Traditional Chinese Medicine nursing protocols for liver cirrhosis Editorial Board of Nursing of Integrated Traditional Chinese and Western Medicine

ABSTRACT: Liver cirrhosis, a chronic progressive liver disease, is an increasing cause of morbidity and mortality in developed countries, caused by different mechanisms of liver damage that can result in neuroinflammation and fibrogenesis. Recently the basic and clinical research on chronic liver diseases has achieved great progress in the field of modern medicine and integrated Chinese and Western medicine, and produced new evidences for preventing and treating liver fibrosis. This article primarily summarized the key points of common syndromes, Traditional Chinese Medicine (TCM) nursing methods and healthy guidance of liver cirrhosis, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

KEY WORDS: liver cirrhosis; Traditional Chinese Medicine nursing; syndrome differentiation; hypochondriac pain; abdominal distension; jaundice

Liver cirrhosis is an increasing cause of morbidity and mortality in developed countries, caused by different mechanisms of liver damage that can result in necroinflammation and fibrogenesis[1]. It is a diffuse hepatic process with the characteristics of structurally abnormal nodules and fibrosis and represents the final histological change for various chronic liver diseases[2]. Clinically, liver cirrhosis has been considered as an end-stage disease that results in death for certain, unless liver transplantation is performed. According to the statistics, liver cirrhosis is the major indication for 5500 liver transplants in Europe annually[3]. Despite not a single disease entity, liver cirrhosis can be classified into disparate clinical stages, with 1-year mortality of 1%-57% based on the stage[4]. It has been proposed that liver cirrhosis can be replaced by advanced liver disease, to emphasize its dynamic processes and flexible prognosis[5].

The pathogens of liver cirrhosis can be accurately diagnosed by the combination of liver biochemistry, molecular biology, immunology, non-invasive diagnostic technique for hepatic fibrosis, imaging, liver histopathological assessment, and traditional Chinese medicine (TCM) syndrome differentiation, and meanwhile the disease severity and prognosis can also be assessed[6]. Previous studies showed that TCM contributed to inhibiting pathological angiogenesis in liver fibrosis, a common feature of almost all chronic liver diseases, thus preventing the occurrence of liver cirrhosis[7-8]. In 2006, the Hepatology Committee, Chinese Association of the Integration of Traditional and Western Medicine issued the Guidelines for the Prevention and Treatment of Liver Fibrosis with Integrated Traditional Chinese and Western Medicine[9]. In recent years, the basic and clinical research on chronic liver diseases has achieved great progress in the field of modern medicine and integrated Chinese and Western medicine, and produced new evidences for preventing and treating liver fibrosis. In view of TCM advantages in the treatment of liver cirrhosis, State Administration of Traditional Chinese Medicine of the People’s Republic of China formulated a TCM nursing protocol for liver cirrhosis, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

Keypointsofcommonsyndromes

Syndromeofdampness-heatinternalretardation: yellow skin and eyes, nausea or vomiting, dry mouth and bitter taste in the mouth or halitosis, scorching pain in the hypochondrium, or anorexia, or abdominal distension, dark colored urine, constipation or viscous stool; yellow and greasy tongue coating.

Syndromeofbloodstasisintheliverandspleen: fixed stabbing pain in the hypochondrium, cinnabar palm, or dark colored spider angioma, or angiotelectasis, hypochondriac masses and pain for a long time, and gloomy complexion; dark purple tongue or with ecchymosis.

Syndromeofliverdepressionandspleendeficiency: distending or scurrying pain in the hypochondrium, restlessness, irritability, preference for a deep sigh, dry mouth and bitter taste in the mouth, or presence of foreign body sensation in the throat, poor appetite or abdominal distension after food intake, belching, distending pain or masses in the breast, and loose stool; light red tongue with thin yellow or white tongue coating.

Syndromeofspleendeficiencywithsuperabundantdampness: poor appetite or abdominal distension after food intake, loose or viscous stool, shortness of breath, lassitude, nausea or vomiting, spontaneous sweating, tastelessness in the mouth, not preference for drinking, and sallow complexion; pale tongue or with more tooth marks, thin white or greasy tongue coating.

