Use of Elevator to the circumference Leg edema, comfort and functionality in Diabetic Foot Ulcers (DFU)

Use of Elevator to the circumference Leg edema, comfort and functionality in Diabetic Foot Ulcers (DFU)

Mayusef Sukmana *, Sagiran **, Falasifah Ani Yuniarti **

* Students of Master program of Nursing in Muhammadiyah University

** Lecturer Master program of Nursing in St. Muhammadiyah University

South ringroad Street. Village Taman Tirta, Bantul City  Daerah Istimewa Yogyakarta Indonesia

Phone. 0274-387656

Email: 200801sukmana@gmail.com

ABSTRACT

Background: Edema of the DFU occur due to failure of venous return. The angle of elevation of the lower limb major effect on venous return. ERLESS (Edema Reduction Elevator Leg Stainless Steel) is designed as an elevator leg considering angle accuracy and comfort. The research objective to analyze the effect of lower extremity elevation angle of 30 ° using the circumference ERLESS edema, comfort and functionality on the client ERLESS DFUS. Methods: quasy experiment, the approach pre post test control group design, sample of respondents 28 clients and 28 nurses. Engineering samples using consecutive sampling. Respondents nurse put ERLESS at 30 ° elevation treatment group and the control group with a pillow for 30 minutes. After the elevation of all groups measured circumference edema. The treatment group ERLESS comfort clients fill out a questionnaire and nurses filled out questionnaires ERLESS function. Statistical test paired t-test, Independent sample t-test and One Sample t-test and multiple linear regression. Results: Circumference edema control group of 30 ° and the value of p = 0.001. Edema circumference difference of 30 ° with the control group p = 0.035. Leisure group ERLESS 30 ° p = 0.005, p = 0.001 ERLESS function. Conclusions: age, albumin, old wounds, history of diabetes affect the circumference decrease edema. Elevation of 30 ° using ERLESS more comfortable than the circumference of pillows and able to reduce edema. Researchers advised to do research at different angles.

Keywords: Elevation of the lower limb, edema circumference, Comfort, Function ERLESS, Diabetic Foot Ulcers.

 

PRELIMINARY

Diabetic foot ulcers (DFU) is one of the most serious complication of diabetes mellitus clients. The incidence of diabetes mellitus DFU client reach 4% and 10% with the future life expectancy of 25% (Armstrong & Lipsky, 2005). DM patients as much as 20% with complications DFU having trouble extension of infection, gangrene, amputation and death. The other problem is healing old wounds that will likely end up with an amputation, it will affect the quality of life and increased mortality (Yazdanpanah, Nasiri, & Adarvishi, 2015; Nabuurs-Franssen & Kruseman, 2005). An important factor of the problem is the length of wound healing (Yotsu, 2014). Healing old wounds resulting in the length of hospitalization. 

The duration of wound healing is affected by edema complicating factor. Edema of the feet found in clients over 50 years of age are caused by venous insufficiency. Venous insufficiency affects more than 30% of the population and 1% occur in heart failure (Ely, Osheroff, Chambliss, & Ebell, 2006). Cases of venous insufficiency there is lots of diabetes mellitus with complications DFU with clinical manifestations appear is the occurrence of edema. 

Edema resulting in a decline in the exchange of substances between the blood and cells. Interstitial fluid accumulation causes are wide gap between blood cells and to transmit nutrients, oxygen and waste materials so that the diffusion speed is reduced and the resulting cells in tissue edema have less blood supply (Sherwood, 2015). Poor blood supply can inhibit wound healing. Even edema were not addressed will potentially damage the skin tissue due to dilatation of intracellular and tissue edema pain and more susceptible to injury when compared to normal tissue (Kozier, 2011). 

