FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA KELUARGA/MASYARAKAT

FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA KELUARGA/MASYARAKAT

Nama Kepala Keluarga      :

Umur                                  :

Suku/Ras                            :

Status Pernikahan               :

Pendidikan                         :

Pekerjaan                            :

Alamat                                            :

Jumlah Anak                                  :

Jumlah Anak Yang Ada Di Rumah :

Jumlah Anak Yang Tidak Ada Di Rumah :

Jumlah Anak Yang Sudah Menikah :

Jumlah Anggota Keluarga Dalam Rumah  :

A. PENGKAJIAN BIOLOGIS

       1. Perumahan              : Permanen/ semi permanen

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       2. Kepemilikan Rumah           : Milik sendiri/ sewa/ kontrakan/ lain-lain

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       3. Kebersihan Rumah  : Bersih/ Cukup Bersih/ Kurang Bersih

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4. Jarak Rumah dengan Rumah Tetangga Terdekat:

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            5. Kebiasaan Perilaku Keluarga yang Menguntungkan (Positif): ....................................................................................................

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            6. Kebiasaan perilaku kelurga yang merugikan (Negatif) : .....................................................................................................

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7. Pelayanan kesehatan yang tersedia :

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8. Mutu pelayanan kesehatan yang tersedia :

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9. Jarak pelayanan kesehatan yang tersedia dengan rumah : ......................................................................................................

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10. Jenis obat yang dikonsumsi keluarga :

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11. Karakteristik lingkungan tempat tinggal  keluarga :

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12. Tradisi yang sering dilakukan keluarga : .....................................................................................................

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13. Sikap keluarga terhadap tradisi tersebut :

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14. Apakah keluarga mau menerima perubahan :

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15. Siapa yang diuntungkan dalam perubahan tersebut :

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B. PENGKAJIAN PSIKOSOSIAL

      

            1. Siapa yang mengambil keputusan dalam keluarga: ....................................................................................................

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            2. Anggota keluarga yang sakit dan penyakitnya : .....................................................................................................

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3. Anggota keluarga (anak) usia < 5 tahun  :

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4. Anggota keluarga (usila) usia > 65 tahun  :

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5. Kasus perceraian dalam keluarga inti : ......................................................................................................

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6.  Anggota keluarga yang abnormal:

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7. Anggota keluarga yang lari dari rumah :

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8 . Kejadian yang dapat menimbulkan masalah : .....................................................................................................

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9. Masalah yang terjadi sampai 2 tahun belakangan ini :

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10. Masalah yang mungkin terjadi 2 tahun ke depan :

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11. Hubungan antar anggota keluarga :

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12.  Kemampuan dan jenis koping keluarga:

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13. Pola hubungan/ interaksi dlam keluarga :

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14 . Keterlibatan keluarga dalam kegiatan masyarakat : .....................................................................................................

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15. Apakah ada orang lain yang sering membantu memecahkan masalah dalam keluarga :

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16. Pemahaman keluarga tentang sehat sakit :

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17. Apakah anggota keluarga pernah dirawat/ berobat karena gangguan jiwa :

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18. Penerimaan lingkungan terhadap anggota keluarga yang pernah dirawat/ berobat karena gangguan jiwa :

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19 . Bentuk penerimaan atau penolakan yang tampak: .....................................................................................................

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20. Pengalaman kejadian/ krisis yang merupakan stressor bagi keluarga :

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21. Harapan keluarga terhadap masa yang akan datang :

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C. MASALAH KEPERAWATAN

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D. DIAGNOSA KEPERAWATAN

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