A.
PENGKAJIAN (Tanggal
I.
: ..................)
DATA UMUM
1.
2.
3.
Pekerjaan KK
4.
Pendidikan KK
5.
Komposisi keluarga
:
Status imunisasi
No
Nama
J/K
1
2
3
4
Genogram :
Hub.
Umur
Pen-
Kel. KK
Dg.
didikan
BCG
Polio
DPT
Hepatitis
1 2 3 4 1 2 3 1
Campak
Ket
6.
Tipe keluarga
7.
Suku bangsa
8.
Agama
9.
.........................................................................................................................................
.........................................................................................................................................
10. Aktivitas rekreasi keluarga
.........................................................................................................................................
.........................................................................................................................................
II.
Fungsi keluarga
24. Fungsi ekonomi
.........................................................................................................................................
.........................................................................................................................................
25. Fungsi mendapatkan status sosial
.........................................................................................................................................
.........................................................................................................................................
26. Fungsi pendidikan
.........................................................................................................................................
.........................................................................................................................................
27. Fungsi sosialisasi
.........................................................................................................................................
.........................................................................................................................................
28. Fungsi pemenuhan keperawatan
a.
.........................................................................................................................................
.........................................................................................................................................
b.
.........................................................................................................................................
.........................................................................................................................................
c.
.........................................................................................................................................
.........................................................................................................................................
d.
.........................................................................................................................................
.........................................................................................................................................
e.
.........................................................................................................................................
.........................................................................................................................................
29. Fungsi Religius
.........................................................................................................................................
.........................................................................................................................................
30. Fungsi rekreasi
.........................................................................................................................................
.........................................................................................................................................
31. Fungsi reproduksi
.........................................................................................................................................
.........................................................................................................................................
32. Fungsi afeksi
.........................................................................................................................................
.........................................................................................................................................
Tn....
Ny....
Tn...
Ny....
VIII.
Harapan keluarga
.........................................................................................................................................
.........................................................................................................................................
B.
I.
Data
Subjektif :
Objektif :
Subjektif :
Objektif :
Subjektif :
Objektif :
Malasah
Penyebab
1.
2.
3.
Kriteria
Kep
1
a.
a. Sifat masalah : . . . .
b.
c.
d.
d. Menonjolnya masalah : . . . .
Total skor
2.
3.
Skor
Pembenaran
Diagnosis keperawatan
Skor
1.
2.
3.
C.
Kriteria
Hasil/standar
Intervensi
D.
IMPLEMENTASI
No.
tanggal &
Diag.Kep
Implementasi
waktu
1.
2.
E.
EVALUASI
Tanggal &
No.Diag.
Waktu
Kep
1.
Evaluasi
S:
O:
A:
P:
2.
S:
O:
A:
P: