Traditional Chinese medicine nursing protocols for herpes zoster

ABSTRACT: Herpes zoster is a viral infection caused by the reactivation of endogenous latent varicella zoster virus resulting in varicella, characterized by pain and vesicles in the restricted dermatomal distribution that occurs along the nerves with dormant virus. Postherpetic neuralgia (PHN) is the most common sequela of herpes zoster, occurs or persists after the rash has resolved. It is currently recognized that both herpes zoster and PHN have a substantial impact on the patients' quality of life and daily activities. In recent years, traditional Chinese medicine (TCM) has shown a certain effect in the treatment of herpes zoster. This article mainly explored the key points of common syndromes, TCM nursing methods and health guidance of herpes zoster in order to further develop the advantages of TCM, improve its efficacy and standardize its nursing behavior.

KEY WORDS: herpes zoster; traditional Chinese medicine nursing; syndrome differentiation; pain; postherpetic neuralgia

Herpes zoster, also termed as shingles, is a viral infection believed to be caused by the reactivation of endogenous latent varicella zoster virus (VZV) resulting in varicella (chickenpox), and is characterized by pain and vesicles in the restricted dermatomal distribution that occurs along the nerves with dormant virus[1]. In general, the disease reactivation will occur when the resistance against this virus declines due to selective cell-mediated immune suppression or there is a generalized immune suppression. According to statistics, there are a quarter of the populations at risk of developing herpes zoster during their lifetime, and two thirds of people with this disease are more than 50 years old[2-4]. The incidence and severity of herpes zoster increase with age[5]. Postherpetic neuralgia (PHN) is the most common sequela of herpes zoster, occurs or persists after the rash has resolved. At present, the cause of PHN is unknown. It is increasingly recognized that both herpes zoster and PHN have a substantial impact on the patients' quality of life and ability to function in their normal activities[6]. In particular, the acute and chronic pain may impact the patients' activities of daily living, social interactions and psychological well-being[7], and may even reduce the capability of patients to maintain an independent way of living[8].

Generally, the occurrence of herpes zoster is related to the immune function in the body[9]. In traditional Chinese medicine, it is believed that the occurrence of herpes zoster is caused by stagnation of dampness-heat and fire toxin in the meridians and collaterals to attack the skin externally due to emotional internal injuries, dietary disorder, disharmony of liver and gallbladder, qi stagnation and dampness retention transforming into heat and fire. The therapeutic principles should be purging heat, resolving toxin, promoting dampness and relieving pain. Huang et al.[10]found that TCM cold compress could shorten the course of treatment, promote the escharosis of vesicles and relieve the pain of patients with herpes zoster. Zhou et al.[11]believed that thumb-jar physiotherapy could effectively alleviate the pain severity of patients with PHN. Hence, TCM has shown a certain effect for herpes zoster. In order to maintain and develop the advantages of TCM, improve its efficacy and standardized its behavior, TCM nursing protocols for herpes zoster are formulated byStateAdministrationofTraditionalChineseMedicineofthePeople'sRepublicofChina.

Key points of common syndromes

Syndrome of heat accumulated in the liver meridian: common in the acute stage. Bright red skin lesion, tense vesicular wall, scorching heat, stabbing pain, bitter taste in the mouth, dry throat, irritability and anxiety, dry stool or yellow urine; red tongue with thin yellow coating or thick yellow coating.

Syndrome of dampness accumulation due to spleen deficiency: light-colored skin lesion, loose vesicular wall, accompanied by pain, no thirst, poor appetite, abdominal distension, loose stool sometimes; light-colored tongue with white or white greasy coating.

Syndrome of qi stagnation and blood stasis: common in the period of PHN. Continuously local pain after deflorescence; dark tongue with ecchymosis, white tongue coating.

Nursing for common symptoms/syndromes Pain

· Assess the part, nature, intensity, duration and concomitant symptoms of pain, 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.

· Take the auricular-plaster therapy according to the doctor's advice, and select the points like lung, liver, endocrine, subcortex, adrenal gland, etc.

· Perform acupoint massage following the doctor's advice, and select the points of Hegu, Yanglingquan, Taichong, etc.; select Ashi point during PHN.

· Take the cupping therapy (pricking blood) following the doctor's advice.

· Apply TCM diagnostic equipment to relieve the pain according to the doctor's advice, such as microwave, low frequency, phototherapy, electrotherapy, magnet therapy, etc.

Papule and vesicles

· Assess the part of skin lesion, size of vesicles, character of vesicular liquid and the intensity of vesicular wall, etc.

