SEKOLAH TINGGI ILMU KESEHATAN
SATRIA BHAKTI NGANJUK
PROGRAM STUDI S1 KEPERAWATAN
Sekretariat :Jl.Panglima
Sudirman VI Nganjuk ,Telp.(0358) 326110
FORMAT PENGKAJIAN KELUARGA
I.
DATA UMUM
1.
Nama Kepala Keluarga :
2.
Alamat / Nomor Telpon :
3.
Pendidikan Kepala Keluarga :
4.
Pekerjaan Kepala Keluarga :
5.
Komposisi Keluarga :
NO
|
NAMA
|
JK
|
HUBUNGAN
DENGAN KK
|
UMUR
|
PENDIDIKAN
|
STATUS IMUNISASI
|
||||||||||
POLIO
|
DPT
|
HEPATITIS
|
CAMPAK
|
|||||||||||||
Genogram :
6.
Tipe Keluarga :
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7.
Suku bangsa :
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
8.
Agama :
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9.
Status social ekonomi keluarga
:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
10.
Aktifitas rekreasi keluarga :
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
II.
RIWAYAT 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.
LINGKUNGAN
15. Karakteristik rumah
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Denah rumah
16. Karakteristik tetangga dan komunitas RW
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
17. Mobilitas geografis keluarga
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
18.
Perkumpulan
keluarga dan interaksi dengan masyarakat
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
19.
Sistem
pendukung keluarga
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
IV.
STRUKTUR KELUARGA
20.
Pola komunikasi keluarga
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
21.
Struktur kekuatan keluarga
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
22.
Struktur peran (formal & informal)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
23.
Nilai dan norma keluarga
________________________________________________________________________________________________________________________________________________________________________________________________
V.
FUNGSI KELUARGA
24.
Fungsi afektif
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
25.
Fungsi social
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
26.
Fungsi perawatan kesehatan
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
27.
Fungsi Reproduksi
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
28.
Fungsi Ekonomi
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VI.
STRESS DAN KOPING
KELUARGA
29. Stressor jangka
pendek dan tangga panjang
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
30. Kemampuan
keluarga berespons terhadap situasi/stressor
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
31. Strategi koping
yang digunakan
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
32. Strategi
adaptasi disfungsional
________________________________________________________________________________________________________________________________________________________________________________________________
VII.
PEMERIKSAAN FISIK
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VIII. HARAPAN KELUARGA
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nganjuk,
…………………….. ,2009
NAMA MAHASISWA
(____________________________________)
|
Lampiran 1
SKALA PRIORITAS PENYUSUNAN
MASALAH KESEHATAN KELUARGA
KRITERIA
|
NILAI
|
BOBOT
|
1. Sifat Masalah
Skala :
ancaman
Tidak sehat
Krisis
|
3
2
1
|
1
|
2. Kemungkinan
masalah dapat diubah
Skala :
dengan mudah
Hanya sebagian
Tidak dapat
|
2
1
0
|
2
|
3. Potensi
masalah untuk dicegah
Skala :
tinggi
cukup
rendah
|
3
2
1
|
1
|
4. Meninjolnya
masalah
Skala :
masalah harus ditangani
Masalah tidak perlu
segara ditangani
Masalah tidak dirasakan
|
2
1
0
|
1
|
Skoring :
1. Tentukan skore untuk setiap kriteria
2.
Skore dibagi dengan angka
tertinggi dan kalikanlah dengan bobot
Skore X
Bobot
Angka
tertinggi
3. Jumlah skore untuk semua kriteria
