Traditional Chinese medicine nursing protocols for COVlD‑19

Mei‑Zhen LIN, Qiao‑Mei WU, Yu LIU, Zhong‑De ZHANG, Gang‑Yi PENG, Chang‑Xiu WAN,Xiao‑Pan WANG, Ying‑Rui MA, Ping XIONG, Hui‑Chao CHEN, Qiu‑Ying DENG, Li‑Li DENG,Ding‑Rong QIU, Lin WEI, Jiu‑Hong YOU, Yang‑Chen LIU, Guang‑Qing ZHANG, Li‑Xia KOU,Ming‑Ming XU0, Yu‑Mei CHEN, Yin‑Qin ZHONG, Xiao‑Qin LU, Han‑Jiao LIU, Jin ZHOU, Hong YE,Xiao‑Zhen GONG, Shi‑Miao LUO, Xi‑Yan HU

1Nursing Department, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, China; 2Hospital Office,Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, China; 3 Health Commission of Guangdong Province,Guangzhou, China; 4Nursing Department, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China; 5Nursing Department, Hubei Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Wuhan, China; 6Nursing Department,Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang, China; 7Nursing Department, Nanchang Ninth Hospital, Nanchang, China; 8Hospital Office, Nursing Department, Southern Hospital of Southern Medical University, Guangzhou,China; 9Nursing Department, Guangdong Provincial Second Traditional Chinese Medicine Hospital, Guangzhou, China; 10Nursing Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China; 11Nursing Department, Foshan Traditional Chinese Medicine Hospital, Foshan, China; 12Nursing Department, Shenzhen Hospital of Guangzhou University of Traditional Chinese Medicine, Shenzhen, China; 13Nursing Department, Dongguan Traditional Chinese Medicine Hospital, Dongguan, China; 14Nursing Department, Shenzhen Bao’an Traditional Chinese Medicine Hospital, Shenzhen, China; 15Nursing Department, Southern Medical University Hospital of Integrated Traditional Chinese and Western Medicine, Guangzhou, China

ABSTRACT

In order to facilitate nurses to understand the key points of COVID‑19’s common syndromes, master the key points of nursing with syndrome differentiation, use the advantages of traditional Chinese medicine (TCM) nursing characteristics, standardize TCM nursing behavior, and improve the TCM nursing effect, through the search of relevant information, combined with the clinical practice experience of more than 1 month of front‑line anti‑epidemic nursing staff, the TCM nursing protocols for COVID‑19 (draft) were formed. After four rounds of expert consultation and discussion, and 15 times of collation and revision, the final version of TCM nursing protocols for COVID‑19 was formed. The TCM nursing protocols for COVID‑19 include the following five parts: key points of common syndromes, nursing for common symptoms/syndromes, TCM special nursing, healthy guidance, and difficulties in nursing; it is scientific and practical, and can provide clinical guidance for nursing of patients with COVID‑19.

Keywords: COVID‑19, nursing, protocol, traditional Chinese medicine

INTRODUCTION

Since December 2019, multiple cases of COVID-19 have been identified in Wuhan, Hubei, and the epidemic has spread rapidly. The National Health Commission of the People’s Republic of China and the National Administration of Traditional Chinese Medicine (TCM) published Diagnosis and Treatment Plan of COVID-19, Trial 5thEdition,[1]Revised 5thEdition,[2]6thEdition,[3]7thEdition,[4]which fully reflects the characteristic advantages of the integration of TCM and Western medicine. The guidance of physician for treatment based on syndrome differentiation tends to be more clear.

In order to facilitate nurses to understand the key points of COVID-19’s common syndromes, master the key points of nursing with syndrome differentiation, use the advantages of TCM nursing characteristics, standardize TCM nursing behavior, and improve the TCM nursing effect, based on the frontline nursing experience of anti-epidemic in Wuhan and relevant information,[5]a number of hospitals and associations (including Guangdong Provincial Hospital of TCM combined with Hubei Provincial Hospital of Traditional Chinese Medicine, Hubei Provincial Hospital of Integrated Traditional Chinese and Western Medicine,Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Nanchang Ninth Hospital, Nursing Speciality Committee of Guangdong Provincial Association of Chinese Medicine, Traditional Chinese and Western Medicine Nursing Speciality Committee of Guangdong Nursing Association, and TCM Nursing Committee of Guangdong Nursing Institution), organized relevant TCM nursing experts to sort out the Traditional Chinese medicine nursing protocols for COVID-19, which can be used as a reference for the majority of nursing staff. All localities can carry out syndrome differentiation for nursing using the recommended protocols according to the condition,local climate characteristics, and different physiques, so as to take full advantages of TCM to provide patients with the best TCM care.

