Model of Social Assessment to Diabetic Foot Ulcer Patients

Gusti Jhoni Putra1, Tisa Gusmiah 1, Usman2, Kharisma Pratama2, Wuriani3

1
Departement of Medical Surgical Nursing, STIK Muhammadiyah Pontianak
2
Department of Basic Science of Nursing, STIK Muhammadiyah Pontianak
3
Department of Maternity, STIK Muhammadiyah Pontianak
gustijhoni@stikmuhptk.ac.id

Keywords: Social Assessment, Diabetic Foot Ulcers

Abstract: Objective: One of the purpose in diabetic nursing care is to Improve the quality of life of patients with diabetic
foot ulcer (DFU). Some aspects must be considered in patients with DFU, the aspects include in Social
Aspects, that are Support of Family, Environtment, Self Esteem and Economy. This is because of the support,
activity and relationship influence on physiological and quality of life. Unavailability of social assessment to
DFU can affect in determining the appropriate diagnosis and intervention. The purpose of this research is to
develop the social support in wound assessment instrument for patients with DFU, so that can be choosen the
right intervention that related to problem founded.
Method: This research method was mixed method with sequential exploratory approach. There were 9
participants for qualitative methods, Aiken’s V was used to Content validity index test for qualitative methode
by 2 experts in Pontianak. 103 respondents for quantitative methods was used the instrument, Instrument
validity test were by Pearson product moment with test retest approach, reliability test was by Cronbach
alpha
Result: Nine themes emerged from the qualitative methods for social support, that are Quality of care, Efforts
to get information, family motivation, family trust, community activities, assertive attitudes, adaptive coping,
self-confidence, family financial management. Result of that themes were modified to 35 items questions in
social instrument, the 35 items measuring instrument obtained a valid (0,372-0,843 > 0,235) and reliable
results (Cronbach alpha 0,959 and 0,976). Result of content validity index is valid by 0,67-0,83.
Conclusion: Themes that was found in qualitative methode is using for develop social support
instrument, the instrument hoped can be used to assess patient needed in social demand. From the
result of assessment can be choosen the right intervention that needed by patient, so quality of life
of patients can be reached fully improved, and directly it can be effect to the wound healing.
1 INTRODUCTION
The incidence of DFU in DM patients continues
to increase and steal the attention of many parties to
develop the latest innovations related to wound care.
The aim of developing this innovation and technology
is to accelerate the wound healing process so that
patients can achieve optimal quality of life. Based on
several factors that influence the healing of DFS, the
development of innovation can be directed at
physical, social, environmental, lifestyle
management, nutrition, family support, interpersonal
relationships, immunity, and psychosocial support
(Suriadi, 2010).
The comfort theory of Kolcaba explains one of
the four aspects of patient comfort, namely the social
aspect. Based on its taxonomic structure Kolcaba
developed an instrument to measure patient comfort,
namely the General Comfort Questionnaire which
aims to improve the quality of life of patients through
the theory of comfort (Alligood, 2014). According to
Kolcaba (2006) the convenience of sociocultural
aspects includes the patient's social development in
the form of self-concept, interpersonal, intrapersonal,
and social environment. Disorders in social
interactions will interfere with the patient's
psychology and result in physiological healing of the
wound. Sibuan (2011) says that high family support
will affect the increase in self-esteem and patient
social interaction so that patients will feel
comfortable. The comfort felt by patients must be a
priority and concern for nurses, in addition to
physical, mental and environmental comfort, it also
needs to be considered from its social aspects (Potter
& Perry, 2005).
Firman (2012) said that a minimum award from
the family is needed to increase self-confidence and
social interaction in DM patients. Grant (2014) said
that individuals spend a lot of time with family and
society compared to the health team, 99% of time will
be spent in families, workplaces and communities so
that the roles and support of family and community
are very influential in healing patients.
Family and social support that is not optimal will
cause stress to the patient. The stress response caused
by disturbances in self-concept and individual social
interaction will affect the work of several hormones,
as said in the journal National Institutes of Health by
Gouin (2013) including glucocorticoids,
catecholamines, oxytocin, vasopressin, and cytokinin
production, which results in wound healing itself. In
the study of Uchino (2012) said that one's health is
very influential on social support which will
ultimately affect the work of the heart,
neuroendocrine and patient immunity.
