ABSTRACT: Fever caused by exogenous pathogens, also called upper respiratory infection (URI), refers to a classification of exogenous diseases induced by invasion of six pathogenic factors into the body leading to disharmony between nutrient Qi and defensive Qi and imbalance of Yin and Yang. As an extremely common symptom or sign, it is frequently seen in various processes of acute and chronic diseases. In recent years, traditional Chinese medicine (TCM) has achieved a certain efficacy in the treatment of fever caused by exogenous pathogens, such as modified formulae, Chinese patent drugs, self-made formulae, acupuncture, moxibustion and so on. This article mainly explored the key points of common syndromes, TCM nursing methods and health guidance of fever caused by exogenous pathogens, in order to further develop the advantages of TCM, improve its efficacy and standardize its nursing behavior.

KEY WORDS: fever; exogenous pathogens; upper respiratory infection; nursing of traditional Chinese medicine

As a multi-component and multi-target agent, traditional Chinese medicine (TCM) can treat a lot of complex diseases in a holistic way, especially infection diseases. Fever caused by exogenous pathogens, also called upper respiratory infection (URI), refers to a classification of exogenous diseases induced by invasion of six pathogenic factors into the body leading to disharmony between nutrient Qi and defensive Qi and imbalance of Yin and Yang. In clinic, it manifests pathologically-increased body temperature, accompanied by aversion to cold, red face, irritation, rapid pulses, etc. As an extremely common symptom or sign, fever caused by exogenous pathogens is frequently seen in various processes of acute and chronic diseases[1].Yang[2]believed that the core of fever caused by exogenous pathogens lied in struggle between pathogenic Qi and healthy Qi in the body. The methods of dispersing and clearing heat, reconciling Shaoyang, harmonizing nutrient Qi and defensive Qi as well as tonifying Qi and nourishing Yin were used at different stages of fever, especially the application of dispersion and reconciliation is adopted in the whole process of treatment. Luo et al.[3]indicated that the fever caused by exogenous pathogens in summer was characterized by rapid onset, progression and changes, and invasion of pathogens into the lung, spleen, stomach and intestine became prominent syndromes in clinic.

Fever caused by exogenous pathogens has been studied for a long time in TCM. In recent years, TCM has achieved a certain efficacy in the treatment of fever caused by exogenous pathogens, such as modified formulae, Chinese patent drugs, self-made formulae, acupuncture, moxibustion and so on[4-5]. Nevertheless, there are no standardized TCM syndrome differentiation system and evaluation criteria for diagnosis and efficacy at present, unfavorable for clinical application and observation. In order to maintain and develop the advantages of TCM, improve its efficacy and standardized its behavior, TCM nursing protocols for fever caused by exogenous pathogens is formulated byStateofAdministrationofTraditionalChineseMedicineofThePeople'sRepublicofChina.

Key points of common syndromes

Syndromeofwind-coldfetteringtheexterior: severe aversion to cold, mild fever, no sweating, rigidity of nape and headache, stuffy nose, running nose, or itching in the throat, cough, white and thin phlegm, no thirst, soreness in the limbs, thin white tongue coating.

Syndromeofwind-heatinvadingtheexterior:sever fever, mild aversion to cold, stuffy nose, yellow nasal discharge, body heat with or without sweating, headache, sore throat, thirst with desire to drink or cough with yellow phlegm, thin yellow tongue coating.

Syndrome of summer-heat and damp invading the exterior: aversion to cold, fever, heavy sensation in the head, distension in the chest and abdomen, nausea, vomiting, diarrhea, weak limbs, lassitude, or sticky and greasy sensation in the mouth, thirst without desire to drink, white and greasy tongue coating.

Syndrome of disease involving Weifen and Qifen: self-conscious sever fever, polydipsia, scanty dark urine, red tongue with yellow coating, aversion to cold or wind, or high fever but chill, running nose, itching and pain in the throat, headache, distension in the head, sneezing, red tongue with thin yellow coating or yellow and greasy coating.

Nursing for common symptoms/syndromes

Aversion to cold and fever

· Observe the condition of body temperature and sweating.

