Pneumonia adalah penyakit infeksi saluran napas bagian bawah yang merupakan penyebab utama kematian pada balita di dunia. Menurut WHO (World Health Organization) angka kematian balita pada tahun 2015 akibat pneumonia masih tinggi mencapai 6 juta anak balita meninggal dunia. Tujuan penulisan ini agar penulis memperoleh gambaran nyata mengenai pelaksanaan dan pendokumentasikan asuhan keperawatan komprehensif pada An.Y dengan penyakit Pneumonia. Metode penulisan ini yaitu studi kasus dengan teknik pengumpulan data melalui wawancara, observasi, pemeriksaan fisik, studi dokumentasi dan kepustakaan. Pemberian asuhan keperawatan menggunakan langkah-langkah proses keperawatan yang meliputi pengkajian, diagnosa keperawaan, perencanaan, pelaksanaan dan evaluasi. Pengkajian yang dilaksanakan mencakup identitas klien, riwayat yang pernah dialam, kesehatan sekarang dan secara keseluruhan. Diagnosa keperawatan yang didapatkan yaitu bersihan jalan napas tidak efektif, pola napas tidak efektif, resiko defisit nutrisi, dan defisit pengetahuan. Intervensi yang telah dilakukan dan kriteria hasil yang telah disusun berdasarkan prioritas masalah. Evaluasi hasil tindakan keperawatan menunjukkan masalah keperawatan yang penulis rumuskan dalam diagnosa keperawatan dapat teratasi sesuai tujuan yang telah ditetapkan. Dari keempat diagnosa tersebut terdapat tiga masalah yang dapat teratasi sesuai dengan tujuan yang telah dilakukan dan terdapat satu diagnose yang belum teratasi karena belum sesuai dengan tujuan, kriteria hasil dan waktu yang telah ditentukan.

Kata kunci: Asuhan Keperawatan, Pneumonia

Pneumonia is a lower respiratory tract infection which is the leading cause of death among children under five in the world. According to WHO (World Health Organization) the under five mortality rate in 2015 due to pneumonia was still high, reaching 6 million children under five died. The purpose of this research was to get a real picture of the implementation and documentation of comprehensive nursing care in child Y with pneumonia. Data in this case study were collected through interviews, observation, physical examination, documentation and literature studies. The provision of nursing care used steps of the nursing process which included assessment, nursing diagnosis, planning, implementation, and evaluation. The assessment carried out included the client’s identity, history of experience, current and overall health. The nursing diagnosis obtained were ineffective airway clearance, ineffective breathing patterns, risk of nutritional deficits, and knowledge deficits. Interventions were carried out and the result criteria were arranged based on priority problems. Evaluation of the results of nursing actions showed that the nursing problems that were formulated in nursing diagnoses could be resolved according to predetermined goals. Of the four diagnoses, there were three problems that could be resolved according to the objectives that were carried out and there was one diagnoses that was not resolved because it was not in accordance with the objectives, outcome criteria and predetermined time. Keywords: Nursing Care, Pneumonia