Guiying LIU, Ling TANG, Shirong HU, Haiyan E, Yanyan ZHANG, Yu YANG, Jing ZHANG

1Department of Neurosurgery, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China; 2Department of Nursing, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China; 3Department of Neurology, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China; 4School of Nursing, Beijing University of Chinese Medicine, Beijing, China

ABSTRACT Cerebral infarction (CI) is also known as ischemic stroke. It is one of the most common cerebrovascular diseases, with high mortality and disability rate, which has seriously threatened human health. To better apply the diagnosis and treatment plan of integrated traditional Chinese and Western medicine to the treatment of patients with CI, the Chinese Association of Integrative Medicine issued the Expert Consensus on the Diagnosis and Treatment of Cerebral Infarction with the Integrated Traditional Chinese and Western Medicine in 2021. It involves etiology and pathogenesis of CI, diagnosis and treatment standards of Traditional Chinese Medicine (TCM) and Western Medicine, syndrome elements of TCM, as well as rehabilitation nursing of CI with integrated traditional Chinese and Western medicine during acute period and recovery period. This study interprets the consensus from routine nursing, dietary nursing, emotional nursing, complication nursing, rehabilitation nursing, and continuous nursing, aiming to provide evidence-based support for clinical TCM nursing practice.

Keywords: Cerebral infarction, expert consensus, integrated traditional Chinese and Western medicine, ischemic stroke, nursing, rehabilitation, traditional Chinese medicine

INTRODUCTION

Cerebral infarction (CI) is also known as ischemic stroke.[1,2]It refers to the ischemic necrosis or softening of localized brain tissue caused by brain blood circulation disorders, ischemia, and hypoxia, which is characterized by high morbidity, high disability rate, high mortality rate, and high recurrence rate.[3]In the world, among all stroke patients, CI patients account for more than 87%.[4]Findings from the Global Burden of Disease Study 2010 showed that it has seriously threatened human health and has become the first cause of premature death and disease burden.[5,6]A previous study showed that Traditional Chinese Medicine (TCM) is beneficial to reducing the mortality and the incidence of complications in CI patients and improve their quality of life.[7]Hence, the Chinese Association of Integrative Medicine issued theExpertConsensusontheDiagnosisandTreatmentofCerebralInfarctionwiththeIntegratedTraditionalChineseandWesternMedicine(hereinafter referred to as “Consensus”).[8]The Consensus is guided by the clinical needs of Chinese and Western medicine and follows the principles of evidence-based medicine. The evidences of the diagnosis and treatment of CI with integrated Chinese and Western medicine in the past 10 years were objectively evaluated and fully discussed. Meanwhile, opinions of experts in clinical medicine, TCM, clinical epidemiology, nursing and clinical pharmacy were widely solicited, in order to provide a diagnosis and treatment plan of integrated Chinese and Western medicine in CI for clinicians, TCM practitioners and rehabilitation and nursing staff. This paper interpreted the Consensus from the perspective of integrated TCM and Western medicine nursing, including routine nursing, dietary nursing, emotional nursing, complication nursing, rehabilitation nursing, and continuous nursing, to provide a basis for clinical TCM nursing practice.

ETIOLOGY AND PATHOGENESIS OF CEREBRAL INFARCTION

The Consensus states that there are multiple causes for CI. The commonly-used classification systems are the Trial of Org 10172 in acute stroke treatment (TOAST) system, Chinese ischemic stroke subclassification (CISS) system and A-S-C-O (Atherosclerosis, Small-vessel disease, Cardiac source, Other cause) phenotypic classification system. Among them, TOAST is the most widely-used causative system,[9]which is specifically categorized into five subtypes: large-artery atherosclerosis, cardioembolism, small artery occlusion, stroke of other determined cause and stroke of undetermined cause.

From the perspective of TCM, the Consensus shows that CI caused by various causes belongs to the “cerebral vessel obstruction”. Therefore, blood stasis is the basic pathogenesis of CI and exists throughout the whole course of the disease. Toxicity damaging brain vessels is the core pathogenesis in the acute phase of CI.[10]

DIAGNOSTIC CRITERIA AND TREATMENT PRINCIPLES OF CEREBRAL INFARCTION

Diagnostic criteria of cerebral infarction

The diagnosis of Western medicine is preferred for acute CI, referring to the Chinese Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke 2018 issued by Neurology Branch, Chinese Medical Association.[11]TCM diagnosis refers to Diagnostic Scale of TCM Syndrome Elements of Ischemic Stroke. Wind, fire, phlegm, blood stasis, Qi deficiency, and Yin deficiency are common syndrome elements of stroke disease. During the acute phase, most of patients often presents superficial excess syndrome such as wind, fire, phlegm, while minority of patients presents Qi deficiency syndrome. The patients are predominated by “intermingled deficiency and excess syndrome” during the recovery period when Qi deficiency and Yin deficiency are the root causes while wind, fire, phlegm are superficial causes. Blood stasis syndrome runs through the whole course of CI. CI is mostly manifested as a combination of two or three TCM syndrome elements.

