Home Care by Ozone Bagging towards Diabetic Foot Ulcers Healing
Devi Mediarti
1
, Rehana
1
and Hidayat Arifin
2
1
Department of Nursing, Polytechnic of Health Palembang, Palembang, Indonesia
2
Faculty of Nursing, Universitas Airlangga, Mulyorejo, Surabaya, Indonesia
Keywords: Wound care, Diabetic Foot ulcers, Ozone bagging, Home care.
Abstract: The global prevalence of DM patients in 2014 is 8.3% of the total population in the world. Increased
prevalence of DM followed by increased incidence of diabetic foot ulcers. The American Diabetes
Association mentioned that in 2010 there were approximately 73,000 cases of non-traumatic limb
amputations with a diagnosis of DM. The purpose of this study was to determine the effect of home care
with modern wound care: ozone bagging towards diabetic foot ulcers healing in Palembang. This research
used quantitative and qualitative approach with mixed methodology design. The samples obtained 42 people
by purposive sampling technique. Quantitative analysis used dependent samples paired ttest and qualitative
used non-statistical analysis through logical inference based on actual considerations and conditions. The
average before treatment were 36.21 with SD = 4.076 and after treatment were 37.17 with SD = 4.316.
Home care with modern wound care: ozone bagging gave effect on wound healing of patients with diabetic
foot ulcers (p = 0.026). All participants expressed feelings of great satisfaction. Therefore, it is necessary to
develop further research, by developing design and intervention in several groups, so it can assess the
effectiveness of ozone bagging for healing diabetic foot ulcers through home care.
1 BACKGROUND
Diabetes Mellitus (DM) was a chronic disease that
occurs when the pancreas does not produce enough
insulin or when unable to effectively use insulin
(WHO, 2015). Diabetes Mellitus was a chronic
hyperglycemic state accompanied by chronic
abnormalities in the eyes, kidneys, and blood
vessels, with lesions in the basement membrane in
examination with an electron microscope (Darmono,
2007). Diabetes Mellitus which does not get optimal
treatment will cause various complications, either
simultaneous or a dominating problem such as
diabetic neuropathy, diabetic nephropathy, diabetic
retinopathy, vascular abnormalities, and diabetic
foot ulcers (Poerwanto, 2012).
American Diabetes Association mentions that
Diabetes Mellitus that causes abnormalities in the
blood vessels can cause stiff blood vessels and
vasoconstriction causing blood flow in the tissue
was disturbed. As a result of the disruption of blood
flow causing the surrounding tissue to become
ischemic, causing injury and causing diabetic foot
ulcers (ADA, 2014).
International of Diabetic Federation (IDF, 2015)
states that the global prevalence rate of DM patients
in 2014 was 8.3% of the total population in the
world and will increase in 2014 up to 387 million
cases of Diabetes Mellitus patients. Indonesia was
the seventh country with 8.5 million DM patients
after China, India and the United States, Brazil,
Russia, Mexico.
The incidence of DM according to data
Riskesdas (2013) increased from 1.1% in 2007 to
2.1% in 2013 from the total population of 250
million people. The prevalence of DM disease in
South Sumatera Province based on integrated
surveillance of non-communicable diseases (NCD)
based on the community found that the number of
people with diabetes mellitus in 2015 was 3180
people (Depkes, 2015), while the Health Service
Data of Palembang in 2014 diabetes mellitus
reached 1553 cases and increased by 2015 amounted
to 1595 cases (Dinkes, 2015).
Increased prevalence of DM followed an
increase of incidence of diabetic foot ulcers which is
one part of complications caused by DM. The
American Diabetes Association (ADA, 2014)
mentions that in 2010 there were approximately
366
Mediarti, D., Rehana, . and Arifin, H.
Home Care by Ozone Bagging towards Diabetic Foot Ulcers Healing.
DOI: 10.5220/0008325403660372
In Proceedings of the 9th International Nursing Conference (INC 2018), pages 366-372
ISBN: 978-989-758-336-0
Copyright
c
2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
73,000 cases of non-traumatic limb amputations in
adults over 20 years old with a diagnosis of DM.
The prevalence of diabetic foot ulcers patients in the
United States was 15-20%, the risk of amputation
was 15 to 46 times higher than those not suffering
from DM. Data Center and Information of PERSI in
2011, it is known that the number of visits DM
clients with diabetic foot ulcers at Cipto
Mangunkususmo Hospital in 2012 amounted to 111
patients. Amounts of amputation accounted for 35%,
consisting of 30% major amputation and 70% minor
amputation, while amputation death rate was about
15%.
