Nursing perspective of expert consensus for diagnosis and treatment of colorectal cancer with integrated traditional Chinese and Western medicine

Shuhong LIU, Ling TANG, Yanan ZHAO,Jingjing HUO, Yan ZHAO, Kang YAN,Baoya ZHAO

1Department of Oncology, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China; 2Department of Nursing, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China

ABSTRACT

As one of the most common malignant tumors in the world, colorectal cancer (CRC) is accompanied by a variety of symptoms in the process of disease development and treatment, which seriously affect the functional state and quality of life of patients.In China, comprehensive intervention measures of traditional Chinese medicine (TCM) play an indispensable role in the treatment and rehabilitation of CRC.In order to further standardize and improve the treatment and management of CRC by medical staff, the Chinese Association of Integrative Medicine issued the “Expert Consensus for Diagnosis and Treatment of Colorectal Cancer with Integrated Traditional Chinese and Western Medicine”in August 2021.This paper interprets this consensus in detail from the perspective of nursing, focusing on the common understanding of the pathogenesis of CRC, TCM diagnosis and syndrome differentiation, integrated traditional Chinese and Western medicine nursing, TCM characteristic therapies, etc., with a view to deepening the understanding and practical application of the consensus among clinical doctors and nurses and improving the level of diagnosis, treatment, and nursing of CRC.

Keywords: Colorectal cancer, consensus, integrated traditional Chinese and Western medicine, nursing, traditional Chinese medicine, treatment

INTRODUCTION

Colorectal cancer (CRC) refers to malignant epithelial tumors of the colon and rectum, including malignant tumors of the ascending colon, transverse colon, descending colon,sigmoid colon, and rectum.[1]CRC belongs to the categories of“accumulation, intestinal wind, intestinal mass, and anorectal carcinoma” in traditional Chinese medicine (TCM).At present,the disease name in TCM is collectively referred to as CRC disease.In recent years, epidemiological data show that CRC is the third most common malignant tumor in men and women,and mortality ranks second among all malignant tumors worldwide.[2]In China, CRC ranks third in malignant tumors and fifth in mortality.[3]A study showed that the survival time of patients with advanced CRC after treatment with the best scheme of Western medicine was up to 33 months,[4]while the large sample study of SEER database in the United States showed that the average median survival time of patients with advanced CRC was only 14 months.[5]Western medicine treatments mainly include surgical treatment, radiotherapy and chemotherapy, immunotherapy, targeted therapy, and so on, which however have had certain limitations so far.Therefore, efforts have been made on exploring the scheme of integrated traditional Chinese and Western medicine in China to improve the short-term and long-term efficacy and quality of life of patients with CRC.

The Chinese Association of Integrative Medicine issued the “Expert Consensus for Diagnosis and Treatment of Colorectal Cancer with Integrated Traditional Chinese and Western Medicine” (hereinafter referred to as “Consensus”)in August 2021.[6]The Consensus, mainly based on the actual situation of the prevention and treatment of CRC in China, covers the application scope of CRC, pathogenesis,diagnosis and classification, treatment, and nursing plan of integrated traditional Chinese and Western medicine as well as rehabilitation.Moreover, the Consensus highlights the characteristics of integrated traditional Chinese and Western medicine and emphasizes to adhere to the cooperation principle of integrated traditional Chinese and Western medicine to promote the mutual complementation and coordinated development of TCM and Western medicine.In this paper, we interpreted the pathogenesis of CRC,TCM diagnosis and syndrome differentiation, integrated traditional Chinese and Western medicine nursing, and TCM characteristic therapies in the Consensus from the perspective of nursing in order to help clinical medical staff to have an insight into the knowledge of CRC-related diseases and provide guidance and reference for clinical nursing of integrated traditional Chinese and Western medicine in CRC.

PATHOGENESIS OF COLORECTAL CANCER

Pathogenic factors of colorectal cancer from the perspective of Western medicine

The Consensus points out that the incidence of CRC is closely related to changes in people’s living habits and dietary structure, family history, obesity, inflammatory bowel disease,heredity, and emotion.[7,8]The American Institute for Cancer Research further reports the living habits (smoking and drinking), dietary structure (high-fat and high-protein diet,excessive intake of red and processed meat, pickled food,and low dietary fiber), obesity and overweight (sedentariness and lack of exercise), and genetic factors (family history of cancer and intestinal polyps) are the risk factors of CRC.[9]In addition, psychological factors also play a crucial role in the occurrence of CRC.Li[10]particularly points out that mental stimulation and psychological stress are high-risk factors for CRC.Therefore, prevention from etiological factors is the key to reduce the incidence of CRC.

