Traditional Chinese Medicine nursing protocols for cholecystitis

Editorial Board of Nursing of Integrated Traditional Chinese and Western Medicine

ABSTRACT: Cholecystitis includes acute cholecystitis (calculous and acalculous) and chronic cholecystitis, in which the former is defined as inflammation of the gallbladder, while the latter occurs when a patient repeatedly suffers from gallbladder inflammation. The most common symptom of cholecystitis is pain. Recently, Traditional Chinese Medicine (TCM) has shown its unique superiority in improving clinical symptoms and contraction function of the gallbladder for patients with cholecystitis. This article primarily investigated the key points of common syndromes, TCM nursing methods and healthy guidance of cholecystitis, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

KEY WORDS: cholecystitis; pain; inflammation; Traditional Chinese Medicine nursing; syndrome differentiation

Cholecystitis can be classified into acute cholecystitis (calculous and acalculous) and chronic cholecystitis. Acute cholecystitis is defined as inflammation of the gallbladder, approximately accounting for 14%-30% of cholecystectomies[1]. It is frequently caused by cystic duct obstruction, in which gallstones or biliary sludge is the most common cause[2]. Most patients with acute cholecystitis are subjected to the right upper quadrant or epigastric abdominal pain, and the pain tends to localize in the right upper quadrant as gallbladder inflammation worsens[3]. Chronic cholecystitis occurs when a patient repeatedly suffers from gallbladder inflammation, leading to increasing scarring and gallbladder dysfunction, and approximately accounts for 79% of cholecystectomies together with biliary colic[4-5]. The most common cause is intermittent obstruction of the cystic duct caused by gallstones, resulting in biliary colic or episodic waves of epigastric pain and discomfort. Similar to acute cholecystitis, pain remains the most prevalent symptom of chronic cholecystitis.

Currently, early surgical management of acute cholecystitis aims to stone extraction, and the early laparoscopic cholecystectomy has been demonstrated to reduce the overall hospital days without increased complications, mortality, or conversion to open procedures[6]. The treatment of chronic cholecystitis is an elective holecystectomy. Although most patients with typical biliary symptoms and gallstones on imaging get improved symptoms after cholecystectomy, the efficacy is not very satisfactory. Recently, traditional Chinese medicine (TCM) has shown its unique superiority in the treatment of cholecystitis. Guo et al. found that for patients with chronic cholecystitis, Chaihu Shugan Powder could effectively relieve the pain and accelerate the gallbladder recovery by improving the symptoms, contraction function of the gallbladder and levels of inflammatory cytokines[7]. Gui et al. reported that modified Chaihu Guizhi Ganjiang Tang could alleviate the inflammatory response of patients with chronic cholecystitis of gallbladder-heat and spleen-cold syndrome, promote the recovery of gastrointestinal function and contraction function of the gallbladder, with better tolerance[8]. In addition, there was an evidence suggesting that Tongdan Decoction combined with Anethol Trithione Capsules was effective in improving clinical symptoms and imaging indicators for chronic cholecystitis[9]. In view of TCM superiority in the treatment of cholecystitis, State Administration of Traditional Chinese Medicine of the People’s Republic of China formulated a TCM nursing protocol for cholecystitis, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

Keypointsofcommonsyndromes

Syndromeofliverandgallbladderstagnation: distension, fullness and pain in the right hypochondrium, pain radiating to the right shoulder and aggravated by anger, chest distress and abdominal distension, preference for a deep sigh, frequent belching, acid regurgitation and belching with fetid odor; white greasy tongue coating.

Syndromeofdampness-heatofliverandgallbladder: distension, fullness and pain in the right hypochondrium, chest distress, anorexia, nausea, vomiting, bitter taste in the mouth, vexation, viscous stool or presence of jaundice; red tongue with yellow greasy coating.

Syndromeofqistagnationandbloodstasis: more severe fixed, unpalpable stabbing pain in the right hypochondrium, gloomy complexion, dry mouth and bitter taste in the mouth; dark purple tongue with ecchymosis on the margin.

Syndromeofliverdepressionandspleendeficiency: distending pain in the right hypochondrium, lassitude, fatigue, depression or vexation, abdominal distension, belching, sighing, bitter taste in the mouth, nausea, vomiting, poor appetite, loose stool or constipation; light or dark-colored tongue with white coating.

