Senin, 19 April 2010

ANALISIS JURNAL KEPERAWATAN

ANALISIS JURNAL KEPERAWATAN

MEDIKAL BEDAH

Suatu Perbandingan efek Chlorhexidine, Air Ledeng dan Normal Saline

pada penyembuhan luka


Oleh:

Kelompok VII

1. Pratiwi Ari Hendrawati J 210 040 054

2. Dewi Suryandari J 210 040 058

3. Yeni Kurniawati J 210 040 069

4. Rizal el fata J 210 040 015

5. Wahyu Wiyono J 210 040 024

PROGRAM PROFESI NERS

FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH SURAKARTA

2009

ANALISIS JURNAL KMB

A. JUDUL

Suatu Perbandingan efek Chlorhexidine, Air Ledeng dan Normal Saline pada penyembuhan luka.

Judul asli : A Comparison of the Effect of Chlorhexidine, Tap Water and Normal Saline on Healing Wounds

B. LATAR BELAKANG

Penggunaan antiseptik pada desinfeksi luka pertama kali dilakukan oleh Joseph Lister pada tahun 1865 yang pertama kali digunakan adalah asam karbol untuk menangani luka akibat compound fracture. (Badoe, et al., 1994). Sejak saat itu banyak agen antiseptik yang digunakan untuk melawan mikroba luka dengan berbagai tingkat keefektifan. Pada saat ini, penggunaan antiseptik telah menimbulkan banyak kontroversi sebagai akibat dari penelitian yang menunjukkan bahwa antiseptik berbahaya terhadap penyembuhan luka (Drosou et al., 2003).

Salah satu antiseptik yang terlibat dalam kontroversi ini adalah chlorhexidine, sebuah biguanide, yang diketahui lebih tidak berbahaya terhadap jaringan dan memiliki aktivitas antibakteri yang tinggi terhadap bakteri gram positif dan negative termasuk beberapa fungsi dan virus (Sibbald et al., 2000 and Crest, 1998). Walaupun tingkat toksisitasnya lebih tinggi daripada saline, Larutan ini masih direkomendasikan untuk membersihkan dan merawat luka. (Sibbald et al.; Morgan, 1999 and Rodeheaver, 1997). Chlorhexidine menyebabkan kerusakan pada jaringan-jaringan baru dan seharusnya tidak bersentuhan langsung dengan membrane mukosa atau meniges karena dapat menyebabkan kerusakan permanen. Keefektivan antimicrobial ini tidaklah total, karena beberapa mikroba diketahui justru tumbuh pada larutan ini, yaitu pseudomonas aeruginosa and Proteus mirabilis(Crest).

Larutan fisiologis merupakan larutan irigasi dan perawatan luka yang lebih di rekomendasikan, karena diketahui sesuai dengan jaringan manusia (Sibbald et al.; Morgan; Crest; Edmonds et al., 2004 and Jacobson, 2004). Larutan ini tidak merusak jaringan baru dan tidak berefek pada fungsi fibroblast dan keratinosit pada penyembuhan luka. Keefektivan larutan ini dalam pencegahan infeksi belum dipastikan (Morgan).

Air ledeng merupakan agen pembersih luka yang menjadi sangat direkomendasikan (Crest). Efek penyembuhan luka antara air steril dan normal saline sama, dan keduanya mendekati ideal untuk irigasi luka (Sibbald et al. and Crest). Kesulitan utama dengan penggunaan air ledeng adalah kepastian sumber, sterilitas (Sibbald et al.) dan perbedaan proses kemurnian di banyak negara (Whaley). Walaupun banyak peneliti telah memutuskan bahwa antiseptic berbahaya terhadap penyembuhan luka, beberapa peneliti yang lain tidak setuju dengan pendapat ini. Dasar utama dari argumen ini adalah bahwa sebagian besar penelitian pada jaringan luka yang mengemukakan efek berbahaya dari antiseptic dilakukan secara in-vitro yang tidak sejalan dengan penelitian in vivo. Drosou et al. Tatnall et al., telah menunjukan bahwa banyak sitotoksisitas disebabkan oleh antiseptik pada penelitian in vitro pada jaringan luka mengacu pada perbedaan dalam konsentrasi serum terhadap antiseptic dan waktu paparan terhadap agen toksisitas secara signifikan. (Tatnall et al.). Akhir-akhir ini, banyak peneliti yang merekomendasikan pencegahan terhadap penggunaan antiseptic terhadap nilai sudut pandang yang berbeda (Morgan and Crest).

Pada pandangan yang kontroversi ini, penelitian in vivo pada penyembuhan jaringan luka telah menjadi penting untuk menentukan relevansi penggunaan antiseptic di klinis. Hal ini juga menjadi penting untuk menentukan agen terbaik untuk digunakan merawat luka. Berdasarkan hal ini, dalam penelitian ini, kami memutuskan untuk membandingkan efek dari tiga agen perawatan luka yang berbeda terhadap penyembuhan luka yang bersih dengan memeriksa jumlah kontraksi luka, rerata penyembuhan, dan morfologi bentuk luka.

C. TUJUAN

Tujuan penelitian ini adalah untuk membandingkan efek dari tiga agen perawatan luka yang berbeda terhadap penyembuhan luka yang bersih dengan memeriksa jumlah kontraksi luka, rerata penyembuhan, dan morfologi bentuk luka.

D. METODOLOGI PENELITIAN

Penelitian dilakukan pada 25 tikus mencit jantan dewasa diambil dan digunakan dalam penelitian di laboratorium selama lebih dari 1 minggu. Tikus-tikus ini diberi makan sesuai standar tempat makan tikus, dari Ladokun dan air ad libitum. Hewan-hewan ini dibagi menjadi 3 kelompok; kelompok aseptik berjumlah 9, air ledeng berjumlah 8, normal salin 8 sebagai kelompok control. Ketiga kelompok ini dibius dengan menggunakan kloroform lalu dibuat luka 2x2 cm pada area dorsolateral kanan setelah sebelumnya dicukur dan dibersihkan dengan alcohol 70%. Kelompok antiseptik diberi irigasi 0.05% chlorhexidine (Purit from Chemical and allied products limited, CAPL) dan kemudian ditutup dengan kasa steril, plester oksida zinc adesif kemudian ditutupkan mengelilingi hewan untuk menahan sisi kasa. Luka pada kelompok air ledeng diirigasi dengan air ledeng dan ditutup seperti kelompok pertama. kelompok control juga dlakukan perawatan luka, diirigasi dengan menggunakan normal saline dan kemudian ditutup seperti pada kelompok sebelmnya. Luka pada setiap hewan dibuka dan dilakui perawatan luka setiap 3 hari sekali. Keadaan luka diperiksa selama perawatan luka. Luka diukur pada hari pertama dan ke sembilan penelitian

E. PEMBAHASAN

Walaupun kemampuan kulit untuk menyembuhkan dirinya sendiri besar, ada keterbatasan kemampuan yaitu meliputi pengeringan permukaan luka dan infeksi (smith, 2005). Normal saline fisiologis menunjukkan penyembuhan luka yang lebih baik daripada non-fisiologis air ledeng dan antiseptik yang ditunjukkan dalam tabel dua. Hal ini sesuai dengan hasil penelitian buffa et al. (1997) yang menunjukkan bahwa canine fibroblast mengalami lebih banyak kerusakan dengan air ledeng daripada dengan normal saline. Penelitian lain telah mendokumentasikan efek normal selain pada penyembuhan luka namun mekanisme kerjanya sampai saat ini belum diketahui (jacobson and lineaweaver et al., 1985). Kemungkinan hal ini disebabkan oleh kemampuan normal salin dalam menjaga kelembaban permukaan luka dan mempengaruhi proses penyembuhan, karena ini adalah larutan fisiologis. Hal ini mungkin menjelaskan alasan adanya sedikit hasil yang lebih baik pada luka yang dirawat dengan normal salin daripada yang dirawat dengan air ledeng. Griffiths et al. (2001) juga tidak menemukan perbedaan secara statistik antara luka yang diirigasi dengan normal salin dan air ledeng. Dari penelitian ini, air ledeng memiliki efek yang lebih baik pada luka daripada agen antiseptik dan menunjukkan tidak adanya perbedaan secara statistik antara air ledeng ini dengan normal salin. Pada tabel ii, jumlah hari pada luka yang dirawat dengan normal salin dan pada luka yang dirawat dengan air ledeng untuk sembuh hampir sama. Kontraksi luka pada kedua kelompok ini hanya berselisih sedikit. Hal ini mungkin mengindikasikan bahwa mekanisme kerja oleh kedua larutan ini pada luka sama. Satu-satunya masalah pada keefektifan penggunaan air ledeng pada pembersihan luka adalah penjaminan sumber dan tingkat sterilitasnya. Alternatifnya adalah penggunaan air steril yang akan lebih aman dan universal (griffiths et al.).

Luka yang dirawat dengan antiseptic pada penelitian ini menjadi lebih buruk dengan cepat beberapa hari setelah trauma. Kesemuanya memiliki eksudat yang kehijauan, yang dapat mengindikasikan pseudomonas spp. (sibbald et al.). Chlorhexidine diketahui dapat memberikan kesempatan pertumbuhan pseudomonas aeruginosa dan proteus mirabilis dan hal ini mungkin terjadi karena persediaan larutan antiseptic telah terkontaminasi oleh bakteri yang akan menjelaskan alasan mengapa luka yang dirawat dengan antiseptik mengalami infeksi (crest). Antiseptik mengganggu migrasi fibroblast dan proliferasinya. Munculnya mikroba pada luka yang kemungkinan dibawa oleh agen antimikroba akhirnya mempengaruhi penundaan penyembuhan luka seperti air ledeng kasus penyembuhan luka pada kelompok antiseptik dan selain itu, keadaan luka juga justru semakin memburuk. Walaupun chlorhexidine berguna dalam disinfeksi kulit dan membersihkan luka traumatic yang kotor, agen ini tidak seharusnya digunakan dalam membersihkan luka yang dalam masa penyembuhan. Efek dari larutan ini terhadap luka dalam masa penyembuhan dapat menyebabkan peningkatan kematian untuk pasien.

F. KESIMPULAN

Penelitian menunjukkan penghambatan yang jelas dari perawatan luka dengan menggunakan larutan chlorhexidine. Penghambatan ini terjadi pada hari ke 9, yang nampak pada tabel 1 dan 2 dengan kontraksi luka yang mengalami kemunduran pada hewan percobaan yang dilakukan perawatan dengan antiseptik ketika dibandingkan dengan kelompok kontrol dan luka yang dirawat dengan air ledeng. Ini berarti juga bahwa waktu penyembuhan semakin lama pada kelompok ini. Perbandingan rata-rata kontraksi luka dan jumlah waktu efektif untuk penyembuhan luka antara kelompok antiseptik dan dua kelompok yang lain sangat signifikan.


http://www.scielo.cl/fbpe/img/ijmorphol/v24n4/tb25-01.jpg


http://www.scielo.cl/fbpe/img/ijmorphol/v24n4/fig25-02.jpg

Infeksi pada luka terjadi pada semua luka yang dilakukan perawatan dengan menggunakan larutan antiseptik. Luka tersebut mengeluarkan eksudat berwarna kehijauan pada permukaannya setiap hari (Edmonds et al.). jaringan yang bergranulasi terhambat perlahan. Hewan percobaan tersebut hanya satu yang sehat dan tiga diantaranya mati menjelang penyembuhan terakhir lukanya. Pada akhir penelitian, luka yang dirawat dengan larutan air ledeng dan larutan fisiologis menunjukkan granulasi jaringan yang baik dan sembuh dengan normal. Tidak ada perbedaan yang signifikan dalam beberapa parameter pada dua kelompok ini, seperti dapat dilihat pada tabel III. Ini berarti kontraksi luka pada hari ke 9 hanya sedikit lebih baik pada kelompok larutan saline daripada kelompok air ledeng.


http://www.scielo.cl/fbpe/img/ijmorphol/v24n4/fig25-03.jpg

Tidak ada kematian pada kelompok air ledeng dan normal saline seperti pada umumnya hewan percobaan mentoleransi prosedur dengan baik. Tidak ada tanda infeksi pada luka dan granulasi jaringan luka pada hewan percobaan pada kedua larutan air ledeng dan kelompok normal saline berwarna merah muda dan mudah berdarah.

