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7/21/2019 Format Pengkajian http://slidepdf.com/reader/full/format-pengkajian-56d9d379c6039 1/37 ASUHAN KEPERAWATAN KELUARGA PADA KELUARGA ......................................................................... A. PENGKAJIAN Tanggal Pengkajian  : ...................................................................... I. Data Umum 1. Kepala Keluaga !KK":...................................................................... #. Umu : ...................................................................... $. Alamat :......................................................................  ...................................................................... N%m% Telep%n :...................................................................... &. Pekejaan KK  :...................................................................... '. Pen(i(ikan KK  :...................................................................... ). K%mp%*i*i Keluaga  : N%. Nama JK Hu+ungan (engan KK Umu !ta,un" Pen(i(ikan Statu* Imuni*a*i P%li% -G DPT Hepatiti* ampak 1 # $ & 1 # $ 1 # $ 1. Gen%gam/ …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… 0. Tipe Keluaga ………………………………………………………………………… . Suku -ang*a …………………………………………………………………………
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ASUHAN KEPERAWATAN KELUARGA

PADA KELUARGA .........................................................................

A. PENGKAJIANTanggal Pengkajian   : ......................................................................

I. Data Umum

1. Kepala Keluaga !KK":......................................................................

#. Umu : ......................................................................

$. Alamat  :......................................................................

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N%m% Telep%n :......................................................................

&. Pekejaan KK    :......................................................................

'. Pen(i(ikan KK    :......................................................................

). K%mp%*i*i Keluaga   :

N%. Nama JK  Hu+ungan

(engan KK 

Umu

!ta,un"Pen(i(ikan

Statu* Imuni*a*i

P%li% -G DPT Hepatiti* ampak  

1 # $ & 1 # $ 1 # $

1.

Gen%gam/

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0. Tipe Keluaga

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. Suku -ang*a

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2. Agama

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13. Statu* S%*ial Ek%n%mi

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11. Akti4ita* Rekea*i Keluaga

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II. Ri5a6at (an Ta,ap Pekem+angan Keluaga

1#. Ri5a6at Pekem+angan Keluaga Saat Ini

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1$. Tuga* Pekem+angan Keluaga 6ang -elum Tepenu,i

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1&. Ri5a6at Ke*e,atan Keluaga Saat Ini

N%Angg%ta

KeluagaRi5a6at Ke*e,atan Da,ulu Ri5a6at Ke*e,atan Saat Ini Keteangan

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1'. Ri5a6at Ke*e,atan Keluaga Se+elumn6a

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III. DATA LINGKUNGAN

1). Kaaktei*tik uma,/

a. Luas rumah : …………………………………………………..

 b. Keadaan lingkungan dalam rumah

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c. Keadaan lingkungan luar rumah

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d. Sumber air minum

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e. Pembuangan limbah rumah tangga

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f. Pembuangan sampah

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g. Jamban

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h. Sanitasi rumah

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Dena, Ruma,

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10. Kaaktei*tik Tetangga (an K%munita*

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1. 7%+ilita* Ge%ga8i* Keluaga

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12. Pekumpulan Keluaga (an Inteak*i (engan 7a*6aakat

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#3. Si*tem Pen(ukung Keluaga…………………………………………………………………………

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I9. STRUKTUR KELUARGA

#1. Stuktu Pean

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##. Nilai atau N%ma Keluaga

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#$. P%la K%munika*i Keluaga

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#&. Stuktu Kekuatan Keluaga

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9. :UNGSI KELUARGA

#'. :ung*i Ek%n%mi

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#). :ung*i 7en(apatkan Statu* Ek%n%mi

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#0. :ung*i Pen(i(ikan

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#. :ung*i S%*iali*a*i

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#2. :ung*i Pemenu,an !Pea5atan;Pemeli,aaan" Ke*e,atan

a. 7engenal ma*ala,

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+. 7engam+il keputu*an mengenai tin(akan ke*e,atan

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<. Kemampuan mea5at angg%ta keluaga 6ang *akit

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………………………………………………………………………(. Kemampuan keluaga memeli,aa;mem%(i8ika*i lingkungan

uma, 6ang *e,at

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e. Kemampuan menggunakan 8a*ilita* pela6anan 6ang *e,at

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$3. :ung*i Religiu*

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$1. :ung*i Rekea*i

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$#. :ung*i Rep%(uk*i

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$$. :ung*i A8ek*i

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9I. STREES DAN K=PING KELUARGA

$&. Ste**% Jangka Pen(ek (an Panjang

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$'. Kemampuan Keluaga -ee*p%n Te,a(ap Ste**%

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$). Stategi K%ping 6ang Digunakan

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$0. Stategi A(apta*i Di*8ung*i%nal

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9II. PE7ERIKSAAN KESEHATAN TIAP INDI9IDU ANGG=TA

KELUARGA

9III.

PeI>. Nama Angg%ta Keluaga

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9III. Haapan keluaga

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>I. PE7ERIKSAAN =-STETRI

1. Kehamilan sekarang direncanakan $%a&tidak': ………………………………

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2. Status (bstretrikus: )…. P …. #…. *sia kehamilan: ………………………

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0. K(ntrasepsi %ang pernah dipakai dan masalah %ang pernah dialami selama

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I>.   ………………………………………………………………………

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L.   ………………………………………………………………………

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-. DIAGN=SIS KEPERAWATAN KELUARGA

I. Anali*i* (an Sinte*i* Data

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