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ADVANCED WOUND CARE:

An experience in diabetic foot ulcer

Saldy Yusuf.,PhD.,ETN

PSMIK, Fakultas Kedokteran UNHAS


Editor in Chief Jurnal Luka Indonesia
Griya Afiat Makassar, Wound Care and Home Care

Kongres Nasional PERS, Novotel Hotel, Palembang 25-27 Juli 2017


Topics

1. Current status DFU in Indonesia


2. Risk Assessment
3. Wound care of DFU
4. Case series.

2
PREVALENSI DIABETES MELLITUS
2013 2035
PREVALENCE DM Populasi DM di Indonesia
Country Millions Country Millions
IN INDONESIA1,3,4 1
4
China 98.4 China 12 Juta 142.7
7.00% 1
5.7% 6% 2India 65.1 India 109.0
6.00% 10
USA 24.4 USA 29.7
5.00% 7 Juta
Brazil
8 11.9 Brazil 19.2
4.00% Russian 10.9 Mexico 15.7
6
3.00% Mexico 8.7 Indonesia 14.1
2.00% 1.63% 4
Indonesia 8.5 Egypt 13.1
1.00% 2
Germany 7.6 Pakistan 12.8
0.00%
Egypt
0 7.5 Turkey 11.8
1983 1 20072 20303
Japan 20107.2 Russian 2030 11.1

Prevalensi DM yang tidak terdiagnosa cukup tinggi sebesar 4.1 %


1. Waspadji S, Ranakusuma A, Suyono S, Supartondo S, Sukaton U. Diabetes Mellitus in an Urban Population in Jakarta, Indonesia. Tohoku J exp Med. 1983;141:219-228.
2. Mihardja L, Delima, Siswoyo H, Ghani L, Soegondo S. Prevalence and determinants of diabetes mellitus and impaired glucose tolerance in Indonesia (a part of basic health
research/Riskesdas). Acta Med Indones. 2009;41(4):169-74.
3. Shaw, J.E., Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(1):4-14.
4. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract.
2014;103(2):137-149.
5. Pramono, L. a, Setiati, S., Soewondo, P., Subekti, I., Adisasmita, A., Kodim, N., & Sutrisna, B. (2010). Prevalence and predictors of undiagnosed diabetes mellitus in Indonesia. Acta
Medica Indonesiana, 42, 216–223. 3
Prevalence Acute and Chronic Wound
Summary Outcome in Wound Care Setting
Prevalensi Acute and Chronic Wound 2013
in Home Care Setting Luka Akut Luka Kronis

26 85.1

15
12 38.4
11 34.6
8 8
7
19.2
3 3 3 14.8
1 1 1 7.6
0 0

Sembuh Rujuk Drop out Meninggal

DFUs is major wound problems in


High number of Drop Out Patients
clinical setting in Indonesia

Saldy Yusuf., Sukmawati.,Mayumi Okuwa.,Junko Sugama. Development Enterostomal Therapy Nurse Outpatient Wound
Clinic In Indonesia: A Retrospective Descriptive Study. 2013. Wound Research and Practice. 21(1):41-47
Prevalence DFUs in Indonesia
• Prevalence of risks (neuropathy and angiopathy) in Hospital
Setting 55.4% (95% CI: 53.7-57.0%)
(Yusuf et al., 2015).
• Prevalence of DFUs:
– Hospital 12% (95% CI: 10.3-13.6%)
(Yusuf et al., 2015).
– Home care 26%
(Yusuf et al., 2013).
• One year observation; healing (64.7%), recurrence (17.6%),
dead (11.8%), unheal (5.9%)
(Baharia et al., 2014)
1. Yusuf, S., Okuwa, M., Irwan, M., Rassa, S., Laitung, B., Thalib, A., … Sugama, J. (2015). Prevalence and risk factor diabetic foot ulcers: A
cross sectional study among DM type 2 in eastern Indonesia. OWM Journal.
2. Yusuf, S., Kasim, S., Okuwa, M., & Sugama, J. (2013). Development of an enterostomal therapy nurse outpatient wound clinic in
Indonesia : a retrospective descriptive study. Wound Practice and Research, 21(1), 41–47.
3. Baharia Laitung, Muhammad Irwan, Saiful Rassa, Sukmawati, Saldy Yusuf. One year recurrence incidence and risk factors of diabetic foot
ulcer in Makassar, eastern Indonesia (pre eliminary study). 1st WOC Scientific Meeting, Yogyakarta 2014. 5
DFU status on 1st admission

NECROTIC INFECTIONS ODOUR UNDERMINING

EDEMA MASERASI CALLUS


POST AMPUTASI

Saldy Yusuf (2013) Current Status of Diabetic Foot Ulcers in Makasar, Indonesia. Baruga AP. Pettarani, 9
Desember 2013
DFU presence in one way
DIABETES MELLITUS