G. IMPLIKASI KEPERAWATAN

Menurut Iwan 2008, di dalam tubuh manusia, selain ada bakteri yang patogen oportunis, ada pula bakteri yang secara mutualistik yang ikut membantu dalam proses fisiologis tubuh. Pengetahuan tentang mekanisme ketahanan tubuh orang sehat yang dapat mengendalikan jasad renik oportunis perlu diidentifikasi secara tuntas. Dengan demikian bahaya infeksi dengan bakteri oportunis pada penderita penyakit berat dapat diatasi tanpa harus menggunakan antibiotika.

Menurut Iwan 2008, Pencegahan infeksi pasca bedah pada klien dengan operasi bersih terkontaminasi, terkontaminasi, dan beberapa operasi bersih dengan penggunaan antimikroba profilaksis diakui sebagai prinsip bedah. Pada pasien dengan operasi terkontaminasi dan operasi kotor, profilaksis bukan satu-satunya pertimbangan. Penggunaan antimikroba di kamar operasi, bertujuan mengontrol penyebaran infeksi pada saat pembedahan.Pada pasien dengan operasi bersih terkontaminasi, tujuan profilaksis untuk mengurangi jumlah bakteri yang ada pada jaringan mukosa yang mungkin muncul pada daerah operasi.

Perawatan luka yang banyak dikembangkan diberbagai rumah sakit di Indonesia saat ini adalah menggunakan Chlorhexidine gluconate 1.5%. serta pemakaian Normal Saline 0,9 %. Saat ini dibeberapa Rumah Sakit Chlorhexidine Gluconate 1.5% merupakan anti septik utama yang digunakan didalam perawatan luka. Hal itu disebabkan Chlorhexidine gluconate 1.5% masih dianggap sebagai anti mikroba paling kuat yang dapat mematikan pertumbuhan bakteri gram positif maupun gram negative termasuk mikroorganisme yang resisten terhadap antibiotic, spora, jamur maupun virus (Fredrick P, 2003). Namun penggunaan Chlorhexidine gluconate 1.5% belum memberikan kontribusi yang optimal. Kandungan Cetrimide yang terdapat pada Chlorhexidine Gluconate 1.5% sering menimbulkan iritasi pada luka, perubahan warna kulit dan memicu timbulnya scarr (Frederick P, 2004).

DAFTAR PUSTAKA

Badoe, E. A.; Archampong, E. Q. & Jaja, M. O. A. principles and practice of surgery including pathology in the tropics. 2nd edition. Assemblies of God Literature Center Ltd., 1994.

Buffa, E. A.; Lubbe, A. M.; Verstraete, F. J. & Swaim, S. F. The effects of wound lavage solutions on canine fibroblasts: an in vitro study. Vet Surg., 26(6): 460-6, 1997.

Crest. General principles of wound care. Recommendations for practice. October 1998. www.n-i.nhs.uk/CREST

Drosou, A.;Falabella, A. & Kirsner, R. S.. Antiseptics on Wounds. An Area of Controversy. Wounds,15(5):149-66, 2003.

Edmonds, M.; Foster, A. V. M. & Vowden, P. Wound bed preparation for diabetic foot ulcers. European wound management association (EWMA). Position document: Wound bed preparation in practice. London: MEP Ltd., 2004.

Griffiths, R. D.; Fernandez, R. S. & Ussia, C. A. Is tap water a safe alternative to normal saline for wound irrigation in the community setting? J. Wound Care, 10 (10):407-11, 2001.

Jacobson, S. The wrong solution. Emerg. Med., 36(8):13, 2004.

Lineaweaver, W.; McMorris, S.; Soucy, D. & Howard. R. Cellular and bacterial toxicities of topical antimicrobials. Plast. Reconstr. Surg., 75:394-6, 1985.

Morgan, D. A. Wound management products in the Drug Tariff. The Pharmaceutical J., 263(7072):820-5, 1999.

Osuagwu, F. C.; Oladejo, O. W.; Imosemi, I. O.; Aiku, A.; Ekpo, O. E.; Salami, A. A.; Oyedele, O. O. & Akang E. E. U. Enhanced wound contraction in fresh wounds dressed with honey in Wistar rats (Rattus norvegicus). West African J. of Medicine. 23:2, 2004

Rodeheaver, G. T. Wound cleansing, wound irrigation, wound disinfection. In: Krasner D, Kane D. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 2nd edition. Wayne, PA. Health Management Publications, Inc., 97-108, 1997.

Sibbald, R.; Williamson, G. D.; Orsted, H.; Campbell, L. K.; Keast, D.; Krasner, D. & Sibbald, D. Preparing the wound bed ­ debridement, bacterial balance, and moisture balance. Ostomy/Wound Management., 46(11):14-35, 2000.

Smith, R. G. Wound care product selection. U. S. pharmacist, 30:8, 2005.

Tatnall, F. M.; Leigh, I. M. & Gibson, J. R. Assay of antiseptic agents in cell culture: conditions affecting cytotoxicity. J. Hosp. Infect., 17(4):287-96, 1991.

Whaley, S. Tap water or normal saline for cleansing traumatic wounds? British J. Community Nursing, 9(11):471-8, 2004.

Correspondence to: Dr. Ayodeji A. Salami Department of Anatomy, University of Ibadan
NIGERIA.Phone: +2348057072670. Email: ayodejisalami@gmail.com

