A. DATA UMUM
2. Umur :
3. Pendidikan : ............................................................................
5. Pekerjaan : ............................................................................
7. Komposisi keluarga :
a. Tempat : .............................................................................................
b. Jenis : .............................................................................................
c. Waktu : .............................................................................................
14. Tahap perkembangan keluarga saat ini (dilihat dari anak tertua)
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Kendala :
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17. Nutrisi
1) Lauk pauk :
2) Sayur-mayur :
3) Buah-buahan :
4) Lain-lain :
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a. BAB :
b. BAK :
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D. PENGKAJIAN LINGKUNGAN
22. Perumahan
d. Lain-lain : .................................................................................................
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E. STRUKTUR KELUARGA
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F. FUNGSI KELUARGA
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( )
NIM.
PENGKAJIAN FISIK SETIAP ANGGOTA KELUARGA
Initial nama:
3 Leher
4 Dada
5 Abdomen
6 Genitalia
7 Punggung
ANALISIS DATA
NAMA KK : .......................................................................
ALAMAT : .......................................................................
HARI/ TGL : .......................................................................
Data Objektif:
…….
……
….
PRIORITAS MASALAH
NAMA KK : .......................................................................
ALAMAT : .......................................................................
HARI/ TGL : .......................................................................
DIAGNOSIS KEPERAWATAN : .......................................................................
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 (SOAP)
/JAM KEPERAWATAN