FORMAT PENGKAJIAN KEPERAWATAN KELUARGA

A. DATA UMUM

1. Nama Kepala keluarga : ............................................................................

2. Umur :

3. Pendidikan : ............................................................................

4. Jenis kelamin : ............................................................................

5. Pekerjaan : ............................................................................

6. Alamat Rumah : ............................................................................

7. Komposisi keluarga :

No Nama Umur JK Pendidikan Pekerjaan Hub. dg KK

8. Riwayat kesehatan keluarga

Susunan anggota keluarga Genogram : ( 3 generasi)

 9. Tipe keluarga : ..........................................................................................

10. Suku bangsa : ..........................................................................................

11. Agama : ..........................................................................................

12. Status sosial ekonomi

a. Pendapatan KK perbulan : .....................................................................

b. Pendapatan tambahan : ......................................................................

c. Biaya yang dikeluarkan keluarga perbulan : ...........................................

d. Barang-barang yang dimiliki keluarga : ...................................................

e. Tabungan dan biaya kesehatan keluarga : .............................................

13. Aktivitas rekreasi keluarga

a. Tempat : .............................................................................................

b. Jenis : .............................................................................................

c. Waktu : .............................................................................................

B. RIWAYAT DAN TAHAP PERKEMBANGAN KELUARGA

14. Tahap perkembangan keluarga saat ini (dilihat dari anak tertua)

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15. Tahap perkembangan keluarga yang belum terpenuhi

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Kendala :

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16. Riwayat kesehatan keluarga inti

Keadaan 6 bln Pelayanan

Penyakit terakhir
No Nama kesehatan yg
Keturunan
Sehat Sakit digunakan

Masalah kesehatan keluarga yang menonjol saat ini :

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C. KEBIASAAN ANGGOTA KELUARGA SEHARI-HARI

17. Nutrisi

a. Frekwensi makan : ..................................................................................

b. Jenis makanan-makanan pokok :

1) Lauk pauk :

2) Sayur-mayur :

3) Buah-buahan :

4) Lain-lain :

c. Makanan selingan : ..................................................................................

d. Makanan pantangan : ..............................................................................

e. Cara mengelola makanan : ......................................................................

 f. Cara menyajikan makanan : ....................................................................

g. Masalah dalam pemenuhan kebutuhan nutrisi keluarga :

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18. Pola istirahat :

a. Waktu istirahat/tidur : ..............................................................................

b. Lama istirahat atau tidur : ........................................................................

c. Masalah dalam pemenuhan kubutuhan istirahat dan tidur : .....................

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19. Pola eliminasi

a. BAB :

b. BAK :

c. Masalah-masalah dalam pemenuhan kebutuhan eliminasi : ....................

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20. Aktivitas olah raga

a. Apakah keluarga senang olah raga : .......................................................

b. Jenis olah raga : ......................................................................................

c. Kapan olah raga biasa dilakukan : ...........................................................

21. Hygiene keluarga :

a. Kebiasaan mandi : ...................................................................................

b. Menggosok gigi : .....................................................................................

 c. Kebiasaan mencuci rambut : ...................................................................

d. Kebiasaan mengganti pakaian : ..............................................................

e. Masalah higiene keluarga : .....................................................................

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D. PENGKAJIAN LINGKUNGAN

22. Perumahan

a. Jenis bangunan : .....................................................................................

b. Jenis lantai : .............................................................................................

c. Jumlah ruangan : .................................................................... (Jelaskan)

d. Ventilasi ruangan : ...................................................................................

e. Denah rumah : .........................................................................................

23. Sarana air bersih

a. Sumber air minum keluarga : ...................................................................

b. Jarak sumber air minim denan septiktank : ..............................................

c. Keadaan fisik air yang digunakan : ..........................................................

d. Lain-lain : .................................................................................................

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24. Air limbah

 a. Tempat pebuangan limbah keluarga : ......................................................

b. Apakah pembuangan air limbah sesuai dengan syarat kesehatan :

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c. Lain – lain : ..............................................................................................

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25. Pengelolaan sampah

a. Tempat pembuanan sampah keluarga : ...................................................

b. Kondisi sampah (TERBUKA / TERTUTUP) : ...........................................

c. Pengelolaan sampah rumah tangga : ......................................................

