本⽂描述⼀位病⼈因腦中風導致身體功能受限，⽇常⽣活需仰賴他⼈協助。原本身體孱弱、多重共病的妻⼦因⽽成為主要照顧者，承受沉重壓⼒。住院期間，主責護理師發現案妻照顧能⼒不⾜、病⼈⽇常⽣活完全依賴他⼈、有銜接長期照顧服務資源的需求，遂轉介出院準備服務護理師協助。⾃ 2018 年 11 ⽉ 22 ⽇至 12 ⽉ 28 ⽇照護期間，透過病歷查閱、照護互動及會談，運⽤ Gordon ⼗⼀項功能性健康型態進⾏評估，確認病⼈⾯臨「身體活動功能障礙、無⼒感及照顧者角⾊緊張」等護理問題。因⾼齡者常有挫折感與學習動機不⾜，護理師於住院期間，透過跨領域合作⽀持病⼈與案妻並共同擬定出院計畫，協助其找到合適步調學習⽣活技能。⽂獻⽀持急性病房與社區共同照護之重要性，藉由透過出院後長照復能資源銜接，提升病⼈⾃我照顧能⼒與⽣活品質，亦減輕照顧者壓⼒，促進「在地⽼化」的實現與出院後照護的延續。

The article discusses a patient who developed significant physical impairments following a stroke, leading to dependence on others for activities of daily living. His wife, despite being frail and having multiple comorbidities, assumed the role of primary caregiver, which subjected her to considerable psychological and physical stress. During hospitalization, the primary nurse assessed the patient’s complete dependence on others for daily activities, recognized the wife’s limited capacity, identified the need for referral to long-term care services. The case was therefore referred to a discharge planning nurse for further intervention. Between November 22 to December 28, 2018, the nursing team delivered care through comprehensive medical record review, direct interactions, and interviews. Assessments were guided using Gordon’s Eleven Functional Health Patterns, which revealed nursing diagnoses including impaired physical mobility, fatigue, and caregiver role strain. Due to the patient’s frequent frustration and lack motivation to engage in learning, the nursing staff collaborated with an interdisciplinary team to assist the patient and his wife in developing a personalized discharge plan and establishing an appropriate pace for acquiring daily living skills. Current literature underscores the significance of integrated care between acute hospital settings and community-based services. Facilitating connections to long-term care and reablement programs following discharge can enhance patients’ self-care abilities and overall quality of life, alleviate caregiver burden, and promote continuity of care while supporting the goal of aging in place.