本文係探討一位77歲男性個案，患有結節性硬化症併發末期腎病變，長期接受血液透析治療的護理過程。筆者運用羅氏護理適應模式加以整體性評估，藉由身體評估、觀察、會談等技巧收集相關資料，與個案建立治療性護病關係，確立個案有高危險性感染、焦慮、妥協性家庭因應能力失調等健康問題。個案住院期間，除提供基本的生理需求外，另與醫療團隊人員溝通個案透析護理問題，並連絡家人及照顧者建立醫療聯絡的溝通管道，藉此控制個案住院期間之感染，運用放鬆療法降低其對疾病之焦慮，引導家人給予正向的鼓勵與關懷，維持良好的支持系統，使照顧者能有一致性照顧觀念，遵循護理人員所教導的知識技能，出院後續照護追蹤，使個案能按時回診。

This article is about the nursing care plan of maintenance hemodialysis in a 77-year-old male patient with end-stage renal disease(ESRD) attributed to tuberous sclerosis. Roy adaptation model was used to assess the patient. By means of physical examination techniques, direct observation, and interview, relevant information was collected and a therapeutic nurse-patient relationship was developed. Meanwhile, nursing diagnoses established were high risk of infection and compromised family coping. During hospitalization, after the basic physiological needs were satisfied, the care plan for hemodialysis treatment was discussed with the patient's primary healthcare physicians and nurses, and the primary caretaker was also contacted to establish a regular medical connection. These skills not only help to mitigate the infection of the patient and maintain a balance between fluids and electrolytes, but they also relieved the patient's anxiety towards the disease especially through relaxation therapy. Family members were also guided to provide positive reinforcement and to maintain a functional support system. Primary caretaker was also instructed to follow the concept of consistent care and caring skills in order to help the patient to be discharged as planned and to attend follow-ups.