本篇個案報告是協助一位因車禍造成失去自我照顧能力的老年病患，在病況穩定後，除提供完整且持續性的照護，並協助出院準備服務，以使返家採居家護理之經驗。在護理期間93年3月4日至5月18日，筆者應用老年人常見健康問題，和主要照顧者的壓力與負擔等文獻，以及出院準備服務之概念，做整體性的護理評估，確立主要護理問題有呼吸道清除功能失效、身體活動功能障礙及照顧者角色緊張。故在護理過程著重在提供後續照護之安排及準備、外傭的訓練及家屬的心理支持，最後病患得以順利返家。此經驗也讓習慣快速出入院的外科病房護理人員更了解較複雜的老年失能病患出院準備服務的過程。

　　　　　This case study describes the comprehensive and continuous care provided to an elderly patient whose self-care ability had been lost in a traffic accident. During the nursing period, from March 4th 2004 to May 18th 2004, we utilized the literature on the health problems of the elderly, concepts of discharge planning, and a comprehensive nursing assessment to confirm that the main nursing issues were clearance of a blocked airway, and impaired mobility. We also helped caregivers to cope with the problems of role strain. During the nursing process, we placed particular emphasis on management and preparation for care after discharge, the training of a maid, and psychological support for the family. The experience enabled surgical ward nurses who were already used to fast discharges of patients to gain a better understanding of discharge planning in complex cases involving the disabled elderly.