KEY POINTS OF COMMON SYNDROMES

Mild case[1,6]

1. Cold-damp constraint in the lung pattern: It is mainly manifested as fever, fatigue, soreness all over the body,cough, expectoration, chest tightness and suffocation,stupefaction, nausea, vomiting, and sticky and greasy stools. The tongue is pale and enlarged with tooth marks or light red, the fur is white, thick, rotten, or greasy

2. Damp-heat accumulation in the lung pattern: It is mainly manifested as slight fever or no fever, slight aversion to cold, fatigue, heavy head and body tiredness, muscle soreness, dry cough, less sputum, sore throat, dry mouth and no desire to drink, or accompanied by chest tightness, no sweat or poor sweating, or vomiting, loose stools, or sticky stools. The tongue is light red, with white-thick-greasy or thin-yellow tongue fur.

Moderate case[1,6,7]

1. Damp-toxin constraint in the lung pattern: It is mainly manifested as fever, cough, less sputum, or yellow sputum, suffocation, shortness of breath, abdominal distension, and constipation. The tongue is dark red and fat, with yellow-greasy or yellow-dry fur

2. Cold-damp obstructing the lung pattern: It is mainly manifested as slight fever not raising body heat, or not hot, dry cough, less phlegm, fatigue, chest tightness,epigastric fullness, or vomiting, loose stool. The tongue is light or reddish, with white or white-greasy tongue fur.

Severe case[1,6‑8]

1. Epidemic toxin blocking the lung pattern: It is mainly manifested as fever, blushing, cough, yellow and sticky phlegm, or blood in phlegm, shortness of breath, fatigue,dry mouth, nausea, unsmooth defecation, short voiding of reddish urine. The tongue is red and the fur is yellow and greasy

2. Blazing of both qi and ying pattern: It is mainly manifested as great heat, polydipsia, shortness of breath, delirium,blurred vision, or macular rash, or hematemesis, epistaxis,or limb convulsions. The tongue has little or no fur.

Critical case[1,6‑8]

Internal blockage and external desertion pattern: It is mainly manifested as dyspnea, frequent asthma or need for mechanical ventilation, with dizziness, irritability, sweating and cold limbs. The tongue is dark purple, and the fur is thick and greasy or dry.

Convalescence[1]

1. Lung-spleen qi deficiency pattern: It is mainly manifested as shortness of breath, tiredness, nausea, epigastric fullness, defecation weakness, loose stool. The tongue is light and fat, and the fur is white and greasy

2. Deficiency of both qi and yin pattern: It is mainly manifested as fatigue, shortness of breath, dry mouth,thirst, palpitation, perspiration, slight fever or nonheat,dry cough and less phlegm, dry tongue with scanty fluid.

NURSING FOR COMMON SYMPTOMS/SYNDROMES

Fever

1. Keep the ward clean and quiet, fresh and ventilated,warm and comfortable to avoid dampness

2. The clothes and quilts of the patients are warm and breathable, and those with aversion to cold should be paid attention to keeping warm. If the body temperature is above 37 ℃, the vital signs and oxygen saturation are closely monitored according to the doctor’s advice, and the changing rules are recorded[9-12]

3. The body temperature in severe and critical patients is often inconsistent with the severity of the disease.Combined with the respiratory frequency of patients,oxygen saturation or oxygenation index, patients are asked about respiratory feelings and mental changes to find severe indications in time[13]

4. Febrile patients with aversion to cold, or with the pathogenesis of depression based on syndrome differentiation, is not suitable for physical cooling such as bath and ice compress, and warm bags should be given if necessary to help relieve symptoms; Febrile patients with the TCM syndrome of blazing of both qi and ying pattern can receive cooling measures such as wiping bath and ice compress as appropriate based on the trend of body temperature

5. Because fever is easy to consume body fluid, resulting in decreased appetite for dry mouth and easy to be complicated with oral infection, oral care should be done well. Patients with obvious red tongue and fluid deficiency should be instructed to gargle with licorice and lotus leaf water or honeysuckle soaking water, which can be used before and after three meals a day and before going to bed

6. Closely observe the changes of body temperature and sweating when using sweating – promote drugs to release the exterior as directed by the doctor. If possible,add rice soup or hot porridge to promote sweating, and those with dry tongue and body fluid deficiency can take more. Patients should be dried in time after sweating,change their clothes, and avoid sweating in the wind or sweating too much to damage vital qi

