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Article(id=1322929558135124842, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322929547464815391, articleNumber=null, orderNo=null, doi=10.12102/j.issn.1009-6493.2026.14.024, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1756742400000, receivedDateStr=2025-09-02, revisedDate=1776614400000, revisedDateStr=2026-04-20, acceptedDate=null, acceptedDateStr=null, onlineDate=1793340585502, onlineDateStr=2026-10-30, pubDate=1784908800000, pubDateStr=2026-07-25, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793340585502, onlineIssueDateStr=2026-10-30, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793340585502, creator=13701087609, updateTime=1793340585502, updator=13701087609, issue=Issue{id=1322929547464815391, tenantId=1146029695717560320, journalId=1220038315760373764, year='2026', volume='40', issue='14', pageStart='2385', pageEnd='2576', issueExtLink='null', onlineDate='null', pubDate='1784908800000', pubDateStr='2026-07-25', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1793340582958, creator='13701087609', updateTime=1793343111003, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext={EN=IssueExt(id=1322940150912790807, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322929547464815391, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1322940150912790808, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322929547464815391, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null, downloadFileDto=null}, startPage=2556, endPage=2560, ext={EN=ArticleExt(id=1322929558390977387, articleId=1322929558135124842, tenantId=1146029695717560320, journalId=1220038315760373764, language=EN, title=Research progress on self-management assessment tools in patients with heart failure, columnId=1220689485315101342, journalTitle=Chinese Nursing Research, columnName=Review Articles, runingTitle=null, highlight=null, articleAbstract=

Self-management assessment tools for patients with heart failure were introduced.The influencing factors in the development process of these tools were analyzed.The limitations were identified,and future directions were proposed.This review aims to provide a reference for clinical practice of self-management in patients with heart failure.

, authors=Yanping LIU1, Haiyu TANG2, Yanli DING1, Honglei YANG1, Yongting YANG3, Meng LI3, Shan LIANG1, authorsList=Yanping LIU, Haiyu TANG, Yanli DING, Honglei YANG, Yongting YANG, Meng LI, Shan LIANG, authorCompany=null, correspAuthors=Yanping LIU, authorNote=null, correspAuthorsNote=null, copyrightStatement=null, copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1322929558772659052, articleId=1322929558135124842, tenantId=1146029695717560320, journalId=1220038315760373764, language=CN, title=心力衰竭病人自我管理评估工具研究进展, columnId=1220689485482873504, journalTitle=护理研究, columnName=科研综述, runingTitle=null, highlight=null, articleAbstract=

介绍心力衰竭病人自我管理评估工具，分析工具编制过程中的影响因素，分析不足之处并进行展望，以期为心力衰竭病人的自我管理临床实践提供参考。

, authors=刘艳萍1, 唐海玉2, 丁艳丽1, 杨红蕾1, 杨永婷3, 李梦3, 梁闪1, authorsList=刘艳萍, 唐海玉, 丁艳丽, 杨红蕾, 杨永婷, 李梦, 梁闪, authorCompany=null, correspAuthors=刘艳萍, authorNote=null, correspAuthorsNote=
LIU Yanping, E-mail:
刘艳萍，主任护师，本科，E-mail:
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心力衰竭病人自我管理评估工具研究进展
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刘艳萍 1 , 唐海玉 2 , 丁艳丽 1 , 杨红蕾 1 , 杨永婷 3 , 李梦 3 , 梁闪 1
护理研究 | 科研综述 2026,40(14): 2556-2560
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护理研究 |科研综述 2026 , 40 (14) : 2556 -2560
心力衰竭病人自我管理评估工具研究进展
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刘艳萍1 , 唐海玉2, 丁艳丽1, 杨红蕾1, 杨永婷3, 李梦3, 梁闪1
作者信息
  • 1河南中医药大学第一附属医院心脏中心，河南 450000
  • 2深圳市中医院老年医学科
  • 3河南中医药大学护理学院
通讯作者:
LIU Yanping, E-mail:
刘艳萍，主任护师，本科，E-mail:
Research progress on self-management assessment tools in patients with heart failure
Yanping LIU1 , Haiyu TANG2, Yanli DING1, Honglei YANG1, Yongting YANG3, Meng LI3, Shan LIANG1
Affiliations
  • 1The First Affiliated Hospital of Henan University of Chinese Medicine, Henan 450000 China
  • 2Shenzhen Traditional Chinese Medicine Hospital
  • 3School of Nursing, Henan University of Chinese Medicine
出版时间: 2026-07-25 doi: 10.12102/j.issn.1009-6493.2026.14.024
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摘要
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介绍心力衰竭病人自我管理评估工具，分析工具编制过程中的影响因素，分析不足之处并进行展望，以期为心力衰竭病人的自我管理临床实践提供参考。

