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PENGKAJIAN KELUARGA

A. Data Umum
1. Nama Keluarga (KK) : ………………………………..
2. Alamat dan Telepon : ………………………………..
3. Komposisi Keluarga :
No Nama J/K Hub. Dg. KK TTL/ Umur Pendidikan

Genogram :

4. Tipe keluarga ...............................................................................................................


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5. Suku ............................................................................................................................
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6. Agama .........................................................................................................................
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7. Status Sosek Keluarga .................................................................................................
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8. Aktivitas Rekreasi Keluarga .......................................................................................
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B. Riwayat dan Tahap Perkembangan Keluarga


9. Tahap Perkembangan Keluarga saat ini ......................................................................
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10. Tahap perkembangan keluarga yang belum terpenuhi ...............................................
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11. Riwayat keluarga inti ..................................................................................................
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12. Riwayat keluarga sebelumnya ....................................................................................
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C. Lingkungan
13. Karakteristik rumah .....................................................................................................
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14. Denah rumah
15. Karakteristik tetangga dan komunikasi RW ...............................................................
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16. Mobilitas geografis keluarga .......................................................................................
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17. Perkumpulan keluarga dan interaksi dengan masyarakat ...........................................
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18. System pendukung keluarga .......................................................................................
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D. Struktur Keluarga
19. Pola komunikasi keluarga ...........................................................................................
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20. Struktur kekuatan keluarga .........................................................................................
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21. Struktur peran ..............................................................................................................
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22. Nilai dan norma budaya ..............................................................................................
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E. Fungsi Keluarga
23. Fungsi Afektif ..............................................................................................................
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24. Fungsi sosialisasi..........................................................................................................
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25. Fungsi perawatan keluarga...........................................................................................
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26. Fungsi reproduksi .........................................................................................................
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27. Fungsi ekonomi ............................................................................................................
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F. Stress dan Koping
28. Stressor jangka pendek.................................................................................................
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29. Stressor jangka panjang ..............................................................................................
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30. Kemampuan keluarga berespon terhadap masalah .....................................................
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31. Strategi koping yang digunakan ..................................................................................
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32. Strategi adaptasi disfungsional ....................................................................................
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G. Harapan Keluarga
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H. Pemeriksaan Fisik
Px. Fisik .
Kepala

Mata

Telinga

Hidung

Mulut
Leher

Dada

Abdomen

Kulit

Ekstremitas
Atas &
bawah
I. ANALISA DATA
No Data Fokus Diagnosa Keperawatan

Skoring dan Prioritas Diagnosa Keperawatan :


Problem : .................................................................................................................................
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Kriteria Skor Bobot Niali Pembenaran
1. Sifat Masalah
2. Kemungkinan
Masalah dapat di
Ubah
3. Potensi Masalah
dapat di Cegah
4. Menonjolnya
masalah
Jumlah

DIAGNOSA KEPERAWATAN
BERDASARKAN PRIORITAS BAYLON MAGLAYA

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2. ...............................................................................................................................................

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