PROGRAM PROFESI

UNIVERSITAS MUHAMMADIYAH KALIMANTAN TIMUR

FORMAT PENGKAJIAN KELUARGA DENGAN IBU/BAYI BERESIKO

(dilengkapi dengan format pengkajian sesuai kondisi klien sebagai point entry)

Nama Mahasiswa : NPM :

Tanggal Pengkajian : Rumah Sakit/Puskesmas:

Inisial Pasien : Usia :

Diagnosa Medis : Agama :

Pendidikan : Pekerjaan :

Alamat :

DATA UMUM

Nama KK : Agama :

Usia : Suku :

Pendidikan Terakhir : Pekerjaan :

1. KOMPOSISI KELUARGA
Nama Jenis Hubungan
NO Usia Pendidikan Pekerjaan
Anggota Kelamin dengan KK

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2. GENOGRAM
(Buat dalam tiga generasi, beri keterangan siapa yang tinggal serumah, yang meninggal,
mengidap penyakit keturunan, riwayat aborsi, kelahiran kembar, dll)

Keterangan Genogram:

3. Jenis Keluarga
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4. Praktek budaya yang mempengaruhi kesehatan
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5. Status Sosial Ekonomi
(pekerjaan, penghasilan, pengeluaran, aset keluarga)
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6. Tahap Perkembangan
 Tahap dan tugas perkembangan keluarga saat ini (jelaskan tahap & tugas
perkembangan sesuai dengan kondisi keluarga saat ini)
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 Tahap dan tugas perkembangan yang belum terpenuhi (hal-hal yang belum
sesuai dengan tahap yang seharusnya tercapai)
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7. Lingkungan
 Karakteristik rumah (yang beresiko terhadap kesehatan seperti: sirkulasi udara,
sinar matahari, tangga, lantai yang licin, dll)
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 Denah rumah (gambar denah rumah keluarga)

8. Fasilitas kesehatan yang tersedia

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9. Struktur Keluarga
 Pola kamunikasi keluarga yang berkaitan dengan kesehatan ( Bagaimana bentuk
komunikasi jika ada masalah kesehatan)
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10. Fungsi Keluarga
(fungsi perawatan kesehatan (self care); bagaimana keluarga merawat dirinya sendiri,
termasuk menjaga kesehatan)
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11. Stress dan Koping Keluarga
 Stress/masalah jangka panjang yang berkaitan dengan kesehatan
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 Stress/ masalah jangka pendek yang berkaitan dengan kesehatan
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 Respon keluarga terhadap masalah/stress-strategi koping
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12. Harapan keluarga terhadap petugas kesehatan
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13. Riwayat Kesehatan

No Anggota Keluarga Riwayat Kesehatan Kondisi Kesehatan saat ini

14. Masalah Keperawatan sesuai prioritas

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15. Tindakan yang telah dilaksanakan
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16. Evaluasi
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