The results of the preliminary study by randomly
interviewing several patients who experienced DFU,
obtained data that 90% of them experience the risk of
interference in interacting with others after
experiencing injuries, such as feeling ashamed of data
at work, following social activities around the place
stay, and feel burdensome to family finances, and at
the Kitamura clinic itself there are no special social
assessment tools available for wounded patients.
Seeing this phenomenon, the authors are interested in
developing a social aspect injury assessment
instrument with the kolcaba theory approach at the
Kitamura Pontianak clinic, so that it can finally be
determined psychosocial interventions that are
specific and appropriate to the patient's needs so that
the optimal quality of life of the patient will be
achieved.
2 METHODS
The method used in this study is a mix method
with sequential exploratory design. This design
combines sequential qualitative and quantitative
research methods, qualitative methods to find
hypotheses, and to explore research topics by
observing participants at the research site, followed
by quantitative methods to test hypotheses found in
previous stages in the wider population (Creswell,
2016).
The sample of this study was DFU patients at
Pontianak's Kitamura Clinic. In the qualitative phase,
the number of participants was 9 people, at the
quantitative stage the number of respondents was 103
people. This research was conducted at the Kitamura
Pontianak Clinic.
The qualitative scope that will be explored, as
follows.
Table 1. Qualitatif Scope
Category
Family Support
Environtment Support
Self Esteem
Economy
Quantitative questionnaires refer to the variables
studied, namely the social aspects of the Kolcaba
theory (self-concept, family support, environmental
and economic support). Quantitative questionnaires
tested for validity and reliability were obtained from
the findings at the qualitative phase. The interview
results were tested for validity with Aiken's V
approach and obtained from valid and reliable results 3.3 Theme for Qualitaif Methods
with a range of values between 0-1. Processing and
analysis of qualitative data using the Creswell model Based on the results of interviews conducted on 9
participants, 9 themes were obtained from 4
(2016), Analysis of validity and reliability of
qualitative scopes. The theme can be seen in the table
assessment instruments using the test-retest approach below ;
using the Pearson Product Moment formula.
Processing and analysis of qualitative data using the Family Quality of care
Creswell (2016) model, followed by analysis at the Support Efforts to get information
quantitative, the course of the research is listed in the Family motivation
following figure. Family trust
Quantitative Test Retest Approach of Instrument Environtment Community activities
Support Assertive attitudes
Self Esteem Adaptive coping
Theme Interpretation
Self-confidence
Economy Family financial management
Theme analyzed among to
grounded theory
From the findings of the theme, then it is developed
social aspect assessment instruments, instruments
Theme
developed from the themes obtained in the qualitative
Qualitative methods which were then combined with General
Questionnaire Comfort (GQC) from the Kolcaba
Data Coding nursing theory (Comfort theory). Furthermore, the
results of theme analysis and GQC were made into
statement and questions with the number of questions
Interpretation Whole Data as many as 38 items.

Transcript of Interview 3.4 Result of Validity and Reliability

This instrument was tested on 103 respondents who
Figure 1. Research procedur were in accordance with the inclusion criteria at the
Pontianak Kitamura Clinic.

3 RESULTS 3.4.1 Validity

Validity of this instrument is done in time series with
the retest test approach, testing is done by testing the
3.1 Characteristic of Qualitatif measuring instrument several times to the respondent,
Participant so in this case the same measuring instrument, the
Of the 9 participants, 77,78% of the participants were same respondent, and at different times. The trial of
female, 55,56% of the participants were in the final this instrument was carried out 2 times, the trial was
adult stage (36-45 years), 66,67% of the participants' given to the same respondent between the first and
education was bachelor degree, 100% marital status second tests, the second test was carried out after 10
of married participants, and the work of participants days from the first test. Items are declared valid,
is 66,67% as civil servant. proven by the results of r count> r table and the value
of Sig. ≤ alpha ().
3.2 Characteristic of Quantitatif
Respondent 3.4.2 Reliability
Of the 103 respondent, 71,2% of the respondent were instruments tested in the first and second stages were
male, 43,8% of the respondent were in the final adult declared reliable, the results of the Cronbachs Alpha
stage (36-45 years), 42,5% of the respondent coefficient were 0.959 in the first stage and 0.976 in
education was bachelor degree, 100% marital status the second stage. Because the value of the reliability
of married respondent, and the work of respondent is coefficient is greater than 0.60, the instrument is
53,4% as private sector. declared reliable.