Received: 24-05-2006, Accepted:28-09-2006

© 2009 Sociedad Chilena de Anatomía

JURNAL GERONTIK


Effects of preventive home visits to elderly people living in


the community: systematic review
Jolanda C M van Haastregt, Jos P M Diederiks, Erik van Rossum, Luc P de Witte,
HarryFJM Crebolder
Abstract
Objective To assess the effects of preventive home
visits to elderly people living in the community.
Design Systematic review.
Setting 15 trials retrieved from Medline, Embase, and
the Cochrane controlled trial register.
Main outcome measures Physical function,
psychosocial function, falls, admissions to institutions,
and mortality.
Results Considerable differences in the
methodological quality of the 15 trials were found, but
in general the quality was considered adequate.
Favourable effects of the home visits were observed in
5 out of 12 trials measuring physical functioning, 1
out of 8 measuring psychosocial function, 2 out of 6
measuring falls, 2 out of 7 measuring admissions to
institutions, and 3 of 13 measuring mortality. None of
the trials reported negative effects.
Conclusions No clear evidence was found in favour
of the effectiveness of preventive home visits to elderly
people living in the community. It seems essential that
the effectiveness of such visits is improved, but if this
cannot be achieved consideration should be given to
discontinuing these visits.
Introduction
The development of effective preventive interventions
aimed at the maintenance of health and autonomy
of elderly people living in the community has received
much attention in the past two decades. In both
North America and north west Europe a substantial
number of randomised controlled trials have exam›
ined the effects of preventive interventions on elderly
people living in the community.We focus on one spe›
cific category of these interventions: preventive home
visits.
On the basis of the definition of comprehensive
geriatric assessment by Stuck,
1
we defined preventive
home visits as visits to independently living elderly
people, which are aimed at multidimensional medical,
functional, psychosocial, and environmental evaluation
of their problems and resources. This evaluation results
in specific recommendations aimed at reducing or
treating the observed problems and preventing new
ones.
In 1993 Stuck et al performed a meta›analysis of
randomised controlled trials examining the effects of
five types of comprehensive geriatric assessment,
1
one
of which concerned elderly people living at home.
This kind of geriatric assessment at home is fairly
comparable to preventive home visits. The authors
concluded that assessment of elderly people at home
seems to have some positive effects on mortality, resi›
dential status (a higher percentage living at home),
and number of hospital admissions.Owing to conflict›
ing results and the small number of trials included in
the analyses, however, many aspects of the potential
effectiveness of such interventions remained unclear.
In the past seven years a substantial number of new
randomised controlled trials have been performed to
gain more insight into the effects of preventive home
visits to elderly people living in the community. Our
systematic review provides an updated and elaborated
qualitative analysis of available such trials. Given the
considerable heterogeneity of the interventions we
decided not to pool the data of the trials. Pooling the
data in case of heterogeneity might lead to
oversimplified conclusions.
23
We aimed to summarise
the effects of preventive home visits on physical func›
tion, psychosocial function, falls, admissions to institu›
tions, and mortality in elderly people living in the
community and to assess the methodological quality
of the trials included.
Methods
Search strategy
We identified randomised controlled trials by search›
ing Medline (1966 to May 1999), Embase (1989 to
March 1999), and the Cochrane Controlled Trials
Register and by screening references given in relevant
systematic reviews and identified trials. No language
restrictions were imposed. For the selection of
randomised controlled trials the first stage of the
search strategy recommended by the Cochrane
Collaboration4
was used in conjunction with a specific
search for the intervention and population at issue.We
used the key words “geriatric assessment,” “home visit,”
“health visit,” and “health screening” combined with
the exploded MeSH term “aged” and any of the words
“prevent,” “screen,” “health education,” or “health
website
extra
A table with details
of the preventive
home visits
appears on the
BMJ’s website
www.bmj.com
Research Division,
Institute for
Rehabilitation
Research, PO Box
192, 6430 AD
Hoensbroek,
Netherlands
JolandaCMvan
Haastregt
health scientist
Luc P de Witte
executive director
Department of
Medical Sociology,
Maastricht
University, PO Box
616, 6200 MD
Maastricht,
Netherlands
JosPMDiederiks
associate professor
Department of
Epidemiology,
Maastricht
University
Erik van Rossum
associate professor
Department of
General Practice,
Maastricht
University
HarryFJM
Crebolder
professor
Correspondence to:
JCMvanHaastregt
jolanda.vanhaastregt@
irv.nl
BMJ 2000;320:754–8
754 BMJ VOLUME 320 18 MARCH 2000 www.bmj.com
on 25 April 2008 bmj.com Downloaded from promotion.” We used wild card characters to ensure
that all forms of words were included.
Selection of articles
We included articles in two stages. At the first stage
all articles were included that described randomised
controlled trials studying the effects of interventions
consisting of home visits to elderly people living in
the community aged 65 and over. Inclusion criteria
were applied independently by two reviewers (JCMvH
and JPMD) to the abstracts, titles, and keywords of the
references retrieved by the literature search. Subse›
quently, the full text of the included articles was
retrieved, and author, institution, and journal name
were removed from the copies. At the second stage the
two reviewers applied the following additional
inclusion criteria to the “blinded” articles to make a
final selection of articles for review: (a) the home visits
were aimed at prevention or reduction of problems
and risks related to ageing; (b) during the home visits
an (multidimensional) evaluation of problems and
resources in at least two of the following categories
was performed: medical, functional, psychosocial, or
environmental. This evaluation resulted in specific
recommendations aimed at reducing or treating the
observed problems and preventing new ones; (c) the
home visits were not exclusively aimed at patients who
had been discharged from hospital; (d) the home visits
were not exclusively aimed at helping patients to cope
with a specific illness; and (e) data on at least one of the
following outcome measures were presented: physical
function, psychosocial function, falls, admissions to
institutions, and mortality. Disagreement between the
reviewers was resolved by consensus.
Criteria based analysis
To assess the methodological quality of the included
trials we used an adapted version of the criteria list by
van Tulder et al (box).
5
The quality assessments were performed inde›
pendently by the two reviewers, with “blinded” copies
of the articles. The maximum quality score for each
study was 19 (“yes,” 1 point; “partly,” 0.5 points; and
“no” or “unclear,” 0 points). Disagreement between the
reviewers was resolved by consensus.
Data extraction
The reviewers independently extracted the following
data from the articles on a structured form: country,
number of subjects in each study group, characteristics
of subjects, duration of follow up, characteristics of the
intervention, and results regarding physical function,
psychosocial function, falls, admissions to institutions,
and mortality.
Results
Search strategy
Overall, 244 abstracts were screened resulting in the
first stage inclusion 29 of potentially relevant
articles.
6–33
After applying the second stage inclusion
criteria to the full text of these articles, 16 studies
remained. One study14
was an elaboration of a
previously published study, so we decided only to
review the previous one. We finally included 15
studies.
9 11 13 15 17 18 19 23 25 26 29 31–33
Methodological quality of the included studies
Table 1 shows the methodological quality of the 15
studies. The quality scores ranged from 29% to 71%,
with a mean score of 54%. The main shortcomings of
the studies were in the areas of blinding the regular
providers of care to the intervention, reporting on the
presence or absence of cointerventions, reporting on
compliance to the intervention, blinding of the subjects
to the intervention, blinding of outcome assessors,
handling of drop outs, and intention to treat analysis.
In less than 50% of the studies, all these criteria were
partly or completely fulfilled.
Characteristics of the interventions
The main characteristics and objectives of the included
trials can be found on the website. Substantial
differences are seen between the interventions of the
15 trials. In most of the trials the intervention was
aimed at the general population of elderly people aged
65 or over, without a specific selection. Six trials
focused on subjects aged 75 or over.
91518232526
In only
one trial was the intervention aimed at subjects with
specific risk factors.
29
In nine trials the interventions
lasted more than two years,
913151923263132
and in seven
trials the intervention consisted of at least two visits a
Criteria list for assessment of methodological
quality of trials
Patient selection
• Were the eligibility criteria clearly specified?
• Was a method of randomisation performed?
• Were the groups similar at baseline regarding the
most (potential) prognostic indicators?
Interventions
• Were the index and control interventions explicitly
described?
• Were providers of regular care blinded to the
intervention?
• Were there no cointerventions?
• Was there good compliance in all groups?
• Were the respondents blinded to the intervention?
Outcome measurement
• Was outcome assessment blinded to the
intervention?
• Were most outcome measures relevant?
• Were there no adverse effects of the intervention on
the participants?
• Was the withdrawal or drop out rate acceptable?
• Was the withdrawal or drop out random?
• Were short term follow up measurements
performed?
• Were long term follow up measurements
performed?
• Was the timing of the outcome assessment in both
groups comparable?
Statistics
• Was the sample size for each group described?
• Did the analysis include an intention to treat
analysis?
• Were point estimates and measures of
variability presented for the primary outcome
measures?
General practice
755 BMJ VOLUME 320 18 MARCH 2000 www.bmj.com
on 25 April 2008 bmj.com Downloaded from year.
9111517232629
In general, preventive home visits
were tailored to the needs of the individual subjects. In
nine trials, however, special attention was given to
tailoring the intervention to the needs of the subjects
by making the number of visits variable and dependent
on the specific needs of the subjects.
913151923293132
Outcomes of the studies
The main results of the included studies are shown in
table 2. Overall, 94 outcome measures were investi›
gated, all of which could be classed in one of the
following five categories: physical function, psychoso›
cial function, falls, admission to institutions, and
mortality. Eight trials reported at least one (significant)
favourable effect of the intervention,
9 11 15 17–19 26 29
five
trials reported no effects,
13 23 25 32 33
and in the two
combined trials of Vetter et al a favourable effect
was reported in Gwent but no effects were reported
in Powys.
31
None of the trials reported negative
effects.
In five of the 12 trials
911171819232526293133
investigat›
ing the effects of the intervention on physical function›
ing, the intervention group showed a major improve›
ment in at least one measure of physical functioning:
basic or instrumental activities of daily living,
11 26
self
rated health or health problem status,
17 19
and balance,
gait, and toilet transfer skills.
29
Eight studies investigated psychosocial function
(including satisfaction with life).
13 17 18 19 23 25 31
In only
one trial were favourable effects observed (attitude to
own ageing, loneliness, isolation and emotional
reaction) in the intervention group.
18
Six trials investigated the number of falls.
91123293233
In two of these a significant reduction in the number of
falls was observed in the intervention group.
929
Seven trials investigated admissions to institu›
tions.
11 15 19 23 25 26 29
In two of these a significant
reduction was observed in admissions to hospital
15
and
permanent nursing homes.
26
Three of the 13 trials
9 11 15 18 19 23 25 26 29 31–33
that
investigated mortality showed a significantly lower
mortality rate in the intervention than control group
(in Gwent in the case of Vetter et al
31
).
15 19
Discussion
No clear evidence exists for the effectiveness of preven›
tive home visits to elderly people living in the commu›
nity. The observed effects of the interventions are
considered to be fairly modest and inconsistent,
especially as preventive home visits are costly and time
consuming. This indicates a need for further improve›
ment in the effectiveness of preventive home visits to
make these interventions more beneficial in the long
term. If substantial improvements in effectiveness can›
not be achieved, consideration should be given to dis›
continuing such visits.
Although we found considerable differences in the
methodological quality of the 15 trials—scores ranged
from low (29%) to good (71%)—generally, the quality
was considered adequate. Considerable methodologi›
cal improvements are, however, still possible in the
blinding of outcome assessors, handling of drop outs,
checking for cointerventions, assessing and reporting
compliance to the intervention, and performing inten›
tion to treat analyses.
Methodological issues
Our results might be criticised for several reasons.
Firstly, although several different search strategies
were used to detect relevant trials it is possible that we
failed to detect unpublished outcome data, owing to
publication bias. Such bias arises when non›significant
or negative outcome data are selectively omitted from
publication. The potential effect of publication bias on
the outcomes of our review might therefore be a
further weakening of the already rather modest
evidence for the effectiveness of preventive home
visits.
Secondly, because some of the trials seem to be
underpowered,
11 13 17
it is possible that we slightly
underestimated the effectiveness of the visits. Pooling
the data of the trials could have shed more light on
this issue, but owing to the considerable hetero›
geneity of the interventions we thought this was not
justified.
Implications
To improve the effectiveness of preventive home visits
it is important to gain a better understanding of the
relation between specific characteristics of the home
visits and favourable outcomes. Based on the
information available, however, we could not reliably
assess this mainly because of the multidimensional
character of the interventions, which makes it difficult
to distinguish the active elements from the total set of
programme elements.
Several other factors complicate the analysis of the
relation between specific intervention characteristics
and favourable outcomes. Firstly, most trials provide
only general information about the characteristics of
the intervention. Secondly, most trials provide little or
no information about the extent to which the
intervention programmes were implemented accord›
ing to plan. Unsuccessful implementation of the inter›
vention protocol could have diminished the effects of
(potentially effective) interventions. Thirdly, in most
Table 1 Methodological quality of trials examining effects of preventive home visits to
elderly people living in community
Study
Quality score
Total (%)
score
(maximum 19)
Patient
selection
(maximum 3)
Interventions
(maximum 5)
Outcome
measurement
(maximum 8)
Statistics
(maximum 3)
Carpenter et al
9
2.5 0.5 5.0 2.5 10.5 (55)
Fabacher et al
11
3.0 1.5 3.5 2.0 10.0 (53)
Hall et al
13
3.0 1.0 6.5 1.0 11.5 (61)
Hendriksen et al
15
2.5 3.0 6.5 0.5 12.5 (66)
Luker
17
1.5 1.0 3.0 0.0 5.5 (29)
McEwan et al
18
2.0 2.0 5.5 1.5 11.0 (58)
Pathy et al
19
1.5 1.5 5.5 3.0 11.5 (61)
Van Rossum et al
23
3.0 1.0 5.5 2.5 12.0 (63)
Sorensen and
Sivertsen25
1.0 1.0 3.5 1.5 7.0 (37)
Stuck et al
26
3.0 1.5 5.5 3.0 13.0 (68)
Tinetti et al
29
3.0 3.0 5.5 2.0 13.5 (71)
Vetter et al, Gwent
31
2.5 0.5 4.0 1.5 8.5 (45)
Vetter et al, Powys31
2.5 0.5 4.0 1.5 8.5 (45)
Vetter et al
32
2.5 0.5 4.5 2.5 10.0 (53)
Wagner et al
33
2.0 2.0 4.5 1.0 9.5 (50)
Total (%) for category 35.5 (79) 20.5 (27) 72.5 (60) 26.0 (58) 154.5 (54)
General practice
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on 25 April 2008 bmj.com Downloaded from Table 2 Effects of preventive home visits to elderly people living in the community. Values are numbers in intervention (control) group
Study (country)
Follow up
period No Physical function Psychosocial function Effect on falls
Admissions to institutions
during follow up
Mortality in
follow up period
Carpenter et al
9
(UK) 3 years 272 (267) No significant effects on
disability score
Not assessed Significant
favourable
effects: 12
(36)*
Not assessed† Not signficant
Fabacher et al
11
(USA) 1 year 131 (123) Significant favourable effects
on instrumental activities of
daily living; no significant
effects on acitivities of daily
living
Not assessed Not significant No significant effects on
admissions to hospital and
nursing homes
Not significant
Hall et al
13
(Canada) 3 years 81(86/81) Not assessed No significant effects on
Memorial University happiness
scale, health locus of control,
MacMillan health opinion
index, University of California
at Los Angeles loneliness
scale, social readjustment
rating scale
Not assessed Not assessed‡ Not assessed‡
Hendriksen et al
15
(Denmark)
3 years 285 (287) Not assessed Not assessed Not assessed Significant favourable effects for
admissions to hospital: 219
(271); no significant effects on
admissions to nursing homes
Significant
favourable effects
for subjects in
intervention
group: 56 (75)
Luker
17
(UK) 5 months 60 (60) Significant favourable effects
on health problem status
No significant effects on life
satisfaction index›A
Not assessed Not assessed Not assessed
McEwan et al
18
(UK) 20 months 151 (145) No significant effects on
elicited health problems,
activities of daily living§,
energy, pain, sleep, or
mobility
Significant favourable effects
on attitude to own ageing,
loneliness, isolation, emotional
reaction; no significant effects
on agitation
Not assessed Not assessed Not significant
Pathy et al
19
(UK) 3 years 369 (356) Significant favourable effects
on self rated health; no
significant effects on
Townsend score or
Nottingham health profile
No significant effects on life
satisfaction index
Not assessed No significant effects on
admission to hospital, or long
term institutional care
Significant
favourable effects
for subjects in
intervention
group: 67 (86)
Van Rossum et al
23
(Netherlands)
3 years 292 (288) No significant effects on self
rated health, health
complaints, instrumental
activities of daily living, or
activities of daily living
No significant effects on
wellbeing, loneliness, or
depressive complaints
Not significant No significant effects on
admission to hospital¶ or long
term institutional care
Not significant
Sorensen and
Sivertsen25
(Denmark)
3 years 585 (777/140) No significant effects on
subjective health or
functional ability
No significant effects on
loneliness or quality of life
Not assessed No significant effects on
admission to hospital or
institutional care
Not significant
Stuck et al
26
(USA) 3 years 215 (199) Significant favourable effects
on basic activities of daily
living; no significant effects
on instrumental activities of
daily living
Not assessed Not assessed Significant favourable effects on
admission to permanent nursing
home: 9 (20); no significant
effects on admission to hospital
or short term nursing home
Not significant
Tinetti et al
29
(USA) 1 year 153 (148) Significant favourable effects
on impairments in balance,
toilet transfer skills, and gait;
no significant effects on
sickness impact profile
(ambulation and mobility),
postural hypotension, or
impairments in leg strength
or motion and arm strength
or motion
Not assessed Significant
favourable
effects: 52
(68)**
No significant effects on
admissions to hospital
Not significant
Vetter et al
31
(Gwent,
UK)
2 years 296 (298) No significant effects on
physical disability or mobility
No significant effects on
anxiety scores, depression,
quality of life, or social
contacts
Not assessed Not assessed Significant
favourable
effects: 35 (60)
Vetter et al
31
(Powys,
UK)
2 years 281 (273) No significant effects on
physical disability or mobility
No significant effects on
anxiety scores, depression,
quality of life, or social
contacts
Not assessed Not assessed Not significant
Vetter et al
32
(UK) 4 years 350 (324) Not assessed Not assessed Not significant Not assessed Not significant
Wagner et al
33
(USA) 2 years 635 (317/607) No significant effects on
restricted activity days††,
bed days, or medical
outcomes study physical
limitations scale
Not assessed Not significant Not assessed Not significant
*Number of falls in month before interview.
†Substantial difference between study and control group in number of admissions in three year study period (335 v 252), but no significance test of this difference was reported; there were,
however, significantly more long term (>6 months) admissions in control group.
‡Hall et al tested the difference between “living at home” v “died or admitted to facility”: this difference was significant between intervention group and first control group.
§In one of 10 measured activities of daily living a significant reduction in experienced problems was observed; this difference, however, was also present at baseline.
¶Van Rossum also calculated risk of being admitted to hospital (subjects in control group had 40% increased risk of being admitted to hospital); this difference was significant.
**Number of falls during one year follow up.
††Only exception was that experimental group had significantly lower proportion of participants who reported an increased number of restricted activity days than visit only group.
General practice
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on 25 April 2008 bmj.com Downloaded from trials sufficient information was lacking about the
compliance of the subjects to the interventions. A low
compliance can negatively influence the effectiveness
of the interventions and can also be an indicator of
poor tailoring of the interventions to the needs of the
subjects. Finally, the selection of the target populations
could also have played a role in determining the level
of success of the interventions. Fourteen of the trials in
our review were targeted at the general population of
elderly people living in the community. Only one
intervention was aimed at the selection of elderly
people with specific risk factors for health problems
(falls).
29
This short term intervention showed some
promising results in reducing the number of falls and
risk factors for falls, especially among subjects with
impairment in balance or transfer skills and those
who took four or more prescription drugs at baseline.
This stresses the importance of choosing the right
target populations in future programmes for home
visits.
Considering the lack of insight into the predictors
of programme success, we expect that it will be a diffi›
cult task to make improvements in the effectiveness of
preventive home visits to elderly people living in the
community.
Contributors: JCMvH devised and instigated the study and
performed the literature searches and with JPMD identified the
articles from the literature search that met the inclusion criteria
for this study, scored the methodological quality and
effectiveness of the trials, and performed the data extraction.
The paper was written by JCMvH, JPMD, EvR, HFJMC, and
LPdeW. HFJMC will act as guarantor for the paper.
Funding: Zorg Onderzoek Nederland and Stichting Onder›
zoek en Ontwikheling Maatschappeljke gezondheidszorg.
Competing interests: None declared.
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The process of care in preventive in›home comprehensive geriatric
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1988;26:307›12.
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13 Hall N, De Beck P, Johnson D, Mackinnon K, Gutman G, Glick N. Rand›
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trial. BMJ 1984;289:1522›4.
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MG. Preventing falls among community›dwelling older persons: results
from a randomized trial. Gerontologist 1994;34:16›23.
17 Luker KA. Health visiting and the elderly. Nurs Times 1981;77:137›40.
18 McEwan RT, Davison N, Forster DP, Pearson P, Stirling E. Screening eld›
erly people in primary care: a randomized controlled trial. Br J Gen Pract
1990;40:94›7.
19 Pathy MSJ, Bayer A, Harding K, Dibble A. Randomised trial of case find›
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20 Ploeg J, Black ME, Hutchinson BG,Walter SD, Scott EAF, Chambers LW.
Personal, home and community safety promotion with community›
dwelling elderly persons: response to a public health nurse intervention.
Can J Public Health 1994;85:188›91.
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et al. Project safety net: a health screening outreach and assessment pro›
gram. Gerontologist 1993;33:557›60.
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Knipschild P. Effects of preventive home visits to elderly people. BMJ
1993;307:27›32.
24 Rubenstein LZ, Aronow HU, Schloe M, Steiner A, Alessi C, Yuhas M, et al.
A home›based geriatric assessment, follow›up and health promotion
program: design, methods, and baseline findings from a 3›year
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relieve unmet medical and social needs of old people. Compr Gerontol B
1988;2:85›91.
26 Stuck AE, Aronow HU, Steiner A, Alessi CA, Büla CJ, Gold MN, et al. A
trial of annual in›home comprehensive geriatric assessments for elderly
people living in the community. N Engl J Med 1995;333:1184›9.
27 Stuck AE,Gafner Zwahlen H,Neuenschwander BE,Meyer Schweizer RA,
Bauen G, Beck JC. Methodologic challenges of randomized controlled
studies on in›home comprehensive geriatric assessment: the Eiger
project. Aging Clin Exp Res 1995;7:223.
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Yale ficsit: risk factor abatement strategy for fall prevention. JAGS
1993;41:315›20.
29 Tinetti ME, Baker DI,McAvay G, Claus EB, Garrett P. Gottschalk M, et al.
A multifactorial intervention to reduce the risk of falling among elderly
people living in the community. N Engl J Med 1994;331:821›7.
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and surveillance in general practice. J R Coll Gen Pract 1979;29:733›42.
31 Vetter NJ, Jones DA, Victor CR. Effect of health visitors working with eld›
erly patients in general practice: a randomised controlled trial. BMJ
1984;288:369›72.
32 Vetter NJ, Lewis PA, Ford D. Can health visitors prevent fractures in eld›
erly people? BMJ 1992;304:888›90.
33 Wagner EH, LaCroix AZ,Grothaus L, Leveille SG,Hecht JA, Arta K, et al.
Preventing disability and falls in older adults: a population›based
randomized trial. Am J Public Health 1994;84:1800›6.
(Accepted 6 December 1999)
What is already known on this topic
A meta›analysis of randomised controlled trials in
1993 examined the effects of five different types of
comprehensive geriatric assessment, one of which
concerned elderly people living in the community
(preventive home visits). Owing to conflicting
results and the small number of studies included,
however, many aspects of the potential
effectiveness of this kind of home visit remained
unclear
In the past seven years a substantial number of
new randomised controlled studies have been
performed
What this study adds
Little evidence exists in favour of the effectiveness
of preventive home visits to elderly people living
in the community
Previous indications that preventive home visits
have favourable effects on mortality and the
number of hospital admissions were not
confirmed by the results of this review
General practice
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ANALISA


