Lampiran 3

SEKOLAH TINGGI ILMU KESEHATAN

STIKES PEMKAB JOMBANG
Jalan dr.Sutomo No. 75-77 Telp / Fax (0321) 870214,
850028 - JOMBANG
PROGRAM STUDI :S-1 KEPERAWATAN, D-III KEPERAWATAN,
D-III KEBIDANAN, PENDIDIKAN PROFESI NERS

Tempat :
Nama Mahasiswa : Muhammad Affan Ash Shiddiqi
NIM : 141602032
Tanggal Pengkajian :

A. PENGKAJIAN
1. Pengumpulan Data
a. Identitas Keluarga
1) Identitas Kepala Keluarga
 Nama Kepala Keluarga :
 Umur :
 Pekerjaan KK :
 Pendidikan KK :
2) Alamat :

3) Komposisi Keluarga
Status Imunisasi
Hub
BC Pol DP He HB Ca
N.o. Nama Kel Umur Pendidikan Ket
G io T pat Com mp
KK
itis bo ak
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2.

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5.
4) Genogram

5) Tipe Keluarga
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6) Suku Bangsa
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7) Agama:
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8) Status Sosial Ekonomi Keluarga:
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9) Aktivitas Rekreasi Keluarga:
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b. Riwayat dan Tahap Perkembangan Keluarga:
1) Tahap perkembangan keluarga saat ini:
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2) Tahap perkembangan keluarga yang belum terpenuhi
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3) Riwayat kesehatan keluarga
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4) Riwayat kesehatan keluarga sebelumnya.
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c. Data Lingkungan
1) Krakteristik rumah
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2) Karakteristik tetangga dan komunitas
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3) Mobilitas Geografis Keluarga
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4) Perkumpulan keluarga dan interaksi dengan masyarakat

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5) Sistem Pendukung Keluarga
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d. Struktur Keluarga
1) Struktur Peran
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2) Nilai dan Norma Keluarga

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3) Pola Komunikasi Keluarga
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4) Struktur Kekuatan Keluarga
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e. Fungsi Keluarga
1) Fungsi Ekonomi
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2) Fungsi Mendapatkan Status Sosial
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3) Fungsi Pendidikan
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4) Fungsi Sosialisasi
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5) Fungsi Perawatan atau Pemeliharaan Kesehatan
a) Kemampuan Mengenal Masalah Kesehatan
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 b) Kemampuan Mengambil Keputusan Mengenai Tindakan
Kesehatan
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c) Kemampuan Merawat Anggota Keluarga yang sakit
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d) Kemampuan Keluarga Memelihara/memodifikasi lingkungan
rumah yang sehat
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e) Kemampuan menggunakan fasilitas kesehatan
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6) Fungsi Religius
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 7) Fungsi Rekreasi
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8) Fungsi Reproduksi
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9) Fungsi Afektif
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f. Stress dan Koping Keluarga
1) Stressor Jangka Pendek dan Panjang
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2) Kemampuan keluarga berespon terhadap stressor
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 3) Strategi koping yang di gunakan
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4) Strategi adaptasi disfungsional keluarga
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g. Pemeriksaan Kesehatan Tiap Individu Anggota Keluarga
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 Pemeriksaan Pasien
 Head To Toe

a) Kepala

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b) Wajah

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c) Mulut dan Faring

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d) Leher

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e) Dada

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f) Abdomen

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g) Genetalia dan anus

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 h) Ekstremitas

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 Pemeriksaan Anggota Keluarga

No Nama Tekanan Nadi Suhu RR

Darah

h. Harapan keluarga

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Jombang, ................................