Effectiveness of Complementary Dressing Care On Healing Diabetic Foot Ulcer: A

Systematic Review

Made Yuni Martini1*, Nur Arifah Astri2, Ossi Dwi Prasetio3, Ferry Efendi4

Faculty of Nursing, Universitas Airlangga Surabaya, Indonesia

*Email: Made Yuni Martini, +628174788892, made.yuni.martini-2020@fkp.unair.ac.id

ABSTRACT

Introduction: Diabetic foot ulcer is a typical wound in diabetics with a long healing time, up

to relatively expensive treatment costs. Complementary dressing care is expected to heal

diabetic foot ulcers effectively.

Objective: The purpose of this study is to find out the effectiveness of complementary

dressing care in healing diabetic foot ulcers, compared to conventional treatment that using

only normal saline or NaCl 0,9% rinse.

Method: This systematic review conducted through Scopus, Science Direct, ProQuest, and

Sage. Inclusion criteria were scientific articles that discussed complementary dressing care

for diabetic foot ulcers for the last 5 years, and the exclusion criteria are articles that were not

written in English, paid articles, and unavailable full text. PRISMA flow charts and JBI

critical appraisal checklists were used to assess bias risk and quality of articles. Three

researchers involved in this review with one corresponding author.

Results: 8 articles were selected to review, that include randomized clinical trials to case

studies. The results of this systematic study are various types of complementary dressings

were found to be effective in healing diabetic foot ulcers including that dominated by honey

and aloe vera complementary dressing care

Conclusions: Complementary dressing care for healing diabetic foot ulcers is effective in

increasing wound healing activity compared to conventional treatment that using only normal

saline or NaCl 0.9% rinse.

Keywords: complementary dressing treatment, complementary ulcer dressing, diabetic

wound dressing care, foot wound.

1. INTRODUCTION

1.1 Background

Diabetic foot ulcers are a serious complication that can be suffered by people with

diabetes mellitus. Various procedures have been applied in the treatment of diabetic foot

ulcers, including debridement, blood sugar control, and infection prevention, but the results

of this intervention are still not good enough (Zhang et al., 2015). Due to the substantially

increasing prevalence of global diabetes, as well as the complex management and

inexpensive costs of treating crippling and recurring ulcers, this has been a therapeutic

challenge to date(David G. Armstrong, D.P.M., M.D. et al., 2017).

Diabetes mellitus alone affects 9.1–26.1 million people worldwide each year and

approximately 19–34% of diabetic experience diabetic foot ulcers at one time in their

lifetime. The prognosis of a patient with diabetic foot ulcer is so invested in the infection and

amputation associated with this wound. The risk of death at 5 years for patients with diabetic

foot ulcers is 2-5 times higher than for patients without foot ulcers, and up to 70% of patients

can die within 5 years after amputation (David G. Armstrong, D.P.M., M.D. et al., 2017).

One of the primary prevention that can be done in foot ulcers is a treatment that is useful

for seeing foot abnormalities early (Oktorina et al., 2019). Foot care in patients with diabetic

ulcers is very important to prevent wound infection and promote wound healing. Treatment

techniques are currently experiencing rapid development using the Moist Wound Healing

(MWH) technique made from alginate, metcovazine, foam, hydrocolloid, hydrogel, and a

combination of complementary therapies using real honey. While conventional treatment still

uses NaCl, betadine, and gauze (Riani & Handayani, 2017). Currently, wound dressings play
an important role in the treatment of diabetic foot ulcers. Various types of wound dressings

can be applied to foot ulcers, especially dressings (Zhang et al., 2015).

Complementary therapy is a non-conventional treatment that can be applied as a

complement to existing therapies and can be used to support conventional medical and non-

medical treatments (Riani & Handayani, 2017). Several studies have shown significant

results where complementary dressing therapy has a positive impact on the improvement of

diabetic foot ulcers. However, to date, there are still few studies that provide sufficient

evidence that complementary therapies are more effective in the treatment of foot ulcers than

other dressings. We conducted this systematic review for the role of complementary therapies

as an effective intervention for the treatment of foot ulcers and for their use in clinical

practice.