ANALISA JURNAL

EFEK KUNJUNGAN RUMAH PADA LANSIA DI KOMUNITAS

Disusun Oleh:

Dewi Suryandari, Skep

Kharisma Pratama, S.Kep

Rizal El-fata, S.Kep

Wahyu Wiyono, S.Kep

Yeni Kurniawati, S.Kep

PROGRAM STUDI PROFESI NERS

FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH SURAKARTA

2010

EFEK KUNJUNGAN RUMAH PADA LANSIA DI KOMUNITAS

Judul Asli: Effects Of Preventive Home Visits To Elderly People Living In The Community: Systematic Review

Penulis: Jolanda CM Van Haastregt.,et.,al

Abstrak

Tujuan: Untuk menilai pengaruh dari kunjungan rumah pada lansia yang tinggal di masyarakat/ komunitas

Design: Penelitian ini menggunakan design systematic review

Strategi : Dengan 15 percobaan yang di dapat dari Medline, Embase dan Cochrane dengan randomized controlled trial.

Variabel yang akan diukur: Fungsi fisik, fungsi psikososial, jatuh, rawat inap pada pelayanan kesehatan dan kematian.

Hasil: Adanya perbedaan yang harus dipertimbangkan terhadap kualitas metodologi dari 15 percobaan yang di temukan, akan tetapi kualitas sudah dirasakan cukup baik.

Kesimpulan: Tidak ada bukti yang jelas tentang kunjungan rumah pada lansia yang tinggal di lingkungan masyarakat. Hal yang terpenting adalah metode dalam kunjungan rumah harus di perbaiki, tetapi jika masih belum tercapai maka kunjungan sebaiknya dihentikan.

A. Pendahuluan

Dalam dua dekade ini usaha preventif untuk memelihara kesehatan lansia di masyarakat menjadi perhatian utama. Di Negara Amerika dan Eropa banyak penelitian yang meneliti efek usaha preventif pada lansia yang tinggal di komunitas. Penelitian ini berfokus pada satu kategori spesifik usaha preventif yaitu kunjungan rumah. Kunjungan rumah dalam penelitian ini adalah kunjungan pada lansia yang hidup sendiri dalam komunitas, dimana intervensi yang dilakukan pada lansia adalah multidimensional medical, psikososial, fungsional, dan lingkungan.

Pada tahun 1993 Suck et al melakukan penelitian yang melihat efek dari lima tipe comprehensive geriatric assessment, salah satunya adalah dengan kunjungan rumah pada lansia. Penelitian ini membuktikan bahwa terdapat efek positif terhadap angka kematian, jumlah rawat inap ke rumah sakit dan yang ditinggal di rumah. Dari tahun 1993-2000 terdapat beberapa penelitian yang menggali secara lebih mendalam efek dari kunjungan rumah. Penelitian ini bertujuan untuk merangkum efek kunjungan rumah terhadap fungsi fisik, jatuh, rawat inap di pelayanan kesehatan dan kematian pada lansia.

B. Metoda

1. Strategi pencarian penelitian

Dengan mengidentikasi penelitian-penelitian randomized controlled trial yang telah dipublikasikan dari tahun 1966-1999 di Medline, Embase, Cochrane.

2. Penyeleksian artikel

Penelitian ini dilakukan dalam dua tahap. Tahap pertama mencari semua artikel yang memuat penelitian tentang kunjungan rumah pada lansia yang berumur lebih dari 65 tahun. Sedangkan tahap kedua melakukan pengkajian yang lebih mendalam tentang efek dari kunjungan dari artikel-artikel tersebut.

C. Hasil Penelitian

Hasil utama yang diperoleh dari penelitian ini terlihat pada tabel 1. Dari 94 hasil penelitian dapat diklasifikasikan dalam lima kategori yaitu fungsi fisik, fungsi psikososial, jatuh, rawat inap pada pelayanan kesehatan dan kematian. Delapan penelitian membuktikan paling sedikit terdapat satu favourable efek. Lima penelitian melaporkan tidak ada efek, dan tidak ada penelitian yang melaporkan adanya efek yang negatif. Lima dari 12 penelitian yang mencari tahu efek dari kunjungan rumah terhadap fungsi fisik menunjukkan perubahan yang umum terhadap fungsi fisik yang meliputi aktifitas keseharian, status kesehatan dan kemampuan untuk toilet transfer. Delapan studi meneliti tentang efek kunjungan rumah terhadap fungsi psikososial. Hanya terdapat satu penelitian yang membuktikan adanya efek yang bagus terhadap fungsi psikososial.

Enam penelitian meneliti tentang angka jatuh pada lansia, dua diantaranya menunjukan penurunan yang signifikan. Tujuh Penelitian meneliti tentang jumlah/ angka rawat inap di pelayanan kesehatan, dua diantaranya menunjukan terdapat penurunan yang signifikan jumlah rawat inap pada lansia yang mendapat kunjungan rumah. Tiga dari 13 penelitian yang meneliti tentang angka mortalitas menunjukan penurunan angka kematian yang signifikan pada lansia yang mendapat kunjungan rumah.

D. Pembahasan

Evidence yang menunjukan keeffektifan kunjungan rumah pada lansia di komunitas dapat dilihat, meskipun efek dari intervensi terlihat tidak konsisten. Sedangkan kunjungan rumah ternyata membutuhkan biaya dan waktu yang tidak sedikit, hal ini menunjukan dibutuhkannya beberapa perubahan agar kunjungan rumah lebih menguntungkan bagi lansia.