Syndromeofyindeficiencyintheliverandkidney: lumbago or soreness and weakness in the lower back and knees, dry eyes, dysphoria in chest, palms-soles or low fever, tinnitus, deafness, dizziness, giddiness, dull pain in the hypochondrium aggravated by overwork, dry mouth and throat, scanty dark urine, and constipation; red tongue with scanty tongue coating.

Syndromeofyangdeficiencyinthespleenandkidney: diarrhea before dawn, lumbago or soreness and weakness in the lower back and legs, impotence, prospermia, tinnitus, deafness, cold limbs, clear abundant urine or frequent enuresis nocturia; pale and plump tongue with moisture tongue coating.

Nursingforcommonsymptoms/syndromes

Hypochondriacpain

·Observe the part, nature, degree, duration, and concomitant symptoms of pain and its relationships with the climate, dietary, emotion and overstrain to avoid inducing factors.

·Keep the ward quiet, reduce the adverse stimulation outside, and stay in bed at the time of pain onset.

·According to the doctor’s advice, perform the local TCM iontophoresis.

·Take a hot medicinal compress therapy following the doctor’s advice, and iron the pain location. It is inappropriate to the patients with syndrome of dampness-heat internal retardation.

·According to the doctor’s advice, perform acupoint application on the points like Ganshu, Zhangmen, Yanglingquan, etc.

·Use treatment instruments for hepatic diseases based on the doctor’s advice.

Abdominaldistension

·Observe the part, nature, degree, duration, inducing factors, concomitant symptoms, and onset frequency of abdominal distension; measure the abdomen circumference and body weight at regular intervals; avoid inducing factors of abdominal distension, such as overeating and low potassium.

·Keep a normal bowel movement, and annularly massage the abdomen clockwise for 15-20 min, 2-3 times a day; according to the doctor’s advice, perform TCM retention enema for the patients with constipation.

·Based on the doctor’s advice, use acupoint application on the point of Shenque.

·Take a hot medicinal compress therapy following the doctor’s advice, and iron the abdomen. It is inappropriate to the patients with syndrome of dampness-heat internal retardation.

·According to the doctor’s advice, perform moxibustion on the points like Zusanli, Zhongwan, and Tianshu. This method is unsuitable for the patients with syndrome of dampness-heat internal retardation and those with fever due to yin deficiency in the liver and kidney.

·According to the doctor’s advice, take an auricular-plaster therapy on the points like the liver, stomach, and large intestine.

Jaundice

·Closely monitor the concomitant symptoms of jaundice. The doctor should be timely informed of rescue if the patient suffers from the rapid exacerbation of jaundice, accompanied by the symptoms like high fever, ascites, wandering in his mind, and restlessness.

·Keep a normal bowel movement. The patient with constipation can take laxatives orally and forbid using the alkaline liquid for enema.

·Guide the patient complicated with cutaneous pruritus to wear cotton, loose, and air-permeable clothes, keep a personal hygiene and avoid scratching vigorously to prevent the skin rupture; forbid using the alkaline things like soap or bath foam when bathing.

·According to the doctor's advice, perform TCM retention enema, TCM enema for total colon and TCM fumigation.

Anorexia

·Observe the patient's dietary condition, oral odor, sensation in the mouth, concomitant symptoms and changes of tongue and tongue coating; keep the mouth clear.

·Keep the air in the ward fresh, and timely remove the vomitus and excreta to avoid the stimulation of the objectionable odor.

·According to the doctor’s advice, massage the points including Zusanli, Pishu and Zhongwan, and conduct moxibustion at the points like Pishu, Zhongwan, and Zusanli.

TCMspecialnursing

Medications

Internalapplicationofherbalpaste

(1) It is appropriate to take warm TCM decoction for the patients complicated with esophageal varices.

(2) It is appropriate to take strong TCM decoction for the patients with syndrome of spleen deficiency with superabundant dampness and take warm TCM decoction for the patients with syndrome of dampness-heat internal retardation.

(3) Others.

·Medicationtime: 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.

·Medicationtemperature: The administered warm is usually adopted. For the patients with special treatment, the herbs should be taken according to the doctor's advice.

·Medicationdose: 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 herbs 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 channels 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.

