FORM PENGKAJIAN KEPERAWATAN KELUARGA

I.

Data Umum
Pengkajian terhadap data umum keluarga meliputi :
1. Nama kepala keluarga (KK) : ..........................................
2. Alamat dan telepon

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

3. Pekerjaan kepala keluarga :

a. PNS/BUMN/TNI/Polri
b. Karyawan Swasta
c.

Petani

d. Buruh
e. Wir
4. Pendidikan kepala keluarga :
a. SD tidak tamat
b. SD
c.

SLTP

d. SLTA
e. Akademi/PT
5. Komposisi keluarga dan genogram
No

Nama

Genogram

6. Tipe keluarga :
a. Inti (nuclear)

Jenis
kelamin

Hub dg KK

umur

Pendidikan

b. Besar (extended)
c.

Campuran (Blended)

d. Ayah/Ibu + anak (single parent)

e. Dewasa sendiri (single adult)
f.

Lansia

g. Lain-lain, sebutkan ...........................

7. Suku bangsa :
a. Sunda
b. Jawa
c.

lain-lain, sebutkan .............................

8. Agama :
a. Islam
b. Protestan
c.

Katholik

d. Hindu
e. Budha
9. Status sosial ekonomi keluarga :
a. Pra Keluarga Sejahtera (Pra KS)
b. KS I
c.

KS II

d. KS III
e. KS III Plus
10. Aktifitas rekreasi keluarga : .......................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
....................................................................................................................................................
II. Riwayat dan tahap perkembangan keluarga
11.

Tahap perkembangan keluarga saat ini

a. Keluarga pemula
b. Keluarga mengasuh anak
c.

Keluarga dengan anak usia prasekolah

d. Keluarga dengan anak usia sekolah

e. Keluarga dengan anak remaja
f.

Keluarga dengan anak dewasa

g. Keluarga usia pertengahan

h. Keluarga usia lanjut

12. Tahap perkembangan keluarga yang belum terpenuhi :

........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
.........................................................................................................................................
13. Riwayat keluarga inti :
........................................................................................................................................................
........................................................................................................................................................
.........................................................................................................................................
14. Riwayat keluarga sebelumnya :
........................................................................................................................................................
........................................................................................................................................................
...........................................................................................................................................
III. Pengkajian lingkungan
15.

Karakteristik rumah
.....................................................................................................................................................
.....................................................................................................................................................
...................................................................................................................................................
Denah :

16.

Karakteristik tetangga dan komunitas RW :

.....................................................................................................................................................
.....................................................................................................................................................
.......................................................................................................................................

17.

Mobilitas geografis keluarga :

.....................................................................................................................................................
.....................................................................................................................................................
.......................................................................................................................................

18.

Perkumpulan keluarga dan interaksi dengan masyarakat :

.....................................................................................................................................................
.....................................................................................................................................................
.......................................................................................................................................

IV. Struktur keluarga

19.

Sistim pendukung keluarga :

.....................................................................................................................................................
.....................................................................................................................................................
........................................................................................................................................

20.

Pola komunikasi keluarga :

.....................................................................................................................................................
.....................................................................................................................................................
........................................................................................................................................

21.

Struktur kekuatan keluarga :

.....................................................................................................................................................
.....................................................................................................................................................
.......................................................................................................................................

22.

Struktur peran :
.....................................................................................................................................................
.....................................................................................................................................................
.......................................................................................................................................

23.

Nilai atau norma keluarga :

.....................................................................................................................................................
.....................................................................................................................................................
.......................................................................................................................................

V. Fungsi keluarga
24.

Fungsi afektif :
.....................................................................................................................................................
.....................................................................................................................................................
......................................................................................................................................

25.

Fungsi sosialisasi :
.....................................................................................................................................................
.....................................................................................................................................................
.......................................................................................................................................

26.

Fungsi perawatan kesehatan :

.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
........................................................................................................................................
27.

Fungsi reproduksi :
.....................................................................................................................................................
.....................................................................................................................................................
......................................................................................................................................
.......................................................................................................................................

28.

Fungsi ekonomi :
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.......................................................................................................................................

VI. Stress dan koping keluarga

29.

Stressor jangka pendek dan panjang

.....................................................................................................................................................
.....................................................................................................................................................
.......................................................................................................................................

30.

Kemampuan keluarga berespon terhadap stressor :

.....................................................................................................................................................
.....................................................................................................................................................
........................................................................................................................................

31.

Strategi koping yang digunakan :

.....................................................................................................................................................
.....................................................................................................................................................
.......................................................................................................................................

32.

Strategi adaptasi disfungsional :

.....................................................................................................................................................
.....................................................................................................................................................
.......................................................................................................................................

VII.

Pemeriksaan fisik
Nama

Hasil PF

Nama

Hasil PF

Nama

Hasil PF

VIII. Harapan keluarga

........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
..........................................................................................................................................

ANALISA DATA
No.

Data Penunjang

Problem

Etiologi

DIAGNOSA KEPERAWATAN KELUARGA

No.

Tanggal Muncul

Diagnosa Keperawatan

RENCANA ASUHAN KEPERAWATAN KELUARGA

No

Diagnose
Keperawatan

Tujuan

Rencana Intervensi

Implementasi

Tanggal

Paraf

EVALUASI ASUHAN KEPERAWATAN KELUARGA

No. Dx

Tanggal

Perkembangan

ASUHAN KEPERAWATAN KELUARGA

Tn. W DENGAN PERILAKU HIDUP BERSIH DAN SEHAT
DI RT 01 RW 07 KELURAHAN RATU JAYA KEC. PANCORAN
MAS KOTA DEPOK

Diajukan Sebagai Tugas Mata Kuliah Aplikasi Keperawatan Komunitas Lanjut I

Koordinator : Wiwin Wiarsih, MN

Setyoadi
NPM : 0806469735

PROGRAM MAGISTER KEKHUSUSAN KEPERAWATAN

KOMUNITAS
FAKULTAS ILMU KEPERAWATAN UNIVERSITAS INDONESIA
TAHUN 2009

ASUHAN KEPERAWATAN KELUARGA Tn. M

DENGAN HERNIA SOKROTALIS RT 01 RW 07 KELURAHAN
RATU JAYA KEC. PANCORAN MAS KOTA DEPOK

Diajukan Sebagai Tugas Mata Kuliah Aplikasi Keperawatan Komunitas Lanjut I

Koordinator : Wiwin Wiarsih, MN

Setyoadi
NPM : 0806469735

PROGRAM MAGISTER KEKHUSUSAN KEPERAWATAN

KOMUNITAS
FAKULTAS ILMU KEPERAWATAN UNIVERSITAS INDONESIA
TAHUN 2009