Traditional Chinese Medicine Nursing Protocols for Diabetic Nephropathy

ABSTRACT: As a dreaded consequence of diabetes mellitus (DM), diabetic nephropathy (DN) accounts for about 40% of end-stage renal disease (ESRD). It is a universal cause of ESRD, and can be considered as an independent risk factor for cardiovascular disease. In recent years, TCM has shown its unique advantages in the treatment of DN. As one of the chronic diseases caused by living styles, DN has the higher requirements for nursing. Nevertheless, TCM nursing based on syndrome differentiation can provide the personalized guidance for the patients with DN according to different syndrome patterns and symptoms. Therefore, this article mainly explored the key points of common syndromes, TCM nursing methods and health guidance of DN in order to further develop the advantages of TCM, improve its efficacy and standardized its nursing behavior.

KEY WORDS: diabetic nephropathy; diabetic nephropathy; end-stage renal disease; traditional Chinese medicine nursing; syndrome differentiation

According to the International Diabetes Federation (IDF) update of 2014, there were 387 million of people with diabetes mellitus (DM) worldwide[1]. With the development of living styles in recent years, the prevalence of DM is on the rise. Nevertheless, kidney disease secondary to DM, also termed as diabetic nephropathy (DN), accounts for over 40% of end-stage renal disease (ESRD)[2]. About 40% patients with type 1 DM have DN, and about 25% patients have DN ten years after the diagnosis of type 2 DM[3-4]. The studies have confirmed that DN is a universal cause of ESRD, and can be considered as an independent risk factor for cardiovascular disease[5].

The pathogenesis of DN mainly includes increased thickness of glomerular basement membrane, proliferation of mesangial matrix and reconstruction of extracellular matrix. It is usually believed that the occurrence of DN is a complex and multifactorial process that appears to be a combination of inflammation, oxidative stress, and epigenetic factors[6-7]. In the early stage of DN, the increased glomerular filtration rate and urine protein content affect the renal function, consequently leading to ESRD. At present, there are no effective therapies for DN in western medicine, and dialysis and renal transplant can bring to patients with ESRD a lot of social and economic burden.

Traditional Chinese medicine (TCM) believes that the diseased site of DN lies in the spleen and kidney, but it is also closely associated with the heart, liver and lung. In recent years, TCM has shown its unique advantages in the treatment of DN. It can not only control the progression of pathological condition, but also can improve the clinical symptoms, suitable for long-term administration of chronic diseases[8]. As one of the chronic diseases caused by living styles, DN has the higher requirements for nursing. TCM nursing based on syndrome differentiation can provide the personalized guidance for the patients with DN according to different syndrome patterns and symptoms. In order to maintain and develop the advantages of TCM, improve its efficacy and standardized its behavior, TCM nursing protocols for DN is formulated byStateAdministrationofTraditionalChineseMedicineofthePeople'sRepublicofChina.

Keypointsofcommonsyndromes

Syndrome of Qi deficiency: listlessness, weak breath, laziness to speak, spontaneous sweating, easy to catch a cold; plump tongue with tooth marks.

Syndrome of blood deficiency: lusterless complexion, light colored lips and nails, scanty and light colored menstruation; light colored plump tongue.

Syndrome of yin deficiency: aversion to heat, sweating or night sweating, dry throat and thirst, dry stool, feverishness in palms and soles or dysphoria in chest palms-soles; red thin tongue with cracks.

Syndrome of yang deficiency: aversion to cold, cold limbs, aversion to cold of waist and knees, bloated face and foot, frequent nocturia; plump tongue with white coating.

Syndrome of blood stasis: positioning stabbing pain aggravated in the night, numbness and pain of limbs, squamous and dry skin, purple lips and tongue, or dark purple lips and tongue with ecchymosis; engorgement of sublingual collaterals.

Phlegm-damp syndrome: chest oppression, abdominal fullness, anorexia, nausea and vomiting, fat body, fatigue, distension in the head, heaviness in the limbs; white greasy tongue coating.

Damp-turbidity syndrome: poor appetite, anorexia, nausea and vomiting, sticky and greasy in the mouth, urine smell in the mouth, sluggish consciousness, or restlessness, skin itch; white greasy tongue coating.