Leg edema due to the failure of venous return when the leg under and dependent (Kawasaki, 2013). Edema in DFU can be reduced by changing the position of the elevation feet (Sims, 1986; Ho, Leigh, & Tsui, 2013). Changes in position when the foot dielevasikan aims will improve venous return and reduce pressure on the veins (FP Dix, 2005). According to Seeley, 2004 in (Wulandari, 2015) elevation of the lower extremities is useful to restore blood flow and reduce pressure at the distal extremities. Activities over 15 minutes with foot pointing down when walking or hanging leg could increase pressure to distal by 20%, thereby increasing the risk of peripheral edema. Peripheral edema distal area will increase pressure and reduces arterial perfusion due to compression. Lower extremity elevation can reduce the pressure, and the expected effect is the increase in the wound healing process DFU (Wulandari, 2015). Intervention edema in the context of wound healing with elevation recommended also by The Australian Wound Management Association for the elevation will improve microcirculation and decrease edema in the legs (National Pressure Ulcer Advisory Panel, 2014). 

Wound care hospitals performed Abdul Wahab Sjahranie and hospitals IAMoeis using pillows to reduce edema have limitations in accuracy desired elevation angle, so the results are not optimal. Angle accuracy is affected by the difference between the angle of the extremities to the heart. When the legs to the heart at an angle of 90 ^°. This angle gives the power of 100% gravity, at an angle of 45 ^° provides 71% power of gravity and the leg horizontal position (angle of 0 ^°) the strength of the gravitational force is 0% (Starkey, 2004). The influence of the angle of elevation of the venous return very big role, it is necessary to use leg braces instrument capable of accurately set the elevation angles. Accurate elevation angle restore effective venous return so as to decrease the edema in DFU clients. In a previous study that recommended the elevation angle is 30 °, 45 °, 60 ° and 90 ° (MY Liaw, 1989). 

ERLESS (Edema Reduction Stainless Steel Leg Elevator) is one leg braces designed by researchers in order to leg edema can dielevasikan with accurate angle setting affects the peripheral venous pressure flow to the heart. The design is to consider the convenience factor and security for clients using and nurses who put it up. Kolcaba Comfort as one of the nursing theory concepts developed the theory of comfort that includes physical comfort, psychospiritual and comfortable environment. Interventions designed to help clients maintain or restore physical function and comfort, prevent complications, restoring comfort due to pain (Alligood, 2014). In a previous study felt most comfortable angle is 30 ° position for 30 minutes. This angle gives a pressure drop (off-loading) on the wound (MY Liaw, 1989). 

ERLESS also has safety criteria currently used. The design of the tools used must consider the risk of injury to the client (Yoga, 2013). ERLESS materials are directly in contact with the client leg skin made of soft material so that the pressure interface can be minimized.The decrease edema can be evaluated through several methods include: measuring depth and recovery pitting edema, measuring 8 places on foot, using water displacement measurements, measurements with modified edema tester, assessment questionnaires and circumference measurements. The results of the reviews indicate measurements circumference at the ankle and the water displacement method is the most accurate measurement (Brodovicz et al., 2009; Kogo, Higashi, and Murata, 2015; Legare, Gammal, Hall, & Horwitz, 2007) Other studies also recommend measurement ankle circumference as a method of evaluation of edema (Mora, 2002). This circumference measurement is the most practical method, easy, fast and accurate (Simon, 2014). 

The research objective of this study to analyze the effect of lower limb elevation at an angle of 30 ° using the circumference ERLESS edema, comfort and functionality on the client ERLESS DFU. Specific Objectives of this study are as follows:

a.    Identify the characteristics of the treatment group, the control, comfort and functionality ERLESS.

b.     Analyze differences in circumference measurements before and after the group elevation angle of 30 ° and a control group.

c.    Analyzing the effect of elevation differences in the group with an angle of 30 ° and a control group against edema circumference measurement.

d.      Analyzing the effect of using ERLESS against DFU client convenience.

e.       Analyzing ERLESS function. 

Diabetic Foot Ulcers (DFU) is an open wound in the skin layer to the dermis, which usually occurs in the feet because of macrovascular and microvascular dysfunction and damage tissue perfusion in diabetes mellitus. DFU can be divided into: neuropathic ulcers, ischemic ulcers and ulcer neuroischaemic (Paul et al., 2013). Edema is swelling caused by the increased volume of fluid in the interstitial cavity (Ely et al., 2006). According to Starkey (2004) edema is excess fluid in the interstitial space due to an imbalance of pressure outside and inside the cell membrane or due to blockage of lymph channels and failure mechanisms of venous return. 