Pathogenesis of colorectal cancer from the perspective of traditional Chinese medicine

The Consensus points out that CRC is located in the intestine and is closely related to the spleen, liver, and kidney.The basic pathogenesis of CRC can be attributed to “spleen deficiency causing dysfunction in transportation” and “accumulation of phlegm and dampness blocking intestinal collaterals.” Among them, spleen deficiency is the root of CRC.A study has shown that the causes of CRC are improper diet (unhygienic diet and diet preference), emotional disorders (worry, depression and anger), attacks of exogenous pathogenic factors, and weak constitution.[11]CRC presents different clinical manifestations in different stages during the process of the struggle between healthy Qi with evil Qi.In the early stage of onset, healthy Qi is prosperous, while evil Qi is weak, so the patients’ clinical symptoms are not obvious; in the middle and late stages,healthy Qi is gradually deficient while evil Qi is gradually strong, so the patients have obvious clinical symptoms.Therefore, strengthening healthy Qi is the key to prevent the invasion of evil Qi.

SYNDROME DIFFERENTIATION, CLASSIFICATION, AND TREATMENT OF COLORECTAL CANCER

According to the Consensus, syndrome differentiation should be carried out for the CRC with early and middle-stage radical resection and metastatic CRC.[12,13]CRC after early and middle-stage radical resection can be classified into“deficient root” and “excessive superficial”.Among them,“deficient root” is often classified into five basic syndrome types, namely liver-spleen disharmony syndrome, spleen deficiency and Qi stagnation syndrome, spleen and kidney Yang deficiency syndrome, liver and kidney Yin deficiency syndrome, and Qi and blood deficiency syndrome.Moreover,the rules of treatment for “deficient root” are mainly to strengthen the spleen and stomach or nourish the liver and kidney.“Excessive superficial” is often divided into phlegmdampness and blood stasis syndrome and residual toxin syndrome and the rules of treatment are predominantly to remove dampness and phlegm, and activate the blood to remove blood stasis.Metastatic CRC is often classified into five basic syndrome types: spleen and kidney Yang deficiency syndrome, liver and kidney Yin deficiency syndrome, Qi and blood deficiency syndrome, internal retention of phlegmdampness, and internal accumulation of static blood and toxin.In this regard, it is recommended that the treatment should be performed based on the disease situation.[14]This is consistent with Professor Hu Kaiwen’s concept of“green treatment of tumor,”[15]in which he divides cancer into acute, chronic, and concealed stages according to the cancer conditions.The treatment strategy varies according to the stages.The interpretation of staging, syndrome differentiation, and treatment of CRC provides an important reference basis for nursing of CRC based on syndrome differentiation.

INTEGRATED TRADITIONAL CHINESE AND WESTERN MEDICINE NURSING

Living care

Bad living habits are an important risk factor for CRC.Therefore, maintaining healthy living habits is crucial to the prevention and treatment of CRC.As for life guidance, the Consensus points out that we should maintain good living habits, such as quitting smoking and alcohol, avoiding spicy and stimulating food, maintaining healthy body mass index,etc.With regard to the adjustment of daily life, the TCM health preservation theory represented byHuangdi’sCanon ofInternalMedicineputs forward that a healthy lifestyle should not only be self-harmonious but also be in harmony with the changes of seasons.Cancer patients often feel lack of physical strength due to the long course of disease,body consumption, and side effects of radiotherapy and chemotherapy.Therefore, they should arrange their work and rest for the purpose of “having regular daily life and not overworking.” This is clearly described as “early sleep and get-up in spring, summer and autumn while early sleep and late get-up in winter” inDiscussiononRegulationoftheSpirit AccordingtotheChangesofSeasons, one chapter ofHuangdi’s CanonofInternalMedicine - PlainQuestions.All year round,patients should get up between 5:00 and 7:00, the time when the large intestine meridian is active and dominant,drink a little water first and then eat when the stomach meridian is active.

