DAFTAR STANDAR TINDAKAN KEPERAWATAN

A. TINDAKAN KEPERAWATAN DASAR

1. KATEGORI I
N
O
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.

KEWENANGAN KLINIS
Bantuan perawatan diri
Bantuan perawatan diri : mandi / hygiene
Bantuan perawatan diri : berpakaian
Bantuan perawatan diri : makan
Bantuan perawatan diri : toileting
Bantuan perawatan diri : transfer
Memandikan
Mengenakan pakaian (dressing)
Memberikan makan
Admission care
Monitor Vital sign
Perawatan rambut
Administrasi medikasi Oral
Bantu toileting
Oral Higiene
Bantu perawatan diri: makan
Bantu perawatan diri: berpakaian
Posisioning
Transport
Monitor nutrisi
Monitor cairan
Perawatan kuku
Perawatan kaki
Perawatan telinga
Heat/cold aplication
Respiratory monitoring

2. KATEGORI II
N
O
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.

KEWENANGAN KLINIS
Reduksi Cemas
Pembatasan Area
Pencegahan Aspirasi
Perawatan bedrest
Pemeriksaan laboratorium di samping TT
Bottle feeding
Teknik penenangan
Perawatan gips: maintenance
Peningkatan komunikasi : defisit pendengaran
Peningkatan komunikasi : defisit penglihatan
Perawatan kontak lensa
Peningkatan batuk
Distraksi

40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.

Perawatan emergensi
Manajemen lingkungan
Manajemen lingkungan :kenyamanan
Bantuan pemeriksaan
Therapi latihan : ambulasi
Pertolongan pertama
Administrasi medikasi: telinga
Administrasi medikasi: mata
Administrasi medikasi: enteral
Administrasi medikasi: inhalasi
Administrasi medikasi: nasal
Administrasi medikasi: oral
Administrasi medikasi: rectal
Administrasi medikasi: kulit
Administrasi medikasi: vaginal
Manajemen mual
Perawatan perineal
Posisioning
Posisioning : neurologi
Perawatan jenazah
Kehadiran
Perawatan ulkus pressure
Perawatan prostesis
Orientasi realita
Therapi rekreasi
Manajemen spesimen
Asistensi pembedahan
Perawatan slang : urinari
Cateterisasi urine
Cateterisasi urine : intermittent
Fasilitasi kunjungan
Discharge planning
Pendidikan Kesehatan
Kontrol Infeksi
Pentahapan diet
manajemen lingkungan
Pencegahan jatuh
perawatan kaki
Interpretasi data laboratorium
Fall prventionpk 1
Fever treatment pk1
Electrolyt monitoring
Bantu perawatan diri: transfer

3. KATEGORI III

N
O

KEWENANGAN KLINIS

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.

Amputation care
Analgesic administration
Bladder irrigation
Bleeding precaution
Bleeding reduction
Bleeding reduction : antepartum uterus
Bleeding reduction : gastrointestinal
Bleeding reduction : nasal
Bleeding reduction : postpartum uterus
Bleeding reduction : wound
Blood product administration
Body image enhancement
Body mechanics promotion
Bowel incontinence care
Bowel incontinence care : encopresis
Bowel irrigation
Bowel management
Bowel training
Bowel examination
Breasfeeding assistance
Capillary blood sample
Chest physiotherapy
Childbirth preparation
Circumcision care
Cutaneous stimulation
Aroma therapy
Dialysis acces maintenance
Diare management
Diet staging
Discharge planning
Electronic fetal monitoring : antepartum
Electronic fetal monitoring : intrapartum
Enteral tube feeding
Environmental manegement : safety
Environmental risk protection
Exercise promotion
Exercise promotion: strength training
Exercise promotion : streching
Exercise therapy : balance
Exercise therapy : joint mobility
Family support
Flatulence reduction
Airway management
Airway suctioning
Gastrointestinal intubation
Incision site care
Phlebotomy : arterial blood sample
Health education
Health screening
Hyperglicemia management
Hypervolemia management
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 IV
N
KEWENANGAN KLINIS
O
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 KOMPLEKS

1. KATEGORI I
N
O
1.
2.
3.
4.
5.
6.
7.

KEWENANGAN KLINIS
Chemotherapy management
Birthing
Bibliotherapy
Hemodialysis Therapy
High Risk Pregnancy Care
Trancutaneus Electrical Nerve Stimulation (TENS)
Exercise Therapy : Muscle Control

8. Family Planning : Infertility

9. Electronic Fetal Monitoring : Antepartum
10. Electronic Fetal Monitoring : Intrapartum
2. KATEGORI II
N
O
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.

KEWENANGAN KLINIS
Intrapartal Care : High Risk Delivery
Labor Induction
Labor Suppression
Wound care : burns pk3
Surveilance : safety pk3
Resuscitation pk3
Positioning : intraoperative pk3
Acupressure
Amnioinfusion
Art Therapy
Autogenic training
Hypnosis
Biofeedback
Case management
Cognitive restructuring
Cognitive stimulation
Conflict mediation
Counseling
Crisis intervention
Eating Disorder Management
Therapeutic Touch

3. KATEGORI III
N
O
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.

KEWENANGAN KLINIS
Hemofiltration therapy pk3
Defibrillator management : external pk3
Defibrillator management : internal pk3
Chemical restrain pk 3
Cerebral edema management pk 3
Cardiac care : acutepk 3
Nutritional counseling
Hemodynamic regulation pk3
Total parenteral nutrition (TPN) management
Mechanical ventilation management : invasive pk3
Mechanical ventilation management : noninvasive pk3
Mechanical ventilatory weaning
Pacemaker management : permanent pk3

45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.

Pacemaker management : temporary pk3

Validationn Therapy
Venous Acces Device (VAD) Maintenance
Airway insertion and stabilizationpk 3
Thrombolytic therapy management pk3
Nutrition Management
Family Therapy
Fertility Preservation
Fiscal Resource Management
Forensic Data Collection
Genetic Counselling
Hormon Replacemen Therapy
Impulse Control Training
Laser Precautions
Medication Administration : Intrapleural
Medication Administration : Intraosseous
Medication Administration : Ventricular Reservoir
Medication Prescribing
Memory Training
Pelvic Muscle Exercise
Peripherally Inserted Central (PIC) Catheter
Pneumatic Torniquet Precautions
Preconseption Counseling
Pregnancy Termination Care
Premenstrual Syndrome (PMS) Management
Program Development
Progressive Muscle Relaxation
Rectal Prolaps Management
Reminiscence Therapy
Reproductive Technology Management
Resuscitation : Fetus
Resuscitation : Neonate
Risk Identification : Genetic
Sedation Management
Self Hypnosis Facilitation
Sexual Counseling
Social Marketing
Substance Use Treatment : Alcohol Withdrawal
Substance Use Treatment : Drug Withdrawal
Substance Use Treatment : Overdose
Support Group
Surveilance : Late Pregnancy
Therapy Group
Trauma Therapy : Child