Traditional Chinese medicine nursing protocols for hemorrhoids (external hemorrhoids)

ABSTRACT: Hemorrhoids, one of the common anorectal diseases, are characterized by painless rectal bleeding during defecation with or without prolapsed anal tissues. It is universally recognized that the occurrence of hemorrhoids is not only related to the conditions that increase intra-abdominal pressure, but also to the aging, obesity, depressive mood, pregnancy, and so on. The treatment for hemorrhoids mainly depends on their types and severity, patient's preference and expertise of physicians. In recent years, traditional Chinese medicine (TCM) nursing has developed rapidly and shown some unique superiorities in the treatment of hemorrhoids. This article mainly explored the key points of common syndromes, TCM nursing methods and health guidance of hemorrhoids (external hemorrhoids) in order to further develop the advantages of TCM, improve its efficacy and standardized its nursing behavior.

KEY WORDS: hemorrhoids; perianal swelling; traditional Chinese medicine nursing; syndrome differentiation

Hemorrhoids, one of the common anorectal diseases, are defined as the symptomatic enlargement and/or distal displacement of anal cushions, clinically characterized by painless rectal bleeding during defecation with or without prolapsed anal tissues[1-2]. The exact prevalence of hemorrhoids is unknown because most patients are asymptomatic and do not seek care from a physician[3]. However, the prevalence of hemorrhoids is gradually increasing. It was found that 39% of patients undergoing routine colorectal cancer screening and 55% of those reporting no symptoms suffered hemorrhoids[4], and 25% of British people and 75% of American citizens were estimated to experience hemorrhoids at some time in their lives, especially in people aged 45-65 years[5-6]. At present, the etiology of hemorrhoids is not well understood, but it is related to the conditions that increase intra-abdominal pressure, such as prolonged straining and constipation. In addition, other risk factors have also been claimed, including aging, obesity, depressive mood, pregnancy, chronic diarrhea, pelvic floor dysfunction, and so on[5].

Generally, hemorrhoids can be divided into internal hemorrhoids and external hemorrhoids. The treatment for hemorrhoids mainly depends on their types and severity, patient's preference and expertise of physicians. External hemorrhoid frequently requires no specific treatment unless it causes patient's discomforts or becomes acutely thrombosed. Although the conservative management with topical therapies is reasonable for thrombosed external hemorrhoids, surgical removal of the thrombus has advantages of rapid symptom remission and lower risk of recurrence[7-9]. The requirements for surgical care is relatively higher because some complications like edema, pain and infections may be occur postoperatively, which can prolong the wound healing time. For the past few years, traditional Chinese medicine (TCM) nursing has developed rapidly in the context of vigorous expansion of TCM advocated by the government and shown some unique superiorities in the treatment of hemorrhoids. Zhou et al.[10]found that TCM fumigation and external dressing could effectively shorten the patient's wound healing time and improve the postoperative symptoms of pain, bleeding and edema. Therefore, TCM nursing protocols for hemorrhoids (external hemorrhoids) are formulated by National Administration of Traditional Chinese Medicine to further maintain and develop TCM advantages, improve its efficacy and standardized its behavior.

KEYpointsofcommonsyndromes

·Syndromeofqistagnationandbloodstasis: a prominent lump in the anal margin that can enlarge at the time of defecation, presence of foreign body sensation, possible occurrence of distending pain or bearing-down pain, and locally palpable hard nodules; dark purple tongue with yellow thin coating.

·Syndromeofdampness-heatdiffusingdownward: an intumescent lump in the anal margin, scorching pain or local presence of secretion, dry stool or loose stool; red tongue with yellow greasy coating.

Nursingforcommonsymptoms/syndromes

Pain

·Observe the pain degree, nature and duration, 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 applied.

·Avoid perianal extrusion and traction. Wash the perianal part after defecation, make it dry with soft napkins by using dipping method to prevent skin injury and keep it clean and dry.

·Take the intermediate-frequency physiotherapy based on the doctor's advice, and select the points like Neiguan, Hehu, Chengshan, Changqiang, etc.

·Take the auricular-plaster therapy according to the doctor's advice, and select the points like sympathia, Shenmen, large intestine, lower rectal segment, anus, etc.

·Perform TCM fumigation, TCM bath, TCM hydropathic compress and external dressing following the doctor's advice.

Perianalswelling

·Observe the edematous degree, peripheral skin integrity, presence or absence of breakage and bleeding.

·Assist the patient to take a suitable position, avoid sitting or standing for a long time.

·Keep the perianal skin clean and dry.

·Keep bowel movements smooth, do not squat and put forth effort for a long time at the time of defecation.