Penelitian tidak menjelaskan secara rinci isi dari kunjungan ataupun kegiatan apa yang dilakukan saat melakukan kunjungan rumah khususnya pada lansia serta berapa kali kunjungan harus dilakukan selama seminggu ataupun selama sebulan, sehingga tidak dapat diketahui faktor apa yang mempengaruhi adanya terhadap perubahan fungsi fisik, fungsi psikososial, angka jatuh, angka rawat inap dan angka kematian pada lansia. Kunjungan rumah pada lansia tentu saja tidak hanya sekedar berkunjung, akan tetapi perlu ada isi atau kegiatan khusus, yang kemungkinan besar isi kegiatan dari kunjungan rumah pada lansia akan sangat mempengaruhi dari berhasil atau tidaknya dari kunujungan rumah yang dilakukan. Kesimpulan yang di ambil oleh peneliti bahwa tidak ada pengaruh yang jelas dari kunjungan rumah terhadap 5 item yang di teliti.

Observasi yang dilakukan oleh Rahwi (2008) pada lansia yang berada di Jepang selama sembilan bulan, mengatakan bahwa fasilitas yang memadai serta support system akan meningkatkan kualitas hidup lansia, sehingga lansia lebih produktif dan dapat melakukan aktivitas yang bermanfaat bagi lingkungannya. Kunjungan rumah yang dilakukan diharapkan mencakup tentang pengadaan fasilitas bagi lansia serta adanya pemberian support sosial yang dengan ini juga diharapkan fungsi fisik dan fungsi psikososial pada lansia menjadi lebih baik dan dengan adanya perbaikkan dari kedua fungsi ini akan dapat menekan angka jatuh, angka perawatan lansia di rumah sakit serta angka kematian.

Pengadaan fasilitas yang dimaksud adalah bersama keluarga untuk memenuhi peralatan yang di butuhkan lansia, seperti tongkat untuk berjalan, kendaraan untuk keluar rumah, alat komunikasi yang sederhana serta alat bantu dengar maupun penglihatan bagi mereka yang mengalami gangguan pendengaran dan penglihatan, dengan fasilitas yang diberikan lansia dapat melakukan interaksi dan komunikasi dengan orang-orang sekitar. Sedangkan support social yang dimaksud adalah melibatkan lansia dalam musyarah keluarga serta pengambilan keputusan dalam memecahkan suatu permasalah, melibatkan lansia dalam kegiatan lingkungan yang sederhana yaitu yang tidak banyak menguras tenaga serta menyediakan waktu bagi lansia untuk berekreasi guna melepaskan kejenuhan (Rahwie, 2008)

E. Imlplikasi

Untuk merubah efektifitas kunjungan sangatlah penting untuk memahami hubungan karakteristik kunjungan dengan outcome yang diharapkan. Sehingga kunjungan rumah dapat lebih efektif bagi lansia.

Daftar Pustaka

Jolanda,. 2000. Effects of Prefentive Home Visits to Eldery Peope living in the Community, Systematic review, BMJ. Diakses dari : http://www.bmj.com/cgi/reprint/320/7237/754?maxtoshow=&HITS=5&hits=25&RESULTFORMAT=&fulltext=geriatric&searchid=1&FIRST INDEX = 25 &resourcetype=HWCIT, tanggal 25 April 2008.

Rahwie. 2009. Perawatan Lansia di Jepang.http://www.beritaiptek.com/पिलिह्बेरिता



ANALISIS JURNAL

HEALING PROCESS OF PRESSURE ULCERS AFTER A CHANGE IN THE NUTRITION REGIMEN OF BEDRIDDEN ELDERLY : A CASE SERIES

Division of Health
Sciences and Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
Abstract
Aim: The aim of the present study was to describe the healing process of pressure ulcers after a change in
the nutrition regimen of seven bedridden elderly patients.
Methods: The healing process of pressure ulcers was described and monitored for 4 weeks prior to and
4 weeks following a change in the nutrition regimen in the seven subjects, who were in long-term care
facilities, while controlling for other factors related to pressure ulcer healing. Changes in the nutrition
regimen included increased caloric intake, supplements, or tube feeding. The healing process was measured
qualitatively using wound sketches and quantitatively using wound surface area and DESIGN score.
Results: Pressure ulcers were predominantly stage III (n = 4) and located in the truncal area (n = 6). There
were qualitative differences in the healing process before and after the nutrition regimen change. Most
notably, in six cases there was early granulation tissue at the wound edge at week 2 after the change, the
color of the granulation tissue improved at week 3, and there was a decrease in wound depth at week 4.
Conclusions: Based on this description of the process of healing of full-thickness pressure ulcers in seven
elderly subjects, it is suggested that a qualitative assessment of improvement in the wound can be made
from the appearance of the granulation tissue following a change in nutrition.
Key words: bedridden elderly, granulation tissue, healing process, nutrition, pressure ulcers.
INTRODUCTION
If elderly people with pressure ulcers are in a stage of
latent protein–energy malnutrition (Sugiyama, 1997),
healing of the ulcers will be delayed (Rijswijk & Polan-
sky, 1994; Mino, 1998), and aggressive nutritional man-
agement is necessary. It has been reported that the area
of the pressure ulcer can be reduced by high-protein
nutritional intervention (Breslow, Hallfrisch, Guy,
Clrawley & Goldberg, 1993; Mulholland, Tui, Wright,
Vinci & Shafiroff, 1943), although another study found
that this intervention did not cause a significant differ-
ence in the area of the pressure ulcers in two groups
established by randomisation with stratification
(Sugiyama, Nishimura, Nonaka, Endo & Oura, 2000).
Therefore, no consensus has been reached concerning
the contribution of nutritional interventions to the heal-
ing of pressure ulcers and the clinical application of
research results has not progressed.
One reason for the delay in clinical application is the
fact that internal research validity has not been estab-
lished, because of the interrelationship of the factors
affecting healing, such as pressure management, skin
care, wound care, disease state, general condition, and
nutrition. The results of the previous studies cannot
be attributed solely to the effects of nutrition alone;
for example, there is a lack of standardization of the
mattress type or positional changes, lack of records of
wound care, and lack of information about the general
condition of the patient.S. Omote et al.
86 Japan Journal of Nursing Science (2005) 2, 85–93
The current study aimed to prospectively describe the
changes in pressure ulcers in elderly patients that are
associated with changes in their nutritional state. It was
considered that close attention to the healing-related
factors in each elderly patient would eliminate the influ-
ence of factors other than nutrition and clarify the rela-
tionship between the healing of the pressure ulcers and
nutrition.
METHODS
Subjects
The study group comprised elderly patients with severe
pressure ulcers at stage II or III, according to the
National Pressure Ulcer Advisory Panel classification
(National Pressure Ulcer Advisory Panel, 1989), who
were in long-term care facilities in Kanazawa City
between December 2001 and October 2002. Of these,
those who had a change in their nutrition regimen, such
as a physician’s order for increased caloric intake, an
oral supplement, or implementation of tube or intra-
venous feeding were enrolled.
To control for factors other than nutrition that affect
pressure ulcer healing, only patients admitted to facili-
ties that provided care according to the standards of
the Prevention and treatment guidelines for pressure
ulcers (Division of the Health for the Elderly, Health
Welfare Bureau for the Elderly & Ministry of Health
and Welfare, 1998) were included. If there was a
change in wound care, pressure management, interface
pressure, skin care, disease state, general condition, or
Braden scale score (Bergstrom, Braden & Laguzza,
1987), the subject was noted as having a change in
drugs, dressings, procedure, or frequency of care. Pres-
sure management changes included use of mattresses,
the internal pressure of the mattress, positioning and
head elevation. The method and frequency of cleaning,
as well as incontinence care, were included in skin care
changes.
Procedure
Pressure ulcers were photographed and sketched each
week by the investigator supervised by a wound care
specialist. The investigator measured DESIGN scores,
wound surface area, and Braden scale scores every 2
weeks. Data on wound care, pressure management, skin
care and general condition were extracted from each
subject’s medical record every 2 weeks. Caloric or
energy intake information was collected daily by the
investigator or trained staff nurses. Anthropometric
measures were collected once during the 4 weeks prior
to and in the 4 weeks after the nutrition regimen change.
Instruments
Healing process
Pressure ulcer state (qualitative). The wounds were
photographed weekly with a single-lens reflex camera
(Nikon, Tokyo, Japan; AF Micro Nikkor 60 mm 1:2.8
D lens and ISO400 film) and sketched using color pen-
cils. Each subject was photographed in the same posi-
tion and the photograph was taken at the same distance
(10 cm) from the wound. The descriptions of the mac-
roscopic findings (i.e. color, shape and size of the ulcer
and the condition and depth of granulation tissue) were
supervised by the wound care specialist to ensure their
accuracy.
Pressure ulcer state (quantitative). During the weekly
observation of the ulcers the DESIGN tool for classify-
ing pressure ulcer severity and monitoring progression
towards healing was used to quantify the healing pro-
cess and enhance the validity of the macroscopic exam-
ination. DESIGN was developed by the Scientific
Education Committee of Japanese Society of Pressure
Ulcers: the Depth of the pressure ulcer is scored from
0–5, Exudate 0–3, Size 0–6, Inflammation/infection
0–3, Granulation tissue 0–5, Necrotic tissue 0–2, and
Pocket 0–4 (Moriguchi et al., 2002). Wounds are
assessed according to the score for each item and the
total score. A decrease in the score indicates an improve-
ment. DESIGN is a reliable tool that provides good
interrater reliability with a standard (simple correlation
coefficient) of r = 0.9 and a high intraclass correlation
coefficient with a standard of r = 0.98 (Sanada et al.,
2004). The selected items were chosen by a working
group consisting of seven wound care specialists of the
Japan Society of Pressure Ulcers and amended after
being presented at the Consensus Symposium of the
Society in 2001, so they were thought to be valid. In the
present study the wound assessment was performed by
the same trained researcher to increase the reliability of
the assessments.
The wound area (cm2
) was calculated from the pho-
tographs of the ulcers using a digital planimeter to trace
the wound outline and an image analysis tool (Scion
Image Beta 4.02, Scion Corporation, MD, USA) that has
been used in many analyses of medical data (Kojima &
Okamoto, 2001). In the study by Thawer, Houghton,
Woodbury, Keast and Campbell (2002) the interrater
reliability of measurements of wound size using manualPressure ulcers and nutrition in the elderly
Japan Journal of Nursing Science (2005) 2, 85–93 87
and computerized techniques by two assessors was
r = 0.96–0.99.
Nutritional state
Nutrient intake. For patients managed by oral nutri-
tion, staff nurses recorded the food intake on an original
oral nutrition rate form. When oral nutrition was
100%, the daily energy and protein intakes were calcu-
lated using the meal composition table of the care facil-
ity. If oral nutrition was less than 100%, the intakes
were calculated on the basis of the 100 kcal/100 g stan-
dard tables of food composition in Japan (Nishimuta,
Chgiwara, Yamashita & Watanabe, 2001). For patients
managed by tube or intravenous feeding, nutrient
intakes were calculated on the basis of the type and
characteristics of the nutritional preparations (Saito,
2001). Prior to study onset, the investigator provided
training for staff nurses in daily food intake data collec-
tion, and to evaluate the content validity, 15 nursing
staff from each facility were asked to comment on the
accuracy of the food intake investigation form.
Anthropometrics. The baseline height, weight, arm
muscle circumference (AMC), and body mass index
(BMI) were determined for each subject 4 weeks prior
to the nutrition regimen change, then all measurements
were carried out again 4 weeks after the change. The
height of the subjects was estimated by using the arm
span method because the intrarater reliability of r = 0.74
for females and r = 0.75 for males indicates a high
correlation (P < 0.001) between height and arm span
(Bassey, 1986; Lehmann, 1991). In patients with joint
contracture, the lengths of the forearm, arm, and pre-
cordial region were measured separately and added. The
AMC was measured by using simple calipers, a portable
tool used in the USA for the measurement of the bra-
chial tricuspid skin fold thickness, because the validity
of measurements using these calipers is r = 0.98 and the
coefficient of variation of the results of two measure-
ments by the same observer in the same subject is
2.4 ± 6.97, suggesting satisfactory reproducibility. The
results of measurements using the calipers show a high
correlation with those obtained using the Eiken skin-
fold thickness meter (Matsuda & Hosoya, 1998). Be-
cause the interrater variation increases in elderly people,
as a consequence of the loss of skin elasticity, the same
investigator performed the measurement each time.
Biochemical analyses. The serum total protein, serum
albumin, and hemoglobin concentrations were tran-
scribed from the monthly clinical records.
Braden scale
The Braden scale comprises six items selected from a
conceptual diagram of the factors involved in the devel-
opment of pressure ulcers. Sensory perception, mois-
ture, activity, mobility, and nutrition are scored 1–4, and
friction and shear are scored 1–3. A lower score suggests
a higher risk of developing pressure ulcers. The Braden
scale was used in the current study to ensure internal
validity because its items are factors that also affect the
healing process. The interrater reliability of the Braden
scale in nurses is r = 0.9 or greater, in both the USA and
Japan (Bergstrom et al., 1987; Sanada et al., 1991). In
a study performed in the USA, the sensitivity and spec-
ificity of the scale for the occurrence of pressure ulcers
were 100% and 64–90%, respectively, in inpatients at
a cut-off point of 16 points; in Japan, they were 100%
and 90%, respectively, in a special nursing home at a
cut-off point of 17 points. The scale has a high predic-
tive power (Bergstrom et al., 1987; Sanada, Sugama &
Sugimura, 1994).
Analytical methods
Qualitative findings
Two wound ostomy and continence nurses (WOCN)
and four expert wound nurses evaluated the qualitative
findings. Based on each weekly sketch, the time course
of the healing process in each subject during the 4-week
period before and after the change in the nutritional
regimen was summarized and from these, a diagram was
created to show the 8-week healing process of the pres-
sure ulcers so that they could be compared, and similar-
ities and differences could be identified.
Quantitative findings
The change in DESIGN score was calculated for each
subject by subtracting the week 1 DESIGN total score
from that for week 4 both before and after the nutrition
regimen change. Thus in both time periods, a positive
change indicated ulcer improvement and a negative
change indicated deterioration. This same process was
used to evaluate changes in the scores for individual
DESIGN items during both time periods. Changes in the
wound surface area during both time periods was cal-
culated by subtracting the week 4 measurement from
that for week 1.
Ethical considerations
The intention of the study was explained to the Hospital
Director and Director of Nursing of each facility and
their approval was obtained prior to the study. TheS. Omote et al.
88 Japan Journal of Nursing Science (2005) 2, 85–93
subjects and their families were informed in writing of
the content and methods. Subjects could withdraw from
the study without compromising their treatment or
nursing. The wounds were photographed and the data
coded so that the subjects could not be identified. For
the safety of the subjects, the research was always car-
ried out by two or more investigators. Informed consent
was given before inclusion in the study.
RESULTS
Characteristics of the subjects
Fifteen patients were enrolled who complied with the
study criteria, and of these, two showed deterioration
in their general condition as a result of changes in the
primary disease, one patient was affected by the medi-
cations used for wound care, and five patients did not
have a change in their nutritional regimen. After exclud-
ing these eight patients, four male and three female
patients completed the study (Table 1). The seven
patients were aged between 70 and 92 years, and the
patients’ primary diseases were cerebrovascular disor-
ders, fracture of the femur, and rheumatoid arthritis.
The majority of pressure ulcers were located in the
truncal region and were stage III. The median DESIGN
total score was 7–22, and the median wound surface
area was 1.16–202.97 cm2
.
The pressure ulcers were in the granulation phase in
six patients and in the epithelialization phase in one
patient. Wound care maintained the lesions in a moist
state.
The total Braden scale scores during the study period
were 9–14, and no change was observed in the scores
for sensory perception, activity, mobility, moisture, or
friction and shear. The activity scores were 1 in six
patients and 2 in one patient.
All patients had added nutrition: regular enteral
feeding product in one patient and supplemental pro-
tein in six patients. The change in the nutritional regi-
men resulted in the patients’ energy intake increasing
from 900–1400 kcal/day (3766–5858 kJ/day) to 980–
1433 kcal/day (4100–5996 kJ/day), and the protein
intake increasing from 0.9 to 1.5 g/kg per day to 0.9–
2.0 g/kg per day (Table 2). No difference in the results
of anthropometric measurements or biochemical analy-
ses was observed during the study period.
Table 1 Demographic data
Patient
no. Age Sex
Primary
disease
Pressure
ulcer site Stage†
Braden
scale
DESIGN
total score
Wound surface
area (cm2
)
Nutritional
change
192M CVD PIC III 12 9 7.37 ICI, ION
270M CVD S III 12 8 1.16 ION
387M CVD S IV 10 18 5.14 ICI, ION
470M CVD S IV 13 22 202.97 ICI, ION
592F FF C II 9 7 41.30 ICI
6 74 F RA PIC III 14 10 13.70 ICI, ION
7 84 F CVD I III 12 15 15.25 ION

