... x 2= ...... 2

...... x 1= ...... 3

....... x 1= ...... 2

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

3. e. Sifat masalah......

f. Kemungkinan masalah dapat diubah...........

g. Potensi masalah untuk dicegah.......h. Menonjolnnya masalah ........

..... x 1= ...... 3

...... x 2= ...... 2

...... x 1= ...... 3

....... x 1= ...... 2

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

PRIORITAS DIAGNOSIS KEPERAWATAN

Prioritas Diagnosis Keperawatan Skor1.

2.

3.

PERENCANAAN

No. Dx.

Tujuan Kriteria Rencana IntervensiKriteriaHasil

1. UMUM: ...............................................

KHUSUS: ..........................................

2. UMUM: ...............................................

KHUSUS: ..........................................

3. UMUM: ...............................................

KHUSUS: ..........................................

IMPLEMENTASI

Tgl. & Waktu No. Dx Implementasi TTD

1.

2.

3.

EVALUASI

Tgl. & Waktu

No. Dx. Evaluasi

1. S : .........................................

O : .........................................

A : .........................................

P : .........................................

2. S : .........................................

O : .........................................

A : .........................................

P : .........................................

3 S : .........................................

O : .........................................

A : .........................................

P : .........................................