Nursing assessment on clients with diabetic foot include the assessment of lower limb movement, moisture, color, temperature, edema, pain and sensation in the feet (Aalaa, Malazy, Sanjari, & Peimani, 2012). DM neuropathy in time will result in arteriovenous shunting, resulting in dilation of the veins and venous distension generates feet and has a tendency to swell (Rebolledo, Soto, Escobedo, and Peña, 2011). 

Management of edema in the form of elevation using gravity to increase the venous and lymphatic flow from the legs. The hydrostatic pressure occurs because gravity is blood in the blood vessels. Peripheral venous and arterial pressure is influenced by gravity. Higher blood vessels from the heart of gravity will increase and decrease the pressure, thereby reducing peripheral edema (Villeco & Otr, 2012).

The effectiveness of the force of gravity returns blood to the heart are influenced by several factors as follows:

a.       Angle extremity to the surface (Starkey, 2004).

b.      Venous Diameter (Irawati, 2010). Age effect on vein diameter, the more we age, the structure of blood vessels undergo changes menebalny a narrowing of the blood vessel wall lumen diameter, changes in endothelial function and stiffness (Byung & Young, 2010).

c.       Normally liquid viscosity is constant, but after the injury, increased blood viscosity due to loss of plasma coming into the surrounding tissue, and dissolved composition to be larger than the solvent (Starkey, 2004) .Viskositas influenced by the speed of blood flow, when the blood flow is slow then the viscosity be high (Irawati, 2010). 

ERLESS is a tool used foot buffer on the client having trouble nursing excess fluid volume (Herdman & Kamitsuru, 2014). The purpose of this tool is to increase the use of reverse flow leg vein into the right atrium to be more effective with angle settings that cause the effects of gravity and increase the comfort of the client through the reduction of pressure on the wound. Therapeutic off -loading reduce pressure on DFU area thus reducing pain. ERLESS have some security indicators as follows: Safe from germ transmission medium. Do not disturb the mobility of the joint motion sedentary patients. No cause new sores. Do not disturb the wound healing. Tools designed to avoid injury. Tool easily in disassembly, carry and disinfected. Tool safe from the possibility of pressure ulcers. According to (Simon, 2014) Elevation 30 ° provided on foot will make the distribution of pressure on the body be moved, the pressure on the heel decreases the load. (Supriya et al., 2014). According to the National Pressure Ulcer Adisory Panel, the European Pressure Ulcers Advisory Panel and the Pan Pacific Pressure Injury aliances (2014) elevation of the heel can prevent the risk of pressure ulcers on the heel because the pressure will be distributed. Interface pressure that occurs during the elevation of the sacrum is measured using indicators Q. Palm ERLESS appliance is safe to use if the interface pressure less than 50 mmHg (Supriya et al., 2014). 

On the client DFU pain is a significant threat to the comfort of the client. The cause of pain in DFU pressure is the pressure that occurs in the wound (Wulandari, 2015). Nursing interventions have the goal of increasing a sense of comfort. Intervention comfort has three categories: standard comfort interventions for improving recovery of physical function, including hemodynamic physiologic body (Aligood, 2014). Physical recovery by stabilizing the hemodynamic done by elevation to increase cardiac output (Monnet, Richard, & Teboul, 2015).

RESEARCH METHODS

This research is a quasi experiment with pretest-posttest control design. Comparing the effect of lower extremity elevation using the circumference ERLESS DFU edema in the treatment group (using ERLESS angle of 30 °) and control (pillow). Population taken in the room Flamboyan Hospital A. Wahab Sjahranie Samarinda and the Karang Asam Hospital Lounge IA Moeis Samarinda. Sampling (sampling) of the respondents client and nurse respondents in this study with consecutive sampling method for 8 weeks with a total sample of 28 respondents 28 respondents clients and nurses. The samples were included in the group of respondents clients elevation of 30 ° and control is done by simple random sampling. The samples were nurses in the group of respondents installation elevation angle of 30 ° or pillows also use simple random sampling. Members of the population comes from clients who meet the inclusion criteria are given the choice of therapy using the elevation extremity edema below 30 ° or using a pillow. 