Neuropathy Angiopathy
Dry SkinToe
Onychocriptosis
Hammer Onychodistrofi Callus
Corn Bunion Onychogriposis Tinea Pedis
Onychomycosis
Hallux Vagus

PREPRE ULCERS:
ULCERS: NAIL
SKIN PROBLEMS
DEFORMITY PROBLEMS
PRE ULCER

PRESENCE DIABETIC FOOT ULCER


DIABETIC FOOT ULCER

Amputation AMPUTATION

11. WGDF, “Pathophysiology of foot ulceration Pathophysiology of foot ulceration,” 2012. 7


Golden Assessment
NEUROPATHY ANGIOPATHY

MONOFILAMENT TEST ABI dan TBI

Its not widely available in health care facilities

Alternative?
8
Alternative Assessment
NEUROPATHY ANGIOPATHY

Ipswich Test Foot palpatian

Diabetic Foot Check Up

How about its validity and reliabity?


Validity and Reliability

Ipswich Test Palpasi Nadi Dorsalis Pedis


• Sensitivity (66.7-100%) dan Posterior Tibialis
• Spesifisity (80.0-94.6%)
(Sulasti, Yusuf, Jafar, & Syam, 2017)

• Reliability between nurses • Sensitivity (25-100%)


(Cohen's Kappa = 0.724-0.909) • Spesificity (97.5-100%)
(Sulasti, Yusuf, Jafar, & Syam, 2017) (Desri, Yusuf, Jafar, & Syam, 2017).

Considerable to be valid and reliable as alternative assessment


10
Risk Category for DFUs
No Neuropathy
No Deformity
No Ischemic
RESIKO 0
No History of Ulcer
No History of amputation

RESIKO 1 RESIKO 2A RESIKO 2B RESIKO 3A RESIKO 3B

Neuropathy + Deformitas + PAOD + History of


ulcers
+ amputation
History of

Avery, D. A. C. L., Lavery, L. A., Peters, E. J. G., Williams, J. R., Murdoch, D. P., Hudson, A., & LAvery, D. C. (2008). Reevaluating the Way We Classify the
International Working Group on the Diabetic Foot. Diabetes care, 31, 154–156. doi:10.2337/dc07-1302.Abbreviations
Our findings

Eligible: 259

Drop Out:
10
Analysis:
249 (inpatient 14)

No DFU: 219 DFU:30

Group 0: Group 1: Group 2A: Group 2B: Group 3A: Group 3B:
90 (36.1%) 14(5.6%) 64 (25.7%) 34 (13.7%) 14 (5.6 %) 3 (1.2%)

Yusuf, S., Okuwa, M., Irwan, M., et al (2016). Prevalence and Risk Factor of Diabetic Foot
Ulcers in a Regional Hospital , Eastern Indonesia. Open Journal of Nursing, 6, 1–10. 12
Advanced Assessment:
Mobile Infra Red Thermography
History
Milestone application infra red thermography in diabetic foot

Identification
Inflammation & sign Diagnosis
for foot disease neuropathy

Identification Identification Evaluation peak


neuropathy Plantar pattern shear stress

2008 2009 2011 2012 2014


(Bharara, (Nishide et al., 2009) (Nagase et al., 2011) (Balbinot, Canani, (Yavuz et al., 2014)
Viswanathan, & Robinson, Achaval, &
Cobb, 2008a and (Roback, Johansson, &
Zaro, 2012)
2008b) Starkhammar, 2009)

Saldy Yusuf: Identification Clinical Features Diabetic Foot Ulcers Using Non-Contact Thermography Based On Mobile Phone: A
Case Series. WCET 2016 Conference, Cape Town, South Africa; 03/2016
Mobile Thermography as advanced assessment

Courtesy: Griya Afiat Makassar


Our Findings
Thermography Features Clinical Features

Dorsal

Plantar

Clinical features showed necrotic area along side dorsal forefoot to medial, However
thermography findings identified “cold pattern” at all fingers and forefoot area.
Yusuf, S., Sukmawati, K., & Laitung, B. (2016). Identification Clinical Features Diabetic Foot Ulcers Using Non
Contact Thermography Based on Mobile Phone: A Case Series. In WCET 21st Biennial Congress.
Screening for risk

Butterly Pattern Asymmetrically Pattern

Our study will investigate infra red thermography based iPhone


as early screening tool in community setting

Sandi, Selina, et al (2017) 17


Thermography: Pressure Ulcer

Thermography dapat digunakan untuk memprediksi terbentuknya


“undermining” pada luka decubitus (Yusuf, S., et al 2016)
Advantages

We noted some advantages:


• Less expensive  amazon(US $217.99).
• Real time  support time serial observation.
• Non contact  no contamination.
• 2 Dimension imaging advanced analysis.
• Pocket size  Useful in various setting.
• Attach to smartphone  easy to capture,
saving, sending, uploading and printing.
Wound Care:
Wound Bed Preparation and TIME

20
TIME CONCEPT
EWMA merekomendasikan:
1. Debridement secara berkala dan radikal.
2. Inspeksi dan kontrol bakteri.
3. Moisture balance untuk mencegah maserasi.