National Pressure Ulcer Advisory Panel classification. CVD, cerebrovascular disease; FF, fractured femur; RA, rheumatoid arthritis; PIC, posterior
iliac crest; S, sacral; I, iliac; C, costal; ICI, increase in caloric intake; ION, implementation of an oral nutrition supplement.
Table 2 Nutritional intake before and after change in nutritional regimen
Patient
no.
Nutritional
intake route
Energy intake (kcal/day, kJ/day in
parentheses)
Protein intake (g/kg per
day)
Before After Before After
1T 980 (4100) 1116 (4669) 1.2 1.9
2T 900 (3766) 980 (4100) 0.9 0.9
3T 900 (3766) 1116 (4669) 1.0 1.5
4T 900 (3766) 1116 (4669) 1.0 1.5
5T 1100 (4602) 1236 (5171) 1.5 2.0
6O 950 (3975) 1250 (5230) 1.0 1.4
7O 1400 (5858) 1433 (5996) 1.5 1.6
O, oral; T, tube feeding. Pressure ulcers and nutrition in the elderly
Japan Journal of Nursing Science (2005) 2, 85–93 89
Changes in the pressure ulcers during the
8-week study period
The changes in the seven pressure ulcers are shown in
Table 3. There was improvement after the change in the
nutritional regimen, particularly in wound surface area,
depth of the wound, and the color and appearance of
granulation tissue, which was reflected in changes in the
DESIGN scores.
Changes in the DESIGN scores
The DESIGN items that decreased from one to three
before the change in the nutritional regimen were
size, granulation, necrosis and pocket, and those that
decreased from one to five were depth, size, exudate,
granulation and necrosis. The largest improvement after
the change in the nutritional regimen was in granula-
tion, which improved in five of the seven subjects
(Table 4).
Changes in the wound area
Although the wound area decreased in six of the seven
cases before the change in nutritional regimen, it
improved in all cases after the change (Table 5).
DISCUSSION
The data for the present study were only collected from
facilities in which the pressure ulcer care standards were
applied (Division of the Health for the Elderly, Health
and Welfare Bureau for the Elderly & Ministry of
Health and Welfare, 1998). In addition, patients who
experienced a deterioration in the primary disease, were
negatively affected by the medications for wound care,
or experienced a deterioration of their general condition
were excluded in order to increase the association
between a change in nutritional state and healing of
pressure ulcers.
Characteristics of the healing process and effects
of nutrition
The characteristic changes in the healing process were
identified from summarized descriptions of the healing
process of the pressure ulcers of seven subjects (Fig. 1).
During the 4-week period before the change in the nutri-
tional regimen, the color of the pressure ulcers was
generally poor. The protein intake of four of the seven
subjects was 0.9–1.0 g/kg per day, which was lower than
the 1.2 g/kg per day recommended for the elderly or the
1.2–1.5 g/kg per day recommended for patients with
pressure ulcers (Agency for Health Care Policy and
Research, 1994). Latent factors of delayed healing in
elderly people (Anderson & Kvorning, 1982; Bergstrom
& Braden, 1992; Robert, 2001), such as protein or zinc
deficiency, during the granulation period of a wound
causes a decrease in fibroblast function and collagen
synthesis (Rijswijk & Polansky, 1994). Therefore, the
Figure 1 Summary of the characteristic changes in pressure ulcers observed during 4-week periods before and after a change in
nutritional regimen.
Week 1------------Week 2--------Week 3---------Week 4--------------Change--------Week 1-------Week 2-------------Week 3---------------Week 4
Undermining in any
area
Yellow necrosis
Irregular wound
surface
Round flat
granulation
tissue
Decreased
wound area
Flat wound surface
Redness
Flat wound surface
Poorly colored
Disappearance
of round
granulation
tissue
Increased area
of undermining
size
Increased
wound area
Decreased
wound area
Undermining in any
area
Yellow necrosis
Irregular wound
surface
Partial undermining
Flat wound surface
Poorly colored
Flat wound surface
Redness
Flat wound surface
Poorly colored
Epithelialization
Improved depth
Shallow
Yellow necrosis
Shallow
Yellow necrosis
Epithelialization
Yellow necrosis
Decreased
wound area
Flat wound surface
Poorly colored
Partial undermining
Decreased
wound area
Granulation
tissue arises
from the site
of attachment
Improved color S. Omote et al.
90 Japan Journal of Nursing Science (2005) 2, 85–93
Table 3 Weekly changes in the pressure ulcers before and after nutritional intervention
Patient
no.
Before nutrition regimen change
Time of change in
nutrition regimen
After nutrition regimen change
Week 1 Week 2 Week 3 Week 4 Week 1 Week 2 Week 3 Week 4
1 Poorly colored
granulation
tissue, flat and
deep wound
surface
WSA
decreased
Unchanged WSA
decreased
Still poorly colored
granulation
tissue, flat and
deep wound
surface
Unchanged Granulation tissue
arising from
wound wall,
slightly red
wound edge
Slightly red
granulation
tissue
WSA decreased,
red granulation
tissue arising
from wound
wall
2 Partial
undermining,
flat and
slightly red
wound surface
Unchanged Poorly
colored
granulation
tissue
Unchanged Partial
undermining,
still flat and
slightly red
wound surface
Faded
granulation
tissue color
Size of
undermining
decreased
Lightly red
granulation
tissue
WSA decreased,
still partial
undermining,
3 Undermining,
thick yellow
necrotic tissue,
deep irregular
wound surface
Unchanged Necrotic tissue
decreased,
more regular
wound
surface
WSA
decreased
Undermining,
partly covered in
yellow necrotic
tissue, deep
wound
Light-pink
colored
granulation
tissue
Yellow
necrotic tissue
decreased,
wound edge
attached
Granulation
tissue color
improved,
granulation
tissue
arising
from
attachment
Wound edge
attached, only
partly
undermined,
epithelialization
4 Undermining,
thick yellow
necrotic tissue,
crevassed
wound bed
Poorly
colored
granulation
tissue
WSA decreased Crevasse
disappeared
Still some yellow
necrotic tissue,
poorly colored
granulation
tissue
Slight redness
of wound
edge
Wound edge
attached, less
undermining
Granulation
tissue color
improved,
depth
decreased
Epithelialization
5 Shallow yellow
necrosis,
papillary layer
observed
Unchanged Unchanged Unchanged Shallow yellow
necrotic tissue,
papillary layer
observed
Yellow
necrotic
tissue
decreased
Epithelialization Unchanged Still some shallow
yellow necrotic
tissue
6 Poorly colored
granulation
tissue, clear
and slightly
thickened
wound edge
Unchanged White granular,
poorly
colored
granulation
tissue
Unchanged White granular,
poorly colored
granulation
tissue,
maceration of
wound edge
Unchanged Depth decreased,
epithelialization
Granulation
tissue
arising
from
wound wall
Improved color of
granulation
tissue
7 Partial
undermining,
white wound
surface
Areas of flat,
round
granulation
tissue on
wound bed
WSA decreased Flat, round
granulation
tissue
disappeared
Still partial
undermining,
white wound
surface
White
granular,
poorly
colored
wound
surface
Granulation tissue
appears from
attached wound
edge
Slightly red
granulation
tissue
Slightly red
granulation
tissue
WSA, wound surface area.Pressure ulcers and nutrition in the elderly
Japan Journal of Nursing Science (2005) 2, 85–93 91
nutrition of the present subjects was inadequate for
wound repair, and thus the healing of the pressure ulcers
was delayed.
During the 4-week period after the change in the
nutritional regimen, there was proliferation of granula-
tion tissue from the wound edge, which was tightly
attached to the wound bed. The proliferation of granu-
lation tissue started in the second week, improvements
in the color of the granulation tissue occurred in the
third week, and a decrease in the depth of the wound
occurred in the fourth week. In the fourth week, the
energy intake of the subjects had increased, and the
protein intake of six of the seven subjects was the rec-
ommended 1.4–2.0 g/kg per day, so the nutritional sup-
plements promoted both fibroblast function, leading to
cell proliferation, and collagen synthesis, leading to pro-
liferation of granulation tissue. Capillary vasculariza-
tion was also considered to have increased, with the
increased tissue blood flow causing the improved color
of the granulation tissue (Moriguchi, 2000; Nagahara,
2000). According to the guidelines for caring for
patients with pressure ulcers, reddening and swelling
around the wounds should disappear 1 week after
removing or reducing compression, and maceration and
thickening of the wound edge should be alleviated 1
week after the beginning of skin care (Sanada & Sug-
ama, 2003). Alleviation of crevasse (one of the symp-
toms of granulating tissue, having the appearance of a
gaping cleft) and a decrease in membranous necrosis
should occur 2 weeks after sliding is prevented, and
proliferation of granulation tissue and improvements
in color should occur 2 weeks after beginning wound
care (Sanada et al., 2002). However, the characteristic
changes after nutritional intervention have not been
reported, which prevents comparisons. In the present
study, progressive changes were characteristically
observed from 2 to 3 weeks after nutritional interven-
tion and thus, observation and evaluation of improve-
ments need to be carried out early after a change in the
nutritional regimen.
Assessment of nutritional change in the elderly
with pressure ulcers
On the basis of the gross changes in wound granulation
observed in the present study, it is believed that an
assessment of the effects of nutritional intervention on
pressure ulcers in elderly patients can be carried out
quickly and appropriately by the nurses who observe
the wounds daily.
Currently, biochemical analysis and anthropometry
are the tools used to assess the effects of nutritional
intervention, but many elderly people with pressure
ulcers are bedridden and may have joint contracture
or deformation and symptoms of dementia. In such
patients, it may be difficult to obtain blood in sufficient
quantities and to accurately measure height and skin
fold thickness because of the anatomical changes of
Table 4 Total and itemized DESIGN scores of the pressure ulcers before and after nutrition regimen change and intervention
Patient
no.
DESIGN items
Depth Exudate Size Infection Granulation Necrosis Pocket Total score
A B C A B C A B C A B C A B C A B C A B C A B C
1 332112111000431000000 986
2 333222111000121000111 898
3 443332211000442110433181611
4 333333433222554110433222016
5 222222221000000111000 776
6 33322222100033200000010108
7 443222111000534100211151211
A: score of each item 4 weeks before the nutrition regimen change. B: score of each item at the time of the nutrition regimen change. C: score of
each item 4 weeks after the nutrition regimen change.
Table 5 Wound surface area before and after nutrition
regimen change
Patient no.
Wound surface area (cm2
)
ABC
1 7.37 6.89 3.66
2 1.16 1.07 0.35
3 5.14 9.40 3.32
4 202.97 132.65 104.34
5 41.30 28.66 14.90
6 13.70 21.70 4.00
7 15.25 9.20 5.32
A: score of each item 4 weeks before the nutrition regimen change. B:
score of each item at the time of the nutrition regimen change. C: score
of each item 4 weeks after the nutrition regimen change.S. Omote et al.
92 Japan Journal of Nursing Science (2005) 2, 85–93
aging, leading to wider interrater errors. In addition,
these measurements require time and can cause discom-
fort to the subjects unless the measurer is highly skilled.
Therefore, it is important to establish methods of eval-
uating the nutritional effect from the changes in the
pressure ulcer.
There are two limitations to the current study, one
being that the investigator was not blinded and the other
being the impossibility of generalizing from this small
sample size. Also, the pressure ulcers were evaluated
only in the granulation phase and the subjects were
elderly patients in a poor nutritional state. A large pro-
spective study evaluating the effect of nutrition on pres-
sure ulcer healing is needed.
Conclusion
The healing process of pressure ulcers was compared
before and after changes in the nutritional regimen of
seven bedfast elderly patients in Japan. There was no
difference in any factor other than the nutritional state
of the patients between the time of the change in the
nutritional regimen and the following 4 weeks. Two
weeks after the supplementation of nutrition, granula-
tion tissue began where the wound edge was tightly
attached to the wound bed and the color of the wound
improved thereafter.
These findings suggest that the state of pressure ulcers
is improved by nutritional supplementation, that
improvements characteristically begin 2 weeks after the
intervention, and that proliferation of granulation tissue
is an index of the healing of pressure ulcers.
ACKNOWLEDGMENTS
We are indebted to the patients, their families, and the
facility staff who generously consented to participate in
the study. This paper was prepared by partially supple-
menting and revising a master’s thesis submitted to
Kanazawa University Graduate School of Medicine in
2002. An abstract of this study was presented at the
23rd Scientific Conference of the Japan Academy of
Nursing Science.
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ANALISIS JURNAL

