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

摘要：

慢性心力衰竭病程迁延、再住院率高，长期结局高度依赖患者及家庭的自我管理。该综述从护理视角出发，归纳护理主导的干预、远程与数字健康支持等自我管理模式的研究现状。现有证据提示，结构化护理主导干预可改善自我照护行为和自我效能，并在一定程度上降低再住院和抑郁等不良结局，但干预内容、随访时长和人群选择异质性较大，老年、脆弱及认知受损患者相关证据明显不足。未来需在高危老年人群中明确护理干预的关键有效成分与适宜模式，并结合客观行为数据和真实世界研究，评估人机协同管理的长期效果，为优化慢性心力衰竭自我管理护理提供依据。

关键词: 心力衰竭, 自我管理, 护理, 老年, 综述