本文描述一位62歲婦人，因脊髓腫瘤壓迫致下肢神經麻痺而臥床，致尾骶骨產生三級壓瘡長達一年無法癒合，造成個案多重的身、心問題，經由居家護理師整合協調整形外科、復健科醫療團隊介入，使壓瘡於一個月內癒合的護理經驗。護理期間自2012年6月8日至9月21日，藉由七次家訪、一次電訪、一次病房探訪，以Gordon11項健康功能型態為評估架構，運用身體評估、觀察、會談等技巧收集資料，發現護理問題有：皮膚完整性受損、潛在危險性感染、身體活動功能障礙、無力感。照護過程居家護理師因考量個案就醫不便及整形外科醫師無法家訪因素，以資訊雲端概念，利用智慧型手機上傳壓瘡照片，及時協助家屬就診與醫師討論，成功架起溝通橋樑，並轉介申請居家物理治療師至案家教導壓瘡個案翻身擺位及肢體復健技巧，且依傷口癒合時期，教導家屬壓瘡照顧及如何預防感染，並將壓瘡癒合照片整理呈現，與個案及家屬一起分享護理過程，由身體組織修復狀況，增加其信心並自願參與照顧，在團隊合作下，有效改善個案健康問題。建議推廣遠距醫療視訊照護模式，協助行動不便、就醫困難的居家個案，透過視訊系統串接更多專業照護團隊，提供立即、完整的評估及照顧。

This paper presents a case of 62-year-old woman who suffered from lower extremity paralysis caused by spinal cord tumor. Due to bedridden status, a grade Ⅲ pressure sore was formed and did not heal after a year of wound care, resulting in her multiple physical and mental problems. This paper is about the nursing experience of a home care nurse in coordinating a multidisciplinary team consisting of a plastic surgeon and a physical therapist. During the care period from June 8 to September 21, 2012, seven home visits, a telephone interview and a ward visit were conducted. Based on the Gordon’s 11 functional health patterns and data collection skills, such as physical assessment, observation and interview, four care problems were identified: impaired skin integrity, risk of infection, impaired physical mobility, and powerlessness. Considering the inconvenience of accessing a clinic and the absence of a plastic surgeon during home visits, the home care nurse used a smartphone to upload pictures of the pressure sore to a cloud storage. A communication channel, therefore, was established. The surgeon was able to discuss the case’s conditions with her family members and prescribe appropriate treatment timely through viewing the pictures. Moreover, the case was referred to a physical therapist who planned and executed a rehabilitation program, including correct positioning support to the case in home. The nurse taught the family members how to take care of the pressure sore and how to prevent infection. The pictures showed the caring process and progress of wound healing which increased the family members’ confidence and motivation to provide appropriate care to the patient. In collaboration with other disciplines the home care nurse, it was able to help the patient’s wound healed within one mouth. The video telemedicine system was able to coordinate a multidisciplinary team to provide clients with disabilities who had limited access to clinics with immediate, complete evaluation and care. Hence, utilizing telemedicine in home care settings is recommended.