In terms of clothing selection, it should be adjusted according to the changes in temperature of four seasons.During spring,attention should be paid to defend cold and keep warm by wearing cotton-padded clothes.During summer, do not wear too light or wet clothes to avoid being attacked by the evil of cold and dampness.In autumn, although the weather turns cool, patients shall not wear too thick and should keep their heads and feet cool.During winter months, patients should keep warm but not wear too thick, so as to avoid Yang Qi leakage along with sweating.[16]

Diet care

It is necessary to carry out perioperative dietary guidance for CRC patients.The Consensus points out that preoperative nutritional risk screening should be carried out routinely and nutritional support treatment should be actively provided.After surgical operation, nurses should help patients to restore oral feeding to a normal diet as soon as possible through helpful exercises, including masticatory function and masseter muscle recovery training and gastrointestinal function recovery training.[17]For restoring masticatory function, patients are instructed to carry out glottis swallowing, vocal cord closing, tongue muscle, and masseter muscle training on the 2ndday after operation, once a day,5 min each time; bedside guidance is given when patients are eating.For recovery of gastrointestinal function, patients are guided to do the recovery training on the 3rdday after operation, once a day, 10 min each time; according to the patient’s conditions, a personalized diet should be formulated starting from water, liquid diet, semi-liquid diet,soft food, and finally to full diet.Oral feeding starts from liquid diet, 8 times on the 1stday and 50 mL each time, then 6 times on the 2ndday, 80 mL each time, and 4 times on the 3rdday, 200 mL each time.If patients have no discomfort,they can drink fruit juice and eat vegetable soup or rice soup on the 4thday, start semi-liquid diet from the 5thday to the 14thday, and start an ordinary diet after 2 weeks.Chewing gum and symptomatic use of drugs to promote gastrointestinal function and help digestion can prevent postoperative intestinal paralysis.In addition, for patients with a stoma, having multiple small meals with high protein,high calorie, high vitamin, and easy digestion is the basic principle.Patients should avoid gas-producing, irritating,and indigestible foods (garlic, potato, onion, etc) or crude fiber foods (celery, bamboo shoots, leeks, etc).[18]Rectal/intestinal dysfunction may occur after CRC surgery, so it is recommended to adjust the dietary structure, such as intake of low-fat foods, using probiotic preparations, and avoiding raw vegetables.

During chemotherapy, diet nursing should be carried out according to the patient’s syndrome and constitution.[19](1)For dampness-heat blockage type, patients are guided to eat foods with cold and cool in property such as poria cocos cake, pueraria powder, mung bean sprouts, goose, duck, lotus root, and water chestnut, or boiled water with bamboo leaves and Chinese wax gourd peel substituting tea drinking.(2) For cold-dampness stagnation type, patients should be directed to eat hot foods, such as ginger juice, ginseng soup, red bean and barley porridge, mutton soup, longan and grape, and other hot foods; those patients accompanied with cough can drink red pear Zhebei (ThunberyFritillaryBulb) soup.(3) For Qi stagnation and blood stasis type, patients should be guided to soak Chishao (RadixPaeoniaeRubra), Sanqi (RadixNotoginseng),honghua (FlosCarthami), and Taoren (SemenPersicae) in water for drinking; hawthorn products are added for those accompanied with poor appetite; Suanzaoren (SemenZiziphi Spinosae) is added for those accompanied with insomnia.(4)For patients with deficiency of both Qi and blood, it is recommended to use hens, pigeon meat, red dates, and donkey-hide gelatin for making soap, supplemented with Shanyao (RhizomaDioscoreae), Huangqi (RadixAstragaliseu Hedysari), Danggui (RadixAngelicaeSinensis), and ginseng to replenish qi and blood.

For preventing CRC, patients should pay attention to their dietary structure.[20,21]It is recommended to eat more fruits,vegetables, poultry, fish or fish oil, nuclear peach, brown rice and ground wheat, and whole grain food but less red meat,refined grains, and concentrated sweets.Meanwhile, intake of Vitamin D and calcium should be ensured.

Emotional nursing

Different psychological problems are common in CRC patients during perioperative period,[22]including negative psychology,fear of surgery and aversion to artificial anostomy psychology,fear of chemotherapy, anaclisis, etc.The Consensus gives different guidance and suggestions for those psychological problems in different periods.Before surgery, the Consensus suggests that patients listen to soothing music, which is helpful to eliminate their perioperative excessive stress state.[23]After operation, the Consensus proposes to adopt music therapy (five-element music) to fundamentally reconstruct the overall balance of body and mind, change the stress response mode of the body, and improve the health level of human body as a whole.In terms of rehabilitation and prevention of CRC, the Consensus points out the health preservation thought of TCM represented byHuangdi’s CanonofInternalMedicine, such as living in peace with joy and anger, avoiding excessive joy, anger, worry and thinking,and emphasizing that people should maintain a quiet and empty mental state.In view of depression and fear of cancer recurrence in patients, the Consensus further proposes that the psychotherapy of Western medicine should be combined with TCM characteristic therapies, such as TCM psychotherapy which includes emotional therapy, music therapy, self-cultivation therapy, behavior therapy, situational therapy, passion therapy, and guided breathing method.A research on TCM emotional therapy has shown that the anxiety and depression in patients with CRC correspond to “worry” in the emotion theory of TCM.Therefore,Gong-mode music in five-tone therapy should be used to treat excessive thinking and anxiety.[24]The representative musics areMoonlitRiverInSpring,TheMoonHighAbove, andMoonlight Sonata.Attention should be paid to eliminate interference as far as possible to make the patients feel better when they are immersed in the artistic conception of music.The volume must be controlled, generally 35-40 dB.

