Objective To explore the challenges in nursing management of elderly patients with comorbid chronic diseases under the DRG payment system, and to provide evidence for improving patient management.Methods Using purposive sampling, semi-structured interviews were conducted with 15 clinical nurses and nursing managers in the geriatrics department.Data were analyzed using conventional content analysis to extract and refine key themes.Results Three overarching themes and eleven subthemes were identified:(1) contradictions between the DRG-based payment system and geriatric care needs (lack of functional items, insufficient evaluation indicators, inadequate reimbursement mechanisms, and incomplete coverage of care processes); (2) practical dilemmas in nursing resource allocation (shortage of human resources, outdated payment standards, limited equipment and technology, and lack of collaborative reimbursement mechanisms); and (3) a dynamic trade-off between cost control and care quality (risk of reduced nursing time, compromise of long-term benefits, and restrictions on caregiving practices).Conclusion Under the DRG-based payment system, nursing management for elderly patients with chronic comorbidities faces significant challenges in balancing cost containment and quality of care. It is recommended to refine the DRG reimbursement mechanism, optimize nursing workforce allocation, promote cross-sector collaboration, advance nursing informatics, and strengthen in-service training to ensure the effectiveness of care quality and resource utilization.