心力衰竭  /  自我管理  /  评估工具  /  量表  /  影响因素  /  综述

Self-management assessment tools for patients with heart failure were introduced.The influencing factors in the development process of these tools were analyzed.The limitations were identified,and future directions were proposed.This review aims to provide a reference for clinical practice of self-management in patients with heart failure.

heart failure  /  self-management  /  assessment tool  /  scale  /  influencing factors  /  review
刘艳萍, 唐海玉, 丁艳丽, 杨红蕾, 杨永婷, 李梦, 梁闪. 心力衰竭病人自我管理评估工具研究进展. 护理研究, 2026 , 40 (14) : 2556 -2560 . DOI: 10.12102/j.issn.1009-6493.2026.14.024
Yanping LIU, Haiyu TANG, Yanli DING, Honglei YANG, Yongting YANG, Meng LI, Shan LIANG. Research progress on self-management assessment tools in patients with heart failure[J]. Chinese Nursing Research, 2026 , 40 (14) : 2556 -2560 . DOI: 10.12102/j.issn.1009-6493.2026.14.024
正文
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心力衰竭（heart failure，HF）是指心脏的结构或功能异常导致心室充盈和射血能力受损，从而引发相关症状或体征。心力衰竭为心血管疾病的终末阶段，可呈现出高发病率、高死亡率以及高入院率的特征[1-2]。《中国心血管健康与疾病报告2025》数据显示，我国心力衰竭病人约为1 370万例，其中≥70岁人群的患病率约为10%，在人口老龄化趋势持续加剧的背景下，预计该疾病的总体负担将进一步扩大[3]。自我管理是病人在管理疾病症状、治疗过程或应对生理、心理、社会变化以及改变生活方式等方面表现出的一种健康行为[4]。有效的自我管理能够提升病人疾病认知，改善症状控制效果，提高生活质量，降低再入院风险和总体死亡率[5]。但心力衰竭病人普遍存在疾病管理水平不足的问题[6]。近年来，随着数字健康干预、远程监测技术及互联网技术的快速发展，心力衰竭病人自我管理评估工具不断优化，自我管理评估工具能够系统量化病人在药物遵从、症状监测、生活方式调整、健康知识与自我效能等方面的执行情况与障碍，提高病人治疗依从性，保持病人行为改变的持续性[7]。现对心力衰竭病人自我管理评估工具的主要内容、特点及影响因素等进行综述，以期为心力衰竭病人的自我管理临床实践提供参考。
1　心力衰竭病人自我管理概述
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20世纪70年代，Creer首先提出“自我管理”一词并应用于儿童哮喘项目[8]，提示病人是治疗的积极参与者。随着国内外关于慢性病自我管理研究的深入，自我管理的概念不断更新。20世纪80年代有学者提出关于慢性病自我管理的定义，认为慢性病自我管理是病人在医护人员帮助支持下通过接受健康教育习得管理疾病所需的技能、知识、信心及与医护人员的沟通技巧，解决慢性病对自身造成的身体和情绪问题[9]。自我管理最早在心血管疾病领域的应用人群为慢性心力衰竭病人。1998年，学者首次探讨了慢性心力衰竭病人的自我管理，认为慢性心力衰竭病人自我管理策略应包括了解症状等客观指标、积极主动地实现目标，并将用药、治疗和症状检测纳入日常生活[10]。2000年，Deaton[11]提出自我管理是病人成长为专家的过程，在这个过程中病人可就心力衰竭的自我管理做出决策，包括学习、了解个体情况和与疾病共存的体验等。Riegel等[12]进行研究后认为，慢性心力衰竭病人的自我护理包括自我护理维持、自我护理管理和自我护理信心3个维度，是一系列与症状评估、症状确定、症状管理及处理措施评价等有关的决策过程。总体而言，心血管疾病病人的自我管理可概括为：在医疗卫生服务人员指导和支持下进行预防性工作及在自我管理技能帮助下进行的自我管理，目的是预防心血管疾病的发生，防止疾病恶化和进展，改善病人健康结局[13-14]。