7. Auricular-plaster therapy: Embed seeds at auricular points. The main acupoints include sympathetic, adrenal,lung, brain stem, and thalamus. The assistant points include cardia, spleen, stomach, bladder, abdomen, large intestine, and Sanjiao. Guide or assist the patient to press correctly, 3–4 times a day, 3–5 min for each time. Press the acupoints until the whole ear is hot

8. Scraping therapy: Do scraping therapy to dredge the meridians and collaterals to reduce fever. Choose the scope of the dorsal segment of the Du-meridian and bladder meridian, starting from 1 inch above the posterior hairline, ending under the spinous processes of thoracic vertebrae 3 (T3), and covering the shoulder well on both sides. The key acupoints are Dazhui, Dazhu,Fengmen, Fengchi, Fengfu, Feishu, and so on. Scraping takes 20–30 min at a time, and it is appropriate to scrape thoroughly. According to syndrome differentiation, the same sites can be re-treated after 5–7 days

9. Blood-letting puncture: Collateral-pricking for blood-letting is chosen to release heat and pathogen.Purge heat measures is conducted to cool down the body when the body temperature is above 38.5℃.The selected acupoints include ear tip, ear wheel,middle finger abdomen, and Quchi. Attention should be paid to disinfection, isolation, and self-protection.The appropriate amount of blood letting should be 5–10 drops/hole

10. TCM foot bathing: Febrile patients with cold-dampness assailing the exterior can use moxa leaf, Sichuan pepper,cinnamon twig, and other medicine foot bathing formula.TCM foot bathing has the effect of relieving the exterior and opening the closure, dispelling cold, and eliminating dampness, thus heat dissipates with sweat

11. Taking care of the spleen and stomach is the principle in diet. Take the acceptance and transportation capacity of the spleen and stomach as the primary condition for evaluation. Choose a nutritious diet as appropriate to improve the nutritional status and enhance the resistance,such as millet congee, tangerine peel rice, and Huaishan porridge. Cold-dampness patients with fever should eat heat-clearing and dampness-drying food containing perilla, spring onions, ginger, and so on. Patients with damp-heat fever should eat food for clearing heat and dampness, such as poria cocos and adzuki bean. Those who suffer from thirst should eat food that quench their thirst, such as black plum and radish. Avoid greasy and thick flavor, such as glutinous rice and fat meat. Avoid raw and cold food, such as cold fruits.

Dry cough

1. Reduce the adverse stimulation of the environment,such as large temperature difference between indoor and outdoor air, and smoke stimulation

2. Observe the degree and duration of cough and the concomitant symptoms such as phlegm sound,vomiting, shortness of breath, and cyanosis. According to the theory of “the interior and exterior relationship between the lung and the large intestine,” keeping defecation unobstructed helps to downbear qi and stop cough. Therefore, we should observe the frequency and character of defecation every day

3. Instruct patients to protect themselves when coughing,cover their mouth and nose with paper towels, fold them inward, and throw in the trash after coughing to avoid droplets contamination. Clean the mouth twice a day to remove bad breath

4. Instruct the patient to take the sitting position and bend down to relax the abdomen when coughing. If the phlegm is sticky and difficult to expectorate, guide the patient to expectorate phlegm effectively. In the case of normal cardiac and renal function, appropriately increase the amount of drinking water. As for patients whose sputum is sticky and unable to expectorate, mechanical suction is acceptable. Airway humidification should be strengthened for patients with ventilator-assisted ventilation

5. Patients with severe or persistent cough, especially the patients whose sleep is affected at night, should be given antitussive drugs according to the doctor’s advice.Sucking lozenges with the function of soothing and moistening throat or promoting salivation effection or drinking a small amount of lukewarm water frequently to reduce the irritation of the pharynx and larynx is feasible.Pay attention to observe the efficacy of the drug and other symptoms during medication. During the cough interval,massage Hegu, Chize, Tiantu, Danzhong, and Taixi to relieve the symptoms. Press each acupoint for 2–3 min,and keep the strength with local acid distension feeling[10]

6. TCM exercise: Some movements of Baduanjin help to reduce adverse reactions and relieve cough, such as“slowly holding two hands with palms upwards over the head for regulating Sanjiao” and “single lifting one arm over the head for regulating spleen and stomach”practicing breath and vomiting techniques such as Six-Word Qigong can help to restrain lung qi and help kidney absorption. Practice lip contraction breathing for 10–20 min each time, twice a day