4 DISCUSSION
4.1 Quality of Care
Patients get good quality family support provided by
family members in the form of providing and
facilitating transportation for maintenance needs,
financial assistance for medical expenses, and
providing time to listen and provide advice on patient
health. The quality of good support and
comprehensive care from the family is the basis of the
support that must be given to patients with DFU.
The support and care given by the family in a
comprehensive manner aims to facilitate patients in
carrying out all activities related to the problems
faced, in this case is the patient's limitations in terms
of the use of facilities and infrastructure, as well as
the need for moral and material support in the
treatment process.
Families are expected to be responsible for fulfilling
the needs of every diverse family member, including
the need for treatment. With comprehensive care and
good quality support for patients with diabetic foot
injuries, it is expected to improve the patient's health
conditions so that they can improve their health status
and quality of life.
4.2 Efforts to get information
In an effort to improve patient knowledge, family
members are expected to be more active in finding
and providing information about the disease and the
risks. The information provided can make patients
feel very valued. From the results of the analysis, the
family plays an active role in fulfilling the patient's
information needs, the family strives to provide the
information needed by the patient.
It is important that this information assistance effort
aims to increase patient enthusiasm and motivation in
order to improve health status optimally. Support for
information provided directly, of course, can reduce
the burden on the family and certainly the burden for
the patient itself, with information obtained, patients
will know the progress of the disease, what
complications and risks might occur, so patients will
be motivated to continue to follow the care process
regularly .
Searching for information about diabetic wounds is
more often accessed via the internet. Inevitably, the
use of technology is now an individual's need, the role
of family and health personnel is needed to direct
patients to find information related to their health. An
accurate source of information and appropriate use
includes forms of support that can be given to patients
to increase knowledge.
4.3 Family Motivation
Responses, attitudes and expressions of supportive
empathy from the family in the treatment process
make the patient feel happy and valuable. The
appreciation felt by the patient will have a positive
impact on him. Support in the form of positive
attitudes and expressions from the family can
influence activities in carrying out their activities, this
means the patient's motivation and self-confidence
are sourced from the family. In other words, patients
who get high quality family support will have high
motivation in carrying out the treatment process.
Another benefit, this family support can also improve
psychosocial status, and patient self-esteem, because
patients are considered still useful and available to the
family, from this condition it is expected that patients
can form healthy behaviors in an effort to improve
their health status.
Family support is expected to be consistent with
patients, given the long process of diabetic wound
healing. If the attitude shown by family members is
unstable, of course it can be felt by the patient, the
negative impact that is not expected is that the patient
feels the support provided by the family is a burden
on the family in caring for the patient, and certainly
affects the patient's motivation.
4.4 Family Trust
Family is the closest person and a place that is
comfortable for each individual. Families can
increase morale and motivation that affect
psychological and mental status, so patients can
manage their emotions. Diabetic foot wound patients
who cannot manage their emotions properly are at
risk of falling into stressful conditions. Stress /
depression has negative implications for wound care
management and patient quality of life. Negative
family support is one of the causes for depression.
Clinical psychological stress can affect wound
healing and the work of several hormones. Hormones
that influence include cortisol, glucocorticoid,
ketokalamin, oxytocin, vasopressin, and citokinin
which can cause wound hypoxia. As is known to
increase cortisol due to stress will affect the increase
in glucose through gluconeogenesis, protein and fat
metabolism. In addition, cortisol can also affect the
absorption of glucose levels in the blood and will
have an impact on the patient's immune system. The
impact that occurs both physically and
psychologically on the patient will certainly greatly
affect the quality of life and the spread of diabetic
wounds on the patient's feet.
With the support of the family, of course it is very
helpful for patients to be able to maintain
psychological health and improve their self-concept.
DFS patients who are in a family environment and are
cared for by their family members emotionally can
cause feelings of security and comfort, so that patients
believe that the family cares for and cares for them,
this will certainly be very beneficial for the recovery
process of patients with DFS.
