PENGKAJIAN KELUARGA

A. Data Umum
Identitas Kepala Keluarga
Nama

:...

Umur

:...

Agama

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

Suku bangsa

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

Pendidikan

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

Pekerjaan

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

Alamat

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

10

KB

Immunisasi
(Lengkap/Tdk
Lengkap)

Keadaan
Kesehatan

Pekerjaan

Pendidikan

Agama

Hubungan
dengan KK

Status Kawin

L
/
P

Suku Bangsa

1
1.

Umur (tahun)

N
O

Nama Anggota
Keluarga

Komposisi Keluarga

11

12

13

2.
3.
4.
5.
6.
7.
8.
9.
10.

PPN ANGKATAN XXIV KEBON WARU RW 07

Genogram

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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PPN ANGKATAN XXIV KEBON WARU RW 07

B. Riwayat dan Tahap Perkembangan Keluarga

Tahap Perkembangan Keluarga Saat Ini
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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

:........................................................................................................
PPN ANGKATAN XXIV KEBON WARU RW 07

Jumlah Jendela

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

Jarak Septic tank

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

Sumber Air Minum

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

Pembuangan Limbah

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

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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PPN ANGKATAN XXIV KEBON WARU RW 07

Sistem Pendukung Keluarga

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Struktur Kekuatan Keluarga
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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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PPN ANGKATAN XXIV KEBON WARU RW 07

Fungsi Perawatan Kesehatan

Mengenal masalah kesehatan

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Mengambil Keputusan untuk Mengatasi masalah

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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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PPN ANGKATAN XXIV KEBON WARU RW 07

E. Stres dan Koping Keluarga

Stressor
Stressor Jangka Pendek
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Stressor Jangka Panjang
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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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PPN ANGKATAN XXIV KEBON WARU RW 07

G. Pemeriksaan Fisik

PPN ANGKATAN XXIV KEBON WARU RW 07

PENGKAJIAN KELUARGA MANDIRI

No

Masalah Kesehatan

Masalah Keperawatan

Kriteria Keluarga Mandiri

1

Kategori
8

10

Kesimpulan

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
1

Kriteria
Sifat masalah
Skala:
- Aktual (tidak/kurang sehat)
- ancaman kesehatan
- keadaan sejahtera
Kemungkinan masalah dapat diubah
Skala:
- mudah
- sebagian
- tidak dapat
Potensial masalah untuk dicegah
Skala:
- tinggi
- cukup
- rendah
Menonjolnya masalah
Skala:
- masalah berat, harus segera
ditangani
- ada masalah, tetapi tidak
perlu segera ditangani
- masalah tidak dirasakan
TOTAL SKORE

Skor

Bobot

3
2
1

2
1
0

3
2
1

Perhitungan untuk Diagnosa

2
1

PPN ANGKATAN XXIV KEBON WARU RW 07

RENCANA KEPERAWATAN KELUARGA

No

Tujuan

Diagnosa Keperawatan
Keluarga

Umum

Kriteria Evaluasi
Khusus

kriteria

Standar

Rencana Intervensi

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

JADWAL KUNJUNGAN KELUARGA

PARAF
TANGGAL

KEGIATAN
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