· Don't keep out the wind and change the clothes immediately when a lot of sweating appears; pay attention to keep warm for the patients with syndrome of wind-cold fettering the exterior.

· Keep oral cavity clean, and encourage drinking much warm water.

· Conduct physical cooling according to the doctor's advice.

· Do scraping at the points including Hegu, Quchi, Dazhui, Taiyang and Fengchi according to the doctor's advice.

· Conduct TCM retention enema according to the doctor's advice.

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

Headache

· Observe the location, nature, degree, concomitant symptoms and duration of headache.

· Be slow when the body position is changed.

· Massage at the points like Taiyang, Yintang, Baihui, Hegu and Fengchi according to the doctor's advice.

· Conduct auricular-plaster therapy, and select the points like Shenmen, subcortex, lung, etc.

Cough and expectoration

· Observe the nature, degree, duration and rule of cough as well as the quantity, color and texture of phlegm.

· Take a semi-reclining position when sever cough occurs.

· Learn effective methods of cough and expectoration, turn over and clap on the back.

· Conduct auricular-plaster therapy, and select the points including lung, trachea, Shenmen, lower tragus point, etc.

Stuffy nose and running nose

· Observe the condition of stuffy nose as well as color and texture of snivel.

· Get hold of correct method of blowing the nose.

· Massage at the points according to the doctor's advice, such as massage the points of Yingyang and Bitong when stuffy nose occurs.

· Conduct auricular-plaster therapy, and select the points including lung, internal nose, external nose, trachea, etc.

TCM special nursing

Drug therapy

Internal application of Chinese herbs

· Medication methods: (1) Take warm superficies-relieving formulae with pungent- and warm-natured drugs, add quilt and nestle down in bed after taking drugs, or take hot and thin porridge for diaphoresis. (2) Take cool superficies-relieving formulae with pungent- and cool-natured drugs and take cool dampness-resolving superficies-relieving formulae. (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, 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 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 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.

External application of Chinese herbs

· 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

Scrapingtherapy

· Conduct scraping therapy following the doctor's advice, and select appropriate scraping tools according to different parts.

· Assess the skin condition and constitution of patients, use it with caution for the thin, and prohibit to use it for the patients with local skin ecchymosis, blister, scar, inflammation and bleeding tendency; evaluate the syndrome manifestation, and select scraping oil and direction based on syndrome differentiation; assess the patients' tolerance to confirm the strength of scraping techniques; prohibit to use it in women during menstruation and pregnancy.

· Keep the room temperature at 22-24℃, expose the scraping location, and pay attention to keep warm and protect the privacy.

· Be attention to the strength of scraping techniques, make the local skin red or have purple petechia. It is unnecessary to have petechia and violence is forbidden.

· Do scraping therapy better 1-2 hours after meals, not to be excessively hungry or full.

· Do not use strong force in the parts, including joints, spine, head and face, and make scraping time short.

· The scraping techniques are characterized by not too much strong force, fast speed and long time for the patients with diabetes mellitus due to poor skin tolerance and increased fragility of blood vessels. It is better to do scraping from the lower to the upper for the patients with varicose vein of lower limbs and those with edema of lower limbs.

· Inquire the discomforts of patients during scraping, and stop it immediately, make the patients lie on the back quickly, drink one cup of glucose saline and inform the doctor to deal with it if dizziness and nausea, even syncope, occur.

· Notifications: The local pain and burning sensation may appear when scraping is performed; The medical staff should be informed promptly if dizziness, nausea and weakness of limbs appear during scraping; Petechia may occur in scraping area, and mild skin pain and itching belong to normal phenomenon 1-2 days after petechia; After scraping, it is better to keep warm, drink a lot of hot water, be away from wind chill and taking bath within 3 hours.

· Record the scraping location and time as well as the patients' feelings after operation.

TCMretentionenema

· Conduct TCM retention enema following the doctor's advice.

· Nursing assessment: presence or absence of inflamed and ruptured perianal skin, history of drug allergy, recent surgeries related to the anus, rectum and colon as well as fecal incontinence. Before operation, the diseased location should be known in order to master the decubitus and depth of anal tube at the time of enema.

