DAFTAR STANDAR TINDAKAN KEPERAWATANA. TINDAKAN KEPERAWATAN DASAR1. KATEGORI INOKEWENANGAN KLINIS

1. Bantuan perawatan diri

2. Bantuan perawatan diri : mandi / hygiene

3. Bantuan perawatan diri : berpakaian

4. Bantuan perawatan diri : makan

5. Bantuan perawatan diri : toileting

6. Bantuan perawatan diri : transfer

7. Memandikan

8. Mengenakan pakaian (dressing)

9. Memberikan makan

10. Admission care

11. Monitor Vital sign

12. Perawatan rambut

13. Administrasi medikasi Oral

14. Bantu toileting

15. Oral Higiene

16. Bantu perawatan diri: makan

17. Bantu perawatan diri: berpakaian

18. Posisioning

19. Transport

20. Monitor nutrisi

21. Monitor cairan

22. Perawatan kuku

23. Perawatan kaki

24. Perawatan telinga

25. Heat/cold aplication

26. Respiratory monitoring

2. KATEGORI IINOKEWENANGAN KLINIS

27. Reduksi Cemas

28. Pembatasan Area

29. Pencegahan Aspirasi

30. Perawatan bedrest

31. Pemeriksaan laboratorium di samping TT

32. Bottle feeding

33. Teknik penenangan

34. Perawatan gips: maintenance

35. Peningkatan komunikasi : defisit pendengaran

36. Peningkatan komunikasi : defisit penglihatan

37. Perawatan kontak lensa

38. Peningkatan batuk

39. Distraksi

40. Perawatan emergensi

41. Manajemen lingkungan

42. Manajemen lingkungan :kenyamanan

43. Bantuan pemeriksaan

44. Therapi latihan : ambulasi

45. Pertolongan pertama

46. Administrasi medikasi: telinga

47. Administrasi medikasi: mata

48. Administrasi medikasi: enteral

49. Administrasi medikasi: inhalasi

50. Administrasi medikasi: nasal

51. Administrasi medikasi: oral

52. Administrasi medikasi: rectal

53. Administrasi medikasi: kulit

54. Administrasi medikasi: vaginal

55. Manajemen mual

56. Perawatan perineal

57. Posisioning

58. Posisioning : neurologi

59. Perawatan jenazah

60. Kehadiran

61. Perawatan ulkus pressure

62. Perawatan prostesis

63. Orientasi realita

64. Therapi rekreasi

65. Manajemen spesimen

66. Asistensi pembedahan

67. Perawatan slang : urinari

68. Cateterisasi urine

69. Cateterisasi urine : intermittent

70. Fasilitasi kunjungan

71. Discharge planning

72. Pendidikan Kesehatan

73. Kontrol Infeksi

74. Pentahapan diet

75. manajemen lingkungan

76. Pencegahan jatuh

77. perawatan kaki

78. Interpretasi data laboratorium

79. Fall prventionpk 1

80. Fever treatment pk1

81. Electrolyt monitoring

82. Bantu perawatan diri: transfer

3. KATEGORI IIINOKEWENANGAN KLINIS

1. Amputation care

2. Analgesic administration

3. Bladder irrigation

4. Bleeding precaution

5. Bleeding reduction

6. Bleeding reduction : antepartum uterus

7. Bleeding reduction : gastrointestinal

8. Bleeding reduction : nasal

9. Bleeding reduction : postpartum uterus

10. Bleeding reduction : wound

11. Blood product administration

12. Body image enhancement

13. Body mechanics promotion

14. Bowel incontinence care

15. Bowel incontinence care : encopresis