The inclusion criteria respondents client is determined as follows: Willing to become a respondent, can read and write, clients diabetes mellitus with edema and wound gangrene, Grade 1 to 5 using a scale WAGNER, DFU types of neuropathic ulcers, clients with edema lower extremity, inspection depth and recovery edema with a value of 2 to 4. exclusion criteria included: the client is experiencing lower limb amputations, diabetes mellitus with complications of heart failure and abnormal renal function. Clients DFU types of ischemic ulcers (arterial ulcers) and neuroischaemic. The inclusion criteria respondents nurses willing to become respondents, Nursing D3 minimal education, work period of more than two months. Exclusion criteria: 1 month new work, education SPK. 

The instrument used to perform elevation is by ERLESS. To measure the convenience of use ERLESS questionnaire ERLESS comfort. To measure Function Function Questionnaire ERLESS is ERLESS. Both questionnaires are designed researchers who have been tested for validity and reliability. The results of the questionnaire Cronbach alpha test ERLESS comfort with value α 0730 and Function questionnaire ERLESS value α 0643. 

Treatment and control groups who have met the inclusion criteria before the examination provided informed concent, clients who choose elevation with a pillow included in the control group, clients who choose elevation of 30 ° in the group of 30 °. Respondents were nurses who had given informed concent given the option of doing elevation angle of 30 ° or pillows. After the nurses were given an explanation and practice ERLESS installation procedure room. After fulfilling the ability to install ERLESS, along with the nurse respondents researchers ERLESS installation on the client. 

Respondents clients who have provided informed concent do pre-test measurement of edema. Respondents who chose the elevation of 30 ° was installed ERLESS by nurse respondents who chose 30 ° and in the group I (a) treatment of the elevation angle of 30 °. Respondents who chose elevation with a pillow included in the control group was given elevation using a pillow. Prior to treatment with the installation process is assigned ERLESS or pillow, do ABI measurement, assessment of injury and edema, and the wound was treated first. In the treatment group, for the treatment of wounds progresses, the nurse did respondents foot elevation. After completion of wound care measured the circumference of ankle edema in the same spot. Then the angle of elevation is done in accordance with the treatment groups for 30 minutes. In the control group, respondents do wound assessment, wound care measurement such as edema and standards applicable in the room, after 30 minutes then do ankle circumference measurements at the same location. During the install ERLESS nurse nurse observation ERLESS security installation with a guide ERLESS Security Observation check list. During the 30-minute elevation will review client complaints of possible discomfort, leg cramps, cold, cyanosis of the legs, the small and weak pulse. Monitoring the pulse rate and oxygen saturation using pulse oxymetri mounted on toes. After completing the treatment and circumference measurement data obtained edema, respondents clients in both treatment groups were given a questionnaire containing about comfort ERLESS containing variable comfort. Respondents nurse who installed ERLESS also given questionnaires ERLESS function. 

Processing and data analysis method in this research is the analysis of univariate each of the variables include: respondents clients include age, sex, occupation, education, long suffering from diabetes and long-suffering DFU, the value of GDS, the value of albumin, a scale of Wagner and convenience of use tool ERLESS. ERLESS function of frequency distribution data. Test data normality using Shapiro - Wilk, edema circumference statistical tests before and after using a paired t-test and two different test groups circumference difference edema using independent sample t-test. Statistical test ERLESS comfort and functionality using one-sample t-test. Linear regression test was conducted to see research confounding variables that most influence on the dependent variable circumference edema.

This research has been worth the ethics test number 093 / EP-FKIK-UMY / III / 2016 of the Research Ethics Committee of the Faculty of Medicine and Health Sciences, University of Muhammadiyah Yogyakarta. This study was approved by the Hospital Director AWS Samarinda letter number 070 547 / Dikl-Quality / II / 2016 and Director of Hospital IA Moeis Samarinda number 070/350 / RSUD.IAM / 2016.

