SEKOLAH TINGGI ILMU KESEHATAN

SATRIA BHAKTI NGANJUK

PROGRAM STUDI D III KEPERAWATAN
Sekretariat :Jl.Panglima Sudirman VI Nganjuk ,Telp.(0358) 326110
FORMAT PENGKAJIAN KELUARGA
I. DATA UMUM
1. Nama Kepala Keluarga

2. Alamat / Nomor Telpon

3. Pendidikan Kepala Keluarga :

4. Pekerjaan Kepala Keluarga

5. Komposisi Keluarga

HUBUNGAN
N
O

NAMA

DENGAN

KK

STATUS IMUNISASI
UMUR

PENDIDIKAN
POLIO

DPT

HEPATITI
S

CAMPAK

Genogram :

6. Tipe Keluarga

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________
7. Suku bangsa

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________
8. Agama

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________
9. Status social ekonomi keluarga :
____________________________________________________________________
____________________________________________________________________

____________________________________________________________________
____________________________________________________________________
________
10. Aktifitas rekreasi keluarga

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________

II. RIWAYAT TAHAP PERKEMBANGAN KELUARGA

11. Tahap perkembangan keluarga saat ini
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________

12. Tahap perkembangan keluarga yang belum terpenuhi

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________
13. Riwayat keluarga inti
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

____________________________________________________________________
________
14. Riwayat keluarga sebelumnya
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________

III.

LINGKUNGAN
15. Karakteristik rumah
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
Denah rumah

16. Karakteristik tetangga dan komunitas RW

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
17. Mobilitas geografis keluarga
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
18. Perkumpulan keluarga dan interaksi dengan masyarakat
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________

19. Sistem pendukung keluarga

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

______________________________________________________________
__________
IV.STRUKTUR KELUARGA
20. Pola komunikasi keluarga
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
21. Struktur kekuatan keluarga
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
22. Struktur peran (formal & informal)
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
23. Nilai dan norma keluarga
______________________________________________________________
______________________________________________________________
______________________________________________________________
______

V. FUNGSI KELUARGA
24. Fungsi afektif
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
25. Fungsi social
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
26. Fungsi perawatan kesehatan
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
27. Fungsi Reproduksi
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

__________
28. Fungsi Ekonomi
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
VI.STRESS DAN KOPING KELUARGA
29. Stressor jangka pendek dan tangga panjang
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
30. Kemampuan keluarga berespons terhadap situasi/stressor
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________
31. Strategi koping yang digunakan
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________

32. Strategi adaptasi disfungsional

______________________________________________________________
______________________________________________________________
______________________________________________________________
______

VII.

PEMERIKSAAN FISIK
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________

VIII. HARAPAN KELUARGA

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
__________

Nganjuk, .. ,2009
NAMA MAHASISWA

(____________________________________)
Lampiran 1
SKALA PRIORITAS PENYUSUNAN
MASALAH KESEHATAN KELUARGA
KRITERIA
1. Sifat Masalah
Skala : ancaman
Tidak sehat
Krisis
2. Kemungkinan masalah dapat diubah
Skala : dengan mudah
Hanya sebagian
Tidak dapat
3. Potensi masalah untuk dicegah

NILAI
3
2
1

2
2
1
0
1

Skala : tinggi

cukup

rendah
4. Meninjolnya masalah

BOBOT
1

1
1

Skala : masalah harus ditangani

Masalah tidak perlu segara

ditangani

Masalah tidak dirasakan

Skoring :
1. Tentukan skore untuk setiap kriteria
2. Skore dibagi dengan angka tertinggi dan kalikanlah dengan bobot
Skore

Bobot

Angka tertinggi
3. Jumlah skore untuk semua kriteria

Lampiran 2.
FORMAT PERENCANAAN
ASUHAN KEPERAWATAN KELUARGA
DIAGNOSIS
N

KEPERAWATAN

KELUARGA

TUJUAN

KRITERIA EVALUASI
RENCANA

UMUM

KHUSUS

KRITERIA

STANDAR

PARAF

FORMAT PELAKSANAAN
ASUHAN KEPERAWATAN KELUARGA

DIAGNOSIS
N

KEPERAWATAN

TUJUAN

KELUARGA

KHUSUS

TANGGAL

IMPLEMENTASI

EVALUASI

PARAF