关键词: 人口老龄化, 共病护理, 整合护理, 护理模式, 应对策略

Abstract:

With the accelerating ageing of China’s population and the growing burden of chronic diseases，multimorbidity has become a common challenge for population health and nursing care. Traditional disease-specific and specialty-centred nursing models are increasingly inadequate for meeting the complex，continuous，and integrated care needs of patients with multimorbidity. This paper analyzes the challenges of multimorbidity nursing care from 3 dimensions—“disease-patient-system”—and proposes recommendations such as advancing integrated care，enhancing holistic management of patients with multimorbidity and reducing treatment burdens；reinforcing health goal-oriented patient care to establish a personalized nursing and self-management loop；improving continuous care，data standards，and talent development systems to strengthen the support framework for multimorbidity nursing care. These measures aim to deepen multimorbidity nursing research，promote the transformation of nursing models，and build a multimorbidity nursing theory and service system tailored to China’s national conditions.

Key words: Population Ageing, Multimorbidity Nursing, Integrated Care, Nursing Models, Coping Strategies