摘 要
慢性心力衰竭是心血管疾病中致残率和死亡率较高的病症，患者长期受病痛折磨且需频繁住院，自我管理能力对改善预后至关重要。本研究旨在全面调查慢性心力衰竭患者自我管理能力现状并探索有效干预措施。选取某地区三家三甲医院共450例慢性心力衰竭患者作为研究对象，采用问卷调查法收集患者一般资料、自我管理行为及影响因素等信息，同时运用Morisky服药依从性量表、欧洲五维健康量表评估患者相关情况。结果显示，患者自我管理能力总体水平较低，仅37.11%的患者能较好地进行自我管理，在药物管理、症状监测、生活方式调整等方面存在不同程度的问题，年龄较大、文化程度低、家庭支持不足等因素与较差的自我管理能力显著相关。基于此，构建了以提高患者自我效能为核心的综合干预模式，包括个体化健康教育、心理支持、家庭参与等内容，干预后患者自我管理能力明显提升，服药依从性由62.89%升至85.33%，生活质量各项指标均有不同程度改善。本研究创新性地将家庭支持纳入干预体系，强调多维度、个性化的干预策略，为提高慢性心力衰竭患者自我管理能力提供了新思路，有助于降低再住院率，减轻医疗负担，对临床实践具有重要指导意义。
关键词：慢性心力衰竭；自我管理能力；干预措施；家庭支持；服药依从性
Abstract
Chronic heart failure is a cardiovascular disease with high rates of disability and mortality, causing prolonged suffering and frequent hospitalizations for patients. The ability to self-manage is critical for improving prognosis. This study aimed to comprehensively investigate the current status of self-management abilities among chronic heart failure patients and explore effective intervention measures. A total of 450 patients diagnosed with chronic heart failure from three tertiary hospitals in a specific region were selected as research subjects. Data on general patient information, self-management behaviors, and influencing factors were collected using a questionnaire survey. Additionally, the Morisky Medication Adherence Scale and the EuroQol Five-Dimension Health Scale were employed to assess relevant patient conditions. The results indicated that overall self-management ability was low, with only 37.11% of patients managing themselves adequately. Issues were identified in medication management, symptom monitoring, and lifestyle adjustments. Factors such as older age, lower educational level, and inadequate family support were significantly associated with poorer self-management abilities. Based on these findings, an integrated intervention model centered on enhancing patient self-efficacy was developed, incorporating personalized health education, psychological support, and family involvement. Following the intervention, there was a noticeable improvement in patients' self-management abilities, with medication adherence increasing from 62.89% to 85.33%, and various quality of life indicators showing varying degrees of improvement. Innovatively, this study incorporated family support into the intervention system, emphasizing multidimensional and personalized intervention strategies, providing new insights for improving self-management abilities in chronic heart failure patients. This approach is conducive to reducing rehospitalization rates and alleviating the medical burden, offering significant guidance for clinical practice.
Keywords：Chronic Heart Failure；Self-Management Ability；Intervention Measures；Family Support；Medication Adherence
目 录
摘 要 I
Abstract II
引 言 1
第一章 慢性心力衰竭患者自我管理现状 2
1.1 自我管理能力评估方法 2
1.2 患者自我管理行为分析 2
1.3 影响自我管理的因素探究 3
第二章 自我管理能力与临床结局关系 4
2.1 自我管理对病情控制影响 4
2.2 自我管理与生活质量关联 4
2.3 自我管理对住院率的影响 5
第三章 现有干预措施的效果评价 6
3.1 常规护理模式分析 6
3.2 专业指导干预效果 6
3.3 家庭支持作用评估 7
第四章 改进自我管理能力的策略 8
4.1 健康教育方案设计 8
4.2 心理支持体系构建 8
4.3 多学科协作机制探讨 9
结 论 11
参考文献 12
致 谢 13
