Keywords: contaminated wounds, water extract of kelakai (Stenochlaena palustris), erythema

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1 THE EFFECT OF CONTAMINATED WOUND CARE WITH WATER EXTRACT OF KELAKAI (STENOCHLAENA PALUSTRIS) IN ACCELERATING THE REDUCTION OF ERYTHEMA ON WHITE RAT (RATTUS NORVEGICUS) 1 Novi Mustahdiati Nasri, 2 Eko Suhartono, 3 Rismia Agustina 1 Program Studi Magister Keperawatan Fakultas Kedokteran Universitas Brawijaya, Banjarbaru, Kalimantan Selatan 2 Departement of Biokimia at Medical Faculty, Lambung Mangkurat University 3 Departement of Medical-Surgical of Nursing at Medical Faculty, Lambung Mangkurat University ABSTRACT Contaminated wounds has inflammation that occurs as a natural response to tissue damage, characterized by erythema that can be reduced using water extract of kelakai as anti-inflammatory. This research was made to make an evidence about that. This study was a true experimental research, used post test only control group design with simple random sampling. The samples were 36 white rats that were divided into 2 groups. Erythema was assessed using Corel Photo-Paint programme. The decline intensity of erythema in the treated group occurred within 4 days 6 hours 43 minutes. The data were analyzed using the Independent Sample T Test, and the result of p-value = 0.00 (p-value <0.05). It means that the average of erythema reduction in the treated group was faster than the control group. Thus, the water extract of kelakai (Stenochlaena palustris) can accelerate the reduction of erythema on white rat with contaminated wound. Keywords: contaminated wounds, water extract of kelakai (Stenochlaena palustris), erythema I. Introduction In Indonesia, the incidence of contaminated wounds caused by accidents of transport, occupational accidents, or natural disasters is recorded at 6 cases per minute, 408 cases per hour, cases per week, cases per month, and cases per year (1). In 2005, the Ministry of Manpower and Transmigration revealed a fact that as many as workers died at work, workers were disabled, and others were injured (2). Meanwhile, based on preliminary study in South Kalimantan province especially Banjarmasin city, January to August 2011 recorded 430 incidents of traffic accidents with 308 deaths, 183 serious injuries and 249 injured. With the high incidence of cases, then the possibility of contaminated wounds is also higher. Contamined wounds are a type of wound left untreated and thus susceptible to infection (3). Types of contaminated wounds include open wounds, accidental injuries, surgery with major damage, acute incision, and nonpurulent inflammation (4, 5). Contaminated wounds are often characterized by inflammation, including erythema or redness (rubor), heat (calor), pain (dolor), swelling (tumor), and loss of function (functiolesa) (6).

2 Erythema is a very easy sign to measure and the result of measurement is objective. The period of erythema will affect the length of the inflammatory phase. When the signs of inflammation decrease, the wound healing process will be faster (5). Contaminated lesions are susceptible to infections with a probable infected rate of 10-17% (5). Therefore, the nurse as a care giver should have an adequate wound care skills to prevent the occurrence of infection. In principle, contaminated wound care management focuses on infection control (7), since infection can inhibit wound healing, resulting in increased morbidity and mortality (8). In addition, if the wound has an infection, then the treatment will be longer. During this time, people are accustomed to using povidone iodine in the process of wound care. Whereas povidone iodine is irritant, allergenic, and leaving residue (9), can cause burning (10), and is toxic to cells (11). To overcome this, people use the existing plants around as an alternative medicine. In addition to the cheap price, the plants are easily obtained. One of the plants that can be used as an ingredient in wound care is kelakai (Stenochlaena palustris). Research Maharani et al (2006) and Suhartono (2010) states that kelakai are antiinflammatory, antioxidant, antimicrobial, and can stimulate the immune system (12, 13). However, previous studies have not revealed anti-inflammatory properties through decreased erythema. Therefore, it is necessary to examine the effects of treatment of contaminated wounds with aqueous water extract in accelerating the decrease in erythema in white rats (Rattus norvegicus). II. Method This research was an experimental research used post test only control group design with simple random sampling technique conducted in Chemical Laboratory of Faculty of Medicine, Lambung Mangkurat University. A. Instrument This study used 36 white rats (Rattus norvegicus) which was divided into 2 groups with 18 white rats in each group. The first group (P0) was a group of rats with contaminated wounds without treatment, and the second group (P1) was a group of rats with contaminated wounds treated with a 0.02 mg/gbb water extract of kelakai. The steps of this research was making of water extract of kelakai, wound incision making, and wound care. Making of water extract of kelakai Water extract of kelakai made by maseration technique. The kelakai was dried first in the sun with a black cloth cover. Once dried, the kelakai was pounded and sifted to obtain a fine powder. Further weighed weighing 70 grams to a constant with analytic balance. The weighed pitcher of debris was inserted into the erlenmeyer flask and soaked with ml of aquades until the entire powder was submerged. Immersion was done for three days. The solvent was filtered with filter paper until a clear filtrate obtained. Smooth with waterbath until thick. The weight of water extract of kelakai was 8 grams, then stored in a dark glass jar and sealed with aluminum foil. Made an incision wound Before the incision wound made, the hands are washed and fitted with gloves. Then mounted base under the body of white rats (Rattus norvegicus).