European Wound Management Association (EWMA). Position Document: Wound Bed


Preparation in Practice. London: MEP Ltd, 2004
MOISTURE BALANCE
Pemilihan Balutan yang Tepat

Moura, L. I. F., Dias, A. M. a, Carvalho, E., & de Sousa, H. C. (2013). Recent advances on the
development of wound dressings for diabetic foot ulcer treatment--a review. Acta
Biomaterialia, 9(7), 7093–114. doi:10.1016/j.actbio.2013.03.033
Proses Perawatan

Cleaning Debridement Dressing

European Wound Management Association (EWMA). Position Document: Wound Bed


Preparation in Practice. London: MEP Ltd, 2004
Metode Debridement
METODE DESKRIPSI KEUNTUNGAN KERUGIAN
Mechanical Menggunakan kasa basah- membersihkan bantalan Non selektif, sehingga
kering atau irigasi cairan luka dari kontaminasi jaringan sehat juga dapat
bakteri. terganggu, dapat
menimbulkan nyeri..
Sharp-sequential Menggunakan scalpel atau Metode debridement Perdarahan merupakan
bedside gunting jaringan yang paling cepat. efek merugikan.

Biosurgeri Menggunakan belatung Belatung Belatung steril tidak


kurang lebih 5-8/cm2 mensekresikan enzim tersedia di semua unit
yang merangsang pelayanan kesehatan.
granulasi.
Autolityc Menggunakan balutan yang Selektif sehingga tidak Sifatnya kerjanya lambat,
menciptakan lingkungan mengganggu jaringan kurang tepat untuk
lembab. yang sehat. nekrotik yang luas dan
Contoh: Hydrogel melekat kuat.

Enzymatic Menggunakan preparat Bersifat selektif, karena Sifatnya yang lambat


enzim hanya bekerja pada dibanding terapi
jaringan nekrotik conservative,.

Bates-Jensen, Barbara.M., MacLean, Catherine.H. (2007) 24


Pencucian Luka
Ada beberapa tekhnik pencucian luka:
1. Menggosok (Swabbing),
2. Mengguyur (Showering), Dan
3. Merendam (Bathing)

namun tidak ada perbedaan yang signifikan diantara tekhnik


tersebut (Moore & Cowman, 2005).
Manfaat pencucian luka
Patient ID 1 2 3 4 5
2nd Toe- 2nd Toe-
5th toe Dorsum
Wound location Sole (Right) dorsum sole
(Left) (Left)
(Right) (Right)
Age (yrs.) 49 49 60 60 56
Gender Male
Duration of DM
14 14 6 6 13
(yrs.)
Neuropathy Neuropathy
ABI 1.18 1.18 0.85 0.85 0.65
Bacteria count
6.33x106 9.78x105 3.47x106 6.68x106 6.74x107
(bedfore cleansing)
Bacteria count (after
1.34x106 3.38x105 1.89x107 1.23x107 1.56x106
cleansing)

26
Makoto Oe, et al 2014., unpublished data
Madu sebagai alternatif
0 day 2 day 5 day 7 day 11 day 14 day Indonesian Honey
group

0 day 2 day 5 day 7 day 11 day 14 day


Manuka Honey group

0 day 2 day 5 day 7 day 11 day 14 day


Control group

Haryanto, Urai, T., Mukai, K., Suriadi, Sugama, J., & Nakatani, T. (2012). effectiveness of Indoensian Honey on the
Aceleration of Cutaneous WOund Healing: An Experimental Study in Mice. WOUNDS, 24(4), 110–119.
Madu sebagai alternatif
2
1.8
Ratio of areas to original areas

1.6 Control
Indo
1.4
Manuka
1.2 ** ** **
**
1
0.8 NS
0.6
0.4
0.2
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Days after wounding

Ratio of the wound area. Value was expressed Mean±SD. n = 6 per group .
ANOVA; Tukey-Kramer (** p < 0.01)

Haryanto, Urai, T., Mukai, K., Suriadi, Sugama, J., & Nakatani, T. (2012). effectiveness of Indoensian Honey on the
Aceleration of Cutaneous WOund Healing: An Experimental Study in Mice. WOUNDS, 24(4), 110–119.
Case Series

