Traditional Chinese medicine nursing protocols for acute myeloid leukemia

Editorial Board of Nursing of Integrated Traditional Chinese and Western Medicine

ABSTRACT: Acute myeloid leukemia (AML) is a form of cancer characterized by infiltration of proliferative,clonal,and abnormally differentiated cells of the hematopoietic system into the bone marrow,blood,and other tissues. Clinically,the eligible AML patients first receive induction therapy to achieve complete remission (CR). Unfortunately,minimal residual diseases usually persist in CR,which will inevitably lead to relapse if treatment is discontinued. In traditional Chinese medicine (TCM),it is believed that the weakness of healthy qi is one of the basic pathologies of leukemia after remission,and is also the major cause for relapse. This article primarily investigated the key points of common syndromes,TCM nursing methods and healthy guidance of AML,aiming at maintaining and developing the strengths of TCM,improving its efficacy and standardizing its behavior.

KEY WORDS: acute myeloid leukemia; lassitude; ostealgia; traditional Chinese medicine nursing; syndrome differentiation

Acute myeloid leukemia (AML) is a form of cancer characterized by infiltration of proliferative,clonal,and abnormally differentiated cells of the hematopoietic system into the bone marrow,blood,and other tissues[1]. It is the most common acute leukemia in adults,approximately accounting for 80% of cases in this group[2]. The incidence of AML is estimated 3-5 cases per 100 000 persons in the United States[3]. A previous study reported that in 2015 alone,an estimated 20 830 new cases of AML were diagnosed,and over 10 000 cases died from this disease[4]. Currently,AML can be cured in 35%-40% of adult patients aged ≤60 years and in 5%-15% of patients >60 years,and the older patients unable to undergo intensive chemotherapy without unacceptable adverse reactions have worse outcomes,with the median survival of only 5-10 months[5].

Clinically,the eligible AML patients first receive induction therapy to achieve complete remission (CR). Unfortunately,minimal residual diseases usually persist in CR,which will inevitably lead to relapse if treatment is discontinued[6]. Hence,a consolidation therapy should be performed to eradicate the residual diseases and achieve permanent remission after favorable responses to induction therapy. In traditional Chinese medicine,it is believed that the weakness of healthy qi is one of the basic pathologies of leukemia after remission,and is also the major cause for relapse[7]. The herbs with the function of strengthening the body resistance can effectively regulate the immune function of leukemia patients in remission[8]. Li et al. found that Shenqi Shabai Decoction combined with chemotherapy for AML could significantly improve the CR rate and overall effective rate,which might provide an opportunity of the next consolidation therapy or hematopoietic stem cell transplantation for more patients[9]. In addition,there was also an evidence showing that the combined treatment of Chinese and western medicine was conductive to improving the clinical efficacy of AML[10]. In view of TCM superiority in the treatment of AML,State Administration of Traditional Chinese Medicine of the People’s Republic of China formulated a TCM nursing protocol for AML,aiming at maintaining and developing the strengths of TCM,improving its efficacy and standardizing its behavior.

Keypointsofcommonsyndromes

Syndromeofpredominantpathogenicfactorsanddeficienthealthyqi: pale complexion,dizziness,lassitude,palpitation and shortness of breath after exercises,or fever,bleeding,and ostealgia; pale tongue with thin white tongue coating.

Syndromeofpathogenicheatexuberance: high fever,thirst,purpura,and oozing of the fresh red blood in the teeth and nose; red tongue with yellow tongue coating.

Syndromeofintermingledphlegmandbloodstasis: scrofula,subcutaneous nodules,hypochondriac hard masses with occasional distending pain,accompanied by low fever,night sweating,and lusterless complexion; dark tongue with greasy tongue coating.

Nursingforcommonsymptoms/syndromes

Lassitude

·Be cautious to have a rest and take moderate exercises. The patients with severe anemia should stay in bed,with a limitation in visit.