16. Bowel irrigation

17. Bowel management

18. Bowel training

19. Bowel examination

20. Breasfeeding assistance

21. Capillary blood sample

22. Chest physiotherapy

23. Childbirth preparation

24. Circumcision care

25. Cutaneous stimulation

26. Aroma therapy

27. Dialysis acces maintenance

28. Diare management

29. Diet staging

30. Discharge planning

31. Electronic fetal monitoring : antepartum

32. Electronic fetal monitoring : intrapartum

33. Enteral tube feeding

34. Environmental manegement : safety

35. Environmental risk protection

36. Exercise promotion

37. Exercise promotion: strength training

38. Exercise promotion : streching

39. Exercise therapy : balance

40. Exercise therapy : joint mobility

41. Family support

42. Flatulence reduction

43. Airway management

44. Airway suctioning

45. Gastrointestinal intubation

46. Incision site care

47. Phlebotomy : arterial blood sample

48. Health education

49. Health screening

50. Hyperglicemia management

51. Hypervolemia management

52. Hypoglicemia management

53. Hypothermia induction

54. Hypothermia treatment

55. Hypovolemia management

56. Immunization/vaccination management

57. Infant care

58. Infection control

59. Infection control: intraoperative

60. Infection protection

61. Intracranial pressure (ICP) monitoring

62. Intrapartal care

63. Intravenous (IV) insersion

64. Intravenous (IV) therapy

65. Invasive hemodynamic monitoring

66. Kangaroo care

67. Massage

68. Medication administration : intradermal

69. Medication administration : intramuscular

70. Medication administration : intraspinal

71. Medication administration : intravenous

72. Medication administration : subcutaneus

73. Nausea management

74. Neurologic monitoring

75. Newborn care

76. Newborn monitoring

77. Oxygen therapy

78. Positioning : wheelchair

79. Postanasthesia care

80. Postpartal care

81. Prenatal care

82. Sleep enhancement

83. Tube care : chest

84. Tube care : gastrointestinal

85. Tube care : ventriculostomy/lumbar drain

86. Urinary incontinentia care

87. Urinary incontinentia care : enuresis

88. Urinary retention care

89. Teaching : desease process

90. Teaching ; foot care

91. Teaching : individual

92. Teaching : infant nutrition

93. Teaching : infant safety

94. Teaching : infant stimulation

95. Teaching : preoperative

96. Teaching : prescribed activity / exercise

97. Teaching : prescribed diet

98. Teaching : prescribed medication

99. Teaching : procedure / treatment

100. Teaching : psychomotor skill

101. Teaching : toilet training

102. Temperature regulation

103. Traction/immobilitation care

104. Vomiting management

105. Wound care

106. Wound care : closed drainase

107. Wound irrigation

108. Ostomy Care

109. Tube Care : Umbilical Line

110. Urinary Bladder Training

111. Urinary Elimination Management

112. Urinary Habit Training

113.

