format pengkajian keluarga
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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
............................................
............................................
...........................................
...........................................
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: ..........................................
EVALUASI
Tgl. & Waktu
No. Dx. Evaluasi
1. S : .........................................
O : .........................................
A : .........................................
P : .........................................
2. S : .........................................
O : .........................................
A : .........................................
P : .........................................
3 S : .........................................
O : .........................................
A : .........................................
P : .........................................