7. Acupoint application: For patients with cold-dampness,prepare moxibustion powder with ginger juice to applicate on Tiantu, Dingchuan, Feishu, Pishu, and other acupoints to diffuse the lungs, relieve cough, and dispell cold and dampness. If there is no skin allergy, it can be applied for 30–60 min, once a day

8. TCM hot ironing: For patients without symptoms of defecation, seeds of Brassica alba, perilla seed, radish seed, and Evodia rutaecarpa are fried and hot ironed on acupoints. Dazhui, Dingchuan, and Feishu have the effect of ventilating the lungs and downbearing counterflow (Zhongwan and Shenque can be added if necessary)

9. Auricular-plaster therapy: Select lung, Shenmen, Qiguan,Zhiqiguan, Pingchuan, Zhen, and other acupoints,combined with Naogan, Xiong, Pizhixia, Shen, and other acupoints considering other symptoms and syndrome differentiation of patients. Massage the whole ear to mobilize qi and blood before auricular-plaster therapy

10. Scraping therapy: Mainly scrape the Du-meridian, the bladder meridian of foot Taiyang and the lung meridian of hand Taiyin, with the key acupoints Dazhui, Dazu,Fengmen, Feishu, Lieqian, Chize, Tiantu and Danzhong,so as to achieve the purpose of release the exterior with sweating, releasing qi and blood, dredging muscles and activating collaterals. For old and weak patients, first scrape the heart meridian, pericardium meridian and lung meridian to stabilize the upper energizer. Disinfect the scraper carefully

11. Eat a light, easy-to-digest diet, avoid greasy, spicy,irritating and cold foods. Have more meals a day but less food at each. Eat food which have the effect of suppressing cough, invigorating the spleen and benefiting the lung, such as tangerine peel and yam root porridge, ginger, almond, and pig lung soup.

Weakness

1. Keep the patients’ room tidy and quiet, with fresh air circulation. Keep the room warm and comfortable

2. Observe the duration of symptoms such as fatigue, body aches, and tiredness. Strengthen observation and life care, take protection to keep patient safety, against falls and pressure ulcers in the case of elderly frail patients with obvious fatigue

3. Music therapy: Playing light music which could soothes the patient’s mood facilitates the recovery of the disease

4. TCM sports: TCM believes that a long time lying in bed makes the “qi” of body be destroyed. It is necessary for the weakness patients to exercise properly (not feel tired). Practice Baduanjin, Six-Word Qigong, etc., These sports can adjust the “qi” and blood movements of the meridians and the internal organs to improve the symptoms of fatigue. The practice time and frequency are determined according to the specific conditions of the patient, and patient should not feel tired

5. Auricular-plaster therapy: Auricular points such as sympathy, kidney, liver, mouth, spleen, subcortical nervous system, physical and mental points (before ear)are used to improve the patient’s fatigue symptoms.Massage the whole ear to promote blood circulation in the ear and around the body

6. Moxibustion: The muscle surface has symptoms such as soreness, strong pain, and fatigue due to cold, dampness,and dampness. Moxibustion Shangwan, Zhongwan,Shenque, Dazhui, Fengmen, Feishu, Spleen, Zusanli and other points. Use moxibustion box and moxibustion box to apply moxibustion when necessary. Pay attention to protection safety and oxygen safety

7. TCM foot-bathing: Patients with cold and damp syndrome can apply the formulation of moxibustion of Ay Tsao,Chinese red pepper, cassia twig, and other medicines.The Chinese medicine foot-bathing can relieve the exterior syndrome, eliminating cold and dampness

8. Patient’s diet should be a small amount of multiple meals. Choose foods which are light and easy to digest and absorb to protect the spleen and stomach, such as orange peel millet porridge, and rice soup, and also can be appropriately added medicines, such as astragalus and codonopsis, to supplement “qi.”

Gastrointestinal dysfunction

1. Strengthen basic nursing, for example, using light salt water or mouthwash to take good oral care and remove odor. The patient with weak constitution or delirium vomits should bend the head to one side to prevent vomitus from entering trachea, causing asphyxia. The patient with diarrhea should keep the anus and perineum clean, scrub with soft paper after defecation and wash with warm water

2. Observe the nature and characteristics of various symptoms of gastrointestinal discomfort, such as the nature and amount of vomitus, the frequency, nature and amount of stool, and the extent of abdominal distension and anorexia[12]

3. Take the medicine according to the doctor’s advice and observe the effect of the medicine

4. Encourage patients to exercise more to promote intestinal peristalsis and reduce abdominal distension. Encourage patients with mild illness to exercise for 20–30 min a day,such as tai chi. Guide the patients with serious condition to undertake active motion in the bed, such as turning over, limb activities, sitting Baduanjin, breathing Six-Word Qigong, or assist to give limb passive motion

5. Acupoint massage: Assist the patient to knead, push and rub for about 5 min clockwise along the circle from Zhongwan—Tianshu (left)--Qihai—Tianshu (right)acupoint. Press each of the above points 30 times,2–3 times a day. Patients with abdominal distension and constipation can be added with acupuncture points such as Tianshu, Pishu, and Dachangshu.

