本文描述一位腦中風婦女因為肢體功能障礙，自我照顧能力缺失，日常生活活動受影響，在急性期後轉入復健單位接受復健訓練，入院後經由護理人員完成出院準備需求評估後照會出院準備服務組收案，筆者運用出院準備服務概念，確認服務需求後給予收案管理，照護期間自民國96年9月6日至10月15日，主要護理問題為身體活動功能障礙、吞嚥功能障礙、無望感、家庭功能支持不足與社會資源缺乏，在跨專業團隊協助與合作下，共同擬定復健計劃目標，召開家庭會議，協調照顧人力問題及決定出院方向，提供適當社會資源資訊與轉介，使個案能適應因疾病造成的肢體障礙，學習日常生活訓練及教導照顧者照顧技巧，使個案能重建肢體功能，增進自我照顧能力，在個案出院後持續電話追蹤一個月，確保個案及照顧者能獲得持續性照顧，協助解決出院後續照護問題，使個案能回歸正常居家生活，提升其生活品質。
This article describes a nursing experience caring for a woman who had central vascular accident (CVA) whose motor impairment severely limited her daily living activities and ability to care for herself. After the acute phase, she was transferred to a rehabilitation unit to accept physical training. The nursing staff assessed her needs and reported them to the discharge planning section who assumed responsibility for the case. The author confirmed the service needs and managed the case from Sep.6 to Oct.15, 2007. The major nursing problems were impaired physical mobility, impaired swallowing, a feeling of hopelessness, insufficient family support, and a lack of social resources. Taking multidisciplinary approach, a rehabilitation plan was devised. A family conference was convened and where she would go after discharge and who would take care of her was decided. The nursing team also provided appropriate social resource information. To help the case regain limb function and improve her ability to care for herself, the nursing staff helped her adapt to her new physical disabilities, gave her daily life training, and taught her caretaker how to take care of her. Telephone follow-up continued for one month after discharge to ensure that the case and the caretaker could get continued assistance. This enabled the case to return to home life and improved her life quality.
