FORMAT PENGKAJIAN KELUARGA

ASUHAN KEPERAWATAN KELUAGA PADA Bp……DENGAN…….DI

LINGKUNGAN……………

I. PENGKAJIAN

A. DATA UMUM
1. Nama KK (inisial) : ………………………
2. Umur : ………………………
3. Pendidikan : ………………………
4. Pekerjaan : ………………………
5. Alamat : ………………………
6. Komposisi Keluarga
NO NAMA UMUR JENIS HUB DGN PENDD PEKERJAAN
(INISIAL) KELAMIN KK

7. Genogram

8. Tipe Keluarga : ..............................................................

9. Budaya
: .......................................................................................................

10. Agama
: .......................................................................................................
11. Status Sosial ekonomi Klg
: ...........................................................................................
 12. Aktivitas Rekreasi atau Waktu
Luang : ............................................................................

B. RIWAYAT DAN TAHAP PERKEMBANGAN KELUARGA

13. Tahap Perkembangan Keluarga Saat Ini : .................................................................

14. Tugas Perkembangan Keluarga Yang Belum
Terpenuhi : ...............................................
.....................................................................................................................................
.......
15. Riwayat kesehatan Keluarga Inti
a. Riwayat Penyakit
Keturunan : ........................................................................................................
.........................
b. Riwayat kesehatan Masing-masing Anggota Keluarga :
.............................................................................................................................
.

16. Riwayat Keluarga Sebelumnya :

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

C. LINGKUNGAN
17. Karakteristik Rumah
- Denah Rumah

- Status Rumah
: ......................................................................................................
 - Tipe Rumah
: ......................................................................................................
- Luas Rumah/
: .....................................................................................................
Keadaan
......................................................................................................
- Kebersihan&
pencahayaan : .........................................................................................

18. Karakteristik Tetangga dan

Komunitas : ..........................................................................
.....................................................................................................................................
.....
19..Mobilitas Geografis
Keluarga : .......................................................................................
......................................................................................................................................
.....
20. Perkumpulan Keluarga dan Interaksi dengan
Masyarakat : .............................................
.....................................................................................................................................
.....
21. Sistem Pendukung
Keluarga : ..........................................................................................
.....................................................................................................................................
.....

D. STRUKTUR KELUARGA

22. Pola Komunikasi Keluarga : …………………………………………………………….

……………………………………………………………………………………………
23. Struktur Kekuatan Kelurga : …………………………………………............................
 ......................................................................................................................................
......
24. Struktur Peran
: ............................................................................................

25. Nilai dan Norma

Keluarga : ..............................................................................................
.....................................................................................................................................
......

E. FUNGSI KELUARGA

26. Fungsi
Afektif : ................................................................................................................
...........................................................................................................
......

27. Fungsi
Sosialisasi : ............................................................................................................
.......................................................................................................
....

28. Fungsi Perawatan Kesehatan (Data Spesifik)

a. Kemampuan Mengenal Masalah Kesehatan :

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

b. Kemampuan Mengambil Keputusan Untuk Melakukan Tindakan :

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

b. Kemampuan Melakukan Pearawatan Terhadap Anggota Keluarga Yang Sakit :

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

d. Kemampuan Menciptakan Lingkungan Yang Dapat Meningkatkan Kesehatan :

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

e. Kemampuan Keluaraga Memanfaatkan Fasilitas Kesehatan Yang Ada :

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

F. STRES DAN KOPING KELUARGA :

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

G. HARAPAN KELUARGA TERHADAP PERAWAT BERHUBUNGAN DENGAN MASALAH YANG

DIHADAPI
 ...........................................................................................................................................
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.......
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.......

H. PEMERIKSAAN FISIK (HEAD TO TOES)

ANGGOTA KLG
KEPALA

LEHER

DADA

ABDOMEN

EXTRENITAS
DATA TAMBAHAN

1. Tanda-tanda vital :

RENCANA ASUHAN KEPERAWATAN KELUARGA

Diagnosa Tujuan Evaluasi Rencana

Keperawata Umum Khusus Kriteria Standar Tindakan
n
 CATATAN ASUHAN KEPERAWATAN KELUARGA

Diagnosa Tgl dan waktu Implementasi Evaluasi

ke …