本文在描述一位腦中風患者於居家期間，因長期臥床所引發之相關護理問題，進而呈現的照護經驗。護理期間自87年8月11日至88年12月8日止。藉由一次病房探視、12次電訪、34次家訪的照護進行資料的收集，經由身體評估、觀察、會談技巧收集個案基本資料。經內容分析整體發現個案這一年多來陸續呈現的護理問題有1、呼吸道清除功能失效　2、身體活動功能障礙　3、皮膚完整性受損　4、照顧者角色緊張　5、家庭因應能力失調。經由居家護理人員定期的介入，並從個案生理、心理、社會層面及主要照顧者的各項互動中，進而協助家屬(主要照顧者)解決照護問題。本文針對如何協助家屬照顧一位腦中風個案的護理過程提出討論，期望在專業的領域中達到經驗的分享。

This report describes the home care nursing of a stroke patient, who was long-term bed-ridden at home. The period of home care nursing lasted sixteen months, during which time data was collected through hospital ward visits, telephone interviews and home visits. The nursing diagnoses were made as (1) ineffective airway clearance, (2) impaired physical mobility, (3) impaired skin integrity, (4) caregiver role strain (5) ineffective family coping. The home care nurses intervened and interacted with patient and her families on physical, psychological and social levels, and further assisted the major caregiver with effective health care management.