Traditional Chinese Medicine nursing protocols for osteoarthrosisEditorial Board of Nursing of Integrated Traditional Chinese and Western Medicine

ABSTRACT: Osteoarthritis (OA) is one of the leading causes of disability worldwide, and its prevalence increases with age. With the aggravated aging of population, OA has negatively impacted the people's physical and mental well-being. For the past few years, Traditional Chinese Medicine (TCM) has shown its predominant advantages in the treatment of OA. It can alleviate pain and improve clinical symptoms in patients with OA, but the standards for syndrome differentiation of OA remains inconclusive. This article primarily investigated the key points of common syndromes, TCM nursing methods and healthy guidance of OA, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

KEY WORDS: osteoarthritis; arthralgia; Traditional Chinese Medicine nursing; syndrome differentiation

Osteoarthritis (OA) is one of the leading causes of disability all over the world, characterized by softening and degeneration of articular cartilage, capsular fibrosis, and formation of new bones at joint margins[1]. It is the most common joint disorder in clinic, with joint pain, deformity, stiffness and loss of function as the major manifestation[2]. The prevalence of OA varies depending on the definition of OA and increases with age[1, 3]. It is more prevalent in women than men after the middle age. The prevalence of OA is 10%-17% in the population aged 40 years, 50% in those aged above 60 years and 80% in those aged more than 75 years[4]. With the aggravated aging of population, OA has negatively impacted the people’s physical and mental well-being.

The treatment for OA primarily focuses on pain relief and improvement of functional status. Currently, a variety of treatment modalities are available for OA, including oral medications (aspirin, acetaminophen, opioids and nonsteroidal anti-inflammatory drugs)[5], local and intra-articular therapies (applied creams or gels, corticosteroid and hyaluronic acid injections)[6], surgical treatments (arthroscopic debridement and joint replacement)[7], as well as non-pharmacological methods (aerobic therapy, physical therapy, transcutaneous electric nerve stimulation, etc.)[8]. However, many non-surgical treatments are limited due to frequent side effects and limited efficacy.

For the past few years, Traditional Chinese medicine (TCM) has shown its predominant advantages in the treatment of OA, including external application of TCM[9-10], TCM fumigation[11], acupuncture and moxibustion[12]. The findings of these studies all revealed that TCM was conductive to pain relief and improvement of clinical symptoms in patients with OA. Therefore, State Administration of Traditional Chinese Medicine of the People's Republic of China formulated a TCM nursing protocol for OA, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

Key points of common syndromes

Syndromeofliverandkidneydeficiency: arthralgia, swollen joints, sometimes mild sometimes severe, inconvenient flexion and extension, or accompanied by clicking of joint, soreness and weakness in the waist and knees, pain aggravation at the time of flexion and extension; or accompanied by joint deformity, muscle atrophy, cold limbs; or burning sensation in five centers, tidal fever in the afternoon. Light-colored tongue or with petechia, white or white greasy tongue coating.

Syndromeofcold-dampnessblockage: sore pain of the limbs and joint or local swelling of joint, inconvenient flexion and extension, local aversion to cold, pale skin, not hot at the time of touching, pain relief by heat and aggravation by coldness, pain aggravation at the time of activity; or accompanied by soreness and weakness in the waist and knees, weak limbs, or accompanied by poor appetite, loose stool, and clear abundant urine. Thin white or white greasy tongue coating.

Syndromeofdampness-heatblockingcollaterals: inflamed and painful joint, inconvenient activity, resistance to press, local scorching pain at the time of touching, fever, thirst, restless; or accompanied by soreness and weakness in the waist and knees, weak limbs, dry stool, yellow urine. Red tongue with yellow greasy coating.

Syndromeofphlegm-stasisobstruction: previous history of trauma, or long-term pain, stabbing pain or dragging pain in the joint, or serious pain, especially at night, fixed pain; or accompanied by numbness of limbs, unable to bend and stretch, repeated onset, stiff and distorted joint, cyanosis in the joint or its peripheral region. Dark purple tongue or the tongue with petechiae, white greasy or yellow greasy coating.

