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PROGRAM PROFESI NERS STIKES INSAN CENDEKIA MEDIKA JOMBANG JLN. KH HASYIM ASHARI NO 171 MOJOSONGO JOMBANG Te lp. 0321-877819 E-mal ! "#$e"%&me%'(m)a*+,a((.&(m F O RMATP ENG KA J I AN KEL UA RG A A .P E N G K A J I A N( t an g ga l : ____ ________ ____ ) I .D a ta U m um 1.K epal a K el u arga : __________________ 2. U m ur : _ _ _ _ _ _ __ _ _ __ __ _ _ _ __ __ __ 3.A l am at d an t elepon :______ _______________ 4.Peke r jaa n K K :__ __ __ __ __ __ __ __ __ __ __ 5.Pendi dikan K K :__ __ __ __ __ __ __ __ __ __ __ 6. K om pos i s i ke l uar ga :__ __ __ N o N a m a J e n i s K e l a m i n H u b . D g n K K Umu r P e n d i d i k a n S tatus i m u n i s a s i Ke t BC G P o l io D PT H e pa ti t is Ca m pa k 1 2 3 4 1 2 3 1 2 3 G e nogr a m : 7.Ti pe K el uar ga : __ __ __ __ __ __ __ __ 8. Suku Bangs a :__ __ __ __ __ __ __ __ __ __ __ 9. A gam a : 10. St at u s soci al eko n om i kel u ar ga _____________ _____________ _____________ ____________ _____________ _____________ ____ _____________ _____________ _____________ ____________ _____________ _____________ ____
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PROGRAM PROFESI NERSSTIKES INSAN CENDEKIA MEDIKA JOMBANG JLN. KH HASYIM ASHARI NO 171 MOJOSONGO JOMBANGTelp. 0321-877819 E-mail : [email protected]
FORMAT PENGKAJIAN KELUARGA
A. PENGKAJIAN ( tanggal : ________________________________ )I. Data Umum1. Kepala Keluarga: ________________________________________________________2. Umur: ________________________________________________________3. Alamat dan telepon:_________________________________________________________4. Pekerjaan KK:_________________________________________________________5. Pendidikan KK:_________________________________________________________6. Komposisi keluarga:____________
NoNama JenisKelaminHub. Dgn KKUmur PendidikanStatus imunisasiKet
BCGPolioDPTHepatitisCampak
1234123123
Genogram :
7. Tipe Keluarga: ________________________________________________________8. Suku Bangsa:_________________________________________________________9. Agama : ________________________________________________________10. Status social ekonomi keluarga___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
11. Aktivitas rekreasi keluarga___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________II. Riwayat dan Tahap Perkembangan Keluarga12. Tahap Perkembangan Keluarga saat ini___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________13. Tugas perkembangan keluarga yang belum terpenuhi___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________14. Riwayat kesehatan keluarga inti___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________15. Riwayat kesehatan keluarga sebelumnya___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
III. Data Lingkungan16. Karakteristik Rumah______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Denah rumah
17. Karakteristik tetangga dan komunitasnya___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________18. Mobilitas geografis keluarga___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________19. Perkumpulan keluarga dan interaksi dengan masyarakat___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________20. System pendukung keluarga___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
IV. Struktur Keluarga21. Struktur peran___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________22. Nilai atau norma keluarga___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________23. Pola komunikasi keluarga___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________24. Struktur kekuatan keluarga___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
V. Fungsi Keluarga25. Fungsi afektif___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________26. Fungsi sosialisasi___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________27. Fungsi pemenuhan (perawatan/pemeliharaan) kesehatana. Mengenal masalah kesehatan_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________b. Mengambil keputusan mengenai tindakan kesehatan_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________c. Kemampuan merawat anggota keluarga yang sakit_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________d. Kemampuan keluarga memelihara/memodifikasi lingkungan rumah yang sehat_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________e. Kemampuan menggunakan fasilitas pelayanan kesehatan_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________28. Fungsi reproduksi___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
29. Fungsi ekonomi___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VI. Stress dan Koping Keluarga30. Stressor jangka pendek dan panjang_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________31. Kemampuan keluarga berespon terhadap stressor (stressor jangka pendek dan panjang)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________32. Strategi koping yang digunakan___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________33. Strategi adaptasi disfungsional____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VII. VIII. Pemeriksaan kesehatan tiap individu anggota keluargaTn.Ny.An.An.An.
Keadaan umumTTV : TD Nadi Suhu RR
KepalaRambut dan kulit kepala
Mata
Hidung
Telinga
Mulut dan faring
Leher
Dada Inspeksi
Palpasi
Perkusi
Auskultasi
Abdomen Inspeksi
Auskultasi
Perkusi
Palpasi
Genetalia
Ekstremitas Atas(kanan kiri)
Ekstremitas Bawah(kanan kiri)
IX. X. Harapan Keluarga____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B. DIAGNOSIS KEPERAWATAN KELUARGAI. Analisis dan sistesis dataNODATAPENYEBABMASALAH
II. Perumusan diagnosis keperawatanNODIAGNOSA KEPERAWATAN (PES)
III. Penilaian (scoring) diagnosis keperawatanNOKRITERIASKORPEMBENARAN
IV. Prioritas diagnosis keperawatan1. 2. 3. 4. 5. 6. C. RENCANA ASUHAN KEPERAWATAN KELUARGADIAGNOSA KEPERAWATANTUJUANKRITERIA HASILINTERVENSI
D. IMPLEMENTASIHARI, TANGGAL DAN WAKTUDIAGNOSIS KEPERAWATANIMPLEMENTASI
E. EVALUASIHARI, TANGGAL DAN WAKTUNO. DIAGNOSIS KEPERAWATANEVALUASI
S :
O :
A :
P :
