PENGKAJIAN KEPERAWATAN KELUARGA

I. Data Umum
Pengkajian terhadap data umum keluarga meliputi:
1. Nama kepala keluarga (KK) : ......................................................................................
2. Alamat dan telepon

: .......................................................................................

3. Pekerjaan kepala keluarga : ........................................................................................

4. Pendidikan kepala keluarga : .......................................................................................
5. Komposisi keluarga dan genogram
No

Nama

Jenis
kelamin

Hub dg
KK

Umur

Pendidikan

1
2
3
4
5
6
Genogram

Keterangan:

6. Tipe keluarga : ..........................................................................................................

7. Suku bangsa : ...........................................................................................................
8. Agama : ....................................................................................................................
9. Status sosial ekonomi keluarga : ..............................................................................
10. Aktifitas rekreasi keluarga : .....................................................................................

II. Riwayat dan tahap perkembangan keluarga

11. Tahap perkembangan keluarga saat ini: ............................................................
............................................................................................................................
12. Tahap perkembangan keluarga yang belum terpenuhi: ......................................
............................................................................................................................
13. Riwayat keluarga inti: ........................................................................................
............................................................................................................................
14. Riwayat keluarga sebelumnya: ...........................................................................
............................................................................................................................

III. Pengkajian lingkungan

15. Karakteristik rumah : ......................................................................................
.........................................................................................................................
Denah :

16. Karakteristik tetangga dan komunitas RW : .......................................................

17. Mobilitas geografis keluarga : .............................................................................
18. Perkumpulan keluarga dan interaksi dengan masyarakat : .................................

IV. Struktur keluarga

19. Sistim pendukung keluarga : ...............................................................................
Informal: ..............................................................................................................
Formal: ................................................................................................................
20. Pola komunikasi keluarga : .................................................................................
..............................................................................................................................
21. Struktur kekuasaan keluarga : .............................................................................
..............................................................................................................................
..............................................................................................................................
22. Struktur peran : ....................................................................................................
..............................................................................................................................
23. Nilai atau norma keluarga : .................................................................................
..............................................................................................................................

V. Fungsi keluarga
24. Fungsi afektif : ....................................................................................................
..............................................................................................................................
25. Fungsi sosialisasi : ...............................................................................................
..............................................................................................................................
26. Fungsi perawatan kesehatan : ..............................................................................
..............................................................................................................................
27. Fungsi reproduksi : ..............................................................................................
..............................................................................................................................
28. Fungsi ekonomi : .................................................................................................
..............................................................................................................................

VI. Stress dan koping keluarga

29. Stressor jangka pendek dan panjang : .................................................................
Jangka pendek: ....................................................................................................
Jangka panjang: ...................................................................................................

30. Kemampuan keluarga berespon terhadap stressor : ............................................

..............................................................................................................................
31. Strategi koping yang digunakan : ........................................................................
..............................................................................................................................
32. Strategi adaptasi disfungsional : ..........................................................................
..............................................................................................................................

VII. Pemeriksaan fisik

Nama

Hasil Pemeriksaan Fisik

VIII. Harapan keluarga

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