Traditional Chinese Medicine nursing protocols for osteonecrosis of the femoral head in adults Editorial Board of Nursing of Integrated Traditional Chinese and Western Medicine

ABSTRACT: Osteonecrosis of the femoral head (ONFH) is a disabling pathology influencing the population averagely aged 33-38 years. It is characterized by a compromised subchondral microcirculation, especially in the small retinacular vessels. The prevalence of ONFH is relatively high in China. At present, the surgery is the optimal treatment modality for ONFH, but it still can result in many complications. In recent years, traditional Chinese Medicine (TCM) has shown unique advantages in ONFH, including internal application and external application of Chinese herbs, TCM fumigation, TCM iontophoresis, TCM Tazi and so on. This article primarily investigated the key points of common syndromes, TCM nursing methods and healthy guidance of ONFH in adults, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

KEY WORDS: osteonecrosis; femoral head; hip pain; traditional Chinese medicine nursing

Osteonecrosis of the femoral head (ONFH), also termed aseptic necrosis of the femoral head (ANFH) or avascular necrosis of the femoral head (AVNFH), is considered as an extremely complicated pathophysiological process that involves venous congestion and the impairment or interruption of the blood supply to the femoral head, consequently leading to the cell death within the femoral head[1-2]. Its major clinical manifestations include necrotic marrow elements, dead osteocytes and insufficient vasculature in a specific region of the femoral head[3]. In China, 8.12 million cases of ONFH were estimated to occur in people aged 15 years or above, and the prevalence was more common in males than females[4].

ONFH is generally caused by direct trauma, such as hip dislocation[5], femoral neck or head fracture[6], and severe hip contusion or sprain[7], and non-trauma. Until now, the pathogenesis of ONFH caused by non-trauma remains unclear, but it is usually believed that the occurrence of ONFH is associated with alcohol abuse, dysbarism, corticosteroid use, smoking, sickle cell disease, pancreatitis and autoimmune diseases[4]. The surgery is regarded to be the optimal treatment modality for ONFH, which can relieve the pain and retain mobility[8-9]. Although the effect of hip replacement on ONFH has been recognized in public, it still results in many complications, such as bone resorption, bone atrophy, recurrent dislocation, prosthetic loosening and pain in the lower limbs[10]. Additionally, more revision surgeries are usually required for some patients once the hip replacement is performed.

In recent years, traditional Chinese medicine (TCM) has shown unique advantages in ONFH, including internal application and external application of Chinese herbs, TCM fumigation, TCM iontophoresis, TCM Tazi and so on. For example, Zhao et al.[11]found that Zhuanggu Decoction was effective in the treatment of ONFH. The syndrome differentiation and nursing are carried out in TCM based on the pathogenesis and clinical manifestations, in which syndrome differentiation and accurate medication play a key role in ONFH. In view of this, State Administration of Traditional Chinese Medicine of the People's Republic of China formulated a TCM nursing protocol for ONFH in adults, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

Keypointsofcommonsyndromes

SyndromeofbloodstasisandQistagnation: fixed stabbing pain in the hip aggravated at night, inconvenient joint flexion and extension; dark red tongue or with petechiae, yellow tongue coating.

Syndromeofkidneyastheniaandbloodstasis: endlessly dull hip pain, stiff joints, accompanied by vexation, insomnia, thirst, dry throat and flushed face; red tongue with yellow dry or yellow greasy coating.

Syndromeofphlegm-stasisaccumulation: heavy hip accompanied by fixed pain, swollen joints, inconvenient flexion and extension, numbness of the skin and obese constitution; grey tongue.

Nursingforcommonsymptoms/syndromes

Hippain

·Assess the pain location, nature, duration and its relationships with the load, activity and body position, 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 used.

·Stay in bed and get out of bed for activities using a walking stick to avoid bearing load of the diseased limb.

·According to the doctor's advice, perform TCM fumigation, Tazi, external dressing and iontophoresis.

Inconvenientjointflexionandextension

·Assess the effect of stiff hip joints and limited motion on the activities of daily living, and offer daily necessities for the patients.

·Based on the doctor's advice, assist the patients to take passive exercises of the hip joint.

·Conduct TCM Tazi and fumigation following the doctor's advice.

TCMspecialnursing

Medications

InternalapplicationofChineseherbs

(1) Syndrome of blood stasis and Qi stagnation: take the warm herbs with the functions of promoting Qi to activate blood and resolving stasis to relieve pain before meals.

(2) Syndrome of kidney asthenia and blood stasis: take the warm herbs with the effects of tonifying liver and kidney and promoting Qi to activate blood after meals.

(3) Syndrome of phlegm-stasis accumulation: take the phlegm-eliminating, dampness-resolving, blood-activating and stasis-resolving herbs between meals.

(4) Others.

·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

·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

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.

TCMTazi

·Perform TCM Tazi according to the doctor's advice.

·Nursing assessment: skin sensory perception. Appropriate temperature is suitable for the patients insensitive to sensory perception. It is used with caution for the patients allergic to TCM or infants. It is forbidden to use for the patients with skin vesicles, scar and rupture in the treatment part and those with active bleeding or tendency of bleeding.