HEALING PROCESS OF PRESSURE ULCERS AFTER A CHANGE IN THE NUTRITION REGIMEN OF BEDRIDDEN ELDERLY : A CASE SERIES

Disusun Oleh:

Sukini, Skep

Pratiwi Ari H, S.Kep

Sarwito R B, S.Kep

Setiyawan, S.Kep

PROGRAM STUDI PROFESI NERS

FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH SURAKARTA

2010

HEALING PROCESS OF PRESSURE ULCERS AFTER A CHANGE IN THE NUTRITION REGIMEN OF BEDRIDDEN ELDERLY : A CASE SERIES

PROSES PENYEMBUHAN LUKA DEKUBITUS SETELAH PERUBAHAN REGIMEN NUTRISI PADA LANSIA YANG MENJALANI BEDREST

Abstrak:

Tujuan : Tujuan dari penelitian ini adalah untuk menggambarkan proses penyembuhan luka dekubitus setelah perubahan regimen nutrisi pada 7 pasien lansia yang menjalani bedrest.

Metode:

Proses penyembuhan luka dekubitus digambarkan dan dimonitor selama 4 minggu sebelum dan 4 minggu sesudah pemberian nutrisi pada ke 7 subjek penelitian yang mendapatkan perawatan jangka panjang, dimana faktor lain yang mempengaruhi dihubungkan dengan penyembuhan luka dekubitus. Perubahan dalam regimen nutrisi termasuk peningkatan intake kalori, suplemen, atau intake parenteral. Proses penyembuhan diukur secara kuantitatif menggunakan gambar luka dan kualitatif menggunakan area tepi luka dan nilai DESIGN.

Hasil :

Dekubitus terutama berlokasi pada area atas luka (n=6) dan memiliki derajat II atau III (n=4). Terdapat perbedaan kualitatif pada proses penyembuhan luka sebelum dan sesudah perubahan regimen nutrisi. Pada 6 kasus terdapat granulasi jaringan lebih awal pada tepi luka pada 2 minggu setelah intervensi, warna granulasi jaringan meningkat pada minggu ke 3 dan terdapat penurunan kedalaman luka pada minggu ke 4.

Kesimpulan :

Berdasarkan gambaran proses penyembuhan luka dari ketebalan luka dekubitus pada 7 lansia, disimpulkan bahwa pengkajian kualitatif terhadap peningkatan luka dapat dilihat dari tampilan granulasi jaringan saat dilakukan perubahan nutrisi.

A. PENDAHULUAN

Lansia dengan luka dekubitus dan mempunyai nilai protein yang rendah – malnutrisi energi, menyebabkan penyembuhan luka akan terhambat dan management nutrisi yang adekuat dibutuhkan. Dilaporkan bahwa area dekubitus dapat dikurangi dengan memberikan nutrisi tinggi protein, walaupun penelitian lain menemukan bahwa intervensi ini tidak menyebabkan perbedaan yang signifikan pada area dekubitus pada 2 kelompok yang dipilih secara acak. Untuk itu tidak terdapat konsensus yang secara jelas menetapkan intervensi nutrisi untuk menyembuhkan luka dekubitus dan aplikasi klinis terhadap penelitian tidak berkembang. Salah satu alasan terlambatnya aplikasi klinis di lapangan adalah bahwa validitas internal penelitian tidak ditegakkan, karena hubungan antar faktor yang mempengaruhi luka seperti management tekanan, rawat luka, rawat kulit, status penyakit, kondisi umum, dan nutrisi. Hasil penelitian sebelumnya tidak dapat semata-mata dihubungkan dengan perubahan status nutrisi. Diharapkan dalam penelitian ini akan menggambarkan hubungan penyembuhan luka dekubitus dengan nutrisi dengan menghilangkan faktor lain selain nutrisi.

B. METODE :

a. Subyek

Subyek yang digunakan dalam penelitian adalah : pasien lansia dengan derajat dekubitus II atau III, sesuai National Pressure Ulcer Advisory Panel classification (National Pressure Ulcer Advisory Panel, 1989), yang menjalani perawatan jangka panjang di Kanazawa City antara December 2001 dan October 2002.

b. Cara

Pasien lansia mendapat perubahan regimen nutrisi sebagaimana permintaan dokter untuk meningkatkan intake kalori, suplement oral, atau nutrisi parenteral dan enteral. Untuk mengontrol faktor lain selain nutrisi terhadap penyembuhan luka, pasien hanya direkomendasikan untuk mendapatkan perawatan sesuai standar Prevention and treatment guidelines for pressure ulcers (Division of the Health for the Elderly, Health Welfare Bureau for the Elderly & Ministry of Health and Welfare, 1998). Jika terdapat perubahan pada perawatan luka, managemen tekanan, perawatan kulit, penyakit yang menetap, kondisi umum atau nilai skala Braden, subjek penelitian dicatat mempunyai perubahan pada obat, balutan, atau prosedur dan frekuensi perawatan. Perubahan management tekanan termasuk penggunaan matras, pengaturan posisi dan elevasi kepala.

C. PROSEDUR PENELITIAN :

Dekubitus difoto dan dibuat gambar tiap minggu oleh peneliti (spesialis perawatan luka). Peneliti mengukur nilai DESIGN, area tepi luka dan nilai skala Braden setiap 2 minggu. Data pada luka, management luka, perawatan kulit dan kondisi umum dicatat dari masing-masing rekam medik tiap 2 minggu. Kalori atau energi dicatat setiap hari oleh pengamat atau staf perawat. Antropometri diukur dan dikumpulkan selama 4 minggu sebelum dan sesudah perubahan regimen nutrisi.

D. INSTRUMEN

Proses Penyembuhan Luka

Derajat Dekubitus (kualitatif)

Luka difoto tiap minggu dengan kamera reflek satu lensa dan digambar menggunakan pensil warna. Masing-masing subjek difoto pada posisi yang sama dan diambil dari jarak yang sama (10 cm) dari luka. Gambaran luka secara makroskopik dapat ditemukan dan diamati oleh spesialis perawat luka secara akurat (contoh warna, tepi dan ukuran luka, kondisi dan kedalaman granulasi jaringan).

Derajat Dekubitus (Kuantitatif)

Selama observasi, pengukuran menggunakan nilai DESIGN digunakan untuk mengklasifikasikan derajat dekubitus dan memonitor kemajuan proses penyembuhan secara kuantitatif. Penilaian DESIGN terdiri dari : kedalaman atau derajat dekubitus diberi skor 0-5, exudate 0-3, ukuran 0-6, inflamasi/infeksi 0-3, granulasi jaringan 0-5, nekrosis jaringan 0-2 dan kantong pada luka 0-4. Luka dikaji sesuai score masing-masing item dan nilainya dijumlahkan. Nilai yang rendah menunjukkan kemajuan penyembuhan luka.

