FORMAT PENGKAJIAN KELUARGA

PRAKTEK KEPERAWATAN KELUARGA MAHASISWA

PRODI DIII KEPERAWATAN BENGKULU JURUSAN KEPERAWATAN POLTEKKES
KEMENKES BENGKULU TA. 2018/2019

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 : ................................................................................

N Nama JK Hubungan Umur Pnddk Status Imunisasi KET

o Dgn
Kepala
Keluarga
BCG Polio DPT Hepatitis Campak
1 2 3 4 1 2 3 1 2 3

Genogram (tiga generasi) :

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 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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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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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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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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 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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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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 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

5 Kepala

6 Leher

7 Thoraks

8 Abdomen

9 Esktremitas

10 Kulit

11 Genetalia

VIII. HARAPAN KELUARGA

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IX. ANALISIS DATA

No DATA ETIOLOGI MASALAH

Data Subjektif :

Data Objektif :

Data Subjektif :

Data Objektif :

Data Subjektif :

Data Objektif :

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X. PRIORITAS MASALAH
DX. I . …………………………………………………………………………………………….

No Kriteria Skor Bobot Pembenaran

1 Sifat Masalah 1
Skala : Tidak / Kurang Sehat 3
Ancaman Kesehatan 2
Keadaaan Sejahtera 1

2 Kemungkinan Masalah dapat diubah 2

Skala : Mudah 2
Sebagian 1
Tidak dapat 0

3 Potensial Masalah Untuk dicegah 1

Skala : Tinggi 3
Cukup 2
Rendah 1
4 Menonjolnya Masalah 1
Skala : Masalah Berat harus segera di tangani 2
Adanya Masalah tetapi tidak perlu ditangani 1
Masalah Tidak Dirasakan : 0
Jumlah

Dx 2. . ………………………………………………………………………………………………….

No Kriteria Skor Bobot Pembenaran

1 Sifat Masalah 1
Skala : Tidak / Kurang Sehat 3
Ancaman Kesehatan 2
Keadaaan Sejahtera 1

2 Kemungkinan Masalah dapat diubah 2

Skala : Mudah 2
Sebagian 1
Tidak dapat 0

3 Potensial Masalah Untuk dicegah 1

Skala : Tinggi 3
Cukup 2
Rendah 1

4 Menonjolnya Masalah 1
Skala : Masalah Berat harus segera di tangani 2
Adanya Masalah tetapi tidak perlu ditangani 1
Masalah Tidak Dirasakan : 0

Jumlah

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 XI. DIAGNOSA KEPERAWATAN SESUAI PRIORITAS

1. ………………………………………………………………………………………………
2. ………………………………………………………………………………………………
3. ………………………………………………………………………………………………
4. ………………………………………………………………………………………………

XII. RENCANA ASUHAN KEPERAWATAN KELUARGA

No Diagnosa Keperawatan Tujuan Kriteria Evaluasi Rencana Intervensi

Tjuan Umum Kriteria Standar

Tujuan Khusus

NB : Rencana dibuat untuk kelima tujuan sesuai tugas keluarga

XIII. PELAKSANAAN DAN EVALUASI

No Tanggal Diagnosis Tujuan Khusus Implementasi Evaluasi

Keperawatan
Keluarga