Syndromeofqiandblooddeficiency: soreness, heaviness and dull pain in the joint, inconvenient flexion and extension, numbness of limbs, weak limbs; or accompanied by weak constitution, pale complexion, aversion to cold after sweating, sometimes feeling of palpitation, anorexia, polyuria, loose stool. Light-colored tongue with thin white coating.

Nursing for common symptoms/syndromes

Arthralgia

·Assess the pain inducements, nature, part, duration, somatic sensation and movement condition, and make the pain score. In order to record the specific score, the numerical rating scale (NRS), a sort of self-assessment tool for pain, can be adopted.

·Keep the functional position of affected limb.

·Make an evaluation on the living ability and safety.

·Perform TCM hydropathic compress and acupoint application following the doctor's advice.

Swollen joints

·Assess the swollen part, duration and movement condition.

·Apply local hot compress for the patients with arthralgia due to coldness and dampness, and pay attention to avoiding empyrosis.

·According to the doctor's advice, conduct TCM hydropathic compress, TCM fumigation, external dressing of TCM and acupoint application. For the patients with shoulder pain, the points including Quchi, Jianyu and Shousanli can be selected; for the patients with knee pain, the points like Zusanli, Weizhong and Yanglingquan can be chosen.

Inconvenient flexion and extension

·Assess the range and duration of limitation of motion, and take safeguard procedures to prevent tumble or other accidents if necessary.

·Based on the doctor's advice, apply TCM smearing, TCM soaking, TCM iontophoresis and wax therapy.

TCM special nursingMedications

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, the herbs should be taken according to 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 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.

ExternalapplicationofChineseherbs

(1) Tell the patients the possible dye due to external application of Chinese herbs.

(2) Others

·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.

Special techniques

TCMhydropathiccompress

·According to the doctor's advice, select the correct drugs and perform TCM hydropathic compress.

·Assess the skin in the part of hydropathic compress. It should be used with caution for the patients with drug/skin allergy and those with rapidly diffused ulcerative abscesses.

·Expose the part of hydropathic compress, and pay attention to keeping warm and protecting the privacy.

·Make the gauze with 5-6 layers dipped into the drug liquid, and keep the humidity of no dripping. Keep the temperature of drug liquid at 38-41℃ to prevent empyrosis.

·Observe local skin reactions during operation. Stop the treatment immediately, inform the doctor and take symptomatic treatment according to the doctor's advice if the symptoms, such as pale skin, erythema, blister, pruritus, pain or rupture, occur.

·Implement corresponding nursing following the doctor's advice if there are special drugs.

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

·Record the part, time and temperature of hydropathic compress, as well as patients' feelings after all the operations are 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 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.

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; forbid to use it for the patients with drug and skin allergy and infants.

·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.

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.

TCMsoaking

·Conduct TCM soaking following the doctor's advice.

·Assess the skin in the part of TCM soaking 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 soaking process and cautions before operation, and communicate with the medical staff promptly once discomforts occur.

·It is inappropriate to soak in fasting state and within 1 hour after meals. Immediate soaking 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 soaking location thoroughly, and make the ankle of two feet soak in the liquid.

·Keep the liquid temperature at 37-40℃ and the soaking 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 TCM soaking.

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

TCMiontophoresis

·Conduct TCM iontophoresis following the doctor's advice.

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

·Inform the patients of iontophoresis process and announcements before operation, and tell the doctor to deal with it if the discomfort appears.

·Keep the operating environment warm, expose the treatment part, pay attention to keeping warm and protecting 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 all the operations are finished.

TCMsmearing

·Perform TCM smearing 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 TCM smearing, and conduct the smearing times 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 smear too much in the local part to avoid clogging pores.

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

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

Waxtherapy

·Conduct wax therapy techniques following the doctor's advice.

·Nursing assessment: prohibit using it for the patients with weak constitution, high fever, acute purulent inflammation, tumors, tuberculosis, cerebral arteriosclerosis, heart and kidney failure, bleeding tendency, hemorrhagic diseases, local skin wound or ulcer and sensory disturbance, as well as the children.