For the psychological problems of patients with enterostomy,nurses should scientifically evaluate the psychological state of patients and formulate personalized psychological guidance for their various psychological problems, including empathy (watching TV dramas and sketches with pleasant plot and humor, 1 h daily), meditation therapy and relaxation therapy (recalling pleasant things in daily life and speaking them out), and music therapy (listening to music with bright rhythm such asDance of Little Four SwansandHigh MountainsandFlowingWater, 30 min daily).The Consensus points out that psychosocial support can benefit patients.Therefore, in addition to informing them of the necessity of enterostomy, teaching them the basic nursing methods of enterostomy, and making them establish a correct understanding of enterostomy, nurses should encourage patients to participate in social activities to obtain the support from family members and friends.Stoma fellowship can be held regularly to strengthen the communication and exchange between patients where patients of long stoma history share their experience with others[25]so that new patients can courageously face the reality with a positive and healthy attitude.

Exercise

A research has proved that fatigue in cancer patients is related to a lack of physical exercise.[26]At present, the main methods in the treatment of CRC including surgery, radiotherapy and chemotherapy, immunotherapy, and targeted therapy can cause cancer-related fatigue in most patients, which exercise has been proved to be an effective means to alleviate.

The Consensus points out that perioperative rehabilitation of CRC can be accelerated through exercise care.Before operation, patients are encouraged to perform small- and medium-intensity aerobic exercise, such as Tai Chi,Baduanjin, and five-animal boxing, which can improve the immune level of patients with CRC, maintain the steady state of intestinal mucosal barrier, and resist the invasion of pathogenic microorganisms.[27,28]As a physical and mental exercise, eight-style Tai Chi which takes eight most essential movements from complex 24-style Tai Chi is recommended for CRC patients as it is easy to learn and has been shown to be effective in preventing and curing diseases.[29,30]Baduanjin conforms to the law of human movement.Patients can fully relax their body and mind during practice, playing roles in dredging meridians, promoting the circulation of Qi and blood, and calming the heart and the mind.[31,32]Five-animal boxing is a kind of exercise of imitating forms of five animals (tiger, deer, bear, ape, and bird) for health preservation.[33]Based on theories of Zang-Fu organs, Yin and Yang, and five elements in TCM, the five kinds of animals are corresponding to the five Zang organs (kidney, liver, spleen,heart, and lung) and the five elements (water, wood, earth,fire, and gold).[34-36]According to their physical conditions,patients can choose all forms or several of them to practice and appropriately adjust the height of action posture to adjust the exercise intensity and amount in the process of practice if required.Moreover, patients are required to pay attention to the regulation of breath during practice.It is best to use abdominal breathing.

The postoperative early activities play roles in improving the sleep quality of patients, promoting the recovery of gastrointestinal function, shortening the length of hospital stay, reducing postoperative pain and complications, and improving the quality of life.[37]After operation, patients return to the ward safely, they are encouraged to do early activities in postoperative 1-3 days if their vital signs are stable.The postoperative early activities include lying in bed with activities (ankle pump exercise, straight-leg raising, hip flexion and extension, hip lift training), bedside activities in sitting position (respiratory muscle training, knee flexion and extension, quadriceps endurance training), and off-bed activities (straight hand lifting training, elbow flexion and extension training, and walking 119 m on the postoperative 1stday, 229 m on the postoperative 2ndday, 294 m on the postoperative 3rdday).The changes of condition and vital signs of the patients are observed during activities, and the activity time, content, frequency, and adverse reactions after activities are recorded.

During the recovery period of CRC, it is recommended that patients undergo moderate-intensity physical training for at least 30 min a week.For Chinese patients with CRC,physical activities such as square dance, fast walking,and mountaineering are more widely accepted, but those activities are not quantified and evaluated.In recent years,TCM health preservation skills represented by Baduanjin and Tai Chi have been promoted in cancer patients.

