PENGKAJIAN KEPERAWATAN KELUARGA

I. IDENTITAS UMUM KELUARGAa. Identitas keperawatan keluarga :

Nama : ……………………. Pendidikan : ……………………Umur : ……………………. Pekerjaan : ……………………Agama : ……………………. Alamat : ……………………Suku : ……………………. No. Telp : …………………….

b. Komposisi Keluarga :

No. Nama L/P Umur Hub Kel

Pekerjaan Pendidikan Status immunisasi

1. 2.3.4.5.6.7.8.9.10.

c. Genogram

d. Type keluarga : Jenis type keluarga : ………………………………………………….. Masalah yang terjadi dengan type tersebut : …………………………….

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e. Suku bangsa : Asal suku bangsa : …………………………………………………. Budaya yang berhubungan dengan kesehatan : …………………………

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...................................................................................................................f. Agama dan kesehatan yang mempengaruhi kesehtan : ..................................

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........................................................................................................................g. Status sosial ekonomi keluarga :

Anggota keluarga yang mencari nafkah : ................................................ Penghasilan : ………………………………………………………….

Upaya lain : ……………………………………………………………

Harta benda yang dimiliki ( perabot, transport dll ) : ………………….…………………………………………………………………………..

h. Aktifitas rekreasi keluarga : ……………………………………………… ……………………………………………………………………………… ………………………………………………………………………………

II. RIWAYAT DAN TAHAP PERKEMBANGAN KELUARGAa. Tahap perkembangan keluarga saat ini ( ditentukan dengan anak tertua ) ….

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.........................................................................................................................b. Tahap perkembangan keluarga yang belum terpenuhi dan kendalanya : .......

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.........................................................................................................................c. Riwayat kesehtan keluarga inti :

Riwayat kesehatan keluarga saat ini : ......................................................................................................................................................................................................................................................................................................................................................

Riwayat penyakit keturunan :......................................................................................................................................................................................................................................................................................................................................................

Riwayat kesehatan masing – masing anggota keluarga

No. Nama Umur BB KeadaanKesehatan

Immunisasi( BCG/Polio

DPT/HB/Campak )

MasalahKesehatan

TindakanYang

telah dilakukan

d. Sumber pelayanan Kesehatan yang dimanfaatkan :................................................................................................................................................................................................................................................

e. Riwayat kesehatan keluarga sebelmnya :................................................................................................................................................................................................................................................

III. PENGKAJIAN LINGKUNGANa. Karakteristik Rumah

Luas rumah : …………………………………………………………. Type rumah : …………………………………………………………. Kepemilikan : …………………………………………………………. Jumlah dan ratio kamar / ruangan : …………………………………….. Ventilasi / jendela : ............................................................................ Pemanfaatan ruangan : ............................................................................ Septic tank : ada/tidak .......................... letak ........................................ Sumber air minum : ............................................................................ Kamar mandi / WC : ............................................................................ Sampah : ...................................... Limbah RT ............................. Kebersihan lingkungan : ................................................................

b. karakteristik tetangga dan komunitas RW kebiasaan : ........................................................................................ aturan / kesepakatan : ............................................................................ Budaya : .........................................................................................

c. Mobilitas Geografis Keluarga : ......................................................................d. Perkumpulan keluarga dan interaksi dengan masyarakat :

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........................................................................................................................e. System pendukung keluarga : ........................................................................

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IV. STRUKTUR KELUARGAa. Pola/cara komunikasi keluarga : ...................................................................

.......................................................................................................................b. Struktur kekuatan keluarga : ........................................................................

......................................................................................................................c. Struktur peran ( peran masing – masing anggota keluarga )

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.......................................................................................................................d. Nilai dan norma keluarga

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.......................................................................................................................V. FUNGSI KELUARGA

a. Fungsi afektif ..............................................................................................................................................................................................................................................

b. Fungsi sosialisasi Kerukunan hidup dalam keluarga :

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Interaksi dan hubungan dalam keluarga :....................................................................................................................................................................................................................................

Anggota keluarga yang dominan ddalam pengambilan kepurusan :..................................................................................................................

Kegiatan keluarga waktu senggang :....................................................................................................................................................................................................................................

Partisipasi dalam kegiatan social :....................................................................................................................................................................................................................................

c. fungsi perawatan kesehatan :........................................................................................................................................................................................................................................................................................................................................................................

d. Fungsi reproduksi. Perencanaan jumlah anak : ..................................................................... Akseptor : Ya .............. Yang digunakan .............. Lamanya .............. Akseptor : Belum .............., alasannya : ...............................................

................................................................................................................ Keterangan lain : .........................................................................

...............................................................................................................e. Fungsi ekonomi

Upaya pemenuhan sandang pangan : ......................................................................................................................................................................

Pemanfaatan sumber dimasyarakat : ......................................................................................................................................................................

VI. STRESS DAN KOPING KELUARGAa. Stressor jangka pendek :

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.......................................................................................................................b. Stressor jangka panjang :

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......................................................................................................................c. respon keluarga terhadap stressor :

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......................................................................................................................d. strategi koping :

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......................................................................................................................e. Strategi adaptasi disfungsional :

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VII. KEADAAN GIJI KELUARGAa. Pemenuhan giji : ...........................................................................................

......................................................................................................................b. Upaya lain : .................................................................................................

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VIII. HARAPAN KELUARGAa. Terhadap masalah kesehatannya :

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.......................................................................................................................b. terhadap petugas kesehatan yang ada :

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IX. PEMERIKSAAN FISIKNo. Variabel Nama Anggota Keluarga

Tn. Ny. An. An1. Riwayat penyakit

saat ini

2. Keluhan yang dirasakan

3. Tanda dan gejala

4. Riwayat penyakit sebelumnya

5. Tanda-tanda vitas

6. System cardiovaskuler

7. System respirasi

9. System pencernaan

10. Sistim muskuloskeletal

11. Systim persyarafan

12. Sistem Genitalia

X. DIAGNOSA KEPERAWATAN.1. ......................................................................................................................

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XI. SKORING PRIORITAS MASALAH

Diagnosa : ......................................................................................................................... ......................................................................................................................... .........................................................................................................................

No. Kriteria Skala Bobot Skoring Pembenaran1. A. SIFAT MASALAH

B. KEMUNGKINAN MASALAH DAPAT DIUBAH

C. POTENSIAL MASALAH UNTUK DICEGAH

D. MENONJOLNYA MASALAH

XII. RENCANA TINDAKAN KEPERAWATAN

No.Dx

Tujuan Kriteria evaluasi intervensiUmum Khusus Kriteria Standart

XIII. IMPLEMENTASI KEPERAWATAN KELUARGA

Diagnosa keperawatan

Tanggal Implementasi Evaluasi