6. Acupoint application: Selecte shenque as the main acupoint, supplemented by Zhongwan, Tianshu, Zusanli,Shangjuxu, Xiajuxu or other acupoints. Patients with asthenia-cold syndrome can be treated with raw ginger juice mixed with evodia officinalis powder, and patients with heat syndrome can be treated with rhubarb powder mixed with honey

7. Auricular-plaster therapy: Perform auricular application on auricular acupoints, select Shenmen, Jiaogan, Pishu,Pizhixia as the main points. In addition, patients with nausea and vomiting can be supplemented by Wei, Gan,Dan, Penmen, Pizhixia under nervous system; patients with diarrhea can ne supplemented by Zhen, Shen,Dachang, Zhichang, Yizhuangjiechang; patients with abdominal distension can be supplemented by Wei, Fu,Fuzhangqu, vagus nerve; patients with constipationcan be supplemented by Fei, Sanjiao, to promote intestinal peristalsis. Because auricular acupoints have the function of bidirectional adjustment, so gastrointestinal symptoms can be relieved using the above acupuncture acupoints

8. TCM hot ironing: Patients without difficult defecation can be given hot compress with white mustard seed,Perilla seed, radish seed, evodia officinatum on acupoints Dazhui, Dingchuan and Feishu, and Zhongwan, if necessary, Shenque acupoint can be added to play the role of promoting lung, reducing adverse effects and promoting spleen and stomach

9. TCM retention enema: Chinese medicine enema can be chosen to improve the symptoms of constipation in patients. Dachengqi decoction and Xiaochengqi decoction are commonly used to retain enema in a small amount, so as to clear the intestines and stabilize intestinal flora

10. It is advisable to choose light food easy to digest and absorb, such as vegetables, fruits, yam, millet and tangerine peel. Patients with nausea and vomiting can chew ginger tablets. Patients with anorexia, bloating,abdominal distension and constipation can eat foods that promote gastrointestinal motility and dietary fiber-rich foods, such as vegetables, rhizomes, coarse grains, and radishes, and use laxatives if necessary.Patients with sticky and unpleasant stool due to hot and humid in the gastrointestinal tract can add lotus root, chrysanthemum and other foods to clear heat and dampness. Loose stool is mainly caused by heavy cold and damp in spleen and stomach, so hot food such as ginger and pepper can be added to the ingredients; while foods that easily cause acid reflux,such as sweets, soy products and sweet potatoes are fasting foods. In addition, greasy thick flavor foods,such as glutinous rice, fatty meat and cold foods are also fasting.

Anxiety and fear

The epidemic is mainly caused by six exogenous pathogenic factors. However, pneumonia is highly contagious and family clusters, so patients often have emotional anxiety and fear,which can lead to emotional illness. Therefore, psychological treatment is as important as disease treatment.

1. Keep a regular sleep schedule, try not to sleep during the day with insomnia, sleep at night on time, and do not do any distractions before going to bed

2. TCM psychological care emphasizes the way of “keeping the spirit inside”, which can encourage patients to empty themselves or observe themselves, and relieve various bad emotions. Do a good job in patients’ psychological care, patiently communicate with patients, encourage patients to listen to the information released by experts and regular news channels, and avoid inexplicable panic

3. Sharing successful treatment cases and encourage self-care as much as possible to enhance patients’confidence. Keep in touch with relatives through audio, video and familiar objects, provide adequate psychosocial support, and improve the cooperation degree of medical care

4. Five-element music therapy: According to the specific syndrome differentiation of patients to choose the appropriate five elements music with treatment. The representative songs are Jiao-tonality music “Eighteen Beats of Hujia,” Zhi-tonality music “Zizhu,” Gong-tonality music “House of Flying Dagobas,” Shang-tonality music“Spring Snow,” Yu-tonality music “Three Plums,” the specific listening time depends on the individual’s condition[10-12]

5. TCM sports: According to the physical strength and condition of each patient, carry out training such as Baduanjin, Yijinjing, 20–30 min each time, 2–3 times a day. The five-element music can be combined with at the same time, until the whole body slightly sweat for degrees