Specialtechniques

Acupointapplication

·Conduct acupoint application following the doctor’s advice.

·Nursing assessment: the skin condition in the part of acupoint application; forbid to use it for pregnancy women.

·Expose the part of acupoint application completely, and pay attention to keeping warm and protecting the privacy.

·Keep a proper thickness of plaster (0.2-0.3 cm) and a certain humidity in order to smear easily.

·Observe the local and systemic condition. Stop to use it and inform the doctor to manage immediately if the allergy occurs, such as erythema, pruritus and vesicles.

·Avoid smoking, drinking alcohol, and taking cold, salty and spicy food, seafood, beef and mutton during application.

·Record the application part, time and patients’ feelings after all the operations are finished.

TCMretentionenema

·Conduct TCM retention enema following the doctor's advice.

·Nursing assessment: presence or absence of inflamed and ruptured perianal skin, history of drug allergy, recent surgeries related to the anus, rectum and colon as well as fecal incontinence. Before operation, the diseased location should be known in order to master the decubitus and depth of anal tube at the time of enema.

·Pay attention to keeping warm and protecting the privacy when the operation is done.

·Warn patients to defecate repeatedly before operation, and conduct cleansing enema following the doctor's advice if necessary.

·Keep the temperature of drug liquid at 39-41 ℃. Low temperature can enhance the intestinal peristalsis and aggravate abdominal pain, while high temperature can result in empyrosis of intestinal mucosa or dilatation of intestine and strong desire to defecate, consequently leading to short retention and less absorption of drug liquid in the intestine.

·Elevate the hip 10 cm, and make the depth of anal tube into the anus be 10-15 cm. When rectoclysis is adopted, the distance of drug liquid level to the anus is about 30-40 cm, with 60-80 drops of dripping speed per minute. It should be noted that the perfusion volume is less than 200 mL every time.

·Perform enema before sleep at night, and don't be up and about after enema. Assist the patients to take a suitable decubitus and keep the drug liquid remain more than 1 hour as soon as possible to improve the efficacy after the drug liquid is perfused.

·The times of defecation increase after TCM retention enema. The perianal skin should be observed and protected. Oiling agent or ointment can be smeared in the local part if necessary.

·Inquire the patients’ feelings, tell him to take a deep breath to relieve the desire to defecate, and prolong the retention time of drug liquid. Stop enema immediately and inform the doctor to take some measures if discomforts occur.

·Record the enema time, retention time and defecation condition after the operation is finished.

TCMiontophoresis

·Conduct TCM iontophoresis following the doctor's advice.

·Nursing assessment: the condition of skin in the part of iontophoresis; it should be used with caution for pregnant women, infants and those with drug and skin allergy.

·Tell the patients the process and notes of iontophoresis before operation, and inform the doctor to deal with it if discomforts occur.

·Keep the operating environment warm, expose the treatment part, and be cautious to keep warm and protect the privacy.

·Select the prescription following the doctor’s advice, regulate the current intensity, and inquire the patients’ feelings during treatment. The current intensity should be regulated on time if discomforts occur.

·Observe the local and systemic condition, and inform the doctor to manage immediately if the allergy occurs, such as erythema, pruritus and vesicles.

·Record the iontophoresis skin condition and patients’ feelings after the operation is finished.

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 using 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 acupoint 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, the improvement 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 the operation is finished.

Moxibustion

·Perform moxibustion following the doctor's advice and select the proper ways of 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.

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 the 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.

TCMenemafortotalcolon

·Conduct TCM enema for total colon following the doctor's advice, and correctly allocate colon irrigating solution.

·Nursing assessment: presence or absence of intestinal diseases, history of intestinal surgery and drug allergy.

·Take the left decubitus and pay attention to keeping warm and protecting the privacy for the patient.

·Make the bowel preparation before lavage. According to the doctor's advice, clean the enema first, and then lavage the colon.

·Mildly indwell the catheter and keep the depth of 50 cm to prevent the bowel lumen from injuring.

·Keep the temperature of drug liquid at 37-39 ℃.

·Observe the patient’s vital signs, complexion and feelings during the treatment, and observe the condition of defecation and intestinal function after the treatment.

·Guide the patient to enhance the perianal care to prevent the occurrence of rupture or eczema.