2. MATERIALS AND METHODS

In this systematic review, we used a six-stage protocol. These protocols include article

search strategies based on PICOT formulations from several databases including Scopus,

Science Direct, ProQuest, and Sage, then evaluation with inclusion and exclusion criteria,

study selection using PRISMA, minimizing or dismissing the risk of articles in choosing the

use of JBI bias that Furthermore, data extraction and synthesis are carried out.

2.1 Search Strategy

The article search strategy that we used before conducting a database search in October

2020 was to compile a Research Question using PICOT, as follows:

Population : Diabetic foot ulcers

Intervention : Complementary Dressing Care

Comparison : Conventional treatment which only uses normal saline solution or NaCl 0.9%

Result : Wound Healing

Time : Acute & Chronic

Based on the PICOT formulation, the research question in exploring this article: what are

the complementary dressing treatments that are effective in healing diabetic foot wounds?

Search and excavation of articles through several databases including Scopus, Science Direct,

ProQuest, and Sage, with a search period from 8 September 2020 to 22 December 2020.

Keywords used are foot ulcer, diabetic ulcer dressing care, complementary dressing care,

bandages. complementary ulcers.

2.2 Inclusion and Exclusion Criteria

The articles were used, filtered, and finally selected according to the inclusion criteria

that had been stipulated, the research design was a randomized controlled trial, the latest

articles up to the last 5 years from 2016 to 2020, containing a discussion of complementary

dressing treatments for the healing of foot ulcers diabetes, short-term to long-term care.

Articles that met the inclusion criteria were then eliminated with the exclusion criteria for

articles not written in English, paid articles, and not available in full text. The data that has

been obtained is reviewed and then selected to be grouped and based on the points.

2.3 Study Selection

In keeping with recent uses in the use of PRISMA, the potential study is the first article

to be retrieved from an electronic database. Following duplicate removal, titles and abstracts

from potential studies were re-screened for use in a systematic review. The full text of each

selected study that met the inclusion criteria was taken for further examination. A secondary

search was carried out from the reference list of studies to identify additional records. Finally,

the study articles we obtained were based on inclusion criteria and were included in the

systematic review. The search and screening process was carried out by three reviewers. Any

disagreements made by reviewers.

2.4 Risk of Bias

The JBI Bias Risk Tool was used to assess the methodology of the included randomized

controlled trials and quasi-experimental studies. The bias of the 13-item randomized

controlled trial included: correctness of randomization of treated participants, the

confidentiality of group being questioned, pre-treatment groups, participants ignorant of

treatment assignments, blind caregivers to care assignments, outcome evaluators not seeing

task treatment, intervention groups with reduced intervention, no follow-up after completion

or differences between groups in terms of adequate and sufficient follow-up were analyzed,

analysis participants in randomized groups, same measurements for treatment groups,

measurement results in a reliable manner, use of appropriate statistical analysis, appropriate

trial design, and calculation of any deviations from the RCT standard design in the conduct

and analysis of the trial. Any domains expressed as high, low, or unclear risk bias by the

criteria stated in the tool. While there is a risk bias for each study, the study is under an

overall low-risk bias if all major domains are low risk (Higgins dan Green, 2011).

Whereas the bias of a quasi-experiment using 9 items includes: cause and effect variables

are apparent where there is no confusion about which variable comes first, participants are

included in the comparison, participants receive care other than reduced exposure, presence

of a control group, there is a measurement of results before and after the intervention, follow-

up or explanation of differences in follow-up, group outcomes in discussions that are

measured in a way that is measured in a reliable way, and use of appropriate statistical

analysis (The Joanna Briggs Institute, 2017).

