Home Care by Ozone Bagging towards Diabetic Foot Ulcers Healing

Devi Mediarti

, Rehana

and Hidayat Arifin

Department of Nursing, Polytechnic of Health Palembang, Palembang, Indonesia

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 t–test 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

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

Sex

Men

Women

40.5

59.5

Total

100

Age

21-39 years

> 40 years

Total

100

Level Education

Medium (High School)

High (University)

54.8

45.2

Total

100

Employment

Not work

Work

Total

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

Mean

36.21

4.076

37.17

4.316

Table 3: Distribution of average diabetic foot ulcers

after treatment.

Variable

Mean

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

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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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