Syndromeofstagnatedheatofgallbladder: scorching, or colic, or distending, or dull, or sharp pain in the right hypochondrium, pain radiating to the right shoulder, uncomfortable abdomen, nausea, vomiting, unsmooth defecation, or presence of jaundice or fever; red tongue with yellow coating.

Nursingforcommonsymptoms/syndromes

Painintherighthypochondrium

· Closely observe the pain location, nature, degree, duration, inducing and alleviating factors, as well as its association with diet, body position and sleep. The doctor should be immediately informed if patients have serious pain, possible presence of bleeding or shock.

· Stay in bed at the time of acute attacks, and administer spiritual comfort; forbid eating and closely observe the pathological changes.

· According to the doctor's advice, perform acupoint application (points: gallbladder, Zhangmen, Qimen, etc.), acupoint massage (points: right Ganshu, right Danshu, Taichong, Xiaxi, etc.), auricular-plaster therapy (points: liver, gallbladder, sympathia, Shenmen, etc.), acupoint injection (points: gallbladder, etc.) and treatment instruments for hepatic diseases.

Distensionandfullnessintherighthypochondrium

· Observe the location, nature, degree, duration, inducing factors and concomitant symptoms of distension and fullness.

· Encourage the patients to take exercises after meals to keep bowel movements.

· Massage the abdomen clockwise.

· According to the doctor's advice, conduct acupoint application (points: Pishu, Weishu, Shenque, Zhongwan, etc.), acupoint injection (points: Zusanli, gallbladder, etc.), auricular-plaster therapy (points: liver, gallbladder, large intestine, sympathia, etc.) and acupoint massage (points: gallbladder, Tianshu, etc.).

Belching,nauseaandvomiting

· Observe the frequencies and degrees of belching, nausea and vomiting, and their relationships with diet.

· Tell the patients not to lie on the back immediately after meals.

· Frequently use a small amount of decoction for patients with vomiting, and drip the ginger juice on the tongue or keep the ginger slice under the tongue to relieve vomiting.

· Based on the doctor's advice, implement acupoint injection (points: bilateral Zusanli, gallbladder, etc.), acupoint massage (points: Hegu, Zhongwan, gallbladder, etc.), auricular-plaster therapy (points: gallbladder, stomach, endocrine, sympathia, Shenmen, etc.), moxibustion (points: Pishu, Weishu, Zhongwan, Zusanli, etc.) and acupoint application (points: Ganshu, Danshu, Zhongwan, Zusanli, etc.).

Anorexia

· Observe the patients’ dietary condition, oral odor and changes of tongue texture and coating, and keep the oral cavity clean.

· Following the doctor’s advice, perform acupoint massage (points: Pishu, Weishu, Zhongwan, Yanglingquan, etc.), auricular-plaster therapy (points: spleen, stomach, small intestine, large intestine, Shenmen, etc.) and acupoint application (points: Zhongwan, Weishu, Zusanli, etc.).

Fever

· Observe the changes of body temperature.

· Keep the skin clean, dry the skin and change clothes after sweating; forbid blowing the wind after sweating.

· Conduct acupoint injection (points: Quchi, etc.) following the doctor’s suggestion.

TCMspecialnursing

Medications

InternalapplicationofChineseherbs

(1) Take warm TCM decoction for patients with syndrome of liver depression and spleen deficiency; frequently take concentrated TCM decoction for patients with nausea and vomiting; take cool TCM decoction for patients with dampness-heat syndrome.

(2)Observe the times and nature of defecation after taking Chinese patent drugs containing rhubarb ingredients, especially for the old and weak patients.

(3) 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.

Specialtechniques

Acupointapplication

· Conduct acupoint application following the doctor’s advice.

· Nursing assessment: the skin condition in the part of acupoint application; forbid to use it for pregnancy women.

· Expose the part of acupoint application completely, and pay attention to keeping warm and protecting the privacy.

· Keep a proper thickness of plaster (0.2-0.3 cm) and a certain humidity in order to smear easily.

· Observe the local and systemic condition. Stop to use it and inform the doctor to manage immediately if the allergy occurs, such as erythema, pruritus and vesicles.

