PENGKAJIAN KELUARGA

A. Data Umum

Identitas Kepala Keluarga

Nama :………………………………………...

Umur :………………………………………...

Agama :.............................................................

Suku bangsa :.............................................................

Pendidikan :.............................................................

Pekerjaan :.............................................................

Alamat :.............................................................

Komposisi Keluarga

NO

Nam

a A

ngg

ota

Kel

uar

ga

Um

ur

(tah

un

)

L/P

Su

ku

Ban

gsa

Sta

tus

Kaw

in

Hu

bu

nga

n

den

gan

KK

Aga

ma

Pen

did

ikan

Pek

erja

an

Kea

daa

n

Kes

ehat

an

KB

Imm

un

isas

i (L

engk

ap/T

dk

L

engk

ap)

1 2 3 4 5 6 7 8 9 10 11 12 131.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Genogram

PPN ANGKATAN XXIV KEBON WARU RW 07

Tipe keluarga

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Suku Bangsa

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Agama

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Status Sosial Ekonomi Keluarga

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Aktivitas Rekreasi Keluarga

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B. Riwayat dan Tahap Perkembangan Keluarga

Tahap Perkembangan Keluarga Saat Ini

PPN ANGKATAN XXIV KEBON WARU RW 07

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Tahap Perkembangan Keluarga yang Belum Terpenuhi

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Riwayat keluarga inti

Riwayat Penyakit Keturunan

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Riwayat Kesehatan Keluarga

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Sumber Pelayanan Kesehatan yang digunakan

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Riwayat Keluarga Sebelumnya

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C. Lingkungan

Karakteristik Lingkungan Rumah

Luas Rumah :........................................................................................................

Tipe Rumah :........................................................................................................

Jumlah Ruangan :........................................................................................................

Jumlah Jendela :........................................................................................................

Jarak Septic tank :........................................................................................................

Sumber Air Minum :........................................................................................................

Pembuangan Limbah :........................................................................................................

PPN ANGKATAN XXIV KEBON WARU RW 07

Denah Rumah

Karakteristik Tetangga dan Komunitas RW

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Mobilitas Geografis Keluarga

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Perkumpulan Keluarga dan Interaksi dengan Masyarakat

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Pola Komunikasi

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Sistem Pendukung Keluarga

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Struktur Kekuatan Keluarga

PPN ANGKATAN XXIV KEBON WARU RW 07

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Struktur Peran (Formal dan Informal)

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Nilai dan Norma Keluarga

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D. Fungsi Keluarga

Fungsi Afektif

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Fungsi Sosial

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Fungsi Perawatan Kesehatan

Mengenal masalah kesehatan

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Mengambil Keputusan untuk Mengatasi masalah

PPN ANGKATAN XXIV KEBON WARU RW 07

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Merawat Anggota Keluarga dengan masalah Kesehatan

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Memodifikasi Lingkungan

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Memanfaatkan Fasilitas Layanan Kesehatan

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Fungsi Reproduksi

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Fungsi Ekonomi

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E. Stres dan Koping Keluarga

Stressor

Stressor Jangka Pendek

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Stressor Jangka Panjang

PPN ANGKATAN XXIV KEBON WARU RW 07

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Kemampuan Keluarga berespon terhadap situasi/ stresor

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Strategi Koping yang Digunakan

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Strategi Adaptasi Fungsional

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F. Harapan Keluarga terhadap Petugas Kesehatan

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G. Pemeriksaan Fisik

PPN ANGKATAN XXIV KEBON WARU RW 07

PENGKAJIAN KELUARGA MANDIRI

No Masalah Kesehatan Masalah KeperawatanKriteria Keluarga Mandiri

Kategori Kesimpulan1 2 3 4 5 6 7 8 9 10

PPN ANGKATAN XXIV KEBON WARU RW 07

ANALISA DATA

No Data Masalah

PPN ANGKATAN XXIV KEBON WARU RW 07

Diagnosa Keperawatan menurut Skala Prioritas

No Kriteria Skor BobotPerhitungan untuk Diagnosa

1 Sifat masalahSkala:

- Aktual (tidak/kurang sehat)- ancaman kesehatan- keadaan sejahtera

321

1

2 Kemungkinan masalah dapat diubahSkala:

- mudah- sebagian- tidak dapat

210

2

3 Potensial masalah untuk dicegahSkala:

- tinggi- cukup- rendah

321

1

4 Menonjolnya masalahSkala:

- masalah berat, harus segera ditangani

- ada masalah, tetapi tidak perlu segera ditangani

- masalah tidak dirasakan

2

1

0

1

TOTAL SKORE

RENCANA KEPERAWATAN KELUARGA

NoDiagnosa Keperawatan

Keluarga

Tujuan Kriteria EvaluasiRencana Intervensi

Umum Khusus kriteria Standar

PPN ANGKATAN XXIV KEBON WARU RW 07

IMPLEMENTASI DAN EVALUASI KEPERAWATAN KELUARGA

No Nomor Dx Tujuan Khusus Tanggal Implementasi Evaluasi

PPN ANGKATAN XXIV KEBON WARU RW 07

PPN ANGKATAN XXIV KEBON WARU RW 07

JADWAL KUNJUNGAN KELUARGA

TANGGAL KEGIATANPARAF

KELUARGA PETUGAS

PPN ANGKATAN XXIV KEBON WARU RW 07

GENOGRAM

PPN ANGKATAN XXIV KEBON WARU RW 07

DENAH

PPN ANGKATAN XXIV KEBON WARU RW 07