Traditional Chinese Medicine Nursing Protocols for Mammary Abscess (Acute Mastitis)

ABSTRACT: Mammary abscess, also termed acute mastitis, is an acute suppurative disease characterized by breast lumps, redness, swelling, heat, and pain. It is commonly seen in primiparous lactating women 3-4 weeks after parturition. It is believed that the occurrence of acute mastitis is closely associated with stress, a surplus of nutrients during pregnancy, overreliance on breast pumps and lack of breastfeeding experience. In recent years, traditional Chinese medicine (TCM) has been extensively applied in the treatment of acute mastitis because of its low cost and high safety, and has been considered to be the first-choice treatment of acute mastitis in China. Therefore, this article mainly explored the key points of common syndromes, TCM nursing methods and health guidance of acute mastitis in order to further develop the advantages of TCM, improve its efficacy and standardized its nursing behavior.

KEY WORDS: acute mastitis; mammary abscess; breastfeeding; traditional Chinese medicine nursing; syndrome differentiation

Mammary abscess, also termed acute mastitis, is an acute suppurative disease characterized by breast lumps, redness, swelling, heat, and pain. It is commonly seen in primiparous lactating women 3-4 weeks after parturition. According to statistics, the incidence of mastitis comes up to 18.6% in China[1]. Breast milk stasis and infection are the two principle causes of mastitis, in which breast milk stasis is usually the leading cause. Therefore, early massage and feeding are very essential to avoid abscess[2].

The development of acute mastitis can be divided into three stages, namely initial stage, pus formation stage, and last stage. Feijen-de Jong et al.[3]proposed that application of antibiotics in the initial stage of acute mastitis caused by bacteria was effective. Nevertheless, acute mastitis is not only caused by bacterial infection under the most conditions, and application of antibiotics is not the best choice in these situations[4]. For some patients, the systemic symptoms can be controlled by antibiotics, but for the others, the local breast lump may continue to fester and systemic symptoms may deteriorate[5]. In traditional Chinese medicine (TCM), various methods which are primarily divided into internal treatments and external treatments (external dressing of TCM, acupoint massage, cupping, scrapping, acupuncture and physiotherapy) can be used to treat acute mastitis in the stagnant stage[6]. In recent years, TCM has been extensively applied in the treatment of acute mastitis because of its low cost and high safety, and has been considered to be the first-choice treatment of acute mastitis in China[7-8].

Nowadays, the incidence of acute mastitis is still high in spite of abundant medical resources and increased awareness of maternal hygiene. It is believed that the occurrence of acute mastitis is closely associated with stress, a surplus of nutrients during pregnancy, overreliance on breast pumps and lack of breastfeeding experience[9]. Thus, high-quality nursing plays an important role in the treatment of acute mastitis except for surgeries and drugs. In order to maintain and develop the advantages of TCM, improve its efficacy and standardized its behavior, TCM nursing protocols for acute mastitis is formulated by State Administration of Traditional Chinese Medicine of the People's Republic of China.

Keypointsofcommonsyndromes

Syndrome of Qi stagnation and heat congestion: galactostasis, normal or slight red skin, swelling, pain, accompanied by aversion to cold, fever, soreness in the whole body, thirst, constipation; red tongue with yellow coating.

Syndrome of blazing heat-toxin: high fever, swelling and painful breast, red skin with scorching heat, soft mass with finger-touched sensation, or unsmooth drainage after incision and apocenosis, continuous redness, swelling and pain; red tongue with yellow greasy coating.

Syndrome of healthy Qi deficiency and lingering toxin: mild swelling and painful breast after festering, but still existence of continuously clear pus in the wound, slow healing or formation of galactorrhea; weakness in the whole body, lusterless complexion or continuously low fever, decreased diet; light red tongue with thin coating.

Nursingforcommonsymptoms/syndromes

Pain

·Observe the nature, duration and concomitant symptoms of pain.

·For the patients undergoing the surgery of pumping pus, take a semireclining position or a decubitus position of the affected side to promote the drainage, and observe the volume, color, nature and smell of pus as well as whether breast milk discharges.

·According to the doctor's advice, take the auricular-plaster therapy, and select the points like chest, liver, Shenmen, heart, sympathia, Ashi, etc.

·According to the doctor's advice, perform external dressing of TCM.

Swelling

·Observe whether the skin is red, swelling, hot or painful, and whether the abscess or ulceration is formed.

·Squeeze out the alluvial breast milk using the method of milk ejection based on the doctor's advice.

·According to the doctor's advice, take the auricular-plaster therapy, and select the points like chest, adrenal gland, endocrine, liver, Shenmen, Ashi, etc.

·According to the doctor's advice, perform external dressing of TCM.