The results of the study using the JBI critical assessment tool:
Table 1. JBI RCT Study Assessment

Kriteria

Sitasi 1 Hasil
1 2 3 4 5 6 7 8 9 11 12 13
0

12/13
Jayalakshmi,

2020 √ √ √ √ √ √ √ √ √ √ √ √ 92%

Table 2. Assessment of the Quasi-Experimental JBI Study

Kriteria Hasil
Sitasi
1 2 3 4 5 6 7 8 9

9/9
Xu et al.,

2018 √ √ √ √ √ √ √ √ √ 100%

7/9
Liu et al.,

2019 √ √ √ √ √ √ √ 77,8%

9/9
Najaf et al.,

2020 √ √ √ √ √ √ √ √ √ 100%

9/9
Rashidi et al.,

2015 √ √ √ √ √ √ √ √ √ 100%

(Sari et al., √ √ √ √ √ √ √ √ √ 9/9

2018)
 100%

(Vitsos et al., √ √ √ √ √ √ √ √ 8/9

2019)
88,9%

(Siavash et √ √ √ √ √ √ 6/9

al., 2020)
66,7%

2.5 Data Extraction

A structured form is used to extract information from including the study, including year,

study design and setting, theoretical framework, participants, sample size, intervention (its

components, mode of presentation and presentation), the outcome of actions used for the

intervention, from data period and findings.

2.6 Data Synthesis

Regarding the heterogeneity of participants and interventions, intervention data, and

outcome measures, a meta-analysis was not carried out. The results are presented in the

intervention and study results, in both narrative and tabular formats.

3. RESULT

3.1 Article Selection

Initial literature searches according to keywords resulted in 1,207 articles (405 from

Scopus, 168 from Science Direct, 592 from ProQuest, and 42 from Sage). After reviewing the

title, as many as 1164 articles were eliminated, 21 of the articles were eliminated again

because they were not available in full text and for a fee until 22 articles were selected for

review as in Figure 1 below:

The study in this review systematic is heterogeneous, 4 articles use the control and

intervention groups in the study, and 4 articles use the in vivo method.

3.2 Study Characteristic

3.2.1 Sample

The sample of these journals varies because the selected journals are heterogeneous. In

research using respondents at most using 160 respondents and research with in vivo design

using a sample of 30-40 samples.

3.2.2 Intervention

The results of the articles were selected using single and combined interventions. The

types of interventions provided are given in the following table:

Table 1 List of types of complementary dressings

No Jenis Balutan Penulis Artikel

1 Daun Neem
2 Curcuma zedoaria
3 Maggot Therapy
4 Teucrium polium
hydroethanolic extract
dan Aloe vera gel
Muthu Srinivasan Jayalakshmi (2020)
Xua,1, Lili Wangb,1, Junjie Guanc, Chao Tanga, Ning Hea,
Wei Zhanga, Shiping Fua, (2016)
Xinjuan Sun, Jin’an Chen, Jie Zhang, Wei Wang, Jinshan
Sun, Aiping Wang (2016)
Morteza Najaf zadeh Gharaboghaza, Mohammad Reza
Farahpourb, Shahram Saghaiec (2020)
 5 Madu, Royal Jelly dan
Olive Oil-Propolis
extract
6 Maggot Therapy
7 Ceratothoa oestroides
Olive Oil Extract
8 Nigella sativa Oil Gel
and Aloe Vera Gel
Based on table 1, the author
Mohammad Kazem Rashidi Naser Mirazi Abdolkarim
Hosseini (2016)
Siavash et al., (2020)
Vitsos et al., (2019)
Sari et al., (2018)
found 8 types of dressings used for diabetic foot ulcers.

There are two dominant types of complementary dressings used for diabetic foot ulcers,

namely honey and aloe vera. Several other types of complementary dressings found in 8

reviewed journals were neem leaves, curcuma zedoaria, maggot therapy, teucrium polium

hydroethanolic extract, ceratothoa oestroides olive oil extract, nigella sativa oil gel, royal

jelly, and olive-propolis oil extract.

3.2.3 Characteristics of the Intervention

The complementary dressings given to diabetic foot ulcers can range from a single

intervention to being given alongside other dressings. Complementary dressings provided

include neem leaves mimba (M. Jayalakshmi, 2020), curcuma zedoaria (Xu et al., 2018),

maggot therapy (Siavash et al., 2020) (Sun et al., 2015), teucrium polium hydroethanolic

extract (Najaf et al., 2020), ceratothoa oestroides olive oil extract (Vitsos et al., 2019),

nigella sativa oil gel (Sari et al., 2018), aloe vera (Maniei et al., 2019) and honey (Rashidi et

al., 2015).