Appropriate traditional Chinese medicine techniques

Patients with CRC often have a deficiency of healthy Qi due to tumor invasion, abnormal operation of Qi mechanism and dysfunction of ascending and descending caused by surgical operation, blockage of meridians of Zang-Fu organs, impairment of spleen and stomach function, and dysfunction of the spleen in transportation caused by chemotherapeutic drugs, kidney injury, essence consumption,or deficiency of Qi and blood.[38]As a consequence, common clinical complications were mainly manifested as fatigue and anxiety, depression, pain, and insomnia caused by tumor itself, chemotherapy-induced gastrointestinal reactions (nausea, vomiting, anorexia, constipation,diarrhea, etc.), bone marrow suppression and peripheral neuropathy, radiation enteritis and radiation cystitis caused by radiotherapy, hypertension caused by targeted drugs, as well as drug-related hand-foot-skin reactions.The Consensus recommends to use the characteristic TCM therapies based on patients’ symptoms and especially points out that TCM treatment (external treatment of TCM) can slow the toxic and side reactions caused by chemotherapy and reduce the rate of tumor recurrence and metastasis, delay the progression of advanced CRC, prolong the survival time of patients, and improve short-term and long-term curative effect and the quality of their life.This is consistent with Professor Hu Kaiwen’s concept of “green tumor care.”[39]Green tumor care takes “green treatment” as the core with TCM characteristic techniques for externally treating diseases based on the TCM theoretical basis of “holistic view” and “treatment based on syndrome differentiation.” TCM characteristic techniques with the advantages of “external treatment” and “direct access to the location of diseases” are particularly suitable for CRC patients with weakness of the spleen and stomach.This paper focuses on the appropriate TCM nursing technologies in the Consensus and the green tumor care technologies applied in clinics.

Acupoint application

Acupoint application is mainly indicated for gastrointestinal reactions (such as nausea and vomiting), pain, insomnia,and bone marrow suppression after surgery, radiotherapy,and chemotherapy for CRC patients.In general, the recommended drugs are Banxia (RhizomaPinelliae),Wuzhuyu (FructusEvodiae), Dingxiang (FlosCaryophylli),Chenpi (PericarpiumCitriReticulatae), Xuanfuhua (FlosInulae),and ginger, etc.The recommended acupoints are Neiguan,Shenque, Zusanli, Zhongwan, Yongquan, etc.The drugs,which are absorbed through acupoints on the skin, act on meridians and Qi, blood and viscera of the whole body, thus alleviating symptoms.

For patients with gastroparesis after CRC surgery, acupuncture combined with acupoint application is used.[40]The recommended prescription for acupoint application consists of Muxiang (RadixAucklandiae) 10 g, Dingxiang (Flos Caryophylli) 10 g, Houpu (CortexMagnoliaeOfficinalis) 10 g,Zhiqiao (Fructus Aurantii) 10 g, Ganjiang (RhizomaZingiberis)15 g, Rougui (CortexCinnamomi) 10 g, Chuanshanjia (Squama Manis) 15 g, and Quanxie (Scorpio) 6 g.Those drugs are ground into powder, mixed with rice wine and honey, pressed into a round shape in the cross gauze, spread evenly on the nonwoven dressing, and made into the plaster.The plaster is heated to 43°C and applied externally to Zhongwan point and Shenque point for 4-6 h daily once a day.

For CRC patients with abdominal distension, Suet al.[41]used Wenjing Acupoint Sticking to reduce the incidence of gastrointestinal reactions caused by platinum-based chemotherapy, and found it had a good effect in relieving abdominal distension.The sticking was applied on acupoints Zhongwan, Neiguan, and Zusanli, 6 h daily and changed every day, 1 week in total.

For CRC patients with insomnia, acupoint aplication combined with manual massage on the basis of routine intervention can improve insomnia.[42]The prescription drugs for acupoint application consist of fried Suanzaoren (SemenZiziphiSpinosae)30 g, Hehuanhua (FlosAlbiziae) 9 g, Huanglian (Rhizoma Coptidis) 6 g, and Rougui (CortexCinnamomi) 6 g.Those drugs are crushed into fine powder, mixed with an appropriate amount of sesame oil, and pasted on Shenque point.

For patients with cancer pain, Wanget al.[43]have integrated the evidence that external application of Chinese medicine combined with three-step analgesia is safe and effective in the treatment of cancer pain, with less adverse reactions and higher quality of life.