Diabetic foot ulcers have several underlying risk
factors, namely peripheral neuropathy, ischemia and
infection (Clayton & Tom, 2009). Peripheral
neuropathy was an important cause of the
occurrence of diabetic foot ulcers. Peripheral
neuropathy in the diabetic client concerns all the
components of the nervous system, sensory, motor
and autonomic nerves that each contribute to the
development of diabetic foot ulcers (Chand et al.,
2012). The most common type of diabetic
neuropathy was the Distal Symmetric Polyuropathy
(DSP). More than 50% of PDS is asymptomatic and
clients at risk of unwitting injury to the foot resulting
in foot ulcers (Boulton, 2005). Ischemia was a state
of tissue lacking oxygen due to low oxygen supply
in the tissue. It caused by the process of
macroangiopathic on blood vessels so that blood
circulation in the tissue decreases. This condition is
characterized by the loss or decrease in pulse in the
tibial artery, dorsalis pedis and popliteal, leg muscles
experience shrinkage, cold and thickened nails.
The angiopathic process in clients of diabetes
mellitus often occurs in the lower legs, especially the
feet, in the form of narrowing and blockage of
peripheral blood vessels, due to perfusion of the
distal tissue of the leg becomes reduced, causing the
occurrence of diabetic foot ulcers (Tambunan,
2010). Diabetic Mellitus sufferers with diabetic foot
ulcers were particularly vulnerable to infection.
Infectious bacteria in diabetic foot ulcers were
Staphylococcus or Streptococcus aerobic bacteria
and anaerobic bacteria Clostridium Perfringens,
Clostridium Noy and Clostridium Septicum (Kateel
et al., 2018).
Complications caused by diabetic foot ulcers
require good holistic penalization. PERKENI (2011)
mentions that in the management of Diabetes
Mellitus is holistic that includes metabolic, vascular,
infectious, pressure, and educational controls.
Wound control is a form of effort in the treatment of
diabetic foot ulcers by performing cleansing and
necrotomy action if necessary on infected tissues on
a regular basis. Infection control is a preventive
measure of the activity of microorganisms that can
cause infection in diabetic foot ulcers. Measures that
can be done include preventing port de entry to a
minimum and perform wound care regularly with
aseptic techniques PERKENI (2011).
Management of infection is very important in the
healing process of diabetic foot ulcers (Pressman,
2007) reveals modern treatments that can be done in
the healing process of diabetic foot ulcers one of
them by using ozone bagging. The use of ozone as a
complementary / alternative therapy is now popular
in Indonesia and has been used since 1992
(Inggraini, 2007). As a molecule that has enormous
energy, Ozone can inactivate bacteria, viruses, fungi
and some types of protozoa. this may occur due to
the presence of radical ions of ozone degradation
results in water in the form of hydrogen peroxide
(HO2) and hydroxyl (HO) (Zhafira, 2012).
The function of ozone in healing diabetic
wounds is as an antimicrobial. It was generally
believed that bacteria are destroyed by the
protoplasm oxidation process. The oxidation of
protoplasm will damage the capsid or outer skin of
the microorganism comprising the unsaturated bond
of phospholipid or lipoprotein, then penetrate into
the cell membrane, react with cytoplasmic
substances and convert the circular plasmid of
closed DNA into an open DNA circular, which can
reduce the efficiency of bacterial proliferation,
directly activate cytoplasmic integrity, and disrupt
some degree of metabolic complexity (Dewayanti et
al., 2009). The purpose of this study was to
determine the effect of home care with modern
wound care: ozone bagging towards diabetic foot
ulcers healing in Palembang.
2 METHODS
This research was a pre-experimental pretest
posttest used quantitative and qualitative research,
which used together through the mixed methodology
design approach model. The type of mixed methods
used explanatory sequential.
This method carried out in sequence, quantitative
research methods first then followed by qualitative
research. Researchers use this design with the
expectation of qualitative findings will help
interpretation or contextualize the results of
quantitative research.
This research conducted in Palembang on
September 18 to December 25, 2017. The population
Home Care by Ozone Bagging towards Diabetic Foot Ulcers Healing
367
of this research was respondent with diabetic foot
ulcers total of 55 people. The samples obtained 42
people by purposive sampling technique according
to the inclusion and exclusion criteria. The inclusion
criteria of this research were: able to read and write;
DM people with diabetic foot ulcers grade 3 and 4
(Wagner Classification); and never get therapy with
ozone bagging. The exclusion criteria of this
research were: DM people with contraindication:
acute alcohol intoxication, acute myocardium
infarct, multi organs bleeding, pregnancy,
hypertoroid, thrombocytopenia, ozone allergy, and
people with heparinization; unable to complete the
process.