4.5 Community Activities
The results of the analysis of social support related to
changes and barriers to activities indicate changes and
obstacles after diabetic foot injuries, such obstacles
must be more careful in activities, not as free as
conditions before illness, and weak physical
condition after illness. This is due to the long duration
of wound healing (long proliferation phase). From the
results of the interviews, participants stated that this
did not become a barrier to keep on doing activities
routinely in the community, so that the quality of life
of patients was well maintained. Social interaction
will be greatly influenced by one's self-image.
Because when someone sees himself well then that
person will not feel ashamed or insecure in social
interaction.
DFU sufferers with long duration do not always have
a poor quality of life. This is due to the positive
adaptation mechanism of these patients. The positive
adaptation behavior refers to coping mechanisms that
are oriented to their roles and functions in society.
Patients suffering from diabetic wounds with long
duration are able to adapt to the environment if they
are able to regulate emotional distress and can
provide self-protection against stress.
4.6 Assertive Attitude
Society shows an adaptive attitude to accept the
patient's condition, this is certainly a good system
support for patients, social support for patients with
LKD obtained from family members, friends,
relatives and health workers is an external source that
can provide assistance to patients in overcoming and
face the disease. The attitude of support and
acceptance of the patient's condition is one form of
positive support given by the community to the
patient, so that the patient feels cared for, valued,
respected, and recognized. Social support that comes
from the closest people such as spouses, family,
friends, nurses and doctors has a big role for
individuals in overcoming the disease.
Social support is not just in the form of giving
assistance or accepting and good relations, but what
is important is how the patient's perception of the
meaning of the help, attitudes and relationships.
Social relationships can help psychological
relationships, strengthen the practice of healthy living
and help recovery when patients can benefit from the
support obtained from the social environment. It is
expected that the patient can feel the tangible benefits
of this form of support for his recovery.
Research conducted by Teare (2010) which examined
the relationship between social support and self-
acceptance in people with diabetes mellitus showed
that social support had a positive correlation with
self-acceptance of patients with diabetes mellitus.
The higher the social support received by patients, the
higher their acceptance
4.7 Adaptive Coping
Based on the results of interviews, patients with
diabetic foot injuries have coping individuals who are
adaptive to their image, so that changes in the
function and shape of the patient's body do not
interfere with the self-image and activities of patients
in the community. This adaptive response includes
adaptive responses to current circumstances, work,
shortcomings, and changes in roles. The patient's self-
concept in the role is also recognized by the patient
that there is no change, both the role in the family and
in the community and workplace. From the patient
statement above, it can be concluded that individual
perceptions and coping on the patient's image and
body image are good.
Based on the results of this study, researchers argue
that adaptive individual perceptions and coping
depend on changes in body function caused by
diabetic ulcer wounds which make patients unable to
function as whole individuals such as walking,
working or doing homework. If the patient sees this
as a positive thing, then the patient has a positive body
image and self-image.
According to Chaplin (2010) states that body image
or body concenpt (the concept of the body or body
image) is a person's idea of his appearance in front of
other people. This statement is supported by Tao
(2011) who states that body image is the basic
foundation of the entire human personality. If you
have a positive way of thinking, you will be able to
accept changes in physical appearance experienced,
but if you think negatively, you will be less accepting
or rejecting his appearance so that it will affect your
self-concept.
4.8 Self Confidence
The impact of long diabetic ulcer wounds on the
continuity of the quality of life of individuals in
addition to requiring a considerable amount of money
and a short time, also affects the psychological
condition of the patient. In addition to psychological
management, this type of dressing is also one of the
things that supports rapid wound healing. The old
method of wound care, commonly known as the
conventional method, while at this time has been
developed wound care method by paying attention to
moisture balance or in other words is moisture.
The wound care method, better known as the moisture
balance principle, pays attention to the type of
dressing applied to the wound. Humid treatment of
wounds that are carried out routinely will accelerate
wound reduction and accelerate the process of
granulation tissue formation and reepithelialization,
moisture in the wound environment will accelerate
the wound healing process. Another benefit felt by
patients with this modern wound care method is
reducing pain during dressing changes and
facilitating the release of gauze that was applied to
previous treatments.
Based on the results of interviews with patients
related to the benefits of regular wound care, some
benefits were felt by the patient, namely the wound
was cleaner, drier, odorless, neat, and reduced pain.