E. STATUS NUTRISI

Intake nutrisi. Untuk pasien yang mendapat nutrisi oral, perawat mencatat pada formulir nutrisi oral. Apabila intake oral mencapai 100%, intake energi dan protein harian dijumlahkan menggunakan table komposisi makanan. Jika intake oral kurang dari 100%, intake dikalkulasikan dengan dasar 100 Kcal/100 gram . Untuk pasien yang dimanagemen dengan NGT atau IV, intake nutrisi dijumlahkan berdasarkan tipe dan karakteristik pengolahan nutrisi. (Saito, 2001). Sebelum penelitian, pengamat melakukan pelatihan terhadap staf perawat untuk mengumpulkan data intake makanan harian dan untuk mengevaluasi validitas, 15 staf perawat dari masing-masing bangsal diwawancarai untuk mengomentari keakuratan lembar monitoring intake makanan.

1. Antropometri

Berdasarkan TB, BB, LLA, dan IMT diukur pada masing-masing 4 minggu sebelum perubahan nutrisi, kemudian semua pengukuran diulangi setelah 4 minggu perubahan.

2. Analisis Biokimia

Total protein serum, albumin, dan konsentrasi Hb didapatkan dari pemeriksaan klinis bulanan.

3. Braden Scale

Skala Braden terdiri 6 item yang dipilh dari diagram konseptual factor yang mempengaruhi perkembangan dekubitus. Persepsi sensori, kelembaban, aktivitas, mobilitas dan nutrisi discore 1-4, potongan pada luka discore 1-3. Score yang rendah mengindikasikan resiko tinggi terhadap perkembangan dekubitus.

F. METODE ANALISIS

1. Kualitatif

Berdasarkan pada masing-masing gambar dapat dilihat proses penyembuhan luka pada masing-masing subjek selama 8 minggu. Sebuah diagram dibuat untuk memperlihatkan proses penyembuhan sehingga dapat dibandingkan dan diidentifikasi persamaan dan perbedaannya.

2. Kuantitatif

Perubahan pada penilaian DESIGN kemudian dijumlahkan pada masing-masing subjek. Nilai ini kemudian dibandingkan dengan nilai DESIGN minggu I dengan 4 minggu setelah perubahan regimen nutrisi. Perubahan positif mengindikasikan membaiknya luka dekubitus dan perubahan negative mengindikasikan kemunduran luka.

G. HASIL

1. Karakteristik Responden

Terdapat lima belas pasien yang telah didata sesuai dengan kriteria penelitian, dan diantara mereka, terdapat dua pasien yang menunjukkan kejelekan keadaan umum (KU) yang nantinya dapat mengubah penyakit primernya, satu pasien telah tergantung pemakaian obat untuk perawatan luka, dan lima pasien tidak ada perubahan dalam regimen nutrisi mereka. Delapan pasien ini dieksklusi. Setelah mengeksklusi delapan pasien ini, empat laki-laki dan tiga perempuan dapat menyelesaikan penelitian ini. Tujuh pasien tersebut berumur antara 70-92 tahun, dan merupakan pasien penyakit primer yang meliputi penyakit cerebrovaskuler (stroke), fraktur femur, dan remathoid arthritis. Kebanyakan dari luka dekubitus terletak di daerah truncal (tonjolan pantat) dan merupakan luka dekubitus derajat III. Median dari total skor DESIGN antara 7-22, dan median dari luas permukaan luka antara 1,16-202,97 cm2.

Luka dekubitus dalam fase granulasi di enam pasien, dan dalam fase epitelialisasi di satu pasien. Perawatan lukanya yaitu dengan cara mempertahankan agar lukanya tetap dalam keadaan basah. Total skor Braden Scale adalah 9-14, dan selama diobservasi tidak ada perubahan dalam skor persepsi sensori, aktivitas, mobilitas, kelembaban, gesekan dan garukan. Skor aktivitasnya senilai 1 di satu pasien dan 2 di enam pasien. Seluruh pasien mendapatkan nutrisi tambahan: produk makanan enterall regular pada satu pasien dan protein tambahan pada enam pasien. Perubahan dari regimen nutrisi telah menghasilkan peningkatan intake energi pasien dari 900-1400 kkal/hari (3766-5858 kJ/hari) ke 980-1433 kkal/hari (4100-5996 kJ/hari), dan peningkatan intake protein dari 0,9-1,5 g/Kg per hari ke 0,9-2.0 g/Kg per hari (tabel 2). Dalam observasi yang dilakukan selama penelitian ini tidak ada perbedaan hasil pengukuran antropometri atau analisis biokimia.

2. Perubahan luka dekubitus selama 8 minggu penelitian

Terdapat kemajuan setelah perubahan regimen nutrisi, terutama dapat dilihat dari luas permukaan luka tekan, kedalaman luka, warna dan penampakan dari jaringan granulasi, dimana tergambar di perubahan skor DESIGN.

3. Perubahan skor DESIGN

Item-item DESIGN yang telah mengalami penurunan skor dari satu ke tiga sebelum perubahan regimen nutrisi adalah ukuran (luas), granulasi, nekrosis dan pocket (kantung luka) dan yang mengalami penurunan skor dari satu ke lima adalah kedalaman, ukuran (luas), eksudat, granulasi, dan nekrosis. Peningkatan terbesar setelah perubahan regimen nutrisi adalah granulasi, dimana meningkat di lima dari tujuh responden.

4. Perubahan luas area luka dekubitus

Walaupun luas area luka dekubitus telah mengalami penurunan di enam dari tujuh pasien sebelum perubahan regimen nutrisi, luas area lukanya mengalami kemajuan (mengecil) di seluruh kasus setelah terdapat perubahan regimen nutrisi.

H. PEMBAHASAN

Data-data untuk study penelitian ini hanya diambil dari fasilitas dimana standar perawatan luka dekubitus diberlakukan (Divisi Kesehatan Manula, Biro Kesehatan dan Kesejahteraan Manula dan Departemen Kesehatan dan Kesejahteraan,1998). Sebagai tambahan, pasien yang mengalami kemunduran (memburuk) penyakit primernya, dimana berpengaruh negatif terhadap pengobatan untuk perawatan luka, atau yang mengalami kemunduran keadaan umum, telah dikeluarkan (eksklusi) dari subyek penelitian dengan tujuan untuk meningkatkan hubungan antara perubahan status nutrisi dengan proses kesembuhan luka dekubitus.

1. Karakteristik proses kesembuhan luka dekubitus dan pengaruh nutrisi

Perubahan karakteristik proses kesembuhan luka dapat diketahui dari ringkasan penjelasan proses kesembuhan luka di tujuh responden. Selama periode empat minggu sebelum perubahan regimen nutrisi, warna luka dekubitus pada umumnya sangatlah buruk. Pemasukan protein empat dari tujuh responden berkisar 0,9-1.0 g/Kg per hari, dimana lebih rendah dari yang direkomendasikan untuk manula yaitu 1,2 g/Kg per hari, atau yang direkomendasikan untuk pasien dengan luka dekubitus yaitu berkisar 1,2-1,5 g/Kg per hari (Agency for Health Care Policy Research, 1994). Faktor tersembunyi yang menyebabkan keterlambatan kesembuhan luka pada manula (Anderson & Kvorning, 1982; Bergstrom & Braden, 1992; Robert, 2001), seperti kekurangan protein atau zinc, dan selama proses granulasi luka menyebabkan penurunan fungsi fibroblas dan sintesis kolagen (Rijswijk & Polansky, 1994). Oleh karena itu proses penyembuhan luka menjadi terhambat.

Selama 4 minggu setelah perubahan regimen nutrisi, terjadi pertumbuhan jaringan yang bergranulasi dari tepi luka. Pertumbuhan granulasi dimulai pada minggu kedua, perbaikan warna jaringan yang bergranulasi terjadi pada minggu ke3 dan kedalaman luka berkurang pada minggu ke4. Pada minggu ke4, intake energi pasien (subjek) meningkat dan 6 dari 7 pasien dianjurkan untuk memenuhi kebutuhan protein 1,4-2,0 gr/Kg BB perhari, jadi suplemen nutrisi meningkatkan fungsi fibroblast yang akan mempengaruhi pertumbuhan sel dan sintesis kolagen yang akan mempengaruhi granulasi jaringan. Peningkatan vaskularisasi kapiler dan aliran darah kejaringan akan memperbaiki warna jaringan yang bergranulasi (Moriguchi,2000; Nagahara,2000). Menurut "Perawatan Pasien dengan Luka Dekubitus" kemerahan dan bengkak di sekeliling luka akan menghilang dalam 1 minggu setelah mengurangi dan menghilangkan penekanan. Maserasi dan penebalan pada tepi luka akan berkurang dalam 1 minggu setelah dilakukan perawatan luka (Sanada dan Sugama, 2003). Berkurangnya "crevasse" (salah satu tanda pertumbuhan jaringan, seperti celah yang membelah), dan berkurangnya membrane yang mengalami nekrosis akan terjadi. Pertumbuhan granulasi jaringan dan perbaikan warna akan terjadi 2 minggu setelah diberikan perawatan luka (Sanada et al,2002).

2. Pengkajian Perubahan Nutrisi pada Lansia dengan Dekubitus

Berdasarkan perubahan nyata saat dilakukan pengamatan pada granulasi luka dipercayai bahwa pengkajian efek dari intervensi nutrisi pada lansia dengan dekubitus dapat berpengaruh cepat, dan hal itu dibenarkan oleh para perawat yang mengamati luka setiap hari.

Pada pasien lansia, vaskularisasi dengan kuantitas yang cukup sulit dicapai, dan pengukuran ketebalan dan lipatan kulit secara tepat juga mengalami kesulitan karena perubahan proses penuaan.

Keterbatasan dalam penelitian ini diantaranya adalah hasil penelitian tidak dapat digeneralisasikan karena ukuran sampel yang kecil. Selain itu dekubitus dievaluasi hanya pada saat fase granulasi dan subjek adalah pasien lansia dengan status nutrisi yang buruk. Disarankan untuk dilakukan penelitian guna mengevaluasi efek pemberian nutrisi terhadap proses penyembuhan dekubitus.

I. KESIMPULAN

Proses penyembuhan luka dekubitus dibandingkan sebelum dan sesudah perubahan regimen nutrisi pada 7 pasien lansia yang bedrest di Jepang. Tidak ada perbedaan pada beberapa factor lain yang mempengaruhi penyembuhan luka dibandingkan dengan status nutrisi pasien antara waktu saat perubahan regimen nutrisi dan 4 minggu setelahnya. Dua minggu setelah suplementasi nutrisi, granulasi jaringan dimulai. Penemuan ini memberikan gambaran bahwa status luka dekubitus dapat diperbaiki dengan pemberian suplemen nutrisi, perbaikan akan dimulai 2 minggu setelah intervensi. Pertumbuhan granulasi jaringan merupakan indeks penyembuhan luka dekubitus.

Adapun nutrisi yang bisa digunakan untuk kesembuhan luka deubitus antara lain : susu sapi, keju, madu, daging ayam, udang, hati, kurma, telur, kacang tanah, kacang hijau, tempe, tahu, sayuran hijau, wortel, buah semangka, buah kiwi, jeruk, jambu, bayam, tomat, petai, pepaya dan daunnya, daun singkong, buah nanas, ikan, kentang, anggur

Daftar Pustaka

Yunita Sari. Luka Tekan: Penyebab dan Pencegahan. 2006. Gerontological Nursing/ Wound Care Management Department. The university of Tokyo,Japan

Yunita Sari. Memonitor Penyembuhan Luka Tekan. 2006. Gerontological Nursing/ Wound Care Management Department. The university of Tokyo,Japan

Shizuko, Junko et al. Healing process of pressure ulcers after a change in the nutrition regimen of bedridden elderly: A case series.

Japan Journal of Nursing Science . 2005







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