·Take a physiotherapy, TCM fumigation, TCM hydropathic compress and external dressing according to the doctor's advice.

Constipation

·Keep bowel movements smooth, do not squat and put forth effort for a long time at the time of defecation.

·Drink warm boiled water no less than 500 mL in the morning. The patients without diabetes mellitus can drink honey water more than 2 000 mL every day.

·Perform abdominal massage and acupoint application following the doctor's advice.

·Take the auricular-plaster therapy according to the doctor's advice, and select the points like lung, large intestine, small intestine, lower rectal segment, Sanjiao, endocrine, etc.

·Conduct acupoint massage following the doctor's advice, and select the points like Tianshu, Quchi, Hegu, etc.

TCMspecialnursing

Medications

InternalapplicationofChineseherbs

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

·Medication temperature: The administered warm is usually adopted. For the patients with special treatment, 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 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 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 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, 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.

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.

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 walk-around 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 min 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.

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.

ExternaldressingofTCM

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

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

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

·Keep the operation environment warm.

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

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

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

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

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

Acupointmassage

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

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

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

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

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

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

Acupointapplication

·Conduct acupoint application following the doctor's advice.

·Nursing assessment: the skin condition in the part of acupoint application; it is forbidden for pregnancy women.

·Expose the part of acupoint application completely, and pay attention to keep warm and protect 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.

Abdominalmassage

·Conduct abdominal massage following the doctor's advice.

·Assess the condition of skin in the part of massage. It is forbidden for the patients with acute abdomen and abdominal tumors. Syndrome differentiation: massage clockwise for sthenia; massage anti-clockwise for asthenia.

·Make the urine empty and wash hands to massage abdomen before sleep at night and getting up.

·Take a supine position with both knees bended.

·Stack up both hands in the abdomen and keep the palm against the navel to knead the abdomen around the navel for 5-10 min.

·Keep a uniform intensity and proper speed during operation, and pay attention to protecting the patient's privacy.

·Record the manipulation and time of abdominal massage, as well as patients’ feelings after all the operations are finished.

TCMnursingintheperioperativeperiod

Perform TCM fumigation according to the doctor's advice.

Dysuria

·Assist the patients to take suitable positions.

·Apply hot compress in the lower abdomen.

·Conduct acupoint massage based on the doctor's advice, select the points like Qihai, Guanyuan, Yinlingquan, Sanyinjiao, etc.

·Take the auricular-plaster therapy according to the doctor's advice, and select the points like brain, kidney, urinary bladder, sympathia, Shenmen, subcortex, etc.

·Take hot medicinal compress therapy according to the doctor's advice, and select the points like Qihai, Guanyuan, Yinlingquan, etc.

·Perform moxa-moxibustion following the doctor's advice, and select the points like Qihai, Guanyuan, Zhongji, etc.

·Perform acupoint application following the doctor's advice, and select the points like Shenque, etc.

Healthyguidance

Dailylife

·Guide the patients to have a good habit of regular bowel movements, and control the defecation time within 10 min every time. Do not put forth effort, read books and newspapers and smoke at the time of defecation. Guide the patients fearing pain to defecate, and fumigate with warm water or TCM after defecation.

·Select the loose cotton underwear and soft toilet tissues.

·Avoid siting, standing or squatting for a long time, and avoid sitting on the overheating, undercooling and wet objects or ground.

·Teach the patients to do levator movements. Methods: contract and raise the anus when taking a deep inspiration, relax the anus slowly when taking an expiration, and do this 20-30 times in the morning and before sleep every day (one contraction and one relaxation as once).

Dietaryguidance: Spicy and stimulating foods, as well as alcohol are forbidden.

·Syndromeofqistagnationandbloodstasis: It is advisable to eat the food that can regulate qi and dredge collaterals, activate blood to remove stasis, such as apple, rose, radish, etc. Dietary formula: Rose tea.

·Syndromeofdampness-heatdiffusingdownward: It is advisable to eat the food that can clear away heat and remove dampness, such as red bean, loofah, lotus root, etc. Dietary formula: Red bean porridge.

Emotionaladjustment

·Reasoning method: Interpret the occurrence of qi movement dysfunction easily caused by contemplation injuring spleen and restless mind to the patients, and guide the patients to overcome unfavorable psychological factors consciously.

·Method of explaining doubts: Attach great importance to the patient's chief complaint, and answer questions timely; organize communicating meetings for patients with the same disease category; guide the relatives to give more support to the patients.

·Mutual conquering method of five elements: Guide the depressed patients to watch or listen to a comedy, cross talk and joyful music; guide the angry and fretted patients to take a deep breath and meditate for relaxation, as well as to listen to music including Mountain and Flowing Water and Fishing Boat in the Evening.