本文陳述一位情感型精神病患因幻聽干擾、自傷意念等症狀及家庭功能不良，反覆發病住院；主護護士於照顧期間，以出院準備計劃的概念，透過護理問題評估，擬出增加服藥遵從性、自我照顧能力以及家屬因應能力等照顧目標，與精神醫療團隊成員及個案家屬協調，使個案返回社區，維持基本社會功能，並於後續追蹤中維持成效。

An affective disordered patient repeatedly admitted to a hospital due to sufferingfrom auditory hallucination, suicide ideation, and family dysfunction. The articledescribed a discharge plan made by the primary nurse. The plan enhances drugcompliance, self-care ability and family coping ability, andworkingwith themedical teamand the family. The final goal of the plan is to maintain the basic social functioning andpreserve the effectiveness of treatment.