Moxibustion

Moxibustion is mainly indicated for gastrointestinal dysfunction caused by colorectal surgery and adverse reactions caused by radiotherapy and chemotherapy.For patients with nausea and vomiting, the recommended optional acupoints are Zusanli,Neiguan, Zhongwan, Gongsun, Shenque, Sanyinjiao, Geshu,Hegu, etc.Chen[44]used moxibustion on Yongquan acupoint in combination with Zusanli acupoint injection on 40 colon cancer patients after chemotherapy, and the effective rate of relieving nausea and vomiting, abdominal distention,abdominal pain, and constipation was 100%.For patients with abdominal distension and constipation, the recommended optional acupoints are Zusanli, Shangjuxu, Tianshu, Qihai,Hegu, Taichong, etc.For patients with gastrointestinal motility disorders, Zhanget al.[45]treated 82 patients with CRC after operation with early application of moxibustion and bilateral Zusanli acupoint injection of Vitamin B1, which can effectively improve gastrointestinal motility disorders, shorten the recovery time of postoperative gastrointestinal function,help to recover normal diet, and reduce the occurrence of gastrointestinal complications.

Auricular plaster therapy

Auricular plaster therapy is suitable for the treatment of nausea, vomiting, constipation, fatigue, and insomnia caused by CRC surgery and chemotherapy.For patients with postoperative nausea and vomiting, the acupoints spleen, stomach, duodenum, large intestine, small intestine,sympathetic, and endocrine are selected for auricular plaster therapy and pressed for 1 min in every 10 min, and the same operation is performed in two ears, alternately every 2 days.[46]The most commonly used acupoint for auricular plaster therapy for treating constipation is the large intestine point, followed by the rectum, spleen,Sanjiao, lung, stomach, and subcortex.[47]The acupoints should be selected based on differentiation according to the condition of constipation.For constipation with excess symdrome, it is recommended to select acupoints large intestine, rectum, constipation point, lung, liver, and Sanjiao; for constipation with deficiency syndrome, it is recommended to select acupoints large intestine, rectum,constipation point, spleen, subcortex, and kidney.[48]For the treatment of insomnia in cancer patients, it is recommended to select acupoints endocrine, subcortical, Shenmen, spleen,and heart.[49]

Chinese medicine ointment massage therapy

Chinese medicine ointment massage therapy is suitable for the treatment of gastrointestinal dysfunction (nausea,vomiting, anorexia, constipation, and diarrhea), pain,and bone marrow suppression caused by surgery or chemotherapy in patients with CRC.The dysfunction of the spleen and stomach is mostly due to spleen and stomach failing to transport and transform, lucid Yang failing to rise,and turbid Yin failing to descend which thus block middle energizer, and its syndrome mostly belongs to intermingled deficiency and excess.[50]For gastrointestinal dysfunction after operation, the recommended prescription consists of Dingxiang (FlosCaryophylli), Muxiang (RadixAucklandiae),borneol, Chuanshanjia (SquamaManis), Quanxie (Scorpio),Houpu (CortexMagnoliaeOfficinalis), Zhishi (Fructus AurantiiImmaturus), Wuzhuyu (FructusEvodiae), and Xiaohuixiang (FructusFoeniculi).Among them, Dingxiang (Flos Caryophylli), Muxiang (RadixAucklandiae), and borneol are fragrant and spicy in property with effect of enhancing drug penetration through skin; Chuanshanjia (SquamaManis) and Quanxie (Scorpio) are used to guide the other drugs direct access to the location of disease; Houpu (CortexMagnoliae Officinalis) and Zhishi (FructusAurantiiImmaturus) are employed to promote gastrointestinal motility; Wuzhuyu (Fructus Evodiae) and Xiaohuixiang (FructusFoeniculi) are to warm the middle energizer, dispel cold, and relieve pain.[51]In addition to the action of drugs, the manipulation of ointment massage is also a crucial factor to increase the curative effect, mainly using the tonifying method and selecting Zhongwan acupoint and Tianshu acupoints.