Principles of treatment of cerebral infarction

The Consensus recommends that the most important treatment for CI at super early stage is vascular recanalization. It is required as early as to evaluate whether patients can accept intravenous thrombolysis and endovascular treatment (such as mechanical thrombolysis and arterial thrombolysis).

According to the patient’s condition, TCM therapies are chosen reasonably, to maintain the patient’s vital signs stable, and ensure the patient’s enough nutrition and liquid intake. After the condition is stable, attention should be paid to the improvement of disease disability degree and daily living ability. At the same time, according to the etiological classification completed by auxiliary examination, the corresponding secondary preventive treatment is given to patients, with the emphasis on the standardized rehabilitation treatment and TCM characteristic rehabilitation therapies.

INTEGRATED TRADITIONAL CHINESE AND WESTERN MEDICINE NURSING

Conventional care

The Consensus emphasizes that patients with acute CI should stay in bed and be closely observed their condition such as breathing, blood oxygen, heart function, temperature, blood pressure, and blood sugar by nurses. Among them, blood pressure change and blood glucose management should be paid close attention to. Specific indicators refer to the Chinese Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke 2018 issued by the Chinese society of Neurology, Chinese stroke society.[11]It is required to prevent pulmonary infection, skin ulceration, urinary infection, pressure injury, and deep vein thrombosis. Meanwhile, oral care is needed during acute stage to keep respiratory tract unobstructed.

In the nursing process, due to their advantages of obvious effect and small side effects, convenience and economy, and easy to be accepted by patients, the nursing technologies with TCM characteristics are widely carried out in clinical practice, such as TCM characteristic cooling method, oral care, and skin care.

Traditional Chinese Medicine characteristic cooling method

The Consensus points out that the body temperature ＞38°C should be given antipyretic treatment. Clinical cooling methods include drug cooling and physical cooling.[12]Here, we mainly elaborate two TCM characteristic cooling methods: blood-letting therapy in ear apex and TCM bath. (1) Blood-letting therapy in ear apex. It is one of the traditional treatments of TCM acupuncture. Nurses knead the patient's ear to make it congestive, and disinfect the ear with 75% alcohol, and use three-prism needle to puncture apex of ear for bleeding. After blood-letting, press the pricked part with medical cotton ball to prevent bleeding.[13](2) TCM bath. While patients take a TCM bath, the active ingredient of Chinese medicine is absorbed into the body through the skin tissue like sweat glands and pores and play its therapeutic effect. The recommended prescriptions are Qingchai Antipyretic Washing Agent and Wind-Dispelling and Blood-Activating Liquid,[14]which are used for scrubbing the skin such as axilla, popliteal fossa, 2-3 min for each body part and ＜30 min in total.

Oral care

The role of TCM oral care in preventing lung infection is becoming more and more definite.[15]It is also recommended that the mouth should be cleaned twice to three times daily. If fungal growth is found, Nystatin Cream should be applied after cleaning. The heat-clearing and detoxification drug liquid or granules made from Huoxiang (HerbaAgastachis), Peilan (HerbaEupatorii), Jinyinhua (FlosLonicerae), and Heye (FoliumNelumbinis) is used for oral care, with good results received.[16]

Skin care

The Consensus recommends external use of Ruyi Golden Cream[17,18]and Blood-Activating and Granulation-Promoting Cream[19]for care of skin with pressure injury according to the different syndrome manifestations. The application of moxibustion, scraping and other TCM techniques which have effects of dredging meridians and collaterals, regulating Qi and blood, and stimulating the body self-healing function to consolidate the constitution, are also effective in wound healing.[20]

Daily life

The Consensus recommends that the CI patients should stay away from passive smoking and those with history of smoking should quit smoking and stay away from smoking areas. The recommended potentially effective ways to quit smoking include advice, nicotine alternatives, or oral smoking cessation drugs. Patients should have regular daily life and diet. Taking appropriate exercise is not only conducive to smooth emotions but also conducive to the recovery of physical function. In addition, patients with physical motor dysfunction need to prevent accidents such as falling or fall from bed.