These benefits increase the motivation of patients to
continue to carry out routine maintenance, because
patients feel the positive benefits of treatment
performed, another impact that can be felt by patients
is high self-confidence when socializing with the
condition of the wound neatly covered by the dressing
used.
4.9 Family Financial Management
The source of medical expenses comes from the
family and the patient's own income, this means the
family provides assistance for the patient's care
process. In addition, the costs of care and family daily
needs have also been well managed. This means the
family has an important role in providing motivation,
system support, and skills in managing finance. This
statement is supported by Schapers (2012) that
financial preparation which is the main concern of
patients with diabetes and ulcers is treatment planning
and family finances.
Participants revealed that the costs used for treatment
and treatment tend to be expensive. The source and
financial support of the family is needed in the current
conditions, because financial support that is less
consistent can influence motivation on care and
treatment in patients with DFS. This will result in a
longer treatment process, so that the maintenance
time and costs incurred will also be more (Upton,
2014).
Health insurance indirectly affects patients to perform
care management, financial limitations will limit
patients to seeking information, care and treatment
for themselves. Related to the support system in this
case, health insurance turns out that so far some of the
participants claimed to have used the health insurance
provided at their place of work, especially for
treatment and care, with these health insurance
patients claimed to be more helpful and reduce costs,
considering diabetic foot wounds are a disease which
is very dependent on routine treatment and care.
4.10 Validity and Reliability
Based on the results of the validity test on the family
support variable, it shows that every diabetic foot
wound patient who is treated at the Kitamura clinic
has a good and comprehensive quality of support
from the family, family members also strive to meet
the patient's information needs regarding disease
information needs, and the family becomes a safe and
comfortable way that is ready to support patients so
as to encourage motivation and confidence in patients
with diabetic foot injuries. This can be seen from the
form of support provided in the form of moral,
material, facilities (facilities and infrastructure) and
caring to patients.
The item statement on the environment support
variable shows that respondents who were treated at
the Kitamura clinic received environmental support
in the form of a positive attitude from the community
to support and accept the patient's condition, so that
the patient still had the desire to socialize in the
community, even though there were obstacles caused
by changes in function body after injury. These
obstacles do not become a barrier for patients, this is
indicated by feeling happy when socializing in the
community and the patient's adaptive response not to
cover up the state of injury that is being experienced.
The validity of the items on the self-concept variable
shows that the patient has an adaptive individual
coping, this is indicated by self-actualization that is
good at its role and function in the community and
workplace. There are several factors that help
increase the confidence of patients with diabetic foot
wounds, namely the benefits of routine care that is felt
immediately, such as the condition of the wound
becomes neater, does not smell, thus helping patients
be more productive and feel comfortable when
interacting with the community. Another factor is that
patients feel very useful because they can still work
and act in the community, these factors also play a
role in improving the patient's self-concept, so that the
patient does not withdraw because the body functions
change.
The results of testing the validity of items on
economic support, patients stated that the family
provided and helped regulate family finances for the
treatment of diabetic foot injuries. Patients also
respond that the cost of treatment that tends to be
expensive is due to the use of modern dressings, but
on the other hand patients respond positively to the
benefits of modern use of these dressings, namely
wounds that heal faster, less pain and a neater
appearance.
According to Friedman (2010) family support is
attitude, action and family acceptance of patients who
are sick. The family also functions as a support
system for its members and family members view that
the family is a supportive person, always ready to
provide help with assistance if needed. Firman (2012)
states that family support is verbal and non-verbal
communication, advice, help and behavior that can
provide emotional benefits or influence the behavior
of recipients.
5 CONCLUSIONS
Based on the results of this study, it was found that
patients with diabetic foot injuries had received
comprehensive support, both from family and
community circles. The form of attention given
comprehensively in the form of attention in the
emotional, financial, and instrumental aspects
(infrastructure), economic support provided by the
family and health insurance is also a source of
motivation for patients in carrying out the treatment
process. Given the current rapid use of technology, so
that the results of this study can be converted into
online-based instruments. Develop and add reference
items to the social aspects needed by patients with
diabetic foot injuries. and Need to do research on the
effectiveness test of the use of social aspects of the
assessment instrument for wound injury in diabetic
foot wound patients to measure the social support of
patients with diabetic foot injuries.
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