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
NO

NAMA

Genogram :

JK DENGAN KK UMUR

PENDIDIKAN

POLIO

STATUS IMUNISASI
DPT HEPATITIS CAMPAK

6. Tipe Keluarga

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7. Suku bangsa

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8. Agama

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9. Status social ekonomi keluarga :
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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. STRUKTUR KELUARGA

20. Pola komunikasi keluarga
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21. Struktur kekuatan keluarga
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22. Struktur peran (formal & informal)
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23. Nilai dan norma keluarga
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V. FUNGSI KELUARGA

24. Fungsi afektif

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25. Fungsi social
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26. Fungsi perawatan kesehatan
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27. Fungsi Reproduksi
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28. Fungsi Ekonomi

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VI.STRESS DAN KOPING KELUARGA
29. Stressor jangka pendek dan tangga panjang
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30. Kemampuan keluarga berespons terhadap situasi/stressor
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31. Strategi koping yang digunakan
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32. Strategi adaptasi disfungsional
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VII.

PEMERIKSAAN FISIK
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VIII. HARAPAN KELUARGA

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Nganjuk, .. ,2009
NAMA MAHASISWA

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Lampiran 1
SKALA PRIORITAS PENYUSUNAN
MASALAH KESEHATAN KELUARGA
KRITERIA

NILAI

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

3
2
1
2
2
1
0
1

Skala : tinggi

cukup

rendah
4. Meninjolnya masalah
Skala : masalah harus ditangani
Masalah tidak perlu segara

BOBOT
1

1
1
2
1

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
NO

TUJUAN

KRITERIA EVALUASI

KEPERAWATAN
KELUARGA

RENCANA
UMUM

KHUSUS

KRITERIA

STANDAR

PARAF

FORMAT PELAKSANAAN
ASUHAN KEPERAWATAN KELUARGA
DIAGNOSIS
NO

KEPERAWATAN

TUJUAN

KELUARGA

KHUSUS

TANGGAL

IMPLEMENTASI

EVALUASI

PARAF