254 Jurnal Ners dan Kebidanan, Volume 4, Nomor 3, Desember 2017, hlm. 254–259 254 OVERVIEW OF ANKLE BRACHIAL INDEX (ABI) VALUES ON DIABETES MELLITUS TYPE 2 IN BLITAR Ulfa Husnul Fata Nursing Study Program, STIKes Patria Husada Blitar email: ulfaners@gmail.com Abstract: Examination of foot vascularization often used for patients with DM who have Perypheral Arterial Disease (PAD) is to measure the value of Ankle Brachial Index (ABI). ABI examination is a non- invasive gold standard measurement to detect vascular disorders of the peripheral arteries and is recom- mended as part of the assessment process to help formulate the diagnosis in at-risk individuals. The purpose of this study was to provide an overview of the value of ABI in people with diabetes mellitus type 2 in Village ofKepanjenKidul and Village KarangsariBlitar City. The method in this research was descriptive with respondent of type 2 diabetes mellitus as much as 32 respondents. Methods of data collection with check list and ABI score. The results of this study indicated that the value of ABI in people with type 2 diabetes with ABI value right and left extremities borderline and abnormal categories at most are female gender, abnormal value many in diabetics who do not routinely consume anti diabetic drugs, abnormal ABI value many in patients who do not exercise regularly, abnormally abnormal ABI values in patients who have never performed foot therapy, and abnormal ABI values are many in patients who do not implement the diet. Therefore, foot examination was very important to be done regularly to reduce the risk of foot ulcers in patients with diabetes mellitus. Keywords: ankle brachial index, ABI, diabetes mellitus type 2 Diabetes mellitus is a group pf metabolic diseases cha r a cter ized by eleva ted blood glucose (hyperglycemia) as a result of abnormalities of insulin secretion, insulin activity or both (American Diabetes Association/ADA, 2009; Smeltzer, et al, 2010). Diabetes mellitus has become a major health problem because its complications are short-term and long term. One form of chronic somplications that often occur in people with diabetes mellitus is diabetic foot ulcer (Prompers et al, 2008). An injury occurrence in the legsof patients with diabetes mellitus is a defect in the integument system of basic structure that can lead to damage to skin integrity and disturbance in physiological function of the network (Carville, 2007). Research conducted in the United States about 85% cases of lower limb amputation caused by diabetes mellitus that begins the foot ulceration. The occurrence of leg a mputa tion ever y 20 seconds due to complications of diabetes mellitus (Boulton et al, 2008). Leg ulcers affect approximately 70% of these ulcer s a r e pr imed by chr onic venous insufficiency (CVI), with 20% to 25% being attributed to arterial or mixed disease (Nelson and Bradley, 2003; Bryant & Nix, 2007: 258). It is difficult to a ccura tely deter mine the pr eva lence a nd incidence of these ulcers and separately (Nelzen, Bergqvist, and Lindhagen, 1996; Bryant and Nix, 2007: 258) Most cases of diabetic foot ulcers are the ultimate manifestation of peripheral neuropathy, vascular abnormalities or a combination of both because of poor blood sugar control conditions (Br ownr igg, 2012). Exa mina tion of foot vascularization often used for patients with DM who have Peripheral Arterial Disease (PAD) is to measure the value of Ankle Brachial Index (ABI) (Potier, et al. 2011), using Doppler Ultrasound. Doppler ultrasound is used to measure blood flow in both arteries and veins. Measurement helps to hp Typewritten text Jurnal Ners dan Kebidanan, Volume 4, No. 3, Desember 2017 DOI: 10.26699/jnk.v4i3.ART.p254-259 IT Typewritten text © 2017 Jurnal Ners dan Kebidanan IT Typewritten text This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) https://creativecommons.org/licenses/by-sa/4.0/ 255Fata, Overview of Ankle Brachial Index (ABI) Values... determine the degree of arterial or venous disease in the leg (Carville, 2007). ABI examination is a non-invasive gold standard measurement to detect vascular disorders from peripheral arteries and is recommended as part of the assessment process to help formulate diagnoses in at-risk individuals (Migliacci, 2008). Inappropriateness in diagnosing PAD results in serious considerations such as functiona l ca pacity aba tement, amputa tions, depression and quality of life. Doppler ultrasound is a tool for translating arterial and venous blood flow. This checks for prevention of arterial or venous blood vessels. Examination is very helpful in establishing a proper nursing diagnosis process.Under normal conditions, the systolic pressure on the foot is equal to the hand or slightly higher. In the event of disturbance in the a r ea of the foot, either venous or a r ter ia l disturbances, it will produce different systolic pressure. Accurate examination results may help diagnostically lead to venous or arterial disorders, so management of care is also different (Gitarja, 2008). In addition to ABI examination, foot care is the primary prevention of injury to the diabetic foot. Measures to be performed on foot care for early foot abnormalities, proper nail cutting, good footwear usage, keeping foot and foot rest. Things that should not be done is to cope alone when there is a problem in the foot or with the use of sharp tools or objects. Patients need to know the care of diabetic feet well so that the incidence of gangrenous ulcers and amputations can be avoided (Tambunan, 2011). Based on the description above, researchers a r e inter ested to conduct r esea r ch entitled “Overview of Ankle Brachial Index in type 2 diabetes mellitus in Sananwetan and Sukorejo Community Health Center BlitarCity”. RESEARCH METHODS This research was a descriptive research. The sample in this research was diabetes mellitus type 2 in work area of Sananwetan and Sukorejo Public Health Center of Blitar City in June 2017 with sample size 32. Sampling methode with purposive sampling according to inclusions and exclusions criteria. Sample inclusion criteria include: (1) patients with diabetes type 2, (2) long suvering with diabetes mellitus more than 1 year, (3) patient age above 40 years. While the exclusion criteria is patients with leg ulcers. Data collection was conducted at Kepanjen Kidul and Karangsari Village, Blitar City. The researcher intifies the prospective respondents by conducting interviews and checks that are adjusted to the inclusion and exclusion criteria. After given informed consent, then filling the data collection sheet followed by ABI exa mination on ea ch respondent. Univariate analysis includes ABI score, age, gender, random blood sugar, long diabetes, oral antidiabetic drug (ANTI DIABETIC DRUGS), exercise, smoking history, foot therapy, and diet. Data analysis was done to find out the ABI values in diabetes mellitus type 2 patients. RESULT Variable Mean Median SD Min – Max Age 56.66 56 8,015 42 - 73 Blood 289.91 291 64,593 182 – 410 Glucose Levels Table 1 Distribution of respondents by age and blood glucose levels in the Village of Kepanjen Kidul and Karangsari, Blitar City, June 2017 (n = 32) Table 1 describe the results of the analysis of the mean age analysis of respondent in this study was 56,66 ± 8,015 years with the age range of 42 – 73 years. While the average level of blood glucose analysis was 289,91 ± 64,593 with the range 182 – 410 mg/dl. Variable Frequency Persentage Gender Male 12 37,5 Female 20 62,5 Anti Diabetic Drugs consumtion Never 7 21,9 Not a routine 17 53,1 Routine 8 25 Table 2 Distribution of respondents by gender and dia- betic drugs consumtion in the Village of Kepanjen Kidul and Karangsari, Blitar City, June 2017 (n = 32) Table 2 describe the distribution of respondents that the majority of respondents were female that a re 20 respondents (62. 