The complementary dressing that is given for 1 month is a complementary dressing made

from neem leaves (M. Jayalakshmi, 2020), 2 weeks (Xu et al., 2018) (Najaf et al., 2020)

(Rashidi et al., 2015), 6 weeks (Siavash et al., 2020), 3 months (Vitsos et al., 2019), 7 days

(Sari et al., 2018), 5 days (Sun et al., 2015).

3.2.4 Effect of Complementary Dressing Interventions

The effect of complementary dressing treatment interventions in the research we

studied showed positive results in diabetic foot ulcer wounds where there were an increase
and acceleration of wound healing such as the honey dressing intervention which showed

increased skin healing and accelerated wound repair in diabetic and non-diabetic rats where

the healed. associated with anti-inflammatory, antioxidant, and antimicrobial activities

(Rashidi et al., 2015). The way honey works in the recovery of diabetic foot ulcers are

supported by the other research journal said that honey has debridement and anti-

inflammatory effects which can be obtained by the anti-oxidant content of honey such as

flavonoids, mono phenolics, polyphenols, and vitamin C, high osmotic pressure in honey, and

the composition of hydrogen peroxide has a debridement effect, reduces edema. and exudate,

a calming effect, stimulates protease activity and increases fibrin-forming activity on the

wound surface. In addition, honey can stimulate tissue growth by the composition of nutrients

such as carbohydrates, amino acids, vitamins, and minerals that are easily metabolized and

high acidity which will increase the release of oxygen from hemoglobin to accelerate

metabolism and collagen tissue synthesis, as well as antibacterial properties by the enzymatic

production of hydrogen peroxide (Putu E.P. Kefani et al., 2018).

In the neem leaf-based treatment intervention, which was given to leg ulcer patients

randomly to the neem extract irrigation group and normal saline irrigation twice a week for 4

weeks. The reduction in ulcer size was higher in neem extract irrigation compared to normal

saline irrigation practice and could be performed by home visiting nurses or at the

Puskesmas. A total of 80 participants or half of the total participants reached approximately

50% of the wound area before treatment, with a ratio of 63.75% healing acceleration in the

neem irrigation group and 36.25% in the normal saline irrigation group. There were no side

effects such as skin reactions or itching in the participants after the intervention. The

intervention of complementary neem leaf dressing has a positive effect on the healing of

diabetic foot ulcers and is more effective than just doing normal saline or 0.9% NaCl

irrigation treatment in diabetic foot ulcer patients (M. Jayalakshmi, 2020).