·Expose the treatment part thoroughly, and be cautious to keep warm and protect privacy.

·Select the appropriate wad based on the treatment part, make the drug liquid soak and keep a proper humidity (no dripping).

·Keep a proper temperature of drug liquid (skin tolerance) to prevent the skin from empyrosis, and soak after reheating if the drug liquid is cold. For Reta and Yanfu, the temperature should be controlled in 45-60 ℃.

·Be cautious to make an inspection tour and observation, stop treatment and inform the doctor immediately to take measures when the erythema, pruritus, redness or vesicles appear in the local skin.

·Record the condition of skin in the treatment part and patients' feeling 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.

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.

TCMnursingintheperioperativeperiod

Dysuria

·According to the doctor's advice, conduct the moxibustion and select the points like Zhongji, Guanyuan and Qihai.

·Hot compress the lower abdomen, combine the acupoint massage and select the points including Zhongji, Guanyuan and Qihai.

Abdominaldistensionandconstipation

·Conduct the acupoint massage following the doctor's advice and select the points like Guanyuan, Zusanli, Daheng and Tianshu.

·According to the doctor's advice, take an auricular-plaster therapy and select the points including larger intestine, small intestine, spleen, stomach and sympathia.

·Perform abdominal massage, and paste Chinese herbs on the navel if necessary.

Healthyguidance

Dailylife

·Stay in bed when severe pain occurs, use a walking stick or sit in a wheelchair after getting out of bed.

·Keep a lower room temperature and cool, moist environment for the patients with kidney-yin deficiency; arrange a sunny ward for the patients with kidney-yang deficiency as soon as possible.

·Teach the patients correct sleeping and sitting postures and avoid the movements, such as squatting, sitting on a short stool, bending down and tying the shoes forward.

·Tell the patients the importance of using a walking stick to the rehabilitation, and teach them to use the walking stick exactly and its maintained method.

·For the patients with the unilateral lesion, insist on using a walking stick and do not take a load-bearing walk; for the patients with bilateral lesions, use a wheelchair to avoid the femoral head collapse.

Dietaryguidance

·SyndromeofbloodstasisandQistagnation: It is advisable to eat the food that can promote Qi to relieve pain and activate blood to resolve stasis, such as white radish, perch, brown sugar, hawthorn, ginger, peach seed and lily. The fried, greasy, sapid and cold foods are forbidden. Dietary formula: Hawthorn & peach seed porridge.

·Syndromeofkidneyastheniaandbloodstasis: a. It is advisable for the patients with kidney-yin deficiency to eat the food with the function of nourishing kidney yin (excluding the radish), including jujube, wolfberry fruit, black sesame, turtle and peach seek. It is unsuitable to take the spicy food. Dietary formula: Wolfberry fruit & jujube porridge. b. It is advisable for the patients with kidney-yang deficiency to eat the food that can warm and invigorate kidney yang, such as black bean, walnut, almond, cashew nut and black sesame. The cold food is forbidden. Dietary formula: Walnut & black sesame porridge. c. It is advisable for the patients with blood stasis to eat the food that can activate blood to remove stasis, such as brown sugar, hawthorn, ginger and peach seed. It is unsuitable to take the fried, greasy and sapid foods.

·Syndromeofphlegm-stasisaccumulation: It is advisable to eat the food that can invigorate spleen, eliminate dampness, promote Qi and activate blood to resolve stasis, such as white radish, Chinese yam, coix seed, red bean and black fungus. It is unsuitable to eat the spicy, dry and greasy foods that can generate phlegm and aggravate dampness. Dietary formula: Coix seed & red bean porridge, rib soup with white gourd.

Emotionaladjustment

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

·Tell the patients and their relatives about the long treatment time, and encourage the relatives to accompany the patients and to give them emotional support.

·Introduce the successful cases to the patients to make them build confidence in defeating the disease.

Rehabilitationguidance

·At the time of carrying, gently, stably and accurately lift the hip at the horizontal position to prevent the dislocation of hip joint.

·According to the doctor's advice, guide the patients to take active exercises of extending and flexing hip joints once or twice a day, 20-30 min per time. It should be noted that the extension and flexion of hip joints are no more than 30° and 90°, respectively.

·Three taboos for the patients after hip replacement: no crossing the legs, no adduction and squatting >90°.

·Postoperative rehabilitation: a. take a horizontal position on the day of operation, lift the diseased limb, keep 15-30° of the hip joint extension in the affected side and place a soft pillow between legs. b. Six hours after operation, guide the patients to take exercises of quadriceps femoris static contraction and dorsal stretch and plantar flexion of ankle joints. c. Take a horizontal position on the second day after operation, and flex the hip joint ≤90° if sitting up.

·After removing the drainage tube, monitor and guide the patients to use the functional rehabilitation machine for the lower limbs, such as continuous passive motion (CPM), to do the extension and flexion of hip joints.