3 Anesthesia was performed by inhalation of ether on white rats. Then the rats mouse hair was shaved along 3-5 cm in the incised area (the location of the wound on the back). Afterwards, an inhalation anesthetic with ether returns, and disinfection of the skin area of rats to be incised with alcohol. The incision was performed by using a scalpel, the length of the wound was about 2.5 cm with depth until the subcutaneous area. The resulting wound was exposed to the contaminant sand and was silenced for eight hours. After that, the wound was cleaned using 0.9% NaCl. Cover the wound using a moist and wrapped gauze. In group I, the incision was bandaged but not treated. In group II, the wound was given 0.02 mg/gbb of water extract of kelakai and then bandaged Wound care procedures Wound care was done once a day every afternoon at WITA. In the first group, the wound cleansed using 0.9% NaCl. Then bandaged using a moist bandage technique. In the second group, the wound smeared using 0.02 mg/gbb of water extract of kalakai, then bandaged. B. Data Collection Wound care was evaluated until signs of erythema decrease within eight days by controlling the wound. If there are signs of inflammation and the sign was reduced from day to day, then immediately made the record. The research data was made by photographing the wounded object using a digital camera. The photos are processed to determine the intensity of erythema color in the area near the wound and the area near normal skin in each group. The application of the Corel Photopaint Suite Graphic 12 Program used for data processing. C. Data Analysis The results obtained in the form of data the mean number of color intensity. Normality of the data checked by using Shapiro-wilk test. Then the data was analysed by using Independent Sample T Test (α = 0,05). III. Results The effectiveness of kelakai as antiinflammatory can be proven in the study by looking directly at changes in signs of inflammation that occur around the wound. Figure 1 can explain the decrease of erythema in contaminated wounds. This decrease in erythema can be accelerated by the presence of antiinflammatory agents in water extract of kelakai.

4 Figure 1 Mean of Decreased Erythema in Rats with Contaminated Wounds Figure 1 shows that there was a decrease in erythema in both groups of rats with contaminated wounds. However, the group of rats who suffered contaminated wounds and performed treatment using a damp swab technique with water extract of kelakai experienced a decrease in erythema earlier than the control group. The average value of the first day reddish color in the control group was Then experience peak erythema on day 3 with an average value of reddish color of The decrease of erythema reaches the reddish level of the first day of this group occurs within 7 days 19 hours 12 minutes. Meanwhile, the mean value of reddish color on the first day of the treatment group was and reached the peak of erythema on day 3 with an average reddish value of The decrease in the mean value of reddish color reaches the redness level on the first day occurring within 4 days 6 hours 43 minutes. Overall, the group of mice that had contaminated wounds and treated using a moist dressing technique with water extract of kelakai had an average reddish-color intensity of erythema lower than the control group. This can be seen in Figure 2. Figure 2. Average of Intensity of Reddish Color on Contaminated Wound