Determination of location based on
recommendation and data of Muhammad Hoesin
Hospital considering DM people which was control
as outpatients in internist polyclinic. The
independent variable in this research was home care
with modern wound care: ozone bagging, and
dependent variable was diabetic foot ulcers healing.
Quantitative data obtained by observation sheet
using Leg Ulcer Measurement Tools (LUMT) and
have been tested for validity and reliability with r
table 0.82. Qualitative data obtained from the
interview, observation and documentation of patient
assessment about diabetic foot ulcers healing, to
determine the rational validity of modern wound
care model: ozone bagging. Then, validated the
treatment that have been given to the respondent,
especially with what is perceived by the respondent,
both the pain associated with ulcers, the frequency
of pain, the feeling during the treatment is done or
the feelings about the quality of life of the
respondents who will come.
Research by using ozone bagging was done for
15 weeks divided into 3 sessions. Each session for 5
weeks with 14 respondents. Before treatment with
ozone bagging, wound care with NaCl solution and
cleansed when there was exudate. Home care helped
by 4 tools of ozone bagging for every day with
duration of each respondent for 10 minutes.
After all data were collected, then analyzed using
univariate and bivariate (dependent sample paired t
test) and qualitative analyzed using non-statistical
analysis through logical inference based on actual
considerations and conditions. This research had
been reviewed and certified for Ethical Approval
with No. 666/KEKP-PTKMKS/XII/2017 on
September 11, 2017 issued by Health Research
Ethics Committee of Health Polytechnic Makassar.
Figure 1: Ozone bagging tools.
3 RESULTS
3.1 Quantitative Results
Table 1 explained most of respondents were women
and more than 40 years old with medium level
education, and not worked.
From Table 2, we can see that the average
condition of diabetic foot ulcers before doing home
care with modern wound care: ozone bagging was
36.21 and standard deviation = 4.076. The average
condition of diabetic foot ulcers after home care
with modern wound care: ozone bagging was 37.17
and standard deviation = 4.316.
Table 1: Distribution of respondents based on
demographic characteristic.
Characteristics
N
%
Sex
Men
Women
17
25
40.5
59.5
Total
42
100
Age
21-39 years
> 40 years
13
29
31
69
Total
42
100
Level Education
Medium (High School)
High (University)
23
19
54.8
45.2
Total
42
100
Employment
Not work
Work
29
13
69
31
Total
32
100
INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research
368
Table 3 showed the result of statistic test got p-
value = 0.026, hence can be concluded treatment
home care modern wound care: ozone bagging
influence to wound healing of diabetic foot ulcers.
3.2 Qualitative Results
3.2.1 Pain Scale
All of participant say did not feel anything on
diabetic foot ulcers while home care treatment by
ozone bagging.
“I did not fell anything on my diabetic foot
ulcers, just like wind touch my leg and diabetic foot
ulcers”.
3.2.2 Feelings about Ozone Bagging
All participants expressed feelings of great
satisfaction with home care treatment by ozone
bagging as the following statement:
No one can take me for treatment again, I want
to take help my children, but their home far away.
They also work so afraid of burdening. So, if the
nurses come to my home, we were very helpful
“The nurses were diligent, care, patient, and
friendly. Which makes comfortable, no need to
queue and tired. I can set my own time when not
bother. Different in hospital, my wound (diabetic
foot ulcers) not well maintained ".
I did not difficult to manage schedule. My
wound looks better, the left one has changed and
dried. The right will soon heal, but sometimes still a
bit wet. "
4 DISCUSSION
The research founded that 90% of respondents stated
comfortable choosing home care and 10% of
respondents said uncomfortable choose home care.
According to the researchers there were respondents
who stated uncomfortable because of using Home
care more than five weeks so they did not familiar
with home care service and feel disturbed. Based on
the interviews it was found that there were patients
who prefer to be treated at home rather than in the
hospital because they closer to the family and the
patient does not feel the activity is limited so it
makes the patient prefer to choose home care.