2　心力衰竭病人自我管理评估工具介绍
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2.1　自我管理量表
2.1.1　心力衰竭自我管理量表（Self-Management of Heart Failure Instrument，SMHF）
SMHF由Riegel等[15]于2000年基于心力衰竭病人症状与体征管理需求开发，该量表共65个条目，分为6个分量表，对应自我管理过程的4个阶段。量表采用“跳过模式”，仅针对病人实际出现的6类症状（气促、突发体重增加、疲乏、夜间阵发性呼吸困难、踝部水肿、心悸）进行追问，因而完成路径因人而异。各条目采用Likert 5级评分法，得分越高表示自我管理行为越充分。全表填写需20~30 min。SMHF由于跳转逻辑复杂、耗时长且测评范围局限于症状-体征维度，缺乏对饮食、用药、运动等广泛自我管理行为的覆盖，临床适用性受限。SMHF的6个分量表Cronbach´s α系数为0.79~0.92。
2.1.2　中文版心力衰竭自我管理量表（Chinese Self-Management of Heart Failure Instrument，CSMHFI）
CSMHFI由施小青等[16]在文献回顾与临床访谈基础上编制，用于测评我国慢性心力衰竭病人的自我管理行为。该量表共20个条目，覆盖药物管理、饮食调控、心理社会适应及症状监测4个维度，其Cronbach's α系数为0.78，量表水平的内容效度指数为0.98，表明条目与构念间具有高度关联性。量表采用Likert 4级计分法，“从不”计1分，“偶尔”计2分，“经常”计3分，“总是”计4分，总分20~80分，得分越高表示研究对象的自我管理行为水平越高，以得分率进行等级划分，<60%、60%~<80%、≥80%依次为低水平、中水平、高水平。赵云[17]将该量表应用于304例老年慢性心力衰竭病人，结果显示，量表具有较好的信效度。CSMHFI符合我国文化特征、内容全面，可作为心力衰竭病人自我管理的精准评估与指导工具。
2.1.3　欧洲心力衰竭自我护理行为量表（European Heart Failure Self-Care Behaviour Scale，EHFScBS）
EHFScBS于2003年由荷兰、瑞典、美国的3名专家共同设计完成，包括12个条目，采用Likert 5级评分方法，从“完全不同意”到“完全同意”依次计1~5分，总分12~60分[18]。王丽萍等[19]对英文版EHFScBS进行系统翻译和评价，并在97例心力衰竭病人中进行测试，结果显示，量表总体的Cronbach's α系数为0.72，重测信度为0.83，具有较好的信度和效度，可用于评价我国心力衰竭病人自我护理行为。中文版量表与荷兰语、瑞典语和意大利语版相比Cronbach's α系数较低[20]，与英语版和日文版相比Cronbach's α系数稍高，可能与文化特异性有关，需进一步测试。王凯选等[21]对EHFScBS进行翻译和回译，经文化调适和预测试后形成又一中文版量表，共9个条目，分为对医疗问题相关自我护理的贡献、对生活方式相关自我护理的贡献2个维度，量表总体的Cronbach's α系数为0.873，重测信度为0.858，具有良好信效度，可作为评估照顾者对慢性心力衰竭病人自我护理贡献度的可靠工具。
2.1.4　心力衰竭自我护理指数量表（Self-Care of Heart Failure Index，SCHFI）
SCHFI由Riegel等[22]编制，包括自我护理信心量表、自我护理管理量表、自我护理维持量表3个分量表，共22个条目，各分量表最终得分由原始评分转化为百分制，得分越高表示自我护理行为越好，>70分为自我护理行为充足，≤70分为自我护理行为不足。祖丽丽[23]对SCHFI进行汉化，形成的中文版量表包括自我护理维持、自我护理管理、自我护理信心3个维度，共22个条目；量表总体的Cronbach's α系数为0.867，自我护理维持、自我护理管理、自我护理信心维度的Cronbach's α系数分别为0.816，0.792和0.885，量表总体的重测信度为0.821，信度和效度较好，在评价我国心力衰竭病人自我护理能力方面具有较好的价值。郭金玉等[24]采用Brislin翻译模型对SCHFI进行汉化，并将其应用于183例慢性心力衰竭病人，结果表明，SCHFI中文版具有良好的测量性能，可以用于评估我国心力衰竭病人的自我护理状况，并指导、评价病人的自我护理干预效果。
2.2　饮食评估量表
