PSIK 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
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2. Tugas perkembangan keluarga yang belum terpenuhi

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3. Riwayat kesehatan keluarga saat ini

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4. Riwayat kesehatan keluarga sebelumnya

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III. Lingkungan
1. Karakteristik rumah
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2. Denah rumah, keadaan lingkungan rumah

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3. Karakteristik tetangga dan komunitasnya

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4. Mobilitas geografis keluarga

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5. Perkumpulan keluarga dan interaksi dengan masyarakat

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6. Sistem pendukung keluarga

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IV. Struktur Keluarga

1. Pola komunikasi keluarga
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2. Struktur kekuatan keluarga

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 3. Struktur peran keluarga
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4. Nilai atau norma keluarga

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V. Fungsi Keluarga
1. Fungsi Afektif
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2. Fungsi Sosial
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3. Fungsi Perawatan Kesehatan

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4. Fungsi Repreduksi
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5. Fungsi Ekonomi
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6. Fungsi Religius
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VI. Stres dan Koping Keluarga
1. Stresor jangka pendek dan panjang
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2. Kemampuan keluarga berespons terhadap stresor

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3. Strategi koping yang digunakan

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4. Strategi adaptasi disfungsional

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VII. Harapan Keluarga

1. Persepsi terhadap masalah
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2. Harapan terhadap masalah

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VIII. Pemeriksaan Kesehatan Tiap Anggota Keluarga

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