 Table 3. Study Characteristics and Findings
Judul
No Penelitian Metode Usia Sampel Intervensi Outcome Kesimpulan
dan Penulis
1. Effect of neem randomized ≥ 20 160 Diabetic The intervention was given to patients with Effectiveness The reduction in ulcer size was
leaves extract control group years foot ulcer leg ulcers randomly assigned to the neem Complementar higher in neem extract
irrigation on ezperimental patient extract irrigation group and normal saline y Dressing irrigation compared to normal
the wound design irrigation twice a week for 4 weeks. Care On saline irrigation practice and
healing Healing can be performed by home
outcome in Diabetic Foot visiting nurses or at the
nurse managed Ulcer Puskesmas for sprue weakness
diabetic foot in the early stages without
ulcers. having to be hospitalized.
Jayalakshmi
(2020)
2. Wound in vivo - 40 Sprague- The rats were randomly divided into five Diabetic This experimental research
Healing diabetic Dawley (SD) groups of 8 animals each and given a wound shows that PRP-Exos / ZWP
Effects of a wound female mice dressing containing C.zedoaria rhizome for treatment is containing hydrogel
Curcuma healing study 15 days, the dressing was changed every 3 safe and works sponge/chitosan silk/silk can
zedoaria days. to speed up the be the desired therapy for
Polysaccharide healing diabetic skin wounds in
with Platelet- accelerating wound healing.
rich Plasma
Exosomes
Assembled on
Chitosan/Silk
Hydrogel
Sponge in a
Diabetic Rat
 Model (Xu et
al., 2018b)
3. Synthesis of In vivo - - Sterile larvae (Lucilia sericata) obtained Improve The results showed that MDT
ZnO (experiment) from our laboratory were provided free of healing of and maggot ES could improve
nanoparticles charge to the patient in charge of this study. diabetic foot the healing of diabetic foot
using radish Young larvae were prepared individually for wounds wounds by proving endothelial
root extract for each patient and applied at a density of one cell activity.
effective maggot per 50-80 / cm2 of the wound area.
wound The maggots are applied for 72 or 120
dressing hours, depending on the patient's tolerance
agents for and medical evaluation of the wound.
diabetic foot
ulcers in
nursing care.
Liu et al.,
(2019)
4. Topical co- In vivo - 108 mouse Animals were randomized into six groups of Enhanced The results showed that the
administration (experiment) 18 animals each, including (I) the control wound healing TPEO and AVGO-treated
of Teucrium group receiving mupirocin (as positive process group accelerated the
polium control or standard drug), (Ⅱ and Ⅲ) mice proliferation and shortened the
hydroethanolic treated with 5 and 10% TPEO, (Ⅳ and Ⅴ) inflammatory stage with the
extract and mice treated with 5% and 10% AVGO and expression of GLUT-1, IGF-1,
Aloe vera gel (Ⅵ) mice received a mixed form of 5% FGF-2, and VEGF. For the
triggered TPEO and 5% AVGO (TPEO + AVGO). most part, current research
wound healing The ointment is applied daily for 14 days in suggests that although different
by accelerating a topical form. The wound area was dosage levels of TPEO and
cell measured with transparent paper over the AVGO in different forms can
proliferation in wound according to the previous method accelerate the healing process
diabetic mouse results in a diabetic wound
model. Najaf model.
et al., (2020)
5. Effect of In vivo - 42 male Wistar Wounds in each animal were treated daily Improved The results showed skin
 topical mixture (experiment) rats with Nika cream and 1% phenytoin in healing of improvement and accelerated
of honey, royal normal and diabetic groups. The control diabetic skin wound repair in both diabetic
jelly and olive group received no treatment. The wound and wounds and non-diabetic rats. The
oil-propolis surface area was measured up to 24 beneficial effects of Nika
extract on skin postoperative days. The time it took to cream on wound healing may
wound healing complete healing was also recorded. be related to its anti-
in diabetic inflammatory, antioxidant, and
rats. Rashidi et antimicrobial activities.
al., (2015)
6. Efficacy of prospective 35-75 42 patients First, the wound and its surroundings and Improved MDT is an effective treatment
Maggot open-label years with type 2 cleaned with sterile saline and sterile gauze. diabetic wound for atypical DFUs that are not
Debridement single (quasy diabetes (26 After the wound area has been cleaned, the healing responsive enough to
Therapy on experiment) men, 16 MDT procedure is performed as follows: to conventional therapy. MDT
Refractory women) keep the maggots in the wound bed, the can be a safe, efficient, and
Atypical wound edges are covered with zinc oxide inexpensive method of wound
Diabetic Foot ointment. The maggots that float in sterile management, especially the
Ulcers. normal saline are transferred to sterile DFU healing process.
Siavash et al., gauze, which is immediately applied to the
(2020) wound bed. There are about 10 to 15
maggots per cm 2 of the wound area. This
sterile gauze is applied to the wound by
covering it around it, leaving most of the
gauze to freeze. Two more layers of sterile
gauze are added over the first layer. This
arrangement facilitates the removal of
wound exudate. The top layer is changed
every day, while the first layer containing
the maggots is stored for 48 to 72 hours.
After this period, the maggots are removed
by gently peeling off the cloth and washing
them with sterilized air salt. Furthermore,
the ulcers are clean and cleaned again with
 sterile saline and sterile gauze. MDT was
repeated 5 times. After the fifth session, if
the wound is completely healed, we
willingly MDT and follow the patient
7. Efficacy of a Pilot Study 40-97 14 patients The wound is cleaned with Ringer's lactate Wound healing This study demonstrated
Ceratothoa years or normal saline. Wounds infected with substantial healing properties
oestroides Pseudomonas aeruginosa were cleaned with when applied to untreated
Olive Oil 2% w / w acetic acid in normal saline chronic wounds leading to a
Extract in solution. Wound care is carried out once a significant reduction in wound
Patients With day. After the wound has been cleaned, a size. In addition, efficient
Chronic thin layer of ointment (oestroides C microbial control by agents
Ulcers. (Vitsos homogenized in olive oil) is applied, applied topically to wound
et al., 2019b) covering the entire area of the wound. The healing, inhibits the recurrence
wound is then bandaged with a suitable of wound infections.
sterile bandage.
8. A Quasy 12 to 12 Male Wistar The rats in this study were divided into 3 The difference The results showed that
Comparative experiment 14 Rats groups, namely AV gel (4 rats), NSO gel (4 in wound wounds treated with AV gel
Study of the week mice), and a control group (4 mice). In the healing rates were significantly smaller than
Effects of s AV and NSO gel groups, 100 μL of the wounds treated with NSO gel.
Nigella sativa With appropriate gel was applied to the wound. Our results also showed that
Oil Gel and a Then, the wound is closed with a transparent inflammation was more
Aloe Vera Gel weigh film dressing. The control group underwent abundant after AV gel than
on Wound t of the same procedure, except that no gel was with NSO gel, and fibroblast
Healing in 170- applied. The area of the wound was infiltration was more abundant
Diabetic Rats. 200 measured using ImageJ software developed after AV gel use than with
Sari et al., grams by the National Institutes for Health. The NSO gel.
(2018) relative wound area was calculated as
follows: (area on day 0 - area on day 0) /
(area on day 0). The wound was also
assessed macroscopically for closure
(wound size, wound bed color, presence of
exudate, and necrotic tissue).
4. DISCUSSION

