Anda di halaman 1dari 5

D III Keperawatan STIKes MP.

Palembang

Format Pengkajian Keperawatan Keluarga

Nama Perawat : .............................................


Hari dan Tanggal Pengkajian : .............................................

I. Data Umum
1. Nama KK : .............................................
2. Usia : .............................................
3. Pendidikan : .............................................
4. Agama : .............................................
5. Pekerjaan : .............................................
6. Alamat dan No. Telepon : .............................................
7. Komposisi Anggota Keluarga : .............................................

No Nama JK Umur Hub dengan Pendidikan Agama Pekerjaan Status


(TTL) keluarga Kes

Genogram :

Keterangan; Laki-laki

Perempuan

Klien laki-laki sakit

Klien perempuan sakit

Meninggal

Menikah
Cerai
Anak angkat

Aborsi

Kembar

Tinggal serumah

8. Tipe Keluarga : .............................................


9. Suku Bangsa : .............................................
10. Status Sosial Ekonomi Keluarga : .............................................
11. Aktivitas Rekreasi Keluarga : .............................................
12. Pola Pengambilan Keputusan : .............................................

II. Riwayat dan Tahap Perkembangan Keluarga


1. Tahap perkembangan keluarga saat ini
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

2. Tugas perkembangan keluarga yang belum terpenuhi


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

3. Riwayat kesehatan keluarga saat ini


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

4. Riwayat kesehatan keluarga sebelumnya


......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
III. Lingkungan
1. Karakteristik rumah
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

2. Denah rumah, keadaan lingkungan rumah


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

3. Karakteristik tetangga dan komunitasnya


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

4. Mobilitas geografis keluarga


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

5. Perkumpulan keluarga dan interaksi dengan masyarakat


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

6. Sistem pendukung keluarga


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

IV. Struktur Keluarga


1. Pola komunikasi keluarga
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

2. Struktur kekuatan keluarga


......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
3. Struktur peran keluarga
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

4. Nilai atau norma keluarga


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

V. Fungsi Keluarga
1. Fungsi Afektif
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

2. Fungsi Sosial
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

3. Fungsi Perawatan Kesehatan


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

4. Fungsi Repreduksi
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

5. Fungsi Ekonomi
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

6. Fungsi Religius
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
VI. Stres dan Koping Keluarga
1. Stresor jangka pendek dan panjang
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

2. Kemampuan keluarga berespons terhadap stresor

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

3. Strategi koping yang digunakan


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

4. Strategi adaptasi disfungsional


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

VII. Harapan Keluarga


1. Persepsi terhadap masalah
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

2. Harapan terhadap masalah


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

VIII. Pemeriksaan Kesehatan Tiap Anggota Keluarga


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