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檢視一位新造口個案的出院準備時間軸，並判斷護理師應如何維持照護的連續性。

Trend

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Time	Data
Postoperative day 1	Client watches pouch emptying but declines hands-on practice, saying, 'I will learn tomorrow.'個案觀看造口袋排空，但拒絕實際操作，說：『我明天再學。』
Postoperative day 3	Client needs step-by-step prompting and cannot maintain the skin seal. The client lives alone. Home-health referral is submitted but not accepted.個案需要逐步提示，且無法維持皮膚密封。個案獨居。居家健康轉介已提交但尚未被接受。
Discharge morning	Vital signs are stable and discharge is ordered. Supply delivery, transportation to the ostomy clinic, and the first home-health visit remain unconfirmed.生命徵象穩定，已開立出院醫囑。衛材運送、前往造口診所的交通，以及第一次居家健康訪視仍未確認。

Q1. How should the nurse interpret the overall trend?護理師應如何解讀整體趨勢？

The client is fully ready because vital signs are stable個案已完全準備好，因為生命徵象穩定 Written instructions are sufficient for a client who lives alone書面指導對獨居個案已足夠 All transition needs can be deferred to the first clinic visit所有轉銜需求可延至第一次診所訪視 Discharge readiness remains incomplete despite medical stability儘管生理穩定，出院準備仍不完整

Q2. What should the nurse do before discharge proceeds?在出院繼續進行前，護理師應做什麼？

Tell the client to ask an unavailable family member for help告訴個案去請一位無法到場的家人幫忙 Coordinate the client, ostomy nurse, case manager, provider, supplies, home health, and follow-up while continuing skill practice協調個案、造口護理師、個案管理師、主要照護提供者、衛材、居家健康與追蹤，同時持續技能練習 Remove the pouch so the client will be motivated to learn at home移除造口袋，讓個案有動機在家學習 Cancel all referrals because the client is physiologically stable取消所有轉介，因為個案生理穩定

Q3. Which update best demonstrates a safer transition plan?哪一項更新最能顯示較安全的轉銜計畫？

The client signs the instruction sheet without explaining the plan個案簽署指導單，但未解釋計畫 The referral remains pending, but a brochure is placed in the bag轉介仍待審核，但袋中放了一本手冊 The client completes return demonstration, supplies and services are confirmed, and follow-up and warning-sign plans are taught back個案完成回覆示教，衛材與服務已確認，且追蹤與警訊計畫已回覆教學 The client agrees to search online if problems occur個案同意若發生問題就上網搜尋

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