Pneumonia adalah suatu radang paru yang disebabkan oleh bermacam-macam etiologi seperti bakteri, virus, jamur dan benda asing. Tujuan penulisan Karya Tulis Ilmiah ini adalah untuk memperoleh pelaksanaan dan pendokumentasian pada pasien bayi dengan Pneumonia secara komprehensif dengan menggunakan proses keperawatan. Metode penulisan adalah deskriptif melalui studi kasus dengan teknik pengumpulan data, melalui wawancara, observasi, pemeriksaan fisik, studi dokumentasi dan studi kepustakaan. Proses asuhan keperawatan menggunakan langkah-langkah proses keperawatan yang meliputi: Pengkajian, diagnosis keperawatan, intervensi, implementasi dan evaluasi. Pengkajian yang dilaksanakan mencakup identitas klien, riwayat kesehatan terdahulu dan sekarang, pemeriksaan fisik dan pengkajian kesehatan secara keseluruhan. Diagnosis keperawatan yang ditemukan pada By. S adalah bersihan jalan nafas tidak efektif dan gangguan pola tidur. Intervensi yang telah dilakukan dengan kriteria hasil telah disusun berdasarkan prioritas masalah. Evaluasi hasil tindakan keperawatan menunjukkan bahwa masalah keperawatan yang penulis rumuskan dalam diagnosis keperawatan sebagian dapat teratasi sesuai tujuan yang telah ditetapkan dan kriteria hasil yang diharapkan. Adapun diagnosis keperawatan yang dapat teratasi yaitu gangguan pola tidur dan masalah belum teratasi yaitu bersihan jalan nafas tidak efektif. Penulis telah memperoleh gambaran nyata secara komprehensif pada By. S dengan diagnosa Pneumonia.

Kata Kunci: Pneumonia, Asuhan Keperawatan Anak

Pneumonia is an inflammation in the pulmonary parenchyma caused by various etiologies such as bacteria, viruses, fungi, and foreign bodies. The objective of this study was to obtain a comprehensive implementation and documentation of an infant patient with pneumonia by using the nursing process. A descriptive method through a case study was employed with data collection techniques through interview, observation, physical examination, documentation, and literature study. The nursing care process used the stages of the nursing process which consisted of assessment, nursing diagnosis, intervention, implementation, and evaluation. The assessment was conducted to identify the client identity, the past and present health and illness history, physical examination, and overall health assessment. The nursing diagnosis found in a baby S was ineffective airway clearance and sleep pattern disturbance. The intervention which was carried out with the outcome criteria was arranged based on the problem priority. The evaluation of the results of intervention showed that the nursing problems formulated in nursing diagnosis were partially resolved according to the goals that had been set and the expected outcome criteria. The nursing diagnosis which was able to resolve was sleep pattern disturbance and that of an unresolved problem was ineffective airway clearance. Overall, the author had obtained a comprehensive overview of a baby S with a pneumonia diagnosis. Keywords: Pneumonia, Child Nursing Care