FORMAT PENGKAJIAN KEPERAWATAN KELUARGA

MODEL FRIEDMAN

A. Data umum

1.Nama KK :……………………………………
2.Alamat : ……………………………………
3.No. Telephon : ……………………………………
4.Susunan Anggota Keluarga :
Hub Tgl Status
Sex Gol
No Nama dg Lahir Pendidikan Pekerjaan Kesehatan
(L/P) Darah
KK (umur)

Genogram ( dibuat 3 generasi )

5. Tipe Keluarga
.......................................................................................................................................................
.............................................................................................................................

6. Latar belakang kebudayaan (etnik)

........................................................................................................................................................
..................................................................................................................................................
7. Identifikasi religius
........................................................................................................................................................
............................................................................................................................
8. Status kelas sosial
........................................................................................................................................................
............................................................................................................................
9. Mobilitas kelas sosial
........................................................................................................................................................
............................................................................................................................
B. Riwayat Keluarga dan Tahap Perkembangan

10. Tahap perkembangan keluarga saat ini

.......................................................................................................................................................
.............................................................................................................................
11. Tahap perkembangan keluarga yang belum terpenuhi
.......................................................................................................................................................
.......................................................................................................................................................
................................................................................................................

12. Riwayat keluarga inti

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

13. Riwayat keluarga asal

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

C. Data Lingkungan

14. Karakteristik rumah

Denah rumah

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

15. Karakteristik lingkungan tempat tinggal dan masyarakat

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

16. Mobilitas geografis keluarga

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

17. Hubungan sosial keluarga dengan masyarakat

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

D. Struktur Keluarga

18. Pola dan Komunikasi Keluarga

.......................................................................................................................................................
.............................................................................................................................
 19. Struktur Kekuatan
.......................................................................................................................................................
.............................................................................................................................

20. Struktur Peran

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

21. Nilai-Nilai Keluarga

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

E. Fungsi Keluarga

22. Fungsi Afektif

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

23. Fungsi Sosialisasi

........................................................................................................................................................
............................................................................................................................
24. Fungsi Perawatan Kesehatan
........................................................................................................................................................
............................................................................................................................

25. Terapi Komplementer dan Alternatif

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

26. Sumber Pembiayaan

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

F. Stress dan Koping Keluarga

27. Stressor jangka pendek

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

28. Stressor jangka panjang

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

29. Strategi koping keluarga

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

30. Adaptasi keluarga

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

G. Harapan keluarga
.......................................................................................................................................................
.............................................................................................................................

H. Pemeriksaan Fisik

No Jenis pemeriksaan Anggota Anggota Anggota Anggota dst

keluarga 1 keluarga 2 keluarga 3 keluarga 4
1. TTV :
Tensi :
Suhu :
Nadi :
RR :
2. Kulit, rambut dan
kuku.
I :
P:
P:
A:
3. Kepala, leher
I :
P:
P:
A:
4. Thoraks dan paru
I :
P:
P:
A:
5. Abdomen
I :
P:
P:
A:
6. Genitalia
I :
P:
P:
A:
7. Ekstremitas atas +
 refleks fisiologis
I :
P:
P:
A:
8. Ekstremitas bawah +
refleks fisiologis
I :
P:
P:
A:
 ANALISA DATA

DATA ETIOLOGI MASALAH KEP

DS:

DO:

DS:

DO:

DS:

DO:
 SKORING PER DIAGNOSIS

No Kriteria Skor Bobot Nilai Keterangan pembenaran

1 Sifat masalah, dengan skala : 1

Tidak/kurang sehat/actual 3

Ancaman kesehatan/resiko 2

Sejahtera / wellness 1

2 Kemungkinan masalah dapat 2

diubah, skala

Mudah 2

Sebagian 1

Sulit 0

3 Potensial masalah untuk dicegah, 1

skala

Tinggi 3

Cukup 2

Rendah 1

4 Menonjolnya masalah, skala 1

Masalah berat, harus segera 2

ditangani

Ada masalah tapi tidak perlu 1

ditangani

Masalah tidak dirasakan 0

Total

Daftar Prioritas Diagnosa :

1. …………..
2. …………..
3. dst
 RENCANA INTERVENSI KEPERAWATAN

DIAGNOSA TUJUAN NOC NIC

KEP
DX 1 TUK 1
TUK 2
TUK 3
TUK 4
TUK 5
DX 2 TUK 1
TUK 2
TUK 3
TUK 4
TUK 5
DX 3 TUK 1
TUK 2
TUK 3
TUK 4
TUK 5

CATATAN ASUHAN KEPERAWATAN KELUARGA

DIAGNOSA TANGGAL/WAKTU IMPLEMENTASI EVALUASI FORMATIF

EVALUASI SUMATIF

DIAGNOSA TARGET NOC CAPAIAN NOC EVALUASI