6. Acupoint massage: Massage Yintang, Taiyang, Touwei and other acupuncture points on the head, the systemic method is called “Kaitianmen head message;” Tanzhong,Hegu, Taichong points, etc., can also be used for soothing emotions. For those who have the conditions, tapping and rubbing acupoints Shentang, Pohu, Hunmen, Yishe,Zhishi, etc., can achieve the purpose of calming the mind.Massage the head acupoints for a total of 15–20 min,and every other point for 2–3 min, 2–3 times a day

7. Auricular-plaster therapy: Perform auricular application on auricular acupoints, select Zhen, Pi, Shenmen, Shenpi,Shenshuaidian, Shenshuaiqu, ect, as the main points,select Xin, Naogan, Kuaihuo, Shenxin as the supplement points, insomniacs can be supplemented with liver,stomach, and more Dream zone (back) points to relieve emotional anxiety and fear, and improve sleep disorders.Do not stimulate these acupoints 1 h before bedtime

8. Scraping therapy: Insufficient yang energy is prone to panic and anxiety, and bad emotions can also prevent the yang qi from rising in an orderly manner. We can wipe the skin that pass through the yang meridian, such as the Du-meridian,the Bladder Meridian of foot-taiyang, to promote the rise of yang qi, then to ease bad emotions. Acupoints such as Danzhong, Hegu, and Taichong are common points for adjusting the qi activities. In addition to back scraping,these points can be used to promote qi circulation.

Dyspnea

1. Assist the patient to take appropriate position, if necessary, take a semi-reclining position to relieve breathing difficulties

2. Observe the duration and concomitant symptom in order to evaluate hypoxia degree. Pay attention to whether the skin is red, warm and sweaty, conjunctiva congestion and other manifestations of carbon dioxide retention

3. Observe the changes of vital signs and oxygen saturation,give oxygen therapy according to the doctor’s advice,adjust the way and concentration of oxygen inhalation according to the results of blood gas analysis, and give high-flow respiratory therapeutic apparatus or noninvasive ventilator assisted ventilation if necessary.In addition, the comprehensive intervention of TCM can improve the body function of patients, reduce the use of ventilator or shorten the treatment time of ventilator

4. Communicate with patients before using auxiliary ventilation to help him overcome his fear and take protective restraint when necessary

5. Guide the patients to exercise respiratory function, such as labial breathing, breathing Six-Word Qigong, and breathing therapy. For those who can leave the bed,follow the “get up trilogy” to guide patients to sit, stand,and mark time on the bedside. To guide the bedridden patients to make fists, lift arms, lift legs and other activities in bed to prevent bedridden complications

6. Abdominal distension in patients undergoing assisted ventilation is more likely to lead to increased breathing difficulties. According to the condition, the patient should be guided or assisted to maintain smooth stool. Clockwise massage of the abdomen and point clicks on related points,such as Tianshu and Zusanli, can promote gastrointestinal transport and defecation; the points of Danzhong, Lieqie,Neiguan, Qihai, Zusanli can synergistically play the role of lowering and relieving asthma. Massage abdomen points for 15–20 min, and press the remaining points for 2–3 min per point, 2–3 times a day[9,10]

7. Acupoint application: Follow the instructions to carry out the acupoint application. Using vinegar to adjust rhubarb,turmeric, cicada slough, zombie and other drugs to match the umbilical, can help the qi activities to restore the rise and fall in or out; using vinegar to adjust rhubarb,thenardite, citrus aurantium, radix seed and Tinglizi or other medicines to match Feishu, Dingchuan, Fuzhong,Yongquan and other acupuncture points can help to relieve asthma, coughing and breathing difficulties

8. When the breathing is hard, we should change the way of eating by using a small amount of frequent serving,and if necessary, put a gastric tube to assist eating.Medicinal diet is presented in the form of soup instead of soup dregs, in order to avoid increasing the burden on the spleen and stomach

9. Following the doctor’s advice to administer the relevant drugs, observe the improvement of respiratory dyspnea after the drug efficacy and adverse reactions.

TRADITIONAL CHINESE MEDICINE SPECIAL NURSING

Drug therapy

Internal application of Chinese herbs

Administration time

For mild and moderate case, each dose of herbs can be taken generally in twice half an hour after breakfast and dinner. It is advisable to have some hot porridge after taking “Qingfei Paidu Decoration.” The patients with dry tongue due to fluid depletion can increase the dosage. For severe and critical case, each dose can be taken generally in 2–4 times/day, more than half an hour after meals in frequent small amount of oral administration or nasal feeding.