4.1 Summary of Findings

In this systematic review, the authors found 8 types of complementary dressings used in

diabetic foot ulcers. The effectiveness of honey as a complementary dressing that is able to

shorten wound healing time, treatment time and minimize the development of

microorganisms due to the content of antibiotics, antioxidants, anti-inflammatory, auto-

debridement, and stimulating growth factors (Rashidi et al., 2015). Not much different from

the use of neem leaf extract, C estroides olive oil, white turmeric, and radish roots also have

a similar effect, which is able to reduce the size of the ulcer compared to normal saline

irrigation (M. Jayalakshmi, 2020; Liu et al., 2019; Najaf et al., 2020; Sari et al., 2018b;

Vitsos et al., 2019a; Xu et al., 2018a). Meanwhile, maggots or maggots are very effective in

the debridement of dead tissue, thereby accelerating the healing process of diabetic wounds

(Siavash et al., 2020).

4.2 Strenght and Limitation

There are several statements regarding the research findings reviewed, including the

research found was dominated by honey dressings followed by the use of aloe and maggots,

while the use of other complementary diabetic wound dressings was still very limited. The

drawback of some other complementary dressings is that some research studies do not

discuss the direct effect of ingredients that do not use or use complementary dressings

without other supporting therapies, for example in the combination of honey, royal jelly, and

propolis oil and the use of aloe vera after infrared therapy (Maniei, et al., 2019; Rashidi et

al., 2016).

This complementary wound dressing is very supportive to do in practice, apart from

being supported by a variety of experimental studies that have been carried out from case

studies to RCTs, these complementary dressing materials are easy to obtain, and do not
require large costs in the procurement of raw materials, so that is the case. so relevant to the

development of nursing science and is expected to be able to practice better nursing /

improved patient outcomes (M. Jayalakshmi, 2020; Vitsos et al., 2019).

Compared with the treatment of diabetic wound dressings in some hospitals outside the

city using only 0.9% saline or NaCl to rinse and clean the wound and then cover it using

sterile gauze, a review of the literature on complementary dressing treatments that are more

effective in healing diabetic foot ulcers, in line with research which showed that the neem

leaf extract intervention had a significant difference in wound size with a p-value <0.05 (M.

Jayalakshmi, 2020).

