FORMAT PENGKAJIAN KELUARGA

PRAKTEK KEPERAWATAN KELUARGA MAHASISWA PRODI DIII

KEPERAWATAN BENGKULU JURUSAN KEPERAWATAN POLTEKKES

KEMENKES BENGKULU

TA. 2014/2015

I. DATA UMUM

1. Nama Kepala Keluarga : ........................................................................................

2. Alamat dan telepon : ........................................................................................

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3. Pekerjaan kepala keluarga : ........................................................................................

4. Pendidikan Kepala Keluarga : ........................................................................................

5. Komposisi Keluarga : ........................................................................................

No Nama JK

Hubungan

Dgn Kepala

Keluarga

Umur Pnddk Status Imunisasi KET

BCG Polio DPT Hepatitis Campak

1 2 3 4 1 2 3 1 2 3

1

Genogram (tiga generasi) :

6. Tipe Keluarga : ........................................................................................

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7. Suku Bangsa : ........................................................................................

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8. Agama : ........................................................................................

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9. Status Sosial Ekonomi : ........................................................................................

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10. Aktifitas Rekreasi Keluarga : ........................................................................................

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2

II. RIWAYAT TAHAP PERKEMBANGAN KELUARGA

11. Tahap Perkembangan Keluarga saat ini :

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12. Tahap Perkembangan Keluarga yang belum Terpenuhi :

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13. Riwayat Keluarga Inti :

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14. Riwayat keluarga sebelumnya :

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3

III. LINGKUNGAN

15. Karakteristik Rumah :

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Denah Rumah :

16. Karakteristik tetangga dan Komunitas RW :

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17. Mobilitas Geografis Keluarga :

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4

18. Perkumpulan Keluarga dan Interaksi dengan masyarakat :

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19. Sistem Pendukung Keluarga :

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IV. STRTUKTUR KELUARGA

20. Pola Komunikasi Keluarga :

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21. Struktur Kekuatan Keluarga :

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22. Struktur Peran Formal dan Informal :

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5

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23. Nilai dan Norma dalam Keluarga :

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V. FUNGSI KELUARGA

24. Fungsi Afektif :

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25. Fungsi Sosial

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26. Fungsi Perawatan Keluarga :

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6

27. Fungsi Reproduksi :

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28. Fungsi Ekonomi :

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VI. STRES DAN KOPING KELUARGA

29. Stresor jangka pendek dan Panjang :

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30. Kemampuan keluarga Berespon terhadap situasi / stresor :

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31. Strategi Koping yang Digunakan :

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7

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32. Strategi Adaptasi Disfungsional

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VII.PEMERIKSAAN FISIK ( HEAD TO TOE ) ( Dikaji pada setiap anggota keluarga )

NO VARIABEL NAMA ANGGOTA KELUARGA

Tn. Ny. An. An.

1 Riwayat penyakit saat

ini

2 Keluhan yang

dirasakan

3 Riwayat penyakit

sebelumnya

4 Tanda-tanda vital

8

5 Kepala

6 Leher

7 Thoraks

8 Abdomen

9 Esktremitas

10 Kulit

11 Genetalia

VIII. HARAPAN KELUARGA

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9

IX. ANALISIS DATA

No DATA ETIOLOGI MASALAH

Data Subjektif :

Data Objektif :

Data Subjektif :

Data Objektif :

10

Data Subjektif :

Data Objektif :

11

X. PRIORITAS MASALAH

DX. I .

…………………………………………………………………………………………….

No Kriteria Skor Bobot Pembenaran

1 Sifat Masalah

Skala : Tidak / Kurang Sehat

Ancaman Kesehatan

Keadaaan Sejahtera

3

2

1

1

2 Kemungkinan Masalah dapat diubah

Skala : Mudah

Sebagian

Tidak dapat

2

1

0

2

3 Potensial Masalah Untuk dicegah

Skala : Tinggi

Cukup

Rendah

3

2

1

1

4 Menonjolnya Masalah

Skala : Masalah Berat harus segera di tangani

Adanya Masalah tetapi tidak perlu ditangani

Masalah Tidak Dirasakan :

2

1

0

1

Jumlah

12

Dx 2. .

………………………………………………………………………………………………….

No Kriteria Skor Bobot Pembenaran

1 Sifat Masalah

Skala : Tidak / Kurang Sehat

Ancaman Kesehatan

Keadaaan Sejahtera

3

2

1

1

2 Kemungkinan Masalah dapat diubah

Skala : Mudah

Sebagian

Tidak dapat

2

1

0

2

3 Potensial Masalah Untuk dicegah

Skala : Tinggi

Cukup

Rendah

3

2

1

1

4 Menonjolnya Masalah

Skala : Masalah Berat harus segera di tangani

Adanya Masalah tetapi tidak perlu ditangani

Masalah Tidak Dirasakan :

2

1

0

1

Jumlah

13

XI. DIAGNOSA KEPERAWATAN SESUAI PRIORITAS

1. …………………………………………………………………………………………

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2. …………………………………………………………………………………………

……

3. …………………………………………………………………………………………

……

4. …………………………………………………………………………………………

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XII. RENCANA ASUHAN KEPERAWATAN KELUARGA

No Diagnosa Keperawatan Tujuan Kriteria Evaluasi Rencana Intervensi

Tjuan Umum

Tujuan Khusus

Kriteria Standar

NB : Rencana dibuat untuk kelima tujuan sesuai tugas keluarga

14

XIII. PELAKSANAAN DAN EVALUASI

No Tanggal Diagnosis

Keperawatan

Keluarga

Tujuan Khusus Implementasi Evaluasi

S

O

A

P

15