·Record the enema time, indwelling catheter time, dose, defecation condition and patient's feelings when the 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, keep warm and protect the privacy.

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

·Keep TCM fumigation for 20-30 min.

·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.

Hotmedicinalcompress

·Apply hot medicinal compress following the doctor’s advice.

·According to the doctor’s advice, prepare the required herbs, then put them into a cloth bag, and make it into a TCM bag of hot compress at 60-70 ℃.

·Nursing assessment: assess the condition of skin in the part of hot medicinal compress, tolerance to the heat, previous history and history of drug allergy. It is forbidden in the abdomen for female patients during menstruation or pregnancy.

·Tell the patients to urinate thoroughly before hot medicinal compress.

·Take a suitable position.

·Keep the temperature of the herbal bag constant during hot medicinal compress, and immediately change another one or reheat after cooling. The temperature should be tolerated by the patients, usually not more than 70 ℃. However, for the elderly, infants and those with sensory disturbance, the temperature should be no more than 50℃ to avoid scalding.

·Observe the patients’ reactions and skin condition, and immediately inform the doctor to take measures when the symptoms like erythema, pruritus, vesicles appear in the local skin.

·Record the temperature, part and time of hot medicinal compress and the patients’ feelings after the operation is finished.

Healthguidance

Dailylife

·Keep the ward clean, the air fresh and the living normal; avoid overstrain and make sure to have an enough sleep.

·Treat the primary disease positively, quit drinking, and correct unhealthy life styles.

·Use drugs under the guidance of doctors to avoid increasing the liver burden and liver function damage.

Dietaryguidance

·Syndromeofdampness-heatinternalretardation: It is suitable to take the cold food with the functions of clearing away heat and remove dampness, such as watermelon, pear, tomato, locus root, white gourd, bitter gourd, cucumber, coix seed, green bean, red bean, carp, etc.

·Syndromeofbloodstasisintheliverandspleen: It is suitable to take the food with the functions of regulating qi, activating blood and resolving blood stasis, such as cumquat, pomelo, orange, lentil, radish, hawthorn, etc.

·Syndromeofliverdepressionandspleendeficiency: It is suitable to take the food with the functions of soothing liver and invigorating spleen, such as hawthorn, Chinese yam, lentil, black bean, lotus root, etc.

·Syndromeofspleendeficiencywithsuperabundantdampness: It is suitable to take the food with the functions of invigorating spleen to remove dampness, such as jujube, Chinese yam, lotus seed, coix seed, sweet potato, carp, crucian, red bean, etc.

·Syndromeofyindeficiencyintheliverandkidney: It is suitable to take the food with the functions of nourishing the liver and kidney, such as lily, wolfberry, chestnut, agaric, duck, soft-shelled turtle, lean meat, etc.

·Syndromeofyangdeficiencyinthespleenandkidney: It is suitable to take the food with the functions of tonifying the spleen and kidney, such as leek, walnut, Chinese yam, mutton, beef, chicken, etc.

·Dietaryprinciples: keep a bland, digestible, low-fat, semiliquid diet; don’t eat the food that can cause flatulence, such as sweet potato and potato; don’t overeat; forbid eating cold, spicy, fried, greasy and hard food; prohibit smoking and drinking. The patients complicated with hepatic encephalopathy should have the low protein diet, with animal proteins as a taboo. The patients using long-term diuretics should eat the food rich in potassium, such as citrus, orange juice, mushroom, etc.

Emotionaladjustment

·Enhance health education for patients with anxiety and reasonably interpret the disease condition to make the patients and their relatives have an accurate cognition on the disease.

·Strengthen communication with scared or bad-tempered patients and introduce successful cases to enhance their confidence in the treatment; illustrate the relationship between the disease and emotions to the patients and encourage them to positively face the disease, consequently improving the treatment compliance; take the therapies like transference and convenience of expression to dredge emotions and stabilize the mood.

·Encourage depressed or disappointed patients to actively participate in social activities and frequently communicate with their relatives, colleagues and friends to establish a better interpersonal relationship, thus promoting rehabilitation.

·Take physical exercises in stable condition, such as Qigong, Tai Chi, Baduanjin, and Wuqinxi exercise.