课堂教学主要分为两部分：教师讲解与学生自主完成实训相结合，教师在课程的开始综合讲解该项目所融合的知识点，然后按模块划分，对每一模块的讲解借鉴“对分”的模式，由于知识点为前期所学知识，对于学生而言并不是很困难，因此每节课分为三部分：首先教师对要讲解的功能模块进行简单概述；其次学生之间进行讨论，对遇到的问题进行组内解决，组内无法解决的提交给老师，由教师汇总后统一解决共性问题；最后学生对自己的实训课题进行完成，进行硬件设计或者软件程序的编写。

For patients with cancer pain, the recommended prescription for Chinese medicine ointment massage consists of Quanxie (Scorpio), Wugong (Scolopendra),Shujiao (Zanthoxylum), Xixin (HerbaAsari), Ruxiang (Olibanum),Moyao (Myrrha), Dried toad skin, and Guizhi (Ramulus Cinnamomi), which has effects of warming Yang, dredging collaterals, activating blood, and relieving pain.[52]The prescription is more effective when combined with rubbing manipulation (on local pain area) and point-pressing manipulation (on Ashi point).

For patients with bone marrow suppression, Danggui (Radix AngelicaeSinensis), Huangqi (RadixAstragaliseuHedysari),Shudi (RadixRehmanniaePreparata), Bajitian (RadixMorindae Officinalis), and Tusizi (SemenCuscutae) are selected to invigorating qi, strengthening spleen, and nourishing blood and kidney.The addition of Danshen (RadixSalviae Miltiorrhizae) and Honghua (FlosCarthami) can activate blood to remove blood stasis.The manipulation of ointment massage is tonifying method and the selected acupoints are Pishu and Shenshu.All together can effectively relieve bone marrow suppression caused by chemotherapy as well as improve the quality of life of patients.

Traditional Chinese medicine anal drip

TCM anal drip is suitable for the treatment of rectal/intestinal dysfunction (constipation, chronic diarrhea) and radiation enteritis.The temperature, insertion depth, and intestinal retention time of TCM anal drip are explained in the bookGreenTumorCareTechnology.[39]The temperature (39°C-41°C)of drug solution for TCM anal drip is continuously maintained using a heating rod which is inserted 20-40 cm deep, at a regulating speed of 40 drops/min.It is recommended that the solution is retained in the intestine for 1 h or more.Yanget al.[53]found that the temperature of enema solution should be increased by 1°C-2°C based on the rectal temperature of the patient, and the appropriate insertion depth of enema was 25-35 cm.When the enemator is inserted more than 20 cm deep, which is right in the sigmoid colon, the enema solution is not directly entering the rectum which avoids stimulating the rectum to cause defecation reflex; meanwhile,the retention time of the enema solution in the intestine is prolonged accordingly.The therapeutic effect can be achieved only when the enema solution is retained in the intestinal tract for 2 h, and the effect is even better above 6 h.[54]

The choice of enema time should be based on the meridian flow theory.[55]The large intestine meridian is most active during the period of the day from 5 a.m.to 7 a.m.when the enema is performed, which is conducive to the absorption of water and nutrients in food and promotes the discharge of residues.Moreover, this period is close to that of the day from 7 a.m.to 9 a.m.- breakfast time when the food intake of patients is increased to produce sufficient liquefied chyme and waste, which is conducive to fecal production.

Traditional Chinese medicine hot pack

TCM hot pack is conducive to relieving abdominal distension symptoms, improving the nutritional status of postoperative CRC patients, and promoting intestinal peristalsis.[56]For postoperative gastrointestinal function recovery of gastric cancer, Huet al.[57]used wormwood salt pack for hot ironing on Shenque acupoint in combination with acupoint application with Chinese medicine on acupoints Zusanli, Sanyinjiao,Hegu, and Quchi to improve recovery of gastrointestinal function, shorten postoperative hospital stay, and reduce the incidence of postoperative complications.For patients with cancer-related fatigue, it is recommended to choose Zusanli, Sanyinjiao, Guanyuan, and Qihai acupoints for hot ironing or push with hot pack on the stomach meridian of foot Yangming.[58,59]For patients with cancerous pain, it is recommended to select Ashi point, Du-meridian, and Huatuo Jiaji points.[60]