· Avoid smoking, drinking alcohol, and taking cold, salty and spicy food, seafood, beef and mutton during application.

· Record the application part, time and patients’ feelings after all the operations are finished.

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.

Acupointinjection

· Perform acupoint injection following the doctor's advice.

· Based on the doctor's advice, use the correct drugs and pay attention to the drug incompatibility.

· Assess the current primary symptoms, previous history, history of drug allergy and the condition of local skin in the part of acupoint injection.

· Strictly abide by aseptic techniques to prevent infection.

· At the time of injection, avoid the location with abundant blood vessels to prevent drugs from entering into blood vessels; drop out the needlepoint a little and then inject when the patient has electrical sensation.

· Closely observe the patient's reactions after administration, and inform the doctor immediately to manage them if discomforts emerge.

· Record the location, drugs and dose of acupoint injection, as well as the patients' feelings after all the operations are finished.

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 the 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.

Moxibustion

·Perform moxibustion following the doctor's advice and select the proper ways of moxibustion, such as moxibustion with moxa cone, moxibustion with moxa stick, moxibustion with moxa box, tec.

·Nursing assessment: the condition of skin in the area of moxibustion and acceptance level of patients to the moxibustion smell. It is unsuitable for moxibustion in the face, in the part of larger vessels as well as in the abdominal and lumbosacral portion of pregnant women.

·Regulate the room temperature timely, and maintain good indoor ventilation.

·Select a reasonable position to fully expose the part of moxibustion, and be cautious to keep warm and protect privacy.

·Do moxibustion from top to bottom, namely the top of the head and chest-back first, and then the abdomen and four limbs.

·During moxibustion, inquire the patients whether they feel a burning sensation, regulate the distance and flip the moxa ash into the kidney basin to avoid burning the skin.

·Pay attention to the moxibustion time. For instance, moxibustion is done for the patients with insomnia before sleep instead of moxibustion immediately before meals or after meals.

·After moxibustion, local reddish scorching skin is normal. The moxibustion-induced small vesicles can be absorbed by themselves, but for the large ones, the doctor should be informed immediately and corresponding measures are taken according to the doctor’s advice.

·Place the moxa cone or moxa stick in the flame-out bottle to extinguish the moxibustion fire immediately after moxibustion.

·Small-dose and short-time moxibustion is applied to the initially-used patients, and the dose is increased gradually when the patients are tolerant.

· After moxibustion, record the way, part and skin of moxibustion as well as the patient's feelings.

Healthyguidance

Dailylife

· Keep the ward quiet, clean and comfortable at temperature and humidity.

· Stay in bed at the time of acute attacks.

Dietaryguidance

·Syndromeofliverandgallbladderstagnation: It is advisable to eat the food that can sooth liver and gallbladder, such as bitter gourd, celery, Chinese cabbage, loofah, etc. The food obstructing qi function like beans, sweet potatoes and pumpkin should be forbidden.

·Syndromeofdampness-heatofliverandgallbladder: It is advisable to eat the food that can clear away dampness and heat, such as coix seed, cucumber, celery, white gourd, etc.

·Syndromeofqistagnationandbloodstasis: It is advisable to eat the food that can sooth liver, regulate qi function and activate blood to remove blood stasis, such as hawthorn, jujube, etc.

·Syndromeofliverdepressionandspleendeficiency: It is advisable to eat the food that can sooth liver and invigorate spleen, such as lotus root, Chinese yam, etc.

·Syndromeofstagnatedheatofgallbladder: It is advisable to eat the food that can clear away heat and purge pathogenic fire, such as white gourd, bitter gourd, chrysanthemum tea, etc.

Emotionaladjustment

· Communicate with patients frequently to understand their psychological states and guide them to remain optimistic.

· Guide the patients to distract attention using a mutually-restricted transference therapy. For example, a suggestive therapy can be used for patients with anxiety or depression change.

· Encourage the relatives to accompany the patients and give them psychological support; guide the patients and their relatives to learn the disease-related knowledge and grasp the simple methods of controlling pain, such as holding a deep breath, relaxing muscles and listening to music.

· Encourage the patients to frequently communicate with each other to improve their recognition on disease prevention and treatment and to enhance their confidence.