29
Case 1: Callus
Kanan
(Ada/absent)
Monofilament Absent
Pin Prick Absent
Palpasi
Dorsalis Pedis Absent
20 Sept 2013 23 Sept 2013 Posterior Tibialis Absent
ABPI
Dorsalis Pedis 1.1
Posterior Tibialis 0.6

27 Sept 2013 2 Okt 2013 5 Okt 2013


Case 1: DFU Wagner IV
Case 2: Abscess

26 Agustus 2015 6 Sept 2015


23Agustus 2015

16 September 2015
21 September 2015 13 Oktober 2015
LAPORAN KASUS
Luka Kaki Diabetic Wagner III
di Klinik Griya Afiat Makassar

Saldy Yusuf, PhD.,ETN1,2.,


Baharia Laitung, S.Kep1., Sukmawati, S.Kep1.

1Griya Afiat Makassar, Wound Care and Home Care Clinic, Makassar, Indonesia.
2Chroni Wound Department, Kanazawa University Japan.
PROSES PERAWATAN

20 Januari 2014 21 Januari 2014 25 Januari 2014

29 Januari 2014 31 Januari 2014 7 February 2014

13 February 2014 19 February 2014 23 February 2014


PROSES PERAWATAN

26 February 2014 1 Maret 2014 11 Maret 2014

14 Maret 2014 19 Maret 2014 24 Maret 2014

28 Maret 2014 2 April 2014 10 April 2014


LAJU PENYEMBUHAN

20 Januari 2014 19 February 2014 11 Maret 2014 10 April 2014


Skor awal BBJ 48 , Skor akhir BBJ 13, laju penyembuhan 35/82 hari = 0.42/hari

Baharia., Sukmawati., Saldy Yusuf (2014) Case Report: Honey Impregnated wound dressing in DFU Wagner III. Data on file.
EFEKTIFITAS

Efektifitas waktu:
• Lama perawatan : 82 hari.
• Frekuensi perawatan : 23 kali.
• Rata rata pergantian balutan : 4 hari.
• Rata-rata waktu perawatan: 30-60 menit.
Efektifitas dressing:
• Tidak nyeri.
• Bau terkontrol.
• Balutan tidak lepas.
Efektifitas hasil:
• Sembuh tanpa komplikasi.
• Sembuh tanpa amputasi (minor atau mayor).

Baharia., Sukmawati., Saldy Yusuf (2014) Case Report: Honey Impregnated wound dressing in DFU Wagner III. Data on file.
LAPORAN KASUS
Diabetic Ulcer Non Foot
di Klinik Griya Afiat Makassar

Saldy Yusuf, PhD.,ETN1,2.


Baharia Laitung, S.Kep1., Sukmawati, S.Kep1.,

1Griya Afiat Makassar, Wound Care and Home Care Clinic, Makassar, Indonesia.
2Chroni Wound Department, Kanazawa University Japan.
Healing Progress

26 JULY 2014 31 JULY 2014 2 AGUSTUS 2014 7 AGUSTUS 2014

23 SEP 2014 28 OKT 2014


11 AGUSTUS 2014 18 AGUSTUS 2014
Wound care
Wound Dressing
phase
Primary Secondary Tertiary Periwound Care
Inflamation • Hydro L • Cutisorb • Hypafix • Metco/Zinc
• Epitel Salf
• Metco
Exudate • Madu • Foam • Hypafix • Metco
Cavity
• Cutisorb
Granulasi • Madu • AlCutisor • Hypafix • Metco
b
• Alginate
Epitel • Film
Graphic 1: Wound Healing Progress
Wound Healing Progress (BBJ Score)
45
39 40 40
40

35
34
29 30 30 29 29
30 27
25 24
25

20 18
15 13
15

10

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Wound Care Series

Duration of care 95 days, Frequency of wound care 15 times,


Baseline BBJ 27, Outcome BBJ 13:
 Wound Care Interval = 6.3 Days
 Wound healing progress= 0.14 BBJ score/days
Kesimpulan
• Di Indonesia Prevalensi DFU cukup tinggi.
• Ipswich test dan palpasi nadi dorsalis pedis-
posterior pedialis dpt digunakan untuk
identifikasi resiko.
• Perawatan DFU berorientasi pada penyebab
dan status luks.
• Wound bed preparation dalam manajemen
DFU dapat menekan biaya dan mengefektifkan
waktu perawatan.
TERIMA KASIH
GRIYA AFIAT
MAKASSAR
Spesialis Perawatan Luka
Jl. Syekh Yusuf V/3 Makssar
Hp: 0812 418 418 00