4.3 Aspects that need to be considered in the care of diabetic foot wounds

In carrying out the treatment of diabetic foot wounds, there are 6 aspects that must be

considered to be controlled in the holistic management of diabetic feet by nurses, namely

mechanical control, metabolic control, vascular control, wound control, infection control,

and educational control. Mechanical Control: In wounds that are dominated by neuropathic

factors, the main goal of mechanical control is the pressure load on the feet, while those

dominated by vascular factors are mainly to avoid injury to vulnerable areas. Wound control

by evacuating adequate necrotic tissue and pus for Cipta as possible, if necessary it can be

done by operative measures and the most recent is amputation (Widyahening et al., 2014).

Infection control, namely in deep, extensive wounds, symptoms of systemic infection that

require hospitalization: broad-spectrum antibiotics can be given which can include gram-

positive, gram-negative, and anaerobic bacteria. So that 2 or 3 classes of antibiotics can be

used. Vascular control, namely vascular surgery or endovascular measures (if there is a

strong indication). Metabolic control with good nutritional planning during the infection and

wound healing process and control of comorbidities (hypertension, dyslipidemia, impaired

liver function, impaired kidney function, electrolyte disturbances, anemia, comorbid

infections, and hypoalbuminemia) and the sixth is control education for patients and their

families regarding Current condition of the patient's foot wound, plan, diagnosis,

management/therapy, complications that may arise, and prognosis are important aspects in

managing the patient better. As in research conducted by (Vitsos, 2019).

5. PRACTICE IMPLICATIONS

Studies that have been carried out in the form of scientific studies show that

interventions in the form of complementary dressing treatments for the healing of diabetic

foot ulcers are effective in increasing wound healing activity and are the right choice

because of their easy access and low-cost use. In handling diabetic foot wounds, nurses must

also pay attention to 4 comfort contexts according to Kolcaba (2008), namely 1. Physical

comfort is related to the disease process and the main problem of comfort is pain. The

presence of DM wounds will have an impact on changes in the structural integrity of the

skin so that various mediator production becomes inflamed so that a balance is needed to be

able to change what happens. 2 psychospiritual comfort which is related to spiritual and

psychological comfort which is viewed holistically. There is a connection between mental,

spiritual, and emotional experiences. Its application in DM wound care can reduce stress

factors that have an impact on the wound healing process. 3. Environmental comfort is

defined as something related to external influences such as light and nature which will affect

the patient's recovery. Application in the treatment of DM wounds is the law of excessive

production which can cause unpleasant odors that will affect the surrounding response. 4.

Sociocultural comfort is related to interpersonal relationships, family and social

relationships that have an impact on client comfort in the wound healing process. The

application form in DM wound care is the need for a caring attitude for all parties involved

in the treatment process so that it has a positive impact so that the treatment process runs

well and the wound healing process does not use dressings and drugs but with the comfort
that nurses have built for patients. also helps in the healing process of diabetic foot wounds.

The results of this research are certainly very useful in the field of nursing science in

providing nursing care to clients. Besides being able to do complementary dressings in the

clinic, it can also be done independently by the family/patient at home as an effort to

empower the family. Due to the role of nurses apart from being nursing care providers,

nurses also act as advocates, educators, coordinators, collaborators, consultants, and

reformers.

6. CONCLUSION

Complementary dressing treatments that are effective in healing diabetic foot ulcers,

namely: neem leaves, curcuma zedoaria, maggot therapy, teucrium polium hydroethanolic

extract, ceratothoa oestroides olive oil extract, nigella sativa oil gel, aloe vera, olive-propolis

oil extract, and honey. Complementary dressing therapy is applied by applying sufficient

complementary therapeutic ingredients to relieve diabetic foot ulcers. Change of dressings is

done periodically from every day to 3 days depending on the type of dressing material. With

the right frequency, time to be given periodically, and the appropriate type of dressing, these

appendages appear to be effective in reducing the size and severity of diabetic foot ulcers

over a period of five days to 3 months.

This complementary dressing treatment for diabetic foot ulcer healing is effective in

increasing wound healing activity, in addition to a relatively short healing time,

complementary dressings are the right choice because they are easy to reach and relatively

cheap to use.
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