腦中風病人合併有吞嚥困難容易引發吸入性肺炎造成呼吸衰竭或死亡。2013年1、2月共2例腦中風病人由口進食時發生嗆咳導致吸入性肺炎發生，分析原因有：護理師對於吞嚥困難及進食指導認知不足、缺乏教育訓練及輔助工具、缺乏參閱指引及監控。故規劃吞嚥困難評估及進食指導教育訓練、製作參閱指引、建置「護理作業系統吞嚥困難評估」系統、設計由口進食指導圖卡採中、英、印語及口訣學習、監控吞嚥困難評估及進食指導執行率；結果吞嚥困難評估及進食指導認知由77.7%提升為97.5％、吞嚥困難評估執行率95%、進食指導執行率94%，故建議重視腦中風病人吞嚥困難評估及進食指導，以提升腦中風病人照護品質。

Stroke patients who suffer from dysphagia are in high risk of aspiration pneumonia which causes respiratory failure or death. In January and February, 2013, two stroke patients had aspiration pneumonia while they ate and choked. These two cases were analyzed. The main reasons were due to their lack of awareness of dysphagia and ingesting instruction, insufficiency of operational training and assistant tools, and not enough guideline and supervision. As a result, we planned dysphagia evaluation and ingesting instruction training, indicated the guideline, set up “nursing process of dysphagia evaluation” system, designed instructional charts with both Chinese and English along with pithy formulas, and monitored the efficiency of dysphagia evaluation and implementation rates of ingesting instruction. The results were that the knowledge of dysphagia evaluation and ingesting instruction rose from 77.7% to 97.5%, and the implementation rates of dysphagia evaluation and ingesting instruction were 95% and 94%, respectively. As a matter of fact, we suggested valuing the importance of evaluating dysphagia and ingesting instruction to improve the quality of caring for stroke patients.