Traditional Chinese drug soaking and washing

Traditional Chinese drug soaking and washing has effects of warming meridians and dredging collaterals, activating blood circulation, and removing blood stasis.For patients with drug-related hand and foot skin reactions, Chinese herbal compound LC09 Granules in combination with Urea Ointment is recommended to effectively relieve pain, improve the quality of life, and lower the discontinuation rate of targeted drugs and the grading of toxic events.[61]LC09 Granules need to be dissolved with warm water at 40°C and then soak hands and feet for 20 min each time, twice a day for 7 days in total.In addition, it is recommended to use Meridian-Warming Blood-Activating Prescription to wash hands and feet for lowering the grade of chemotherapy-induced peripheral neurotoxicity and improved Karnofsky Performance Status score.[62]Meridian-Warming Blood-Activating Prescription,which consists of Jianghuang (RhizomaCurcumaeLongae) 30 g,Aiye (FoliumArtemisiaeArgyi) 30 g, Sangzhi (RamulusMori)30 g, Daxueteng (CaulisSargentodoxae), 30 g, Lulutong (Fructus Liquidambaris) 30 g, Honghua (FlosCarthami) 30 g, and prepared Chuangwu (RadixAconitiPreparata) 10 g, is put into a cloth bag and decocted with 2000 mL water for 30 min.The decocted liquid is poured into a container and used to soak hands and feet at 38°C-42°C for 20 min daily in the evening.

In addition, for hand and foot skin reactions caused by anti-angiogenic tyrosine kinase inhibitors and capecitabine,the Consensus points out that the treatment of Western medicine is mainly skin nutrition drugs such as Vitamin E milk,while the treatment of TCM includes internal and external use.Internal use mainly focuses on tonifying deficiency and activating blood.External use focuses on promoting blood circulation and removing blood stasis, together with clearing heat, warming meridians, or removing dampness.For patients with mild reaction in hand and foot skin, oral prescription for comprehensive conditioning is used with the addition of symptomatic treatment drugs, and the dregs of the oral prescription drugs are decocted for fumigating or soaking the affected skin.In severe cases, it is suggested to select modified Taohong Siwu Decoction or Chinese herbal compound LC09 Granules for oral taking, external fumigation,or soaking hands and feet according to different disease syndromes of patients.[63,64]

Traditional Chinese medicine gargle

TCM gargle can reduce the oral problems caused by radiotherapy and chemotherapy in cancer patients.Zhuet al.[65]used Kangfuxin Liquid for oral care of cancer patients after chemotherapy and found that it can effectively beat bad breath and pain after chemotherapy.Shenji Decoction self-made by Duet al.[66]can effectively reduce the symptoms of oral ulcer and dry mouth after radiotherapy and promote the healing of oral mucosa, prevent co-infection as well as relieve pain, which indicates the advantages of TCM syndrome differentiation and treatment.

Nursing care of colorectal cancer stoma

There were 20%-30% of patients with CRC who underwent Mile’ abdominoperineal resection and carried enterostomy for life after surgery.[67]The common complications after enterostomy include skin mucosal separation, stoma necrosis, stoma retraction, stomal stenosis, stomal prolapse,parastomal hernia, stomal injury, etc.The common complications around enterostomy include intestinal mucosal edema, dermatitis associated with humid environment around stoma, fungal/Candida infection, allergic contact skin,mechanical injury of skin around stoma, varicose veins around stoma, etc.The nursing measures should be implemented accordingly for different complications with reference toBestPracticeforPerioperativeNursingofRectalCancerunderthe ConceptofERAS.[68]

CONCLUSION

The Consensus comprehensively and systematically expounds treatment thoughts of CRC based on the disease differentiation and syndrome differentiation and combs TCM nursing technologies used for the common symptoms of CRC, so as to make the key links of the application of nursing technology clearer and to promote the exertion of the characteristic advantages of TCM nursing.Integrated traditional Chinese and Western medicine nursing is explained in detail, including living care, diet care, emotional nursing,exercise, and appropriate TCM nursing techniques (acupoint application, moxibustion, auricular plaster therapy, Chinese medicine ointment massage, TCM anal drip, hot pack, etc.),so as to provide reliable and operable information for health education.The formation of standard dialectical thoughts and operable integrative nursing for CRC are of significance to delay the progress of advanced CRC, prolong the survival of patients, improve the short-term and long-term curative effect, and improve the quality of life of patients.

One issue that we should note is that patients with CRC face many problems such as long-term and repeated treatment,multiple complications, and disease recurrence.However,with the continuous improvement of medical technology and in-depth development of high-quality nursing, the traditional care model has been unable to meet the nursing needs of patients after discharge.Therefore, it is extremely urgent to apply the treatment idea of the Consensus to the continuous care of patients with CRC, so as to provide patients with individualized, comprehensive nursing care,which can be extended to home-based care, so that tumor patients can have physical and mental peace and survive with tumor.In particular, the green, safe, and direct care with TCM characteristics is very critical in improving patients’symptoms, regulating patients’ constitution, and even providing the whole process high-quality TCM nursing service for discharged patients with CRC.

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Conflicts of interest

There are no conflicts of interest.