Nursingforcommonsymptoms/syndromes

Edema

· Evaluate the edema degree, and monitor the body weight and abdomen circumference.

· Observe the times and amount of urination; for the diuretic-used patients, observe the changes of electrolyte and vital signs.

· Make the edematous scrotum underlaid locally to avoid being pressed; take a fowler position for the patients with severe pleural effusion and ascites.

· According to the doctor's advice, take the auricular-plaster therapy, and select the points like spleen, kidney, endocrine, etc. It should be noted that the auricular-plaster therapy is forbidden for the patients with edematous ears.

Cutaneouspruritus

· Wear the soft cotton clothes instead of those made from chemical fiber, down feather and cashmere; keep the water temperature below 40 ℃ at the time of bath or foot soak.

· Trim the nails, and tell the patients not to scratch the skin.

· Conduct external application of TCM following the doctor's advice.

· Perform TCM bath following the doctor's advice; keep the liquid temperature below 40 ℃, and keep 20 minutes of medicated bath better.

· Perform TCM fumigation following the doctor's advice. It is forbidden for the patients with ruptured skin.

Proteinuria

· Observe the amount of foam in urine and its discutient time.

· Closely observe the effect of the factors including fever, fatigue, etc. on the proteinuria of patients.

· Do moxa-wool moxibustion following the doctor's advice, and select the points like Zusanli, Shenshu, Pishu, Qihai, Sanyinjiao, etc.

Nauseaandvomiting

· Keep the oral cavity clean.

· Put the fresh ginger slice on the lingual surface to relieve vomiting.

· Rinse the mouth with cold boiled water or lemonade for the patients with ammoniacal odour in the mouth.

· Do moxa-wool moxibustion following the doctor's advice, and select the points like Geshu, Weishu, Shenque, etc.

· Perform acupoint massage following the doctor's advice, and select the points like Zusanli, Neiguan, Hegu, etc.

Distensionintheheadandweaknessinthelimbs

· Monitor the blood pressure timely. The patients with crisis of hypertension should stay in bed completely, and the doctor should be informed as soon as possible.

· Keep a normal bowel movement, don't hold the breath or defecate vigorously. Massage the abdomen clockwise.

· Perform acupoint massage following the doctor's advice, and select the points like Sanyinjiao, Zusanli, Fengchi, Baihui, Taiyang, etc.

· According to the doctor's advice, take the auricular-plaster therapy, and select the points like heart, brain stem, Shenmen, etc.

TCMspecialnursing

Medication

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

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.

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 to use 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.

Moxa-woolmoxibustion

· Perform the moxa-wool moxibustion following the doctor's advice and select the proper ways of moxa-wool moxibustion, such as moxibustion with moxa cone, moxibustion with moxa stick, moxibustion with moxa box, tec.

· Nursing assessment: the condition of skin in the area of moxibustion and acceptance level of patients to the moxibustion smell. It is unsuitable for moxibustion in the face, in the part of larger vessels as well as in the abdominal and lumbosacral portion of pregnant women.

· Regulate the room temperature timely, and maintain good indoor ventilation.

· Select a reasonable position to fully expose the part of moxibustion, and be cautious to keep warm and protect privacy.

· Do moxibustion from top to bottom, namely the top of the head and chest-back first, and then the abdomen and four limbs.

· During moxibustion, inquire the patients whether they feel a burning sensation, regulate the distance and flip the moxa ash into the kidney basin to avoid burning the skin.

· Pay attention to the moxibustion time. For instance, moxibustion is done for the patients with insomnia before sleep instead of moxibustion immediately before meals or after meals.

· After moxibustion, local reddish scorching skin is normal. The moxibustion-induced small vesicles can be absorbed by themselves, but for the large ones, the doctor should be informed immediately and corresponding measures are taken according to the doctor's advice.

· Place the moxa cone or moxa stick in the flame-out bottle to extinguish the moxibustion fire immediately after moxibustion.

· Small-dose and short-time moxibustion is applied to the initially-used patients, and the dose is increased gradually when the patients are tolerant.

· After moxibustion, record the way, part and skin of moxibustion as well as the patient's feelings.

ExternalapplicationofTCM

· Perform external application of TCM following the doctor's advice.

· Nursing assessment: previous history, allergic history and the condition of skin in the medicated part.