·Pay attention to observing the patient’s complexion,skin,mucosa and subjective symptoms; monitor the levels of hemoglobin,white blood cells and granulocytes,as well as the platelet count.

·For patients with palpation,shortness of breath and dizziness,inhalation of oxygen should be given based on the doctor’s advice.

·According to the doctor’s advice,take the auricular-plaster therapy at the points like heart,Shenmen,sympathia,subcortex,endocrine,etc. This method is forbidden for the patients with agranulocytosis (<0.5×109/L).

·Perform acupoint application following the doctor’s advice,and select the points including Pishu,Shenshu,Zusanli,and so on.

Fever

·Closely observe,monitor and record the changes of the body temperature.

·Put an ice bag on the head,axilla and groin for patients with high fever,or take a physical cooling with an ice blanket machine,and take antifebriles based on the doctor’s advice; timely change clothes and bedclothes to prevent cold when sweating.

·Ensure adequate rest,limit to look after the patient by staying in hospital and visit to avoid the cross infection.

·According to the doctor’s advice,massage the points like Hegu,Quchi and the tip of ears. This method is forbidden for patients with bleeding tendency.

·Conduct TCM fumigation or hydropathic compress following the doctor’s advice.

Ostealgia

·Stay in bed to reduce activities and change the body position gently.

·Keep the limbs at a functional position to avoid being pressed; take a local cold compress to relieve the pain.

·According the doctor’s advice,massage the points,such as Taiyang,Yintang,Touwei,Shangxing,Baihui,Fengchi,Fengfu,Lieque,Hegu,and Ashi. This method is forbidden for patients with bleeding tendency.

·Based on the doctor’s advice,take the auricular-plaster therapy at the points like brain,forehead,Shenmen,and liver. This method is forbidden for patients with agranulocytosis (<0.5×109/L).

Bleeding

·Observe the bleeding part,changes of color,texture and quantity,as well as the symptoms. The doctor should be informed immediately when the symptoms,such as pale complexion,shortness of breath,cold sweating,cold limbs or sudden headache,occur.

·Nasalcavitybleeding: assist the patients to take a sitting or semireclining position and tell the doctor; stuff the nasal cavity with Yunnan Baiyao cotton balls following the doctor’s advice. For patients with large amount of bleeding and the deeper bleeding location,ask E.N.T. consultation for packing. Based on the doctor’s advice,take the auricular-plaster therapy at the points like inner nose,lung,adrenal gland and forhead. This method is forbidden for patients with agranulocytosis (<0.5×109/L).

·Gingivalbleeding: tell the doctor,and press the local area with hemostatics on cotton swabs according to the doctor’s advice,or externally apply Yunnan Baiyao/panax pseudoginseng cotton balls on the gum,or rinse the mouth by use of TCM decoction with the function of cooling blood to stop bleeding based on the doctor’s advice; make oral care.

·Skinmucosalbleeding: closely observe the bleeding part and protect the skin; press the puncture position for over 15 min to avoid bleeding after the treatment or injection.

TCMspecialnursing

Medications

InternalapplicationofChineseherbs

·Medicationtime: 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.

·Medicationtemperature: The administered warm is usually adopted. For the patients with special treatment,the herbs should be taken according to the doctor's advice.

·Medicationdose: 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.

TCMgargle

According to the doctor’s advice,perform TCM gargle 5 times a day,2-3 times for a gargle of 10-20 mL. Rinse the mouth first with the clean water,and then hold TCM decoction in the mouth for 30 seconds,finally rinse the mouth impulsively for 1 min to make the gargle completely touch the gum and oral mucosa. It is forbidden to brush teeth,drink water and eat 10 min after TCM gargle.

Injection

(1) Arsenious acidlnjection: It can be injected within 3-4 h after dilution,and an infusion pump can be used to control the infusion speed. Gastrointestinal reactions should be observed.

