目的 探讨对脑卒中患者实施延续性护理的效果。 方法 将在某三级甲等医院就诊的522例脑卒中患者按居住地分为试验组和对照组。 两组均给予常规治疗程序。 试验组患者由社区护士定期上门随访及电话随访。 于患者出院时和出院6个月时对患者日常生活活动能力、心理健康状况、护理服务满意度进行评估。 结果 出院时两组日常活动能力和心理健康状况差异无统计学意义（P>0.05）；出院后6个月试验组日常活动能力和心理健康状况优于对照组，差异有统计学意义（P＜0.05）。 结论 延续性康复护理能有效改善脑卒中患者的康复情况、心理健康，提高患者生活质量及护理服务满意度。

Objective To evaluate the effect of continuing rehabilitation nursing for stroke patients. Methods Totally 522 stroke patients discharged from a tertiary upper hospital were divided into the experimental group and the control group according to their residence community. All patients received routine nursing care. In addition， community nurses visited patients in the experimental group regularly to give the rehabilitation intervention through home visit and telephone follow up. The patients‘ physical，mental condition and their satisfaction with nursing service were evaluated when they were discharged and 6 months after. Results There was no significant difference between the two groups when the patient were discharged. After 6 months，the Barthel Index and mental condition in the experimental group were better than those in the control group significantly （P<0.05）. Conclusion Continuing rehabilitation nursing can effectively improve the rehabilitation and mental health of patients with stroke，improve the quality of life and satisfaction.