 

RESULTS

1. The frequency distribution characteristics of respondents clients by age, As Blood Sugar, albumin, long suffering from diabetes, old wounds and Wagner scale.

Table the frequency distribution characteristics of respondents

variable	30		Pillow
	mean ± SD	min-mak	mean ± SD	min-mak
Age	50.42 ± 6:41	39-61	57.5 ± 9:21	37-74
GDS	191.36 ± 63.61	70-312	163.5 ± 28.63	110-208
Alb	3:05 ± 0:34	2.3 -3.6	3:07 ± 0:28	2.60-3.70
old DM	4:28 ± 2.84	1-10	7:14 ± 6:58	2-4
old wounds	1:07 ± 0.67	0.5-3	1.92 ± 1:38	0.5-5
Wagner	3:14 ± 0:53	2-4	2:29 ± 0:46	2-3

Source: Primary Data 2016

2. Frequency distribution client using ERLESS to comforting

Data frequency distribution characteristics of respondents clients using ERLESS will be presented in tabular form as shown below:

Table results The frequency distribution of the use of comfort ERLESS elevation              angle of 30 ° n = 14

No.	Statement	SS		S		TS		STS		Σ	%
		n	%	n	%	n	%	n	%
1.	The client's perception, a strong supporting tool.	7	50	7	50	0	0	0	0	14	100
2.	Perception client tool is easy to use nurse.	3	21.4	11	78.6	0	0	0	0	14	100
3.	Clients are comfortable and not worried about falling.	4	28.6	10	71.4	0	0	0	0	14	100
4.	Pain is felt in the wound increases.	1	7.1	2	14.3	8	57.1	3	21.4	14	100
5.	Thighs, legs and the injured area more comfortable.	3	21.4	10	71.4	1	7.1	0	0	14	100
6.	Worried fall.	1	7.1	0	0	11	78.6	2	14.3	14	100
7.	Practical tool.	5	35.7	9	64.3	0	0	0	0	14	100
8.	Fatigue in the limbs.	0	0	0	0	10	71.4	4	28.6	14	100

Sources: Primary data 2016

3. The frequency distribution of the votes Function ERLESS

The frequency distribution table function ERLESS n = 14

No.	Statement	SS		S		TS		STS		Σ	%
		n	%	n	%	n	%	n	%
1.	Assist the work of nurses, reduce edema	12	42.9	16	57.1	0	0	0	0	28	100
2.	During the foot propped nurse noticed clients feel comfortable.	7	25	21	75	0	0	0	0	28	100
3.	Tool helps to keep the foot can dielevasikan 30 °	4	14.3	24	85.7	0	0	0	0	28	100
4.	Assessment tools can decrease edema nurse.	10	35.7	18	64.3	0	0	0	0	28	100
5.	Practical tool to use.	10	35.7	18	64.3	0	0	0	0	28	100
6.	Affordable tool procurement.	2	7.1	21	75	5	17.9	0	0	28	100

Sources: Primary data 2016

4. circumference measurements edema before and after elevation of 30 ° and elevation control group.

Table analysis circumference difference before and after elevation

variable		n	Mean ± SD	Differences Mean ± SD	CI 95%	P
				circumference
30 °	Before	14	26 314 ± 3563	1192 ± 0708	1602-0783	0001
	After	14	25 121 ± 3660
control	Before	14	23 971 ± 2234	0664 ± 0270	0820-0508	0001
	After	14	23 307 ± 2235

Sources: Primary data 2016

5. 30 ° elevation difference of influence and control over the circumference measurement of edema.

Table Analysis of differences influence of elevation of 30 °

and control of the circumference edema

variable dependent	elevation		Difference mean	CI 95%	p
circumference edema	30 °		0528	1017 - (- 0040)	0035
	Control		-0528	-0400 - (- 1:01)

 Sources: Primary data 2016    

6.  ERLESS use your influence on client convenience.

Table Analysis client convenience using ERLESS

the angle of elevation	Test Value = 24
	t	df	the mean difference	CI 95%	p
30 °	3,371	13	1.64286	2695 -0590	0 .005

Sources: Primary data 2016 

On the use ERLESS an angle of 30 ° p value = 0.005, this shows that the installation ERLESS at an angle of 30 ° effect on comfort. Qualitative comparison between elevation pillow and ERLESS, clients say more happy and comfortable using ERLESS compared with pillows. At the time of ERLESS used, the client says that the legs as a whole can be supported without any parts hanging and without fear there is a shift to the left or right foot while using a pillow that are hanging on the knee so that clients feel less comfortable.

