PROGRAM STUDI PROFESI NERS

FAKULTAS KEPERAWATAN DAN KEBIDANAN

UNIVERSITAS NAHDLATUL ULAMA SURABAYA
Jl. Smea 57 Surabaya, Tlp. 031 828450, 8291920, Faks.
(031) 8298582

FORMAT PENGKAJIAN KEPERAWATAN KELUARGA

PENGKAJIAN
Hari/tanggal :
Metode :
1. Data Umum
a. Identitas kepala keluarga :
1) Nama KK :
2) Jenis Kelamin :
3) Umur :
4) Pendidikan :
5) Agama :
6) Pekerjaan :
7) Alamat :
8) Suku/kebangsaan :
9) Jumlah anggota keluarga :

b. Susunan anggota keluarga

No Nama Umur Sex Hubungan Pendidikan Pekerjaan Keterangan
dengan KK
c. Genogram

d. Tipe keluarga

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1) Kewarganegaraan/suku bangsa:...............................................................
2) Agama:.....................................................................................................
3) Status Sosial Ekonomi Keluarga
a) Penghasilan Keluarga
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b) Jenis Pengeluaran Keluarga Tiap Bulan
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c) Tabungan Khusus Kesehatan
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4) Aktifitas Rekreasi
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2. Riwayat dan Tahap Perkembangan Keluarga
a. Tahap Perkembangan Keluarga Saat Ini
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b. Tahap Perkembangan Keluarga yang Belum Terpenuhi
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c. Riwayat Kesehatan Keluarga Saat ini
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d. Riwayat Kesehatan Keluarga Sebelumnya
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3. Faktor Lingkungan dan Masyarakat
a. Karakteristik Rumah
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b. Karakteristik Tetangga dan Komunitas
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c. Mobilitas Geografi Keluarga
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d. Perkumpulan Keluarga dan Interaksi dengan Masyarakat
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e. Sistem Pendukung Keluarga/Fasilitas Keluarga
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4. Struktur Keluarga
a. Pola Komunikasi Keluarga
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b. Struktur Peran
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c. Nilai dan Norma Keluarga
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5. Fungsi Keluarga
a. Fungsi Affektif
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b. Fungsi Sosial
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c. Fungsi Perawatan Kesehatan
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d. Fungsi Reproduksi
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 e. Fungsi Ekonomi
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6. Stress dan Koping Keluarga

a. Stressor Jangka Pendek dan Jangka Panjang
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b. Kemampuan Berespon Terhadap Stress
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c. Strategi Koping Yang Digunakan
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d. Strategi adaptasi disfumgsional.
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7. Pemeriksaan Fisik
a. Pemeriksaan secara umum
No Nama KU TTV Penglihatan Pendengaran Pencernaan Eliminasi Keluhan

b. Pemeriksaan secara khusus

1) Vital Sign
Tekanan darah :
Nadi :
Temperatur :
Respirasi Rate :
2) BB : kg , TB : Cm
3) Cepalokaudal
a) Kulit, rambut, dan kuku :
b) Kepala dan leher :
c) Telinga :
d) Mulut, tenggorokan dan hidung :
e) Thoraks dan paru-paru :
f) Jantung :
g) Abdomen :
h) Genetalia :
i) Rektal dan anus :
j) Vaskularisasi perifer :
k) Refleks tendo :
l) Neurologik :

8. Harapan Keluarga
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 ANALISIS DATA
Data Masalah Etiologi

DIAGNOSIS KEPERAWATAN
1
2
3
4
5
SKORING PRIORITAS MASALAH
1.................................................................................................................
Kriteria Skala Bobot Scoring Pembenaran

2.................................................................................................................
Kriteria Skala Bobot Scoring Pembenaran

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 3.................................................................................................................
Kriteria Skala Bobot Scoring Pembenaran