Diet care

The Consensus recommends that patients with a clear consciousness and no swallowing disorders should be given a nutritious and easy-to-digest diet. If the patient has a consciousness disorder but no vomiting and upper gastrointestinal bleeding, nasogastric fluid diet can be given to ensure nutrition. The stomach tube should be rinsed with warm water after each nasogastric feeding to prevent the food remaining in the tube from spoiling.[21]And then, the end of the tube should be tied up well to prevent the stomach contents from overflowing. TCM believes that medicine and food have the same origin; hence, dietary nourishment is better than medicinal nourishment. Like Chinese medicine, foods have the characteristics of four properties (hot, warm, cold, and cool), five tastes (pungent, sweet, sour, bitter, and salty), meridian distributions, and ascending, descending, floating, and sinking.[22]Diets based on syndrome differentiation is the key of TCM diet nursing. Based on this, the established principles include “mutual restraint of four properties and five tastes”, “compatibility of five tastes,” “treating cold with hot drugs,” “treating heat with cold drugs,” “treating excess syndrome with purgative methods,” and “treating deficiency syndrome with tonifying methods.”[23-25]Diet nursing based on syndrome differentiation for common syndrome types of stroke is as follows: (1) for patients with syndrome of wind-phlegm and blood stasis blocking colleterals, the recommended food ingredients are Shanyao (RhizomaDioscoreae), Yuxingcao (houttuyniacordataThunb), Jineijin (EndotheliumCorneumGigeriaeGalli), Fuling (Poria), Tianma (RhizomaGastrodiae), Chenpi (Pericarpium Citri Reticulatae), orange peel, fried coix seed, etc. The recommended medicated diets are japonica rice porridge with orange peel (twice daily, 2-3 days weekly) and dim sum with Shanyao (RhizomaDioscoreae) and Fuling (Poria). (2) For patients with Qi deficiency and blood stasis syndrome, the recommended food ingredients are lamb tripe, japonica rice, roasted Huangqi (RadixAstragaliseuHedysari), Hongshen (RadixGinsengRubra), Dazao (FructusJujubae), Danggui (RadixAngelicaeSinensis), Dangshen (RadixCodonopsis), etc. The recommended medicated diets are ginseng pork tripe soup (1-2 times weekly), lamb tripe porridge (3 times daily, 1-2 days weekly), and ginseng-date rice. (3) For patients with syndrome of stirring wind due to Yin deficiency, the recommended ingredients are black bean, black sesame, black fungus, lily, Shihu (HerbaDendrobii), Maidong (RadixOphiopogonis), Shashen (RadixAdenophorae), etc. The recommended medicated diets are lily-tremella soup (proved recipe, 1 small bowl/time, twice daily) and flavored soybean wine (proved recipe, moderate wine drinking, 3 time daily).

Medication care

Chinese medicine is a common choice for the treatment of CI.[26]The Consensus recommends nine kinds of Chinese medicine injections, 21 types of Chinese patent medicines and 16 prescriptions. It also explains the dosage and frequency of oral taken Chinese medicines and the decocting method of special medicines. Different nursing methods are given to the intravenous infusion and oral administration of Chinese medicines.

The following nine aspects in the intravenous infusion of Chinese medicines should be paid attention to:[27,28](1) Ask the patients whether they have a history of allergies before applying Chinese medicine injections. Patients with allergic constitution or a clear history of allergies should avoid using similar drugs. When it must be used, it is necessary to perform a skin allergy test. (2) In the first application of Chinese medicine infusion, the infusion rate should be 20-40 drops per minute, and should be closely observed. (3) Pay attention to check the contraindications of drug compatibility, and avoid using two types of Chinese medicine preparations simultaneously. It is necessary to flush the infusion tube using normal saline before and after the infusion of Chinese medicine injections. (4) The precision filtration infusion (filter medium pore size is 2.2-5 μm, drug adsorption ＜2.86%) is used for Chinese medicine injections. (5) The flexible, thick, and straight blood vessels should be chosen. In case of the infusion time longer than 4 h, a large amount of fluid infusion, or the treatment course longer than 3 days, for the elderly, children, or restless patients, intravenous indwelling needles are needed. (6) It is required to strengthen medication guidance, explain to patients the effects of medications and possible common adverse reactions, but to avoid false positives in patients with excessive emotional stress. (7) In case of symptoms such as fever, rash, itching, dizziness, headache, dyspnea, or even shock during the application of Chinese medicine injections, it is treated according to the Emergency Plan for Adverse Drug Reactions. (8) Chinese medicine injections are prepared for immediate use so as not to cause adverse reactions due to decomposition or polymerization of some components in the injections if long placed after preparation. (9) Before changing the Chinese medicine injection, the nurse should carefully check the prepared solution for any abnormal phenomena such as insoluble particles, sediment, and turbidity. If any abnormality is found, it is strictly forbidden to use.

