本文為描述照顧一位因呼吸衰竭導致氣切造口留置並合併呼吸器使用的長期住院病人，運用出院準備服務計劃，順利轉介出院的護理經驗。自2006年5月12日至7月9日護理期間，經醫療與照護需求、家庭系統、社區資源評估後，發現護理問題有「身體活動功能障礙」、「焦慮」及「照顧者角色緊張」。經由主動與病人及家屬共同擬定護理計畫，重建健康行為；並透過護理活動介入，讓家屬學得相關的照護技巧、面對病人需長期性照護的需要以接受轉介出院，使病人出院後可以獲得較好的後續照護。筆者藉由此一照護經驗，提出與臨床護理人員分享，也勉勵自己能運用「出院準備服務概念」，提供給需長期照護的病人及家屬得到適當的服務，讓病人可以獲得持續性照護。

This report describes a discharge planning experience for nursing a long-term hospitalized case using ventilator and tracheostomy due to respiratory failure. During the caring period, from May 12th 2006 to July 9th 2006, we introduced the concept of discharge planning to evaluate the medical treatments, caring demands, household systems, and community supporting resources for this case. After that, the major nursing problems were identified as impaired physical mobility, anxiety, and caregiver role strain. We tried to retrain their health habits by setting-up goals and making plans with the patient and family together. Meanwhile, through nursing intervention, we educated the family with caring skills, and let them understand the needs of long-term care, so that they would accept the referral discharge to obtain better care quality afterward. This experience enables nurses with similar context to handle discharge planning for cases involving long-term care needs.