慢性病共病患者护理管理模式的范围综述

doi:10.3761/j.issn.0254-1769.2026.18.018

中华护理杂志 ›› 2026, Vol. 61 ›› Issue (18): 2579-2586.DOI: 10.3761/j.issn.0254-1769.2026.18.018

慢性病共病患者护理管理模式的范围综述

王阳秭¹(), 冯洁惠²^,^*(), 李旭芳¹

¹ 浙江大学医学院附属第一医院心脏大血管外科杭州市 311100
² 浙江大学医学院附属第一医院护理部杭州市 311100

收稿日期:2025-12-23 出版日期:2026-09-20 发布日期:2026-09-23
*通讯作者: *冯洁惠，E-mail：1503026@zju.edu.cn
作者简介:王阳秭：女，硕士，护师，E-mail：wangyangzi0830@zju.edu.cn
第一联系人：作者贡献声明
王阳秭：确定选题、文献检索、资料提取与总结、论文撰写与修改；冯洁惠：选题指导、研究质量把控、论文修改指导、基金支持；李旭芳：文献检索、资料分析、论文修改指导
基金资助:
浙江省自然科学基金项目(LMS26H020005)

A scoping review of nursing management models for patients with multiple chronic conditions

WANG Yangzi¹(), FENG Jiehui²^,^*(), LI Xufang¹

¹ Department of Cardiac and Great Vessel Surgery, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 311100, China
² Nursing Department， the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 311100， China

Received:2025-12-23 Online:2026-09-20 Published:2026-09-23
* Corresponding author: *FENG Jiehui，1503026@zju.edu.cn
Funding program:
Zhejiang Natural Science Foundation Project(LMS26H020005)

摘要/Abstract

摘要：

目的对慢性病共病患者护理管理模式进行范围综述，为构建本土化干预方案提供参考。方法根据范围综述方法学指南，检索中国知网、万方数据库、维普数据库、PubMed、Embase、Web of Science、CINAHL、Cochrane Library，检索时限为建库至2025年8月31日，对纳入文献进行整理及分析。结果共纳入26篇文献，涵盖14种慢性病共病患者护理管理模式，包括咨询与决策类、系统与流程重塑类、服务延伸与协调类3种类型。护理管理措施涉及宏观系统层（提供制度与平台支持）、中观照护层（优化服务流程、开展团队协作）、微观互动层（对患者赋能、提供疾病管理支持）3个层面。结局指标包括患者健康与功能状态、医疗服务效率与可持续性、患者体验与赋能3个维度。结论慢性病共病患者护理管理模式呈现整合化、多层次特点。未来需结合国内临床情境，开发本土化模式与评估工具，并通过高质量研究验证其长期应用效果。

关键词: 慢性病共病, 护理管理模式, 整合照护, 范围综述

Abstract:

Objective A scoping review of nursing management models for patients with multiple chronic conditions was conducted，aiming to provide references for developing localized intervention programs. Methods Following the methodological guidelines of scoping review，searches were conducted in CNKI，Wanfang Database，VIP Database，PubMed，Embase，Web of Science，CINAHL，and Cochrane Library from inception to August 31，2025，and the included literature was analyzed and discussed. Results A total of 26 articles were included，covering 14 care management models for patients with multiple chronic conditions. These models were categorized into 3 types：consultation and decision-making，system and process remodeling，and service extension and coordination. The intervention measures cover 3 levels：the macro-system level（providing institutional and platform support），the meso-care level（optimizing service processes and implementing team collaboration），and the micro-interaction level（empowering patients and providing management support）. The outcome indicators include 3 dimensions：patient health and functional status，healthcare service efficiency and sustainability，and patient experience and empowerment. Conclusion Nursing management models for patients with multiple chronic conditions demonstrate integrated and multi-level characteristics. In the future，it is necessary to develop localized models and assessment tools tailored to the domestic clinical context，and to verify their long-term application effects through high-quality research.

Key words: Multiple Chronic Conditions, Nursing Management Models, Integrated Care, Scoping Review

王阳秭, 冯洁惠, 李旭芳. 慢性病共病患者护理管理模式的范围综述[J]. 中华护理杂志, 2026, 61(18): 2579-2586.

WANG Yangzi, FENG Jiehui, LI Xufang. A scoping review of nursing management models for patients with multiple chronic conditions[J]. Chinese Journal of Nursing, 2026, 61(18): 2579-2586.

图/表 2

参考文献 37

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慢性病共病患者护理管理模式的范围综述

A scoping review of nursing management models for patients with multiple chronic conditions

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