Observe the sweating timely after taking the medicine, avoid wind chill after sweating, and avoid excessive sweating to consume healthy qi.

Medication temperature

The decoction should be administered warmly, with the temperature between 43℃ and 50℃. The medication for self-care patients can be prepared according to their daily habits, and the patients with tube-feeding should be prepared according to specification.

Medication dose

100–150 mL is taken per time for the mild and moderate cases; 100 mL is taken per time for the severe and critical cases. For elder patients with heart failure or those need controlling the dose or with significant bloating, better use concentrated decoction about 50 mL per time.

Nursing after medication

Patients take the medication which contains herbs for resolving exterior syndrome, such as Mahuang (Ephedrae Herba), Guizhi (Cinnamomi Ramulus), Xixin (Asari Radix et Rhizoma) should avoid wind chill, or put on more clothes, have some hot porridge or rice soup to induce diaphoresis. Patients who sweat ceaselessly should avoid excessive sweating to consume body fluid. Patients with pharyngeal dryness and sore throat can fumigate the nose and mouth with medication steam. If sweating a lot, feeling hot or lips dry, patients should be replenished water timely according to color and volume of urine and sputum. The black plum tea or raw licorice decoction can help relieve hot and regenerate fluid.

Observation after medication

Observe the condition and changes of body temperature,cough, fatigue, and gastrointestinal discomfort and tell doctors timely to deal with condition changes.

Internal application of Chinese patent medication

For details, please refer to the General Rules of Chinese Medicine Nursing Plan (Trial) formulated by the National Administration of TCM.

Injection

For details, please refer to the General Rules of Chinese Medicine Nursing Plan (Trial) formulated by the National Administration of TCM.

Special techniques

1. Auricular-plaster therapy

2. Acupoint application

3. Acupoint massage

4. Scraping therapy

5. Moxibustion

6. TCM sports.

HEALTHY GUIDANCE

Daily life

The disease is mainly spread through respiratory droplets and close contact. It may be spread through aerosols when exposed to high concentrations of aerosols for a long time in a relatively closed environment, and the population is generally susceptible. Suspected and confirmed cases should be isolated and treated in designated hospitals with effective isolation and protection equipment. Suspected cases should be treated in isolation in a single room, and confirmed cases can be admitted to the multiperson room.[1,5]

The room should be kept in a ventilated condition. The Chinese medicine sachets contain drugs with spicy and dryness effect can be hanged indoors to help dehumidify and clean up the air. Drugs such as Cangzhu (Atractylodis Rhizoma)or moxa sticks also can be burned to clean up the air. Every patient should wear a mask and avoid wind chill.

Patients should develop good living habits and avoid staying up late and overusing electronic products to care for yang qi.

Self-care and exercises: Teach patients to massage points,such as Hegu, Chize, Zusanli, and Taichong, which have the function of improving patients’ health. Tai Chi and Baduanjin can be added based on cardiopulmonary rehabilitation exercise. For patients with abdominal breathing, pursed lips breathing and breathing exercise can also be done to improve the lung capacity and respiratory function.[9]

TCM believes that the abdomen, back of the neck, shoulders,knees, and feet are vulnerable to cold evil. Those body parts should be always kept warm and dry, especially during the period of body temperature decline.[9-11]

Help patients develop regular bowel habits. Intervene as soon as possible when patients have a poor bowel movement.

Diet guidance

It’s better to have a balanced diet. Spicy and greasy food,tobacco, and alcohol should be forbidden. The meals should be arranged based on TCM syndrome differentiation and the digestive system function of the patients.[12-18]

Mild case

1. Cold-damp constraint in the lung pattern: Foods with effects of dispersing cold and removing dampness are recommended, such as ginger, scallion, coriander, and black beans. Some TCM recipes such as Wuhu soup,scallion porridge, and onion ginger brown sugar water are recommended

2. Damp-heat accumulation in the lung pattern: Foods with effects of clearing heat and promoting diuresis are recommended, such as burdock, tempeh,chrysanthemum, and red bean. Some TCM recipes such as almond barley porridge, soup with dried almond pork lung, and chrysanthemum lily drink are recommended.

Moderate case

1. Damp-toxin constraint in the lung pattern: Foods with effects of invigorating spleen for eliminating dampness and removing toxic substance are recommended, such as barley and Yinchen. Some TCM recipes such as barley dandelion tea, porridge of barley, and Yinchen crucian carp soup are recommended

2. Cold-damp obstructing the lung pattern: Foods with effects of dispelling cold, eliminating dampness and dispersing lung qi are recommended, such as perilla leaves, Chenpi, and Fushen. Some TCM recipes such as perilla soup and Chenpi lentil drink are recommended.