Comfort is a concept that has a strong
relationship in nursing. Some comfort types are
defined as follows: (1) Relief, a state in which a
recipient has a specific needs fulfillment; (2) Ease, a
state of calm and pleasure; (3) Transcendence, a
state in which an individual reach above the
problem. Then derivate the above context into the
following: (1) Physical, with respect to body
sensations; (2) Psychospiritual, with respect to the
internal self-consciousness, which includes self-
esteem, self-concept, sexuality, the meaning of life
to a relationship of higher needs; (3) Environment,
with respect to the environment, conditions, external
influences; (4) Social, with regard to interpersonal,
family, and social relationships. Providing home
care services can support patient comfort and
independence at home (Kolcaba & DiMarco, 2005).
According Katrina M et al. (2013) the benefits of
home care services for clients include the needs of
clients fulfilled and people will be more comfortable
and satisfied with professional nursing care.
Meanwhile, according to Lechner et al. (2017) stated
the environment at home felt more comfortable for
some clients and compared the hospital treatment so
healing of diabetic foot ulcers rapidly. It showed that
comfort has a chance to influence in choosing home
care for diabetic foot ulcers treatment.
Nursing Law no 38 of 2014 in one article set
about the practice board nurse. If the nurses want to
open independent practice, they must establish a
nameplate, if they do not put a nameplate, the nurse
practice is considered illegal practice (nursing law
no 38, 2014). Nursing practice can apply in
hospitals, clinics, health centers and also at home
clients as home care. Health care activities in home
care included: medical services, nursing services and
care, medical rehabilitation services, nutrition
services, maternity visits, maternity visits, high risk
infant visits, installation or replacement of medical
devices such as gastric hoses, catheters, respiratory
Table 2: Distribution of average diabetic foot ulcers
before and after treatment.
Number of Average Diabetic Foot Ulcers
Pretest
Posttest
SD
Mean
SD
4.076
37.17
4.316
Table 3: Distribution of average diabetic foot ulcers
after treatment.
Variable
Mean
SD
SE
P
Value
Diabetic foot
ulcers
Healing
- 0.952
2.677
0.413
0.026
Home Care by Ozone Bagging towards Diabetic Foot Ulcers Healing
369
tubes and others, certain laboratory preparations,
wound and stoma treatments, drug delivery via
muscular and intra-vein, and infant massage (Karota
2012)
Alavi et al. (2014) explained diabetic foot
disorders occur because the control of sugar levels
was not well and lasted continuously for years. The
main causes were nerve damage (diabetic
neuropathy) and blood vessel disorders. Nerves that
have been damaged make diabetes patients unable to
feel pain, heat, or cold on the hands and feet. In
Indonesia, there are 1785 diabetic patients with
neuropathy complications (63.5%), retinopathy
(42%), nephropathy (7.3%), macrovascular (16%),
microvascular (6%), diabetic foot injuries (15%).
Wound treatment techniques using a moist bandage
aims to maintain the insulation of the wound
environment that remains moist. Wound conditions
that remain moist will help the wound healing
process as much as 45% and reduce infectious
complications and residual tissue growth.
Wound care aims to get the wound healed and
prevent and overcome the infection so as not to
spread to other organs. Deaths from wound
infections that spread to the heart will not occur if
wound care is done early on. There were 7 factors
that inhibit wound healing consists of age, infection,
hypovolemia, hematoma, foreign body, ischemia,
diabetes and treatment (Lefrancois et al., 2017).
Modern wound care was a wound treatment that
uses the principle of maintaining the wound
environment to keep it moist. In maintaining the
wound moisture, the dressing used ideally is a closed
or occlusive dressing. Closed dressing is a bandage
that prevents air from entering the wound or lesions
and maintains moisture, temperature and body fluids
and provides benefits, including: reducing the
surface of the necrotic wound, preventing the wound
from drying out, reducing pain, stimulating growth
factor, activating the required enzymes for
debridement as well as preparing wound protection
(Vowden & Peter, 2017).
Ozone has a role in wound healing, which is as
an antimicrobial and can accelerate the formation of
growth factors. Ozone which is a powerful oxidant
can kill microorganisms by destroying the
microorganism's capsid consisting of an unsaturated
bond of phospholipid followed by damage to RNA
and DNA from the corresponding microorganism
(Leusink, 2010).
The process of mechanics in the ozone is to
inactivate bacteria, viruses, fungi, yeasts and
protozoa: Ozone therapy interferes with the integrity
of bacterial cells through the oxidation of
phospholipids and lipoproteins. In fungi, ozone
inhibits cell growth at some stage. In the virus,
ozone destroys the viral capsid and disrupts the
reproductive cycle by disrupting the virus-to-cell
contact by peroxidation. The weak enzyme layers in
cells that make them vulnerable to invasion by
viruses make them susceptible to oxidation and
elimination from the body, which subsequently
replaces them with healthy cells (Elvis & Ekta,
2011). Diabetic complications are associated with
oxidative stress in the body, ozone is found to
activate antioxidant systems that affect glycemic
levels. Ozone prevents oxidative stress by
normalizing organic peroxide levels by activating
superoxide dismutase (Zeng & Lu, 2018).
