本文描述一位心衰竭患者因症狀反覆發作而入住加護病房的照護經驗，以Gordon十一項功能性評估為引導，確立個案有「氣體交換障礙」、「活動無耐力」、「無力感」及「心臟居家照護知識缺失」四項健康問題。藉由持續性監測、氧氣治療及限制水份來改善氣體交換障礙，同時安排適切的心臟復建計畫，提高活動耐受力，增強居家復健意願，鼓勵家屬共同參與照顧，增加個案對疾病的控制，改善無力感。期望藉由此經驗分享，作為心衰竭反覆入院全面性臨床照護參考，提升護理品質以降低反覆再住院率。

This paper describes ICU nursing care for a patient with heart failure who was repeated hospitalized due to recurring cardiopulmonary distress. Using Gordon 11 functional assessment and analysis, we identified that the case had impaired ventilation, a deficit of home care knowledge, an intolerance for exercise intolerance, and a sense of powerlessness, The patient’s vital signs were monitored periodically, he received oxygen therapy, and his fluids were balanced to improve ventilation. Cardiac rehabilitation programs were introduced at the appropriate time point. The patient exercise tolerance improved after discharge and family members were encouraged to participate in home care, leading to an improvement in disease condition and mood. We hope that this report of our nursing experience can serve as reference underlying the importance of comprehensive clinical care of heart failure and the need for patient and family member involvement to obtaining the best quality of life for such patients.