关键词: 心力衰竭, 自我管理, 护理, 老年, 综述

Abstract:

Chronic heart failure is characterized by a protracted disease course and high readmission rates，with long-term outcomes heavily dependent on the self-management of patients and families. From a nursing perspective and drawing on chronic disease self-management theory and temporal self-regulation theory，this review summarizes current research status of the self-management support models such as nurse-led interventions，collaborative care，and telehealth/digital health approaches. Existing evidence suggests that structured nursing interventions can improve self-care behaviors and self-efficacy and，to some extent，reduce adverse outcomes such as readmission and depression. However，there is substantial heterogeneity in intervention components，follow-up duration，and population selection，with a notable lack of evidence specific to older，frail，and cognitively impaired patients. Future studies should clarify the key active components and appropriate models of nursing interventions in high-risk older populations and，by integrating objective behavioral data and real-world research，evaluate the long-term effectiveness and cost-effectiveness of human-technology collaborative management，thereby providing evidence to optimize self-management-oriented nursing care for patients with chronic heart failure.

Key words: Heart Failure, Self-Management, Nursing Care, Elderly, Review