心脏饮食自我效能量表（Cardiac Diet Self-Efficacy Instrument，CDSEI）由Mickey等[25]于1992年基于自我效能理论开发，该量表用于评估病人对遵循健康饮食行为是否有信心、是否具备必要的健康饮食技能。该量表共16个条目，从“非常没有信心”到“非常有信心”依次计1~5分，得分越高表示采取健康饮食行为的信心越强；量表的Cronbach's α系数为0.90。Chen等[26]对量表进行翻译，形成繁体中文版CDSEI，在老年人群中应用后显示出良好的信度和效度，其Cronbach's α系数为0.79，重测信度为0.85。2012年，张梅霓等[27]将繁体中文版CDSEI转化为简体中文版，包括社会情境下的饮食行为能力、健康饮食技能、饮食行为控制信心和体质量控制信心4个维度，共16个条目；量表Cronbach's α系数为0.915，具有良好的信度、效度。2015年，Shao等[28]对CDSEI进行修订，形成的量表包括健康饮食行为、减少脂肪和胆固醇、抵抗复发、增加纤维和蔬菜、减少糖和减少盐6个维度，共18个条目，该量表更加符合我国老年人饮食体验的文化价值观。CDSEI条目较少、简单且易于理解，可行性、可理解性较强，但测试人群样本量较小，且中文版与原量表存在一定差异，需要在大样本人群中进一步验证。
2.3　服药依从性量表
Morisky用药依从性量表（Morisky Medication Adherence Scale，MMAS）由Morisky于1986年编制，用于评估病人用药依从性，包括4个条目。2012年，司在霞等[29]将MMAS修订为中文版本，包括8个条目，总分0~8分，得分越高表示服药依从性越好，<6分表示依从性差，6~7分表示依从性中等，8分表示依从性好；量表总体的Cronbach's α系数为0.81。陈强等[30]分析中文版MMAS的8个条目，并评价其在心血管慢性病病人用药依从性中的信效度，结果表明，中文版量表评价心血管慢性病病人用药依从性的信效度较好。
3　心力衰竭病人自我管理评估工具的比较
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3.1　基本情况比较
SMHF共65个条目，条目数较多，量表采用“跳过模式”，仅针对病人实际出现的6类症状进行测评，临床适用性受限。CSMHFI共20个条目，涵盖药物管理、饮食调控、心理社会适应及症状监测4个维度，符合我国文化特征，可作为心力衰竭病人自我管理的评估与指导工具。EHFScBS共12个条目，涵盖医疗相关及生活方式相关的自我护理行为。SCHFI为多维度自我护理能力评估量表，包括自我护理信心量表、自我护理管理量表、自我护理维持量表3个分量表，共22个条目，中文版重测信效度较高，可以区分不同的护理效果，可用于临床评估。CDSEI为饮食自我效能专项评估量表，原量表16个条目，中文版量表包括16个条目和18个条目2个版本，其聚焦于健康饮食信心与技能（如减少盐/糖、增加蔬菜等），中文版量表适配于我国饮食文化，但测试的样本量较小。MMAS为用药依从性专项评估量表，中文版包括8个条目，其信效度良好，可广泛用于心血管疾病病人的用药评估。
3.2　应用情况比较
SMHF因条目较多、跳转复杂，在我国应用有限。CSMHFI简洁实用，已在我国临床与研究中广泛用于评估病人药物、饮食、心理及症状管理水平。EHFScBS适用于整体自我护理行为的综合评价，强调维持自我护理，如限制液体摄入、每天测量体重、锻炼或与医疗卫生保健提供者保持联系，汉化后量表条目简单，为评估受试者的自我护理行为采用了自我报告的方式，但这种评估方式可能导致受试者在条目选择时受社会期望影响，且部分条目可能过于简单，无法准确反映受试者的自我管理行为。SCHFI主要用于评估病人在日常生活中采取的自我护理行为（如按时服药、控制饮食等）、病人在症状改变时的决策过程（包括寻求医疗帮助和调整治疗计划等）、病人对自己管理症状能力的信心水平，该量表有利于帮助医护人员了解病人的自我护理能力和行为、制定有效的自我管理策略。CDSEI聚焦饮食管理。MMAS用于评估病人用药依从性。合理用药自我效能表示病人坚持用药的信心，与目标、结果期望及感知环境障碍等共同作用，可影响个体的用药决策[31]。谢赫男等[32]研究表明，服药依从性得分越高，老年慢性心力衰竭病人合理用药自我效能得分越高，与Chuh等[33]调查老年高血压病人自我效能与服药依从性的结果相似。Sony等[34]研究表明，韩国老年高血压病人的自我效能与服药依从性呈正相关。自我效能指个人在执行促进健康行为时是否有信心，这种信心和能力会直接影响病人的服药依从性，若病人自我效能不足则其用药安全也会受到影响[35]。用药参与决策行为较好的病人往往合理服药自我效能较好，其对于药物管理的反应为积极参与型，反之，消极参与型的病人往往合理服药行为不佳，自我效能较低[36]。
4　心力衰竭病人自我管理评估工具编制的影响因素
