Pneumonia is an inflammatory condition of the lung, which is the alveoli may fill with fluid. Pneumonia commonly suffered by infants and children. The most cases occur on children under 3 years old and the most death number on infants younger than 2 months. Pathophysiology of this disease occurs increased sputum production, thus it causes ineffective airway clearance, there is an inability to clean the secretions to maintain the airway patency. This study aims to find nursing care description of pneumonia in children with ineffective airway clearance. This study used descriptive method with case study design on two subjects by documentation study in Cilinaya Ward Mangusada Badung Hospital. In data collection, the researcher used observation sheet filled by himself concerning on the data listed in the nursing documents. This study result shows assessment was different from the theory, nursing diagnosis that used is ineffective airway clearance. In planning, there are some difference with the theory. In implementation, there some actions are not done. Evaluated using SOAP and the problem was resolved. The result shows that the documentation of nursing care is influenced by the theory that used as reference by nurses and by the researcher.
Keywords: Pneumonia, Ineffective Airway Clearance