· Pay attention to keep warm and protect the patient's privacy when operation is done.

· Warn patients to defecate repeatedly before operation, and conduct cleansing enema following the doctor's advice if necessary.

· Keep the temperature of drug liquid at 39-41℃. Low temperature can enhance the intestinal peristalsis and aggravate abdominal pain, while high temperature can result in empyrosis of intestinal mucosa or dilatation of intestine and strong desire to defecate, consequently leading to short retention and less absorption of drug liquid in the intestine.

· Elevate the hip 10 cm, and make the depth of anal tube into the anus be 10-15 cm. When rectoclysis is adopted, the distance of drug liquid level to the anus is about 30-40 cm, with 60-80 drops of dripping speed per minute. It should be noted that the perfusion volume is less than 200 mL every time.

· Perform enema before sleep at night, and don't be up and about after enema. Assist the patients to take a suitable decubitus and keep the drug liquid remain more than 1 hour as soon as possible to improve the efficacy after the drug liquid is perfused.

· The times of defecation increase after TCM retention enema. It should be pay attention to observe and protect the perianal skin, and oiling agent or ointment can be smeared in the local part if necessary.

· Inquire the patient's feelings, tell his to take a deep breath to relieve the desire to defecate, and prolong the retention time of drug liquid. Stop enema immediately and inform the doctor to take some measures if discomforts occur.

· Record the enema time, retention time and defecation condition after operation is finished.

TCMsoaping

· Conduct to wash with Chinese herbs following the doctor's advice.

· Assess the washing skin and sensory perception of lower limbs to the temperature, use it with caution for the patients with skin lesion and those with drug and skin allergy, and prohibit to use it for the patients with severe cardiopulmonary dysfunction and hemorrhagic disease.

· Inform the patients of washing process and cautions before operation, and communicate with the medical staff promptly once discomforts occur.

· It is inappropriate to wash with Chinese herbs in fasting state and within 1 hour after meals. Immediate washing after meals can affect digestion due to local peripheral vasodilation.

· Keep the operation environment warm, close door and windows, and be cautious to keep the patients warm and protect their privacy.

· Expose the washing location thoroughly, and make the ankle of two feet soak in the liquid.

· Keep the liquid temperature at 37-40℃ and the washing time for 20-30 min. Take the difference of disease categories into account to prevent from burn.

· Observe the local and systemic conditions of patients during treatment, and inform the doctor immediately to deal with it if the symptoms including erythema, pruritus, palpitation, sweating and dizziness occur.

· Gently make the skin dry with light towel after washing, especially interphalangeal skin, and trim the toenails if they are long.

· Inform the patients of drinking 200 mL of warm water after washing with Chinese herbs.

· Record the washing temperature, time, skin condition and the patients' feelings 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 to use 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.

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 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 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.

Healthy guidance

Dailylife: Elderly people and those with repeated fever caused by exogenous pathogens should practice Chinese traditional health exercises like Tai Chi and baduanjin qigong to enhance their constitution.

DietGuidance: It's better to have a bland diet, and spicy and greasy food as well as tobacco and alcohol should be forbidden.

· Syndrome of wind-cold fettering the exterior: It is advisable to eat foods that can relieve superficies and disperse cold, such as ginger, fistular onion stalk, brown sugar, etc. Dietary formulae: Brown sugar and ginger decoction.

· Syndrome of wind-heat invading the exterior: It is advisable to eat foods that can dispel wind and clear heat as well as diffuse lung to resolve phlegm, such as watermelon juice, water chestnut juice, lonicera japonica tea, etc.

· Syndrome of summer-heat and damp invading the exterior: It is advisable to eat foods that can clear summer-heat, regulate qi and resolve dampness, such as loofah, white gourd, mung bean soup, etc.

· Syndrome of disease involving weifen and qifen: It is advisable to eat foods that can nourish yin and permeate heat as well as tonify lung to generate fluid, such as lotus root juice, pear juice, water chestnut juice, etc.

Rehabilitation guidance

· Reinforce to communicate with patients to avoid negative emotions.

· Introduce the occurrence, progression and prognosis of disease to the patients.