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1）地域文化：自我管理评估工具受地域文化影响导致聚焦范围不同，部分工具侧重于健康信念，部分工具侧重饮食。我国重视饮食文化，工具条目常涉及生活方式和饮食，但也有工具，如CDSEI更聚焦于健康饮食信心与技能。2）社会人口学特征：社会支持、慢性病管理自我效能、个人月收入、居住地、性别是老年慢性心力衰竭病人自我管理轨迹的影响因素[37]。因此，心力衰竭病人自我管理评估工具的编制也常受上述因素影响。3）量表结构与维度：量表一方面应包括关键维度，如知识、技能、态度、行为、自我效能、疾病认知、症状监测、药物管理等，另一方面应避免重要维度缺失。同时，子量表的独立性及其可单独解读性也应明确，避免仅以总体得分解读各维度[38]。此外，题项的覆盖深度与广度应该进行平衡，充分覆盖日常自我管理情境，避免冗长与信息空白[39]。题型方面需与所评估的自我管理能力层级相匹配，以区分不同水平。4）实用性及实施难度：评估工具的使用需考虑其完成时间与题量、对设备/电子系统/数据管理平台等的依赖程度以及自我解释性与可理解性、数据输入与管理难度、隐私与伦理要求。此外，在实施过程中还需考虑用户体验，关注题目表达的清晰度、题目是否容易产生歧义以及答题疲劳与顺序效应等问题，在量表使用过程中还应考虑到被调查者的参与性以及文化敏感性对不同背景人群的潜在影响[40]。
5　不足与展望
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目前，心力衰竭病人自我管理评估工具发展迅速，但仍存在一些不足之处。1）构念界定与理论基础薄弱：部分评估工具缺乏明确的理论框架支撑（如倡导的自我效能、自我调节理论、信息-动机-行为模型等），不同工具的自我管理维度不一致，导致横向比较困难，跨研究的综合性分析困难增多。2）简化版与长版等效性验证不充分：为提升临床可操作性，部分团队开发了简版量表，但简版量表与长版量表在维度覆盖、信息损失及预测精度方面的一致性检验样本量偏小，且多基于单中心数据，尚难支持“简版可完全替代长版”的推论，为临床分诊与科研随访带来选择困难。3）可靠性与效度的证据等级参差不齐：部分评估工具在小样本或单中心研究中初步进行了信效度检验，但缺乏多中心、不同地区人群的外部效度验证。纵向研究不足，难以区分稳定性与时间变化带来的测量误差。4）数字化与远程适用性研究缺位：随着移动健康技术与远程监测技术的普及，评估工具应答负担、触屏可读性及语音交互成为新瓶颈。多数评估工具仍以纸质长问卷形式开发，未进行条目简化或计算机自适应测验优化，难以嵌入可穿戴设备或医院-家庭一体化管理平台。未来可以聚焦理论驱动的工具开发以及情境化、个体化评估的深入融合，力求在不同教育水平、地域与照护体系中实现一致性与可比性；也可嵌入电子健康记录与移动健康平台，实现自动化数据收集、动态评分与即时反馈，推动个性化教育与行为干预，提升干预的时效性和持续性；可通过纵向多中心研究与真实世界数据验证，明确自我管理评估与临床结局间的关系，增强工具的预测力与临床转化。
6　小结
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心力衰竭病人的自我管理已成为研究热点，各国学者已开发多个相关量表，为辅助医护人员筛选自我管理行为较差的病人提供了一定助力，但大多数量表尚未广泛应用于临床，建议在选择评估工具时应结合研究目的、人群特征以及文化背景，并注意动态随访。临床实践中可进一步结合可穿戴设备与物联网技术，构建全周期智能化健康管理体系，为心力衰竭病人提供更精准的生活质量提升策略。可结合智能设备实现实时动态评估，以提升心力衰竭病人自我管理评估的质量和效果。未来研究需扩大样本来源范围，为心力衰竭自我管理支持项目的实施提供参考。

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doi: 10.12102/j.issn.1009-6493.2026.14.024
  • 接收时间：2025-09-02
  • 首发时间：2026-10-30
  • 出版时间：2026-07-25
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  • 收稿日期：2025-09-02
  • 修回日期：2026-04-20
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    1河南中医药大学第一附属医院心脏中心，河南 450000
    2深圳市中医院老年医学科
    3河南中医药大学护理学院

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Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
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