·Control the wax temperature and protect the treatment part. Do not squeeze vigorously.

·Keep the time of each wax therapy for 30-60 min.

·Pay attention to the patients' feelings to the heat during operation, and immediately take relevant measures when burning sensation or discomforts occur.

·Tell the patients to keep warm and have a half-an-hour rest, record the wax therapy part, time and patients’ feelings after all the operations are finished.

Healthy guidanceDaily life

·Keep warm for the joint, prevent the wind chill and moisture, and do not blow up at sweating.

·Pay attention to protecting the joint in daily activities, and wear the waist supporter, kneecap and neck collar to reduce accidental injuries, such as joint sprain and bruise. The patients with the lesion in cervical vertebrae should avoid lowering their heads for a long time, incorrect positions should also be corrected; those with the lesion in lumbar vertebrae, knees and hip joints should avoid walking and standing for a long time.

Dietary guidance

·Syndromeofliverandkidneydeficiency: It is advisable to eat the food that can replenish the liver and kidney, strengthen tendons and bones, such as black bean, black sesame, mutton and Chinese chives.

·Syndromeofcold-dampnessblockage: It is advisable to eat the food that can warm meridians to disperse cold, such as coix seed, Chinese chives, mutton and dry ginger. The cold food is forbidden.

·Syndromeofdampness-heatblockingcollaterals: It is advisable to eat the food that can clear away heat, promote dampness and dredge collaterals, such as loofah, white gourd, red bean and corn stigma. Spicy, greasy foods and alcohol are forbidden, but it is necessary to drink a lot of water.

·Syndromeofphlegm-stasisobstruction: It is advisable to eat the food that can resolve phlegm and remove stasis, including radish and hawthorn. The food that can result in phlegm and dampness should be prohibited.

·Syndromeofqiandblooddeficiency: It is advisable to eat the food that can invigorate qi and blood, such as jujube, longan and donkey-hide gelatin, and the food including animal liver and spinach which is rich in iron

Emotional adjustment

·Introduce the development, progression and prognosis of OA to the patients and make them cooperate.

·Assess the patients' social psychological status timely to remove the negative emotions.

·Strengthen the inspection tour for the patients with emotional disturbance, and advise them to invite the psychological consultant for treatment.

Rehabilitation guidance

(1) For improving the muscular strength and endurance, guide the patients in bed or those difficulty performing daily activities to do the joint active or passive movements; take exercises gradually or properly after remission.

(2) It is advisable for the patients with acute-phase severe arthralgia to stay in bed to relieve the joint load. After remission, the patients can gradually take non-weight-bearing exercises to strengthen the muscular strength and endurance. They can appropriately get out of bed for activities at remission stage, and increase the activity level gradually at restoration stage, such as walking and swimming.

(3) According to the joint lesion part, degree and symptoms, select the proper functional training methods under the guidance of medical staff. For example, the patients mainly with the facet joint lesions can do the movements, including the method of catching empty air and holding things; the patients primarily with spondyloarthropathy can do the movements of expanding chest and bending down, as well as the movement like swallows; the patients with the major lesion in both knees can do the movements involving riding bicycles, swimming and walking.

(4) Do movements gently and slowly, avoid taking strenuous exercises; pay attention to keeping warm for the knees, and prevent the wind chill from invading the body; cooperatively use the waist supporter, kneecap and walking stick to relieve the joint burden.

(5) Take rehabilitation exercises under the guidance of medical staff.

·The method and intensity of functional training should be based on the doctor's advice.

·The principle of functional training is to stretch the joint maximumly under no conditions of pain and exhaustion. It does not meant that the more activities, the better and the more painful, the better.

·Chose appropriate ways of exercises, such as walking and swimming. The activities that can increase the burden of knees are unadvisable, including climbing hills, deep squat and climbing stairs.

·Take moderate exercises to reinforce muscle contraction, improve joint flexibility and prevent osteoporosis; tell the patients that unreasonable exercises can aggravate the joint burden.