4. KATEGORI IVNOKEWENANGAN KLINIS

114. Allergy management

115. Anaphylaxis management

116. Anticipatory guidance

117. Artificial airway management

118. Asthma management

119. Autotranfusion

120. Behavior management

121. Behavior management : overactivity / inattention

122. Behavior management : self harm

123. Behavior management : sexual

124. Behavior modification

125. Behavior modification: social skill

126. Cardiac care

127. Cardiac care : rehabilitative

128. Cardiac precautions

129. Caregiver support

130. Cast care : wet

131. Cerebral perfusion promotion

132. Circulatory care : arterial insufficiency

133. Circulatory care : mechanical assist device

134. Circulatory care : venous insufficiency

135. Circulatory precautions

136. Code management

137. Communicable desease management

138. Comunication enhancement : speech deficit

139. Constipation/Impaction management

140. Consultation

141. Controlled substance checking

142. Coping enhancement

143. Decision making support

144. Delegation

145. Delirium management

146. Delusion management

147. Dementia managemen

148. Developmental care

149. Developmental enhancement : adolescenct

150. Developmental enhancement : child

151. Documentation

152. Dying care

153. Disreflexia management

154. Dysrhythmia management

155. Electronic convultion therapy (ECT) management

156. Electrolyte management

157. Embolus care : peripheral

158. Embolus care : pulmonary

159. Embolus precautions

160. Emotional support

161. Endotracheal extubation

162. Energy management

163. Fluid/electrolyte management

164. Fluid management

165. Fluid resuscitation

166. Guided imagery

167. Hallucination management

168. Heat exposure treatment

169. Hemorrhage control

170. Hope inspiration

171. Lactation counseling

172. Lactation suppresion

173. Learning facilitation

174. Lower extremity monitoring

175. Malignant hyperthermia precaution

176. Medication management

177. Meditation facilitation

178. Milieu therapy

179. Mood management

180. Music therapy

181. Mutual goal setting

182. Nutrition therapy

183. Nutritional monitoring

184. Oral health maintenance

185. Oral health promotion

186. Oral health restoration

187. Pain management

188. Paperipheral sensation management

189. Peritonial dyalisis therapy

190. Pessary management

191. Phlebotomy : blood unit acquisision

192. Phlebotomy : cannulated vessel

193. Phlebotomy :venous blood sample

194. Phototherapy : mood/sleep regulation

195. Phototherapy : neonate

196. Physical restrain

197. Physician support

198. Preoperative coordination

199. Pressure management

200. Pressure ulcer prevention

201. Product evaluation

202. Pruritus management

203. Relaxationn therapy

204. Religius ritual enhancement

205. Selft esteem enhancement

206. Shift report

207. Shock management

208. Shock management : cardiac

209. Shock management : autogenic

210. Shock management : volume

211. Shock prevention

212. Sibling support

213. Skin care : topical treatment

214. Spiritual growth facilitation

215. Spiritual support

216. Subarachnoid hemorhage precaution

217. Surgical preparation

218. Suturing

219. Swallowing therapy

220. Ventilation assistance

B. TINDAKAN KEPERAWATAN KOMPLEKS1. KATEGORI INOKEWENANGAN KLINIS

1. Chemotherapy management

2. Birthing

3. Bibliotherapy

4. Hemodialysis Therapy

5. High Risk Pregnancy Care

6. Trancutaneus Electrical Nerve Stimulation (TENS)

7. Exercise Therapy : Muscle Control

8. Family Planning : Infertility

9. Electronic Fetal Monitoring : Antepartum

10. Electronic Fetal Monitoring : Intrapartum

2. KATEGORI IINOKEWENANGAN KLINIS

11. Intrapartal Care : High Risk Delivery

12. Labor Induction

13. Labor Suppression

14. Wound care : burns pk3

15. Surveilance : safety pk3

16. Resuscitation pk3

17. Positioning : intraoperative pk3

18. Acupressure

19. Amnioinfusion

20. Art Therapy

21. Autogenic training

22. Hypnosis

23. Biofeedback

24. Case management

25. Cognitive restructuring

26. Cognitive stimulation

27. Conflict mediation

28. Counseling

29. Crisis intervention

30. Eating Disorder Management

31. Therapeutic Touch

3. KATEGORI IIINOKEWENANGAN KLINIS

32. Hemofiltration therapy pk3

33. Defibrillator management : external pk3

34. Defibrillator management : internal pk3

35. Chemical restrain pk 3

36. Cerebral edema management pk 3

37. Cardiac care : acutepk 3

38. Nutritional counseling

39. Hemodynamic regulation pk3

40. Total parenteral nutrition (TPN) management

41. Mechanical ventilation management : invasive pk3

42. Mechanical ventilation management : noninvasive pk3

43. Mechanical ventilatory weaning

44. Pacemaker management : permanent pk3

45. Pacemaker management : temporary pk3

46. Validationn Therapy

47. Venous Acces Device (VAD) Maintenance

48. Airway insertion and stabilizationpk 3

49. Thrombolytic therapy management pk3

50. Nutrition Management

51. Family Therapy

52. Fertility Preservation

53. Fiscal Resource Management

54. Forensic Data Collection

55. Genetic Counselling

56. Hormon Replacemen Therapy

57. Impulse Control Training

58. Laser Precautions

59. Medication Administration : Intrapleural

60. Medication Administration : Intraosseous

61. Medication Administration : Ventricular Reservoir

62. Medication Prescribing

63. Memory Training

64. Pelvic Muscle Exercise

65. Peripherally Inserted Central (PIC) Catheter

66. Pneumatic Torniquet Precautions

67. Preconseption Counseling

68. Pregnancy Termination Care

69. Premenstrual Syndrome (PMS) Management

70. Program Development

71. Progressive Muscle Relaxation

72. Rectal Prolaps Management

73. Reminiscence Therapy

74. Reproductive Technology Management

75. Resuscitation : Fetus

76. Resuscitation : Neonate

77. Risk Identification : Genetic

78. Sedation Management

79. Self Hypnosis Facilitation

80. Sexual Counseling

81. Social Marketing

82. Substance Use Treatment : Alcohol Withdrawal

83. Substance Use Treatment : Drug Withdrawal

84. Substance Use Treatment : Overdose

85. Support Group

86. Surveilance : Late Pregnancy

87. Therapy Group

88. Trauma Therapy : Child