Stimulation of oxygen metabolism: Ozone
therapy causes an increase in the rate of red blood
cell glycolysis. This leads to a 2,3-
diphosphoglyceric stimulation that causes an
increase in the amount of oxygen released into the
tissues. Ozone activates the Krebs cycle by
increasing the oxidative carboxylation of pyruvate,
stimulating the production of ATP. It also causes
significant decrease in NADH and helps oxidize
cytochrome C. There is a stimulation of enzyme
production that acts as a free radical scavenger and
cell wall protector: glutathione peroxidase, catalase
and superoxide dismutase. Production of
prostacyclin, vasodilator, also induced by ozone
(Viebahn-Hänsler, 2015). Immune activation: Ozone
given at concentrations between 30 and 55 μg/cc led
to the greatest increase in interferon production and
the largest output of tumor necrosis factor and
interleukin-2. Production of interleukin-2 launches
the entire subsequent immunological reaction (Zeng
& Lu, 2018).
Figure 2: Mild oxidative stress induced by ozone
therapy.
INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research
370
Research conducted by Agosti et al. (2016)
shows care reports on youths who have had traffic
accidents and amputations in the tibia and fibula
dextra suggesting injuries to rehabilitation for
treatment. At that time the wound was ulcerated but
afebrile without signs of inflammation and
negativity to the blood test. At 2 months of trauma
despite proper care and dressing, the wound
gradually improves and the patient complains of
pain. For this reason, other than the standard
dressing he undergoes ozone therapy. After 5 weeks
of treatment, the wound healed. In patients with non-
healing injuries, ozone-oxygen therapy can help
speed healing and reduce pain thanks to disinfectant
properties and with enhancement of endogenous
oxygen free restorer properties. Compared with
standard dressings and other treatments reported in
the literature, this shows a shorter course of action.
Oxidative stress has an important role in the
development of complications in diabetes. Because
ozone therapy can activate the antioxidant system,
affect the level of glycemia and some markers of
endothelial cell damage, the purpose of this study
was to determine the therapeutic efficacy of ozone in
the treatment of type 2 diabetic patients and diabetic
feet and to compare ozone with antibiotic therapy.
Ozone treatment increases glycemic control,
prevents oxidative stress, normal levels of organic
peroxide, and activated superoxide dismutase. The
pharmacodynamic effects of ozone in the treatment
of patients with neuroinfection. Diabetic feet may be
considered to be derived from the possibility of
being a superoxide scavenger. Superoxide is
considered a link between four metabolic routes
associated with diabetic pathology and its
complications. Furthermore, healing of lesions
improved, resulting in fewer amputations than in the
control group. No side effects. These results suggest
that medical ozone treatment may be an alternative
therapy in the treatment of diabetes and its
complications (Martínez-Sánchez et al., 2005).
Research in vitro evaluation of wound healing
and antimicrobial potential of ozone therapy
performed by (Borges et al., 2017), although ozone
therapy is widely applied when wound repair and
antimicrobial effects, little is known about the
cellular mechanisms of this process. The effects of
ozone on cell migration are evaluated through initial
wound healing and trans well migration tests. The
minimum inhibitory concentrations for Candida
albicans and Staphylococcus aureus were
determined. Ozone does not show cytotoxicity on
the cell line, while chlorhexidine significantly
reduces cell viability. Although no significant
differences between control cells and ozone treated
cells were observed in the initial test, a substantial
increase in migration of fibroblasts was observed in
cells treated with an ozonation solution of 8 mg/ mL.
In addition, a study conducted by (Weinstein, 2012)
which concluded based on research conducted in
two groups of respondents in the ozone group
showed the healing process in foot ulcer is very
significant for 12 weeks.
5 CONCLUSIONS
Home care by ozone bagging affects the wound
healing of diabetic foot ulcers and all participants
expressed do not feel anything in the wound when
home care is applied with modern wound care:
ozone bagging, as well as expressing a very satisfied
feeling.
Modern wound care treatment: ozone bagging
for healing diabetic foot ulcers through home care
needs to be done further development. Further
development is expected to be done in several
groups and can be followed the development of
diabetic foot ulcers healing with several
measurements. as well as a series of ozone bagging
tools can be made more simple and portable when
home care therapy
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