FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA
KELUARGA / MASYARAKAT
Nama Kepala Keluarga :
U m u r :
Suku / Ras :
A g a m a :
Menikah/tidak menikah/janda/duda :
Pendidikan :
Pekerjaan :
Alamat :
Jumlah Anak :
Jumlah Anak yang ada dirumah :
Jumlah Anak yang tidak ada dirumah :
Jumlah Anak yang sudah menikah :
Jumlah Anggota keluarga dalam rumah :
I. A. PENGKAJIAN BIOLOGIS
1. Perumahan : Permanen/semi permanen.................
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2. Kepemilikan rumah : Milik sendiri/Sewa/Kontrak/ Lain-lain
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3. Kebersihan rumah : Bersih/cukup bersih/kurang bersih....
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4. Jarak rumah keluarga dengan tetangga terdekat
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5. Kebiasaan perilaku keluarga yang positif (menguntungkan)
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6. Kebiasaan perilaku keluarga yang negatif (merugikan)
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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 keluarga
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10. Jenis obat yang sering 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 dengan perubahan itu
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B. PENGKAJIAN PSIKOSOSIAL
16. Siapa pengambil keputusan dalam keluarga
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17. Anggota keluarga yang sakit dan sebutkan jenis penyakitnya
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18. Anggota keluarga (anak) usia < 5 tahun
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19. Anggota keluarga (usila) > 65 tahun ..................................................................
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20. Kasus perceraian dalam keluarga inti ..................................................................
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21. Anggota keluarga yang abnormal ..................................................................
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22. Anggota keluarga yang lari dari rumah ..................................................................
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23. Kejadian yang dapat menimbulkan masalah
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24. Masalah yang pernah terjadi sampai 2 tahun kebelakang
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25. Masalah yang mungkin terjadi pada 2 tahun kedepan
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26. Hubungan antar anggota keluarga ..................................................................
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27. Kemampuan dan jenis koping keluarga ..................................................................
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28.Pola hubungan/interaksi dengan tetangga
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29. Keterlibatan keluarga didalam kegiatan kemasyarakatan
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30. Apakah ada orang lain yang sering membantu memecahkan masalah dalam keluarga ..................................................................
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31. Pemahaman keluarga tentang sehat – sakit jiwa
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32. Adakah anggota keluarga yang pernah dirawat / berobat karena mengalami gangguan /sakit jiwa, sudah sembuh atau belum, dan sekarang dirawat / tinggal dimana
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33. Penerimaan lingkungan terhadap anggota keluarga yang pernah dirawat/berobat karena gangguan jiwa ..................................................................
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34. Bentuk penerimaan atau penolakan yang tampak
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35. Pengalaman kejadian krisis yang merupakan stressor bagi keluarga
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36. Harapan keluarga terhadap masa yang akan datang
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II. A. MASALAH KEPERAWATAN KESEHATAN JIWA KELUARGA
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B. DIAGNOSA KEPERAWATAN KESEHATAN JIWA KELUARGA
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III. RENCANA TINDAKAN KEPERAWATAN KESEHATAN JIWA KELUARGA
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IV. IMPLEMENTASI DAN EVALUASI
NO DAN TANGGAL | IMPLEMENTASI KEPERAWATAN KESEHATAN JIWA KEL / MASY | EVALUASI |
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ASPEK PRESIPITASI DAN PRERDISPOSISI SERTA PENJELASAN TENTANG POIN POINT PENGKAJIAN
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