5 IV. Discussion Result of normality and homogeneity of data of decrease of erythema by using Shapiro wilk and Levene's Test test showed that the data were normal distribution and homogeneous (p> 0,05). Furthermore, the Independent Sampe T Test was done on the data of the decrease speed of erythema and resulted the value p = 0,00 (<0,05). Thus, it was an evident that there was a treatment effect of water extract of kelakai (Stenochlaena palustris) in accelerating the reduction of erythema in rats (Rattus norvegicus). The decrease of erythema in the treatment group was faster compared to the control group. This was because the moist dressing given to rats in the control group was only moisturizing, not functioning as anti-inflammatory. As a result, the inflammatory phase in the control group will only gradually disappear naturally. The group given the extract water of the kelakai decreased the intensity of reddish color from erythema more quickly. This was because the water extract of kelakai contains bioactive substances such as flavonoids as much as 3.010% in 100 grams of stems and 1.750% in 100 grams of leaves, alkaloids as much as 3.817% in 100 grams of stems and 1.085% in 100 grams of leaves, steroids as much as 2.583% in 100 grams of stems and 1.650% in 100 grams of leaves, as well as vitamin C as much as 264 mg in 100 ml of stem and 219,7 mg in 100 ml of leaves (13). In addition to being antipyretic, alkaloids and steroids have antiinflammatory effects. Vitamin C bioactive substances work synergistically with eating, among others, by binding metal ions, hydroxine radicals, and singlet oxygen (14). Flavonoids exhibit anti-inflammatory activity that has major effects on human health. On leaves of kelakai, the flavonoid content of 14.5 mg/ml QE (15, 16). The mekanism of flavonoids to inhibit the inflammation process in two ways, namely by inhibiting capillary permeability and inhibit the metabolism of arachidonic acid and also secretion lysosomes enzyme from neutrophils cells and endothelial cells. Flavonoids play an important role in maintaining the permeability and increase the resistance of capillary blood vessels. The occurrence of capillary vessel damage due to inflammation leads to increased capillary permeability, so that blood (especially blood plasma) will come out of the capillary tissue, followed by an inflammatory response. Flavonoids primarily work on microvascular endothelium to reduce the occurrence of hypermeal and inflammation (17). Flavonoids also work by binding the superoxide radicals involved in the formation of prostaglandins. This binding can be shown by decreased activity of superoxide dismutase enzyme. In addition, the flavonoid is also expected to reduce levels of peroxidase, which is the active side of PGHS another cyclooxygenase enzyme, which is responsible for the production of prostaglandins (18). In addition to flavonoids, water extract of kelakai also contains other active substances, steroids. Steroid action is by suppressing excessive proinflamation processes by inhibiting phospholipase enzyme activity so can prevent the formation of prostaglandins (19). In addition, steroids also inhibit the metabolism of arachidonic acid, reduces microvascular leakage, preventing the direct migration of cells pyretic, and inhibit the production of cytokines (12). This explains why the water extract of kelakai can accelerate the end of the inflammatory process. Steroids do not allow the formation 103