·According to the doctor's advice, perform TCM fumigation

Fever

·Observe the body temperature and sweating condition, keep skin clean, and assist to change the clothes and bedclothes timely.

·According to the doctor's advice, rinse the mouth using TCM mouthwash to keep the oral cavity clean.

·Perform acupoint massage following the doctor's advice, and select the points like Hegu, Quchi, etc. Meanwhile, the medium including peppermint oil and gingerade can be selected at the time of massage.

·According to the doctor's advice, take the auricular-plaster therapy, and select the points like chest, ear tip, Shenmen, endocrine, etc.

·According to the doctor's advice, perform TCM soaping.

TCMspecialnursing

Medications

InternalapplicationofChineseherbs

·Medication time: Each dose of herbs can be taken generally in twice or three times. The specific medication time depends on the property and function of herbs as well as the patients' pathological condition. Chinese herbs for relieving exterior and clearing heat should be taken 1 h before meals, in which application of exterior-reliving Chinese herbs should avoid wind chill, or putting on more clothes or having some porridge induces diaphoresis. Chinese herbs for promoting digestion, purgation, expelling parasites, tranquilization and tonification are taken respectively after meals, before meals, on an empty stomach in the morning, before sleep and on an empty stomach. Emergency drug use follows the doctor's advice.

·Medication temperature: The administered warm is usually adopted. For the patients with special treatment, it should be followed the doctor's advice.

·Medication dose: 200 mL is taken per time for the adult; 100 mL is taken per time for the patients with heart failure and those of controlling the dose. The elderly and children should take according to the doctor's advice.

Injection

·Inquire the history of allergy carefully before medication.

·Make allocation and administration according to the requirements and injection speed recommended in the drug instructions.

·Apply TCM injection alone, and use it right after it was ready.

·Chinese and western drugs should be separated when Chinese and western injections are in combination.

·It is inappropriate to use a venous channel for two or more kinds of drugs except for special instructions.

·Medication reactions are observed closely, especially for the elderly, children, people with liver and kidney dysfunction and those that use TCM injections initially. Medication is suspended, and the doctors should be told to deal with it if adverse reactions occur.

·Nursing for allergic reactions: stop to use the drugs immediately, change the infusion channel and inform the doctor; seal the liquid and channel that cause adverse reactions; do allergic identification and inform patients and their relatives firmly to avoid re-medication; guide the patients to have a bland diet during the treatment of allergic reactions, forbid to eat the food like fish, shrimps, etc.

ExternalapplicationofChineseherbs

·Keep dry and clean skin before medication, and do local debridement if necessary.

·Observe reactions closely after medication. For example, the doctor should be informed immediately if local symptoms like scorching heat, redness, pruritus and stabbing pain appear; The medication should be stopped immediately if the symptoms, such as dizziness, nausea, palpitation and shortness of breath, appear, and meanwhile, corresponding measures should be taken and the doctor should be informed.

·Use with caution for patients with allergic constitution.

Specialtechniques

ExternaldressingofTCM

·According to the doctor's advice, perform external dressing of TCM.

·Nursing assessment: assess the condition of skin in the external dressing part and patients' sensory perception to the temperature. The patients with drug and skin allergy and infants are forbidden to use.

·Tell the patients the process and notes of external dressing of TCM before operation; Inform the doctor to take corresponding measures immediately if discomforts occur.

·Keep the operation environment warm.

·Expose the part of medication thoroughly, and pay attention to keeping warm and protecting privacy.

·According to the doctor's advice, confirm the part of medication and the medication area larger than the diseased area.

·Smear TCM evenly, keep some humidity and appropriate dressing of external fixation.

·Observe the local and systemic condition, immediately inform the doctor, and then take some measures following the doctor's advice if some adverse reactions like erythema, pruritus and blister appear.

·Record the condition of skin in the external dressing part and patients' feelings after operation.

Auricular-plastertherapy

·Embed beans at auricular points and select acupoints correctly according to the doctor's advice.

·Assess the condition of ear skin and degree of tolerance to the pain, prohibit to use them in the inflammatory, ruptured and frozen skin as well as in pregnant women.

·Keep the intensity of probe moderate and accurately seek the sensitive point in acpoint area.

·Scrub the ears with 75% alcohol.

·Observe the patients' condition, stop immediately and inform the doctor to deal with it if discomforts occur.

·Select one ear for routine performance, keep the beans usually for 3-7 days and use them in two ears alternately; guide the patients to press them correctly.

·Observe the fixed degree of auricular point sticking and the condition of symptoms and ear skin (redness, swelling, rupture, etc.).

·Record the bean-embedded location and time at auricular points as well as the patients' feelings after performance.

TCMfumigation

·Perform TCM fumigation following the doctor's advice.