26. Jamban/ WC keluarga yang digunakan

a. Jenis WC keluarga yang digunakan : .......................................................

b. Status jamban/ WC yang digunakan : ......................................................

c. Apakah jamban/ WC yang digunakan sesuai dengan syarat kesehatan :

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d. Lain – lain : ..............................................................................................

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27. Kandang ternak

a. Apakah keluarga mempunyai kandang ternak : .......................................

b. Jarak kandang ternak dengan rumah : .....................................................

c. Kebersihan kandang ternak : ...................................................................

d. Lain – lain : ..............................................................................................

28. Karakteristik tetangga dan komunitas RW

a. Lingkungan fisik sekitar : ..........................................................................

b. Apakah ada aturan/kesepakatan penduduk setempat : ..........................

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c. Budaya setempat yang mempengaruhi kesehatan : ...............................

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E. STRUKTUR KELUARGA

29. Pola komunikasi keluarga : ............................................................................

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30. Struktur kekuatan keluarga : ..........................................................................

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31. Pembagian peran dalam keluarga : ...............................................................

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32. Nilai / Norma yang dianut keluarga : ..............................................................

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F. FUNGSI KELUARGA

33. Fungsi afektif : ...............................................................................................

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34. Fungsi reproduksi : ........................................................................................

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35. Fungsi sosialisasi : .........................................................................................

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36. Fungsi ekonomi : ..........................................................................................

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37. Fungsi perawatan kesehatan (termasuk pengkajian lima tugas kesehatan

keluarga:

Kemampuan keluarga mengenal masalah:

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Kemampuan keluarga mengambil keputusan:

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Kemampuan keluarga merawat anggota keluarga yang sakit:

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Kemampuan keluarga memodifikasi lingkungan rumah:

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Kemampuan keluarga memanfaatkan fasilitas yankes:

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G. STRES DAN KOPING KELUARGA

38. Stressor jangka panjang dan jangka pendek : ...............................................

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39. Strategi koping yang digunakan : ...................................................................

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H. PENGKAJIAN FISIK SETIAP ANGGOTA KELUARGA

N
ASPEK PENGKAJIAN HASIL PENGKAJIAN
O
1 Penampilan umum
(tingkat kesadaran, BB, TB,
IMT, TD, Nadi, Suhu,
Frekuensi Napas)
2 Kepala dan Wajah

3 Leher

4 Dada

5 Abdomen
 N
ASPEK PENGKAJIAN HASIL PENGKAJIAN
O

6 Genitalia

7 Punggung

8 Ekstremitas atas dan bawah

40. Harapan keluarga

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41. Catatan tambahan

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Yang Melakukan Pengkajian

 ( )
NIM.
ANALISIS DATA

NAMA KK : .......................................................................
ALAMAT : .......................................................................
HARI/ TGL : .......................................................................

NO DATA DIAGNOSIS KEPERAWATAN

 PRIORITAS MASALAH

NAMA KK : .......................................................................
ALAMAT : .......................................................................
HARI/ TGL : .......................................................................
DIAGNOSIS KEPERAWATAN : .......................................................................

Kriteria Skor Bobot Pembenaran

1. Ada/ tidaknya masalah  
Skala:
Defisit (aktual) 3 1
Ancaman (risiko) 2
Krisis yang akan datang 1

2. Kondisi masalah untuk diubah  

Skala:
Mudah untuk diubah 2 2
Sebagian mudah untuk diubah 1
Tidak dapat diubah 0

3. Potensial masalah untuk

dicegah
Skala:
Tinggi 3 1
Sedang 2
Rendah 1

4. Menonjolnya masalah
Skala:
Masalah butuh perhatian 2 1
segera
Masalah tidak butuh perhatian 1
segera
Tidak dianggap sebagai 0
masalah yang membutuhkan
perubahan

Total skor 3
 DIAGNOSIS KEPERAWATAN

NAMA KK : .......................................................................
ALAMAT : .......................................................................
HARI/ TGL : .......................................................................

DIAGNOSIS
NO TUJUAN (NOC) INTERVENSI (NIC)
KEPERAWATAN
 IMPLEMENTASI DAN EVALUASI

NAMA KK : .......................................................................
ALAMAT : .......................................................................

HARI/TGL DIAGNOSIS
IMPLEMENTASI EVALUASI
/JAM KEPERAWATAN