(2) Harringtonine injection: It tends to damage the myocardium and cardiac conduction,with a limitation of less than 40 drops/min in infusion speed. Changes of cardiac rhythm and blood pressure should be closely observed.

(3) Others.

·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.

·Traditional Chinese and western drugs should be separated when traditional 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

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.

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.

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.

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 the liquid temperature at 50-70 ℃. Sitz bath and wash can be conducted to prevent empyrosis when the liquid temperature is decreased to 37-40 ℃.

·Keep TCM fumigation for 20-30 min.

·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.

TCMhydropathiccompress

·ccording to the doctor’s advice,select the correct drugs and perform TCM hydropathic compress.

·Assess the skin in the part of hydropathic compress. It should be used with caution for the patients with drug/skin allergy and those with rapidly diffused ulcerative abscesses.

·Expose the part of hydropathic compress,and pay attention to keeping warm and protecting the privacy.

·Make the gauze with 5-6 layers dipped into the drug liquid,and keep the humidity of no dripping. Keep the temperature of drug liquid at 38-41℃ to prevent empyrosis.

·Observe local skin reactions during operation. Stop the treatment immediately,inform the doctor and take symptomatic treatment according to the doctor’s advice if the symptoms,such as pale skin,erythema,blister,pruritus,pain or rupture,occur.

·Implement corresponding nursing following the doctor’s advice if there are special drugs.

·Pay attention to disinfection and isolation to avoid cross infections.

·Record the part,time and temperature of hydropathic compress,as well as patients’ feelings after all the operations are finished.

Healthyguidance

Dailylife

·Keep the ward quiet and clean,and open the window at regular time for ventilation.

·Ensure adequate rest,and restrain to look after the patient by staying in hospital and visit. Patients with severe AML should stay in bed,and those with agranulocytosis should be isolated protectively.

·Guide the patient to form a good lifestyle,keep the oral cavity clean,rinse the mouth frequently,brush teeth with a soft toothbrush,and avoid picking and blowing his nose vigorously.

·Guide the patient to keep normal bowel movements,wash the perianal region with warm water after defecation,and pay attention to menstrual hygiene for women.

·Encourage the patient to take moderate exercises,avoid bumping,take a shower with warm water,do not scratch the skin vigorously and keep the skin clean.

Dietaryguidance

·Syndromeofpredominantpathogenicfactorsanddeficienthealthyqi: It is advisable to eat the food that can tonify qi and nourish yin,such as white fungus,Chinese yam,lotus seed,etc. The food cold in nature should be forbidden,such as seafood and green bean.

·Syndromeofpathogenicheatexuberance: It is advisable to eat the food that can clear heat and remove toxicity,such as white gourds,green beans,bamboo shoots,etc. The spicy food and that warm in nature should be avoided eating,such as mutton and pepper.

·Syndromeofintermingledphlegmandbloodstasis: It is advisable to eat the food that can eliminate phlegm and resolve blood stasis,such as almonds,white radishes,orange peels,etc. Sweet and greasy food like fat meat and cream should be prohibited.

·The patients with high fever should drink much water or juice,including watermelon juice,pear juice,orange juice,or fresh reed rhizome soup as the tea. The patients with much sweating can appropriately drink light salt brine,which is forbidden for patients with deficiency-cold of spleen and stomach.

·The food rich in iron is appropriate for patients with anemia,including peas,black beans,sesame paste,yolk,blood curd,pork liver,etc.

·The patients with bleeding tendency should avoid eating hard or barbed food like nuts,chops,fish and shrimps.

Emotionaladjustment

·Illustrate the disease-related knowledge including predisposing factors,treatment methods and notes during chemotherapy to the patient and his relatives,encourage him to accurately face the disease and positively cooperate the treatment and care.

·Pay attention to adjusting emotions,keep a peaceful mind and avoid rage and adverse stimulation outside. A transference or suggestive therapy can be used to relieve depression.

·Organize the wardmate meeting at regular intervals to enhance the patient’s confidence in triumphing over illness.