· Guide the patients to trim fingernails to avoid rubbing and scratching, and keep the skin lesion clean and dry. Hot water and soap are contraindicated for the local skin, and chemical detergents are contraindicated for the clothes to avoid stimulating the skin.

· Guide the patients to take a decubitus of the health side to prevent squeezing-induced vesicular rupture.

· Encourage the patients to do the blink movements to prevent adhesion when the skin lesion involves the eyes; apply eye drops (once per 2-3 h in the daytime) and eye ointment (use at night, and cover the eyes with the gauze) following the doctor's advice; closely observe the changes of pathological condition in the ocular region and vision to prevent ulcerative keratitis.

· Cut out the local hair to keep the wound clean when the skin lesion occurs in the hair part, such as the scalp, armpit, vulva, etc.

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

· Apply TCM diagnostic equipment to relieve the pain according to the doctor's advice, such as microwave, low frequency, phototherapy, electrotherapy, magnet therapy, etc.

TCM special nursing

Medications

InternalapplicationofChineseherbs

· Medication time: Each dose of herbs can be taken generally 2 or 3 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, it should be followed 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 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 should be observed closely, especially in 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 drug-induced adverse reactions.

· 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.

Special techniques

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 to use them in the inflammatory, ruptured and frozen skin as well as in pregnant women.

· Keep the intensity of probe moderate and accurately seek the sensitive point in acupoint area.

· Scrub the ears with 75% alcohol.

· Observe the patients' condition, stop immediately and inform the doctor to deal with it if discomforts occur.

· Select one ear for routine performance, keep the beans usually for 3-7 days and use them in two ears alternately; guide the patients to press them correctly.

· Observe the fixed degree of auricular point sticking and the 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 performance.

Cuppingtherapy

Sterile operations should be conducted when pricking blood with cupping is done.

· Do cupping following the doctor's advice, and select the correct cupping parts and methods.

· Nursing assessment: observe the condition of skin in the cupping part and the patients' tolerance to the pain. Cupping therapy is unsuitable in the parts including skin ulcer, edema, much hair, large blood vessels, and in the lumbosacral part of pregnancy women. It is also unsuitable for the patients with convulsion due to high fever and disturbances of blood coagulation.

· Take a reasonable position to make cupping part exposed completely, and pay attention to keep warm and protect the privacy.

· Check whether there is a break at the edge of jars, and whether it is glossy. Select proper cupping jars according to different parts.

· Observe the adhesion condition and skin color during cupping. Inquiry the patients' feelings, and take off the jars immediately to avoid empyrosis if discomforts appear.

· Do cupping accurately, rapidly and steadily, and don't pull the jars when taking off them.

· Keep a comfortable distance for the arrangement of many jars to avoid the pain induced by jar traction.

· Generally, the local flushed or cyanosis (blood stasis) skin is normal after the jars are taken off, and it will disappear spontaneously. It is unsuitable to do cupping in the previous site if local blood stasis is severe. It is unnecessary to deal with local vesicles, but if the vesicles are bigger, the liquid in them should be extracted using the injector after the local skin is sterilized, and the sterilized dressing is covered.

· Record the cupping part, time and patients' feelings after all the operations are finished.

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.

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.

Healthy guidance

Daily life

· Keep the bed sheet and clothes clean, wear loose and cotton clothes to avoid injuring the skin, leading to discomforts or wound infection.

· Keep the hands clean, and trim the fingernails frequently to avoid scratching the skin lesion.

· Encourage the patients to take exercises properly, such as walking, doing eight trigrams boxing and Tai Chi, etc.

Dietary guidance

· Syndrome of stagnant heat in the liver meridian: It is advisable to eat the food that can clear fire in the liver and gallbladder, such as fresh leaf vegetables, watermelon, white gourd, cucumber, orange, bitter gourd, mung bean, etc. The seafood and allergic food are forbidden.

· Syndrome of dampness accumulation due to spleen deficiency: It is advisable to eat the food that can invigorate the spleen and promote dampness, such as Chinese yam, hyacinth bean, jujube, sweet potato, pearl barley, etc. The cold food is forbidden.

· Syndrome of qi stagnation and blood stasis: It is advisable to eat the food that can promote qi circulation and activate blood to remove stasis, such as white radish, citrus, agaric, oilseed rape, black soya bean, etc. Sweet food and the food easy to cause flatulence are forbidden.

Emotional adjustment

· Establish a good relationship with the patients actively to remove their strangeness and nervousness, and to make them receive the treatment and nursing happily.

· Introduce the cause of pain, disease course and methods of pain remission to the patients to remove their dread feeling to the pain.

· Guide the patients to relax and distract the attention by chatting or listening to the radio to relive the pain.