5%), as well a s the 256 Jurnal Ners dan Kebidanan, Volume 4, Nomor 3, Desember 2017, hlm. 254–259 Table 3 describe the frequency distribution indicating that the majority of respondent were not active in exercise of 19 repondents (59.4%). Almost all respondents never did not foot therapy as much as 31 respondents (96.9%). The results of smoking history analysis showed that the majority of respondents never smoked of 25 respondents (78.1%), and the most respondents dit not implement diabetes mellitus diet as much as 23 respondents (71.9%). Table 4 showed that the value of ABI in right extremity is almost half abnormal of 13 respondents (40.6%). Likewise with the left extremity that almost half of the respondent with ABI values in the abnormal category of 14 respondents (43.8%). distribution of respondents by consumtion of the diabetic drugs most respondents did not routine consume diabetic drugs 17 respondents (53.1%.) Variable Frequency Persentage Physical exercise Never 7 21,9 Not a routine 19 59,4 Routine 6 18,8 Foot therapy No 31 96,9 Yes 1 3,1 Smoking history Never 25 78,1 Past 3 9,4 Active 4 12,5 Diet No 23 71,9 Yes 9 28,1 Table 3 Distribution of respondents by physical exer- cise, foot therapy, smoke history, and diet in the Village of Kepanjen Kidul and Karangsari, Blitar City, June 2017 (n = 32) Variable Frequency Persentage ABI right extremity Normal 8 25 Borderline 11 34,4 Abnormal 13 40,6 ABI Left extremity Normal 9 28,1 Borderline 9 28,1 Abnormal 14 43,8 Table 4 Distribution of respondents by ABI values in the Village of Kepanjen Kidul and Karangsari, Blitar City, June 2017 (n = 32)  %  %  % Gender Male 3 25 2 16.7 7 58,3 Female 5 25 9 45 6 30 Anti Diabetic Drugs Consumtion Never 2 28.6 2 28.6 3 42.8 Not a routine 4 23.5 6 35.3 7 41.2 routine 2 25 3 37.5 3 37.5 Physical exercise Never 1 14.2 3 42.9 3 42.9 Not a routine 7 36.8 4 21.1 8 42.1 routine 0 0 4 66.7 2 33.3 Terapi Kaki Yes 0 0 1 100 0 0 No 8 25.8 10 32.3 13 41.9 Riwayat Merokok Never 8 32 9 36 8 32 Pas 0 0 1 33.3 2 66.7 Active 0 0 1 25 3 75 Diet Yes 1 11.2 4 44.4 4 44.4 No 7 30.4 7 30.4 9 39.2 Table 5 Cross tabulation of ABI values in right extrem- ity by gender, Anti Diabetic drugs consumtion, exercise, smoking history, foot therapy, and diet in Village of Kepanjen Kidul and Karangsari, Blitar City, June 2017 (32) Variabel ABI Right Extremity Normal Borderline Abnormal Table 5 indicates that type 2 diabetics with ABI values of the right extremity categories borderline and abnormal are female gender, abnormal values are high in diabetics who do not routinely consume anti diabetic drugs, abnormal ABI values are many in patients who do not exercise regularly, abnormal ABI values are many in patients who have never performed foot therapy, and abnormal ABI values are high in patients who do not carry out diet. 257Fata, Overview of Ankle Brachial Index (ABI) Values... 11 peoples (34.4%) and abnormal 13 peoples (40, 6%). While the value of ABI on left extremities in normal category 9 peoples (28.1%), borderline 9 peoples (28.1%) and abnormal 14 peoples (43.8%). Dia betic foot with ulcer is a fr equent complication of diabetes. Diabetic foot ulcers are caused by the process of peripheral neuropathy, peripheral arterial disease, or a combination of both. Thus increasing morbidity, mortality, and reducing the quality of life of patients (Perkeni, 2015). Therefore, in diabetesmellitus needs to be done vascular examination of the foot or commonly called ABI examination.Ankle Brachial Index is a non- invasive vascular screening test for identifying large blood vessels, peripher al a rter ial disease by comparing cytologic blood pressure in the ankle to systolic pressure in the brachialis performed using Doppler Vascular. The goal of ABI examination is to support the diagnosis of vascular disease by providing an objective indicator of arterial perfusion to the lower extremities. Abnormal ABI values reflect atherosclerosis. (WOCN Wound Commite, 2012). Peripheral vascular damage in