Pneumonia adalah infeksi akut yang mengenai jaringan paru-paru (alveoli) yang dapat disebabkan oleh berbagai mikroorganisme seperti virus, bakteri, jamur, dan pajanan bahan kimia. Bakteri yang biasa menyebabkan pneumonia adalah Streptococcus pneumoniae dan Mycoplasma pneumoniae, sedangkan virus yang menyebabkan pneumonia adalah virus Sitomegali, Influenza Virus, serta Respratory Syncytial Virus (RSV). Gejala penyakit pneumonia yaitu menggigil, demam, sakit kepala, batuk, mengeluarkan dahak, dan sesak napas (Maryunani, 2010). Menurut WHO (World Health Organization) angka kematian balita pada tahun 2013 masih tinggi mencapai 6,3 juta jiwa. Kematian balita tertinggi terjadi di negara berkembang sebanyak 92% (29.000 balita/hari), terlihat dari rendahnya pelaporan kasus pneumonia di daerah baik dari puskesmas maupun rumah sakit Word Health Organization (WHO, 2014). Kematian balita sebagian besar disebabkan oleh penyakit menular seperti pneumonia (15%), diare (9%), dan malaria (7%) (WHO, 2014). Indonesia menduduki peringkat ke 6 dalam kasus pneumonia yaitu sebanyak 19.000 kasus. Tujuan penulisan adalah agar dapat menerapkan, membandingkan kesenjangan antara teori dan kasus, memecahkan masalah pada klien. Dalam penyusunan tugas akhir ini penulis menggunakan metode deskriptif dengan tipe studi kasus, pengumpulan data meliputi observasi, wawancara, pemeriksaan head to toe, dokumentasi keperawatan, kepustakaan dan subjek adalah ibu klien. Hasil yang didapatkan pada An.M diagnosis keperawatan ketidakefektifan bersihan jalan napas, ketidakefektifan pola napas, resiko defisit nutrisi dan defisit pengetahuan. Sikap kooperatif pasien dan orangtua yang terbuka serta berkerjasama dengan perawat.

Kata kunci: Pneumonia, Dokumentasi Keperawatan, Asuhan Keperawatan

Pneumonia is an acute infection that effects the lung tissue (alveoli) which can be caused by various microorganisms such as viruses, bacteria, fungi and chemical exposure. The bacteria that usually cause pneumonia are streptococcus pneumoniae and mycoplasma pneumoniae, while the viruses that cause pneumonia are cytomegaly virus, influenza virus, and respiratory syncytial virus (RSV). Symptoms of pneumonia in include chills, fever, headache, cough, sputum, and shortness of breath (Maryunani, 2010). According to WHO (Word Health Organization) the under-five mortality rate in 2013 was still high, reaching 6.3 million people. The highest under-five mortality occurred in developing countries as much as 92% (29,000 children under-five/day), as seen from the low reporting of pneumonia cases in areas both from public health centers and Word Health Organization hospitals (WHO, 2014). Most of the under-five deaths were caused by infectious diseases such as pneumonia (15%), diarrhea (9%), and malaria (7%) (WHO, 2014). Indonesia is in 6th place in pneumonia cases with 19,000 cases. The aim of the study is to apply, compare the gap between theory and cases, and solve problems for clients. In the preparation of this final project the writer uses a descriptive method with case study type, data collection includes observation, interview head to toe examination, nursing documentation, literature, and the subject is the client’s mother. The results obtained on An.M are nursing diagnoses of ineffective airway clearance, ineffective breathing patterns, risk of nutritional deficit and knowledge deficits. Patient and parent cooperative attitude that is open and cooperates with nurses. Keywords: Pneumonia, Nursing Documentation, Nursing Care