本文旨在描述一位60歲已婚女性，因腹膜炎行腹部手術數次反覆住院，擔心再次復發併發症，無法照料家庭，引發生理、心理衝擊和家庭角色調適障礙。自2018年6月20日至7月19日，以Gordon 11項功能性健康型態評估，確立個案有皮膚完整性受損、知識缺失及焦慮等健康問題。依照各階段應用不同策略傷口照護、飲食衛教，運用正向心理支持，適時提供醫療資源，減輕對傷口預後不確定感所引發的焦慮，改善腸液外滲到皮膚的狀況順利出院。此外，提供完善的居家傷口自我照護計畫，教導案子傷口照護技巧及回覆示教，並適時轉介出院準備服務、居家照護，協助料理三餐、家務，使個案返家後能回歸生活正常軌道。藉此個案建議臨床護理師在住院期應及早諮詢及轉介合適醫療資源，確立適切的傷口護理計畫，有效減少傷口周圍皮膚浸潤，促進癒合；並需及早評估個案居家照護的困難，有效的轉介各項居家照護資源，才能使個案獲得持續性、完整性，銜接良好的傷口居家照護計畫。

A 60-year-old married woman had undergone several abdominal surgeries for peritonitis and was anxious about the recurrence of complications. She could not care for her family due to repeated hospitalization, which led to physical and psychological shocks and family role adjustment disorders. Gordon's Functional Health Patterns was used to assess the patient's integrity from June 20 to July 19, 2017. In addition to a lack of knowledge, the main health-related concerns identified in the patient were skin integrity impairment and anxiety. Considering the different illness stages, varied wound care strategies and nutrition education were applied. Thus, the intestinal fluid leakage onto the patient's skin was alleviated, and therefore, the patient was discharged from the hospital. The patient's home care program mainly focused on teaching wound care techniques to her family through demonstration. In addition, the anxiety caused by the uncertainty of wound prognosis was alleviated through empathy and listening to the patient's concerns and by providing positive psychological support and timely medical care. Finally, both the patient and her family were rehabilitated and returned to daily life with a reduced psychological burden. This process was facilitated by using home caregivers who assisted by cooking three meals and performing housework. The author recommends that patients should be referred to appropriate medical resources as soon as possible during the hospitalization period. This can aid in isolating the fistula from the surrounding tissue and promote healing of the surrounding tissue while protecting the surrounding skin and granulation tissue from irritation or caustic fluid. In addition, home care is often possible when the patient is stable. Assisting patients and their families, as early as possible, with home care is crucial and can provide them with the knowledge and techniques required to care for the patients effectively in their homes.