Severe case

1. Epidemic toxin blocking the lung pattern: Foods with effects of removing toxic substance and dispersing lung qi are recommended, such as mung beans, honeysuckle,houttuynia cordata, almonds, etc., Some TCM recipes such as houttuynia mung bean drink and Chenpi almond pork are recommended

2. Blazing of both qi and ying pattern: Foods with effects of clearing heat and promoting fluid production, benefiting qi and ying are recommended, such as sydney, pakchoi root, and adenophora. Some TCM recipes such as dendrobium lean gravy and tremella lily lotus seed soup are recommended.

Critical case

Internal blockage and external desertion pattern: Foods with effects of strengthening vital for relieving depletion and nourishing yin for fluid production are recommended, such as astragalus, lotus seeds, and codonopsis. Some TCM recipes such as puree with lotus seed and Qianshi, and ginseng lean gravy are recommended.

Convalescence

1. Lung-spleen qi deficiency pattern: Foods with effects of strengthening spleen and nourishing lung are recommended, such as millet, Chinses yam, codonopsis,astragalusetc. Some TCM recipes such as yam lotus seed porridge, millet red date porridge, Astragalus black chicken soup are recommended

2. Deficiency of both qi and yin pattern: Foods with effects of benefiting qi and nourishing yin are recommended,such as Shenmai custard, honey jujube drink, astragalus yam soup, etc.

3. For patients with poor digestive function, and severe or critical cases, the soup and porridge water without residue are recommended to reduce gastrointestinal burden.

Emotional adjustment

1. Conduct psychological counseling and instruct patients and their families to understand the occurrence,development, and outcome of the disease to enhance confidence in treatment.[13,19]

2. Strengthen ward rounds to find the patients in a low mood as early as possible. Encourage the relatives to support patients and give them psychological support.Leiten to the patients’ heart patiently and avoid negative emotional stimulation.[20-22]Tell patients the effect of emotional factors on the disease.

3. Instruct patients with emotional distress to divert their attention and to dilute or even eliminate bad emotions using empathic therapy; for patients with anxious or depressed mood changes, satisfying their mental requirements or using suggestive therapy is feasible.

4. The appropriate five-element music is recommended to improve the emotional state of patients.[9,10]

5. TCM exercise, such as Baduanjin and Six-Word Qigong,are very helpful to relieve the bad mood.

6. Acupoint massage also helps in mood regulation. It is recommended to choose Hegu, Taichong, Baihui, etc.,to massage, 3–5 min/point.

Discharge guidance

Postdischarge management should be according to the requirements of medical plan. The designated hospital should have a good contact with the primary medical institutions and share medical records with them promptly.

It is recommended that 14 days of isolation management and health monitoring should be continued after discharge. The patients should wear masks, live in a well-ventilated single room if possible, reduce close contact with family members,have meals alone, and avoid going out.

It is recommended to follow-up and return to the hospital in the 2ndand 4thweeks after discharge.

Patients should develop good living habits, avoid staying up late and overusing electronic products, maintain a healthy diet, keep positive and stable emotion, choose appropriate exercise methods, and pay attention to body changes.

DIFFICULTIES IN NURSING

First, patients have insufficient confidence in the efficacy of TCM nursing, and their understanding and cooperation need to be improved. In the view of this, solutions are as follows: (1) strengthen the promotion of TCM culture, and fully communicate with patients before implementation through vivid images to enhance patients’ understanding. (2)The specific TCM nursing techniques should be transitioned from noninvasive to minimally invasive techniques, such as trying acupoint massage first, and then performing scraping therapy, to maintain a more comfortable experience for patients. (3) After the implementation of the characteristic technology, observe and listen to the patient’s feedback. If the response is good, continue the nursing plan; if the effect is not good, adjust or continue the nursing plan after nursing rounds, doctor guidance, and nurse–patient communication.

Second, it is difficult for the nursing staff to perform special treatments under strict protection. In the view of this,solutions are as follows: (1) According to the characteristics of symptoms and evidence-based experience, carefully analyze the advantages of therapy and choose easy and less time-consuming nursing techniques with good curative effect. (2) After clinical practice, observe and summarize the curative effect in time, and adjust the acupoint selection or manipulation techniques according to the evidence. (3) Pay attention to the disinfection of the materials and tools used in TCM nursing techniques to prevent cross infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.