7. ERLESS function.

Table Analysis of the respondents' assessment of the function ERLESS nurse.

the angle of elevation	Test Value = 18
	t	df	the mean difference	CI 95%	p
30 °	3915	27	1,321	2013-0629	0001

Sources: Primary data 2016

DISCUSSION

This study aimed to analyze the effect of lower extremity elevation to the circumference decrease edema, comfort and functionality ERLESS.

1. Characteristics of Respondents

The average age of the control group and the treatment in this study was relatively similar, at 53 years old. Edema of the feet found in clients over 50 years of age are caused by venous insufficiency while there are many cases of venous insufficiency in clients with diabetes mellitus who developed complications DFU the clinical manifestations appear is edema (Ely et al., 2006). Average Blood Sugar When (GDS) of each group is 173 mg / dl. GDS high causing endothelial damage and blood vessel walls in the form of a thickening of the basement membrane, thereby causing impaired capillary physiology release of protein and platelets resulting in decreased tissue oncotic pressure and the occurrence of local edema (Hidayat, 2000).

Albumin in both treatment groups was relatively similar to the average 3:05. Albumin is a major protein that affects the colloid osmotic pressure of plasma maintaining excessive spending insterstitial capillaries into space so that it can control the volume of plasma (Sherwood, 2015). History of diabetes in the group of 30 ° elevation with an average value of 4.2 years, whereas in the control group with an average value of 7:14 years. History of diabetes over 5 years will lead to microangiopathy. On the change of conditions mikroangiopati endothelial basement membrane becomes thickened, not elastic and easy to leak plasma protein (Hidayat, 2000). Thickening of the basement membrane will increase capillary hydrostatic pressure (Veves, Giurini, & Logerfo, 2006).

Old wounds there are differences in the three groups. The average length of the wound in groups of 30 ° is 1:07 months and 1.92 months in the control group. Old wounds are closely related to the inflammatory process. In inflammatory inflammatory mediators such as histamine, prostaglandins, bradykinin is released and causes increased capillary permeability and capillary hydrostatic pressure increases, it will increase the accumulation of fluid in the interstitial (Jeyakhanthan, 2006). Wagner scale group obtained 30 ° has the highest scale is 3.14. Wagner scale shows the breadth and depth layers of the wound. Inflammatory mediators during the injury occurred will cause an increase in capillary walls which allows more plasma proteins out of the capillaries into insterstisium fluid through the capillary pores dilation triggered by histamine in tissue injury (Sherwood, 2015; Starkey, 2004).

2. Differences in circumference measurements before and after the group elevation angle of 30 ° and a control group.

The results showed groups of 30 ° greater losses than the control group. Previous research also showed differences decrease edema at an angle of 30 °, 45 °, 60 ° and 90 ° (MY Liaw, 1989). Circumference edema is closely related to the skin covering the circumference of the ankle. The skin can swell if there is an accumulation of fluid in the interstitial space (Sherwood, 2015). The effect of gravity when the elevation of 30 minutes will reduce peripheral venous pressure, interstitial fluid into the veins and into venous circulation. The pace of decline is strongly influenced by the elevation angle greater the elevation angle, the greater the pressure exerted on the flow of blood from a peripheral vein to the heart (MY Liaw, 1989; Wulandari, 2015; Starkey, 2004; Sherwood, 2015). Elevation angle of 30 ° provides a higher pressure than the elevation using a pillow. Another factor is the ability to support the foot ERLESS more stable than the pillow.

