FORMAT PENGKAJIAN KELUARGA

I. Data Umum
1. Nama KK : ............................................................................................
2. Alamat : ............................................................................................
3. Komposisi Anggota Keluarga

No Nama JK Hubungan Keluarga Usia Pendidikan

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Genogram

Keterangan:
.................................................................................................................................................................................................................................................................................................
.................................................................................................................................................................................................................................................................................................
..........
.................................................................................................................................................................................................................................................................................................
.................................................................................................................................................................................................................................................................................................
..........
4. Tipe Keluarga
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................

5. Suku
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................

6. Agama
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................

7. Status Sosial Ekonomi

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

8. Aktifitas Rekreasi Keluarga

...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................
II. Riwayat Tumbuh Kembang Keluarga

1. Tahap Perkembangan Keluarga Inti

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

2. Tahap Perkembangan Keluarga Yang Belum Terpenuhi

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

3. Riwayat Keluarga Inti

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

III. Lingkungan
a. Karekteristik Rumah
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
................................................................................................................................................

Denah Rumah
 Keterangan:
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
................................................................................................................................................

b. Karakteristik Tetangga dan Komunitas

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

c. Mobilitas Geografis Keluarga

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

d. Perkumpulan Keluarga dan Interaksi dengan Masyarakat

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

e. Sistem Pendukung Keluarga

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

IV. Struktur Keluarga

 a. Pola Komunikasi Keluarga
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................

b. Struktur Kekuatan Keluarga

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

c. Struktur Peran Keluaga

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

d. Nilai dan Norma Keluarga

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

V. Fungsi Keluarga
a. Fungsi Afeksi
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................

b. Fungsi Sosialisasi
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................

c. Fungsi Perawatan Keluarga

 ...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
......................................
VI. Stres dan koping Keluarga
a. Stresor Jangka pendek
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................

b. Stresor jangka Panjang

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

c. Kemampuan Keluarga Berespon Terhadap Masalah

...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................
d. Strategi Koping Yang Digunakan
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................
 e. Strategi Adaptasi Disfungsional
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................

Harapan Keluarga
VII.
.................................................................................................................................................................................................................................................................................................
.................................................................................................................................................................................................................................................................................................
........................................................................................................................................
LAMPIRAN HASIL PEMERIKSAAN FISIK :

Pemeriksaan fisik Anggota keluarga

a. Tanda vital
Suhu
Nadi
RR
TD
b. Fisik :
ANALISA DATA :

No. Data Diagnosa Keperawatan

SKORING MASALAH :

Kriteria Bobot Pembenaran

Sifat Masalah

Kemungkinan untuk diubah

Potensial dicegah
Menonjolnya masalah

Skore
Rencana Asuhan Keperawatan pada Keluarga ………..

No Dx Keperawatan Tupan Tupen Rencana Tindakan Kriteria Evaluasi

Kriteria standar