6 of different types of prostaglandins. As a result, prostaglandins that act as triggers of pathophysiologic response in the body are no longer produced and symptoms of inflammation may soon disappear. The formation of steroids is inseparable from the role of vitamin C in its metabolic processes. Steroids are arranged on elements of lipids and by vitamin C will occur so that the hydroxylation reaction will form the synthesis of steroid (13).Vitamin C also inhibits the activation of nuclear factor B (NF-B) which is the maker of inflammatory gene expression (20). As an antioxidant, the role of vitamin C in preventing the incidence of inflammation is by giving acidic (H + ) groups to bind to superoxide radicals (2O 2 ). As a result, superoxide radicals can not bind to arachidonic acid to form prostaglandins (18). Another active substance that is owned by the water extract of kelakai is alkaloids. The alkaloid is a member of the body of a complex and has a basic structure. The nitrogen atoms present in the structure are part of the heterocyclic system and may cause pharmacological activity (13). Alakaloid works as anti-inflammatory by inhibiting the formation of prostaglandin which is the most influential inflammatory mediator in the process of inflammation (19). As part of the team who responsible for wound care, nurses have several roles including care giver, advocate, counselor, case manager, and health educator. As a care giver or case manager, nurses must be able to decide appropriate wound care actions for clients. Meanwhile, as a health educator the nurse should also be able to provide appropriate information on wound care, as well as teach the correct way in wound care management so that clients can do wound care independently. V. Conclusion Based on the results of research that has been done, it can be concluded that there are effects of treatment of contaminated wounds with water extract of kelakai (Stenochlaena palustris) in accelerating decrease in erythema in white rats (Rattus norvegicus). And then, the community will know the efficacy kelakai as antiinflamasi so that will make efforts cultivation kelakai plants to be a source of alternative choice in the act of wound care. References 1. Yulian WU, Anis M, Sumarno. (2009) Efek perawatan luka terkontaminasi dengan ekstrak bawang putih lanang dalam mempercepat penurunan eritema. Jurnal Kedokteran Yarsi; 17 : Endroyo B. (2006). Peranan manajemen K3 dalam pencegahan kecelakaan kerja kontruksi. Jurnal Teknik Sipil; 3 : Maureen B. (2006). Healing and wound classification. Journal of Community Nursing; 31 : Richard S. (2005). When is a wound really healed? Advances in skin & wound care. The Journal for Prevention and Healing; 18 : Kozier B. (2000). Fundamental of nursing, conceps, process, and practice. 4 th edition. Addison Wesley: Publishing Company Inc. 6. Mansjoer A, dkk. (2000). Kapita selekta kedokteran edisi III. Jakarta : Media Aesculapius FKUI. 7. Himatusujanah, Faizah BR. (2008). Hubungan tingkat kepatuhan protap perawatan luka dengan kejadian infeksi luka post sectio caesarea (SC) di Ruang 104

7 Mawar I RSUD DR. Moewardi Surakarta. Berita Ilmu Keperawatan; 1 : Morison MJ. (2003). Manajemen Luka. Jakarta : EGC. 9. Kalpokas I, Perdigon F, Rivero R, et all. (2010). Effect of a povidone-iodine intrauterine infusion on progesterone levels and endometrial steroid receptor expression in mares. Acta Veterinaria Scandinavica; 52 (66); Yavascan O, Anil M, Kara OD, et all. (2011). The comparison of exit-site care with normal saline and Povidone-Iodine in preventing exit-site infection and peritonitin in children on chronic peritoneal dialysis treatment. Saudi J Kidney Dis Transpl; 22 : Walker D. (2000). Back to basic choosing the correct wound dressing. American nursing Journal; Suhartono E, Bakhriansyah M, Handayani R. (2010). Effect of Stenochlaena palustris extract on circulating endothelial cells Marmota caligata induced fever. Majalah Farmasi Indonesia; 21 : Maharani DM, Haidah SN, Haiyinah. (2006). Studi potensi Kalakai (Stenochlaena palustris (Burm.F) Bedd) sebagai pangan fungsional. Jakarta : Departemen Pendidikan Dan Kebudayaan Indonesia. 14. Posthauer ME, Becky D, Collins N. (2010). Nutrition: a critical component of wound healing. Wound Care Journal; 23 : Suhartono E, Viani E, Rahmadhan MA, et all. (2012). Total flavonoid and antioxidant activity of some selected medicinal plants in South Kalimantan of Indonesian. Elsevier; 0 (0) : Suhartono E, Viani E, Rahmadhan MA, et all. (2012). Screening of medicinal plant for total flavonoid and antioxidant activity in South Kalimantan of Indonesian. International Journal of Chemical Engineering and Applications; 4 (3) : Fitriyani A, Winarti L, Muslichah S, et all. (2011). Uji antiinflamasi ekstrak metanol daun sirih merah (Piper crocatum Ruiz & Pav ) pada tikus putih. Majalah Obat Tradisional; 16 (1) : Yunanto A, Bambang S, Eko S. (2009). Peran radikal bebas pada intoksikasi dan patobiologi penyakit. Banjarmasin : Pustaka Banua. 19. Widodo AD, Tumbelaka AR. (2010). Penggunaan steroid dalam tata laksana sepsis analisis kasus berbasis bukti. Sari Pediatri; 11 (6) : Wulandari DC, Suryana K, Suwitra K. (2008). Pengaruh vitamin C terhadap c- reactive protein sebagai petanda inflamasi pada gagal ginjal kronik dengan hemodialisis reguler. J Peny Dalam; 9 (3) :

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