·Nursing assessment: the condition of skin in the part of fumigation. It is used with caution to the patients with drug and skin allergy, heart, lung and brain disease, enema as well as the weak and elderly patients. It is unsuitable for pregnancy women and those during menstruation to take a sitz bath or fumigate the vulva.

·Before operation, tell the patients the process and notes of TCM fumigation, and communicate with the medical staff immediately if discomforts occur.

·Keep a warm operation environment, and close the door and window.

·Expose the fumigated part, and pay attention to keep warm and protect the privacy.

·Keep 50-70 ℃ of the liquid temperature. Sitz bath and wash can be conducted to prevent empyrosis when the liquid temperature is decreased to 37-40 ℃.

·Keep 20-30 min of TCM fumigation.

·Inquire the patients' feelings, and regulate the liquid temperature timely.

·Tell the patients to have a rest for 30 min after TCM fumigation, and then go out in order to prevent invasion of exogenous pathogens.

·Observe the local and systemic condition of patients during operation, and immediately inform the doctor and deal with it if discomforts occur.

·Record the temperature and time of TCM fumigation as well as the skin condition and feelings of patients after operation is finished.

TCMsoaping

·Conduct to wash with Chinese herbs following the doctor's advice.

·Assess the washing skin and sensory perception of lower limbs to the temperature, use it with caution for the patients with skin lesion and those with drug and skin allergy, and prohibit using it for the patients with severe cardiopulmonary dysfunction and hemorrhagic disease.

·Inform the patients of washing process and cautions before operation, and communicate with the medical staff promptly once discomforts occur.

·It is inappropriate to wash with Chinese herbs in fasting state and within 1 hour after meals. Immediate washing after meals can affect digestion due to local peripheral vasodilation.

·Keep the operation environment warm, close door and windows, and be cautious to keep the patients warm and protect their privacy.

·Expose the washing location thoroughly, and make the ankle of two feet soak in the liquid.

·Keep the liquid temperature at 37-40 ℃ and the washing time for 20-30 min. Take the difference of disease categories into account to prevent from burn.

·Observe the local and systemic conditions of patients during treatment, and inform the doctor immediately to deal with it if the symptoms including erythema, pruritus, palpitation, sweating and dizziness occur.

·Gently make the skin dry with light towel after washing, especially interphalangeal skin, and trim the toenails if they are long.

·Inform the patients of drinking 200 mL of warm water after washing with Chinese herbs.

·Record the washing temperature, time, skin condition and the patients' feelings after operation.

Acupointmassage

·Conduct acupoint massage according to the doctor's advice.

·Assess the skin condition around the massage area and degree of tolerance to the pain; prohibit using it in women during menstruation and pregnancy.

·For the operator, trim the fingernails to prevent the skin from injury.

·Keep the strength even and moderate, and pay attention to keep warm for the patients and protect their privacy.

·Observe the patients' reactions closely when operation is done; stop the massage and take corresponding measures once discomforts occur.

·Record the massage acupoints, techniques and time as well as the patients' feelings.

Healthyguidance

Dailylife

·Tell the patients self-demand breastfeeding, and empty the rest breast milk after breastfeeding; stop breastfeeding when high fever or abscess appears.

·Hold up the affected breast using triangular bandage or loose bra to reduce the movement of upper limbs.

·Maintain the breast and nipple clean. The yolk oil, sesame oil or olive oil can be smeared for chapped nipples.

·Tease the reast duct using a wood comb to prevent acute mastitis 6 months after pregnancy.

Diet Guidance: The soup should be drank 48-72 h after parturition. Greasy and irritant food should be forbidden.

·Syndrome of Qi stagnation and heat congestion: It is advisable to eat foods that can sooth liver and regulate Qi as well as dredge breast to remove swelling, such as white radish, Chinese cabbage, etc. Dietary formula: turnip strip soup.

·Syndrome of blazing heat-toxin: It is advisable to eat foods that can clear heat and toxin as well as promote pus drainage, such as kalimeris, fresh lotus root, mung bean, purslane, etc. Dietary formula: kalimeris with tofu.

·Syndrome of healthy qi deficiency and lingering toxin: It is advisable to eat foods that can tonify qi, coordinate nutrient qi and promote toxin, such as eggs, fish, animal liver, bean products, milk, etc.

Emotionaladjustment

·Communicate with the patients frequently to make them understand the disease correctly.

·Guide the worried, irritated, terrified and nervous patients to take the therapy of transference interaction to distract attention; guide the anxious or depressed patients to take suggestion therapy or the therapy of obeying the emotion to meet physical and mental demands.

·Encourage the relatives to accompany the patients frequently and give psychological support.

·Encourage to communicate the experience of prevention and treatment with other patients in order to enhance the treatment confidence.