· Wash the local skin before external application of TCM, and conduct the times of applying medicine according to the doctor's advice.

· The bottle cap should be stuffed up after aqueous solution and tincture are used. The suspension liquid is embrocated after being shaken equably. The cream should be rubbed repeatedly by the palm or fingers to make it penetrate into the skin.

· Don't apply medicine too much in the local part to avoid clogging pores.

· Prevent the medicine from entering into the mouth and eyes when it is used on the face.

· Stop to apply medicine immediately and inform the doctor to deal with it when papule, itching or swelling appears in local skin.

TCMbath

· Perform TCM bath following the doctor's advice.

· Nursing assessment: It is forbidden for the patients with acute infectious disease, severe heart, lung and brain disease, severe anemia, soft tissue injury and acute hemorrhage as well as for the women with pregnancy and menstruation. It is used with caution to the patients the patients with drug and skin allergy.

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

· It is unsuitable for medicated bath on an empty stomach and one hour after meals.

· Keep a warm operation environment, close the door and window, and maintain good indoor ventilation.

· Pay attention to the medicated bath temperature and control of water level.

· Enhance walkaround inspection during medicated bath. Inform the patients with much sweating of taking warm saline water to prevent prostration. Observe the local and systemic condition of patients, and immediately inform the doctor and deal with them according to the doctor's advice if the symptoms like erythema, itching, palpitation, sweating and dizziness appear.

· Keep 20-30 minutes of the medicated bath.

· Tell the patients to move slowly to prevent postural hypotension after medicated bath.

· Require a specially-assigned person to accompany the elderly and the weak patients during the whole medicated bath.

· Equip the rescue drugs and things in the medicated bath room.

· Pay attention to disinfection and isolation to avoid cross infection.

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

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 minutes of TCM fumigation.

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

· Tell the patients to have a rest for 30 minutes 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.

Healthyguidance

Dailylife

· Maintain good indoor ventilation to avoid cross infection.

· Keep good personal hygiene.

· Assess the patients' activities of daily living degree, monitor the blood glucose at regular intervals, and take the low-, moderate-intensity aerobic exercise, such as walking, jogging, bicycling, etc.

· Guide the patients to take the exercise of TCM health preservation, such as Baduanjin qigong, Tai Chi, etc.

· Conduct health education before dialysis in order to make the patients fully understand the best opportunity of dialysis as well as the indications, contradictions, advantages and disadvantages of hematodialysis and peritoneal dialysis.

Dietguidance

Individualized diet guidance should be enhanced, and intake and output volume should be recorded.

· Syndrome of Qi deficiency: It is advisable to eat foods that can replenish qi, such as lean meat, white hyacinth Bean, quail, etc.

· Syndrome of blood deficiency: It is advisable to eat foods that can replenish blood, such as animal blood products, red peanut, black bean, etc.

· Syndrome of yin deficiency: It is advisable to eat cool and refreshing foods, such as white fungus, lotus seed, polygonatum odoratum, etc.

· Syndrome of yang deficiency: It is advisable to eat the warm-natured foods that tonify kidney yang and warm spleen and stomach, such as chicken, Chinese chives, ginger, dried ginger, Sichuan Pepper, etc.

· Syndrome of blood stasis: It is advisable to eat foods that can activate blood to remove blood stasis, such as rose, oilseed rape, etc.

· Phlegm-damp syndrome: It is advisable to eat foods that can resolve phlegm and remove dampness, such as papaya, water chestnut, nori, lentil, small red bean, cabbage, coix seed, crucian, carp, etc. It is unadvisable to eat the sour food like pomelo, loquat, etc.

· Damp-turbidity syndrome: It is advisable to eat foods that can remove dampness and resolve turbidity, such as peanut, etc.

· Reduced intake of porridge and soup: Water intake is based on the patient's daily urine volume. Generally, 500 mL of water is added to the total volume of output on the previous day, and meanwhile the animal protein is increased.

Emotionaladjustment

· Communicate with the patients frequently to make them understand the relationship between the disease and emotions so as to maintain an optimistic mood.

· Nursing interventions: Inform the doctor immediately for the patients with the risk of intracranial hemorrhage; observe the symptoms (depression and anxiety) of patients, and take the methods of confusion explanation and emotional restriction to intervene according to different emotional problems.