3. The different effect on the elevation angle of 30 ° group and the control group c ircumference edema.

On the influence of different test results there are differences in the effect. The average value of albumin, a group of 30 ° is 3:05 mg / dL in the control group 3:07 mg / dL. On multivariate testing against confounding variables, that the value of albumin in this study effect of 32% to the decrease edema circumference measurement. Albumin is a plasma protein that forms the osmotic gradient between the blood and interstitial fluid. The existence of albumin can inhibit overproduction of plasma from the capillaries into the liquid insterstisium enabling it to maintain plasma volume (Sherwood, 2015).

Differences between groups of 30 ° with the control group except albumin factors caused by differences in elevation angle. Angle of 90 ° provides the gravitational force of 100%, while at an angle of 30 ° gives the force of gravity 71%. If at a 90 ° angle effect will put pressure on the venous blood flow by 90 ° bottom mmHg, then by 30 ° elevation will put pressure toward the heart by 90 mm Hg x 71% = 63.9 mmHg (Starkey, 2004).

During the procedure of elevation, the client in a state lie back and relax, as a result of relaxed breathing becomes irregular activity. According to Sherwood (2015) due to respiratory activity of pressure in the chest cavity average of 5 mmHg below atmospheric pressure. This pressure difference squeeze blood from veins in the lower part toward the chest veins, thereby increasing venous return. Conditions were comfortable reclining clients during the procedure of elevation, may account for the increased venous return. Resting conditions make the heart's normal rate is in the range of 60-100 beats / min. Normal heart pumps provide the charging effects and effective cardiac output. The right atrial pressure under normal conditions is below zero or below atmospheric pressure. In situations like this the heart has the ability to suck the blood that will go into the right atrium and venous return becomes faster (Hall, 2014). Elevation maximize venous drainage and lowers capillary pressure and postural changes dielevasikan legs will increase venous flow inside and reduce pressure on the veins (FP Dix, 2005).

4. ERLESS use your influence on client convenience DFU

In the test user comfort ERLESS elevation angle of 30 ° p value was 0.005. Previous research has for the comfort of the most recommended angle is 30 °, and performed for 30 minutes (Liaw, 1989; Collins & Seraj, 2010) Convenience is a condition basic needs will be calm. According Kolcaba improve the comfort of clients defined if nurses provide strength, support and assistance of entertainment expectations (Alligood, 2014). Clients expressed convenient if the nurse is able to free from pain, and avoid injury. The risk of injury is prevented by design powerful and robust tool equipped with a fastener on any part of either foot lower leg, knee and thigh. Pain is also a significant threat to the comfort of the client. The cause of pain in DFU according Wulandari (2015) is the pressure that occurs in the wound. Therapy elevation causes the pressure on the wound will be reduced, the pressure drop will reduce the sensation of pain to the client. ERLESS expensive material comfort soft leather is able to reduce the pressure interface with the results of stress tests interface average 31.88 mmHg.

5. ERLESS function.

In ERLESS function measurements obtained significant results. It is influenced by several factors one of which conducted trials ERLESS before installation on the client. The trials comfort tools to demonstrate the value of reliability Cronbach alpha of 0.730. The trial shows the value of reliability function ERLESS 0643. Both questionnaires have high reliability. The test results showed a 100% security tools do not cause injury, did not cause a new wound, do not add injury, appropriate size of the foot, and was able to arrange a 30 ° angle test result of pressure ulcer secure tool against the risk of pressure ulcers by pressure interface average of 31.88 mmHg. Another factor is a design created to consider the strength, comfortable material and practical tools to be used. 

CONCLUSION

Based on the research results can be concluded:

1. Respondent characteristics such as age, albumin, old wounds and history of diabetes affect the circumference edema.
2. There are significant differences measurements of circumference edema before and after elevation using the elevation group ERLESS at 30 ° and the control group. The treatment group had an average reduction in circumference edema greater than the control group.
3. There is significant influence ERLESS and elevation using a pillow against the circumference edema . Group 30 ° more effectively decrease the circumference edema when compared to controls .
4. There is the influence of elevation using E RLESS to client comfort at an angle of elevation of 30 ° . Elevation angle of 30 ° is felt more comfortable for clients compared with a pillow
5. Elevation of 30 ° using ERLESS significantly influence ERLESS function.

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