Oral administration of Chinese medicine mainly refers to the oral administration of Chinese herbal decoction. Chinese herbal decoction is a liquid dosage form of decocting processed herbs after soaked for a period of time. Chinese herbal decoction should be taken warm, slightly warmer in winter and slightly cooler in summer. It should be taken cold for treating heat syndrome and taken warm for treating cold syndrome. In general, it is advisable to eat less beans, meat, raw cold and other indigestible foods when taking decoction. The blood-activating decoctions should be taken warm with warm yellow wine, to promote blood circulation, warm the meridians and dregde the collaterals.[29]In addition, the Chinese herbal decoction has requirements on the following points: Utensils, solvent, water consumption, decocting time, water temperature, frequency, special decocting method, and decocting sequence.[30]

Emotional care

Bad mood after CI is mainly depression and anxiety which seriously affect the diagnosis, treatment and recovery of CI, and even induce and aggravate CI.[31,32]The Consensus points out that the guiding concept and method of “relax” and “peaceful” should be reflected in the process of rehabilitation treatment of CI, which require patients to be calm and patient, not eager to recover and do excessive exercise, and coordinate with the doctor’s treatment. In recent years, the TCM techniques and methods have been used in more and more studies for the treatment of anxiety and depression in patients with CI. Duet al.[33]have applied the relaxation method to effectively relieve depression and anxiety of patients. Its core relaxation methods are breathing relaxation, posture relaxation, gentle mental relaxation, etc. Tai Chi and Qigong are a physical and mental exercise that combines posture and gentle movements with mental concentration and breathing relaxation. A previous study[34]shows that Tai Chi and Qigong may be effective in reducing depressive symptoms. When caring hospitalized patients with CI, nurses usually pay attention to humanistic care.

Rehabilitation nursing

Dyskinesia rehabilitation nursing

The Consensus shows that rehabilitation intervention can be immediately started for patients with clear consciousness, no serious mental and behavioral abnormalities, stable vital signs, no serious complications or comorbidities after the onset of CI. The Consensus emphasizes that the rehabilitation of motor dysfunction mainly includes placement of good limb position, passive exercises of the joint, adaptive training for body position change, active exercise training in bed, training from sitting to standing position, balance training, and inhibition of spasms.

The Consensus recommends early placement of good limb position for the prevention and rehabilitation of shoulder-hand syndrome. If there is no contraindication, the patient should be instructed to perform active and passive exercises of the hand as early as possible to prevent the occurrence of shoulder-hand syndrome or reduce its degree. The ultra-early correct placement of good limb position can significantly improve the self-care ability and prognosis of patients with CI.[35]

Passive rehabilitation training is suitable for bedridden patients in the early stage of CI. On the basis of acupoint massage, the active exercise of the affected limbs of the patient is gradually increased, such as joint extension training mainly for the upper limbs and joint flexion training mainly for the lower limbs, to promote the recovery of limb function. A study conducted by Jing[36]showed that the application of active rehabilitation training in patients with CI can effectively improve the compliance of patients with functional exercise and improve the motor and balance function of patients. The Consensus recommends that the exercise appropriate for the recovery period of spasticity is Tai Chi. American scholar Taylor-Piliae and Coull[37]confirmed that Tai Chi exercise can improve aerobic endurance in stroke patients with hemiplegia. Fu and Zhang[38]found that patients in Tai Chi group had better balance function, walking function, and maximum walking speed than those in non-Tai Chi group. Baduanjin is another an effective and easy to manage physical and mental exercise that can improve executive function and brain self-regulation in young and healthy people.[39]

The Consensus recommends drugs for promoting blood circulation and removing blood stasis, together with invigorating Qi and dissipating dampness or warming meridians and dredging collaterals (such as Fuyuan Tongluo Liquid) for wet compress, fumigation or medicinal bath for patients with cerebral infarction. Weiet al.[40]confirmed that Fuyuan Tongluo Liquid fumigation has a good effect in the treatment of hemiplegic limb swelling after stroke. TCM fumigation is mostly used in combination with acupuncture, moxibustion, and intermediate frequency therapy in clinical practice.

Massage manipulation is recommended in the Consensus. The head and face manipulation mainly includes point pressing, sweeping, finger kneading and thenar kneading. Limb massage manipulation should be slightly heavier, and meridian massage, point pressing, plucking, holding, finger pecking, and finger kneading can be used. Zhanget al.[41]pointed out that rehabilitation massage can effectively improve the neurological function and relieve clinical symptoms of patients with CI.

The Consensus recommends moxibustion for patients with cerebral infarction. In general, mild moxibustion with the moxa stick is used, with tonifying method on the selected acupoints Quchi, Waiguan, Hegu, Zusanli, Sanyinjiao, and Xuanzhong. Moxibustion is performed appropriately until the skin is reddish. Chenget al.[42]showed that moxibustion can effectively improve the neurological function of convalescent patients with CI.

Dysphagia rehabilitation nursing

Dysphagia is one of the complications after CI. Dysphagia may lead to the occurrence of malnutrition, dehydration, and aspiration pneumonia and decreased quality of life.[43]A study has shown that dysphagia prolongs the length of hospital stay and increases the risk of death,[44]so the screening, evaluation, and treatment process of dysphagia is particularly important.[45]Dysphagia screening is an vital part of the clinical diagnosis and treatment process, which can reduce the incidence of aspiration pneumonia and is also part of the guidelines established by the American Heart Association and the American Stroke Association.[46]In reviewing the recent literature on dysphagia rehabilitation after CI, there are mainly nerve stimulation and biofeedback.[47]TCM can improve dysphagia.[48]The Consensus also recommends acupuncture for neuromuscular electrical stimulation, oral ice stimulation, etc. Duet al.[49]confirmed that the application of TCM ice and fire therapy in swallowing rehabilitation nursing can enhance the coordination of swallowing muscle groups and improve dysphagia in patients with dysphagia after CI. A study on the choice of intervention time reporting enhanced neuroplasticity occurring early after the onset of CI showed that it is very beneficial to implement interventions in the acute and subacute phases of CI.[50]

Speech-language disorder rehabilitation nursing

In the acute phase of CI, damage to speech and language regions of the brain can lead to aphasia (a language disorder), apraxia of speech (AOS, speech motor planning/programming disorder), and/or dysphonia (a speech execution and control disorder).[51]The Consensus recommends rehabilitation training, which mainly improves individual communication ability through a variety of strategies, such as helping individuals use and improve residual language ability, restoring individual language ability as much as possible, compensating for language impairment by formulating strategies, and learning other communication methods. Liu and Wang[52]pointed out that it could be induced to increase the amount of expression information, increase the interest of rehabilitation process, improve its control ability of muscles, and improve the language expression ability by oral counterpoint training for patients and look-and-say method.

Continuity of care

Continuity of care after CI belongs to the “disease prevention” in TCM. Effective prevention is an important means to reduce the recurrence and death of CI. The Consensus suggests that nurses’ continuous care of patients after CI includes the improvement of lifestyle, the control of risk factors, and the improvement of medication compliance. The healthy lifestyle of patients with CI includes smoking cessation, regular exercise, Mediterranean diet, reduced salt intake, and drinking.[53]Controlling risk factors include controlling blood pressure, blood sugar, blood lipid, and homocysteine. Taking antiplatelet or anticoagulant medication as directed can reduce the risk of CI recurrence and cardiovascular events.[54]

CONCLUSION

The Consensus provides evidence-based support in the clinical diagnosis and treatment of different stages of CI, complication management, rehabilitation treatment, secondary prevention, and nursing. Nurses must keep pace with the times, actively update their ideas in real time, challenge the higher standards, dynamic grasp of the new progress of diagnosis, treatment, and nursing of integrated traditional Chinese and Western medicine in CI. This paper interprets the Consensus from the perspective of integrated traditional Chinese and western medicine nursing. On the basis of the routine care of Western medicine, the TCM characteristic nursing techniques such as TCM cooling, TCM oral care, and skin care are mainly introduced. In the dietary care, the medicinal diets are recommended according to syndrome differentiation and classification. In terms of medication care, the precautions of intravenous injection and oral administration of TCM are stressed. Appropriate exercises such as Tai Chi, Qigong, Baduanjin, etc., are recommended for emotional nursing. TCM fumigation, massage and moxibustion and other appropriate techniques are recommended for rehabilitation nursing of patients with CI. Those together provide evidence-based support for nursing care of integrated traditional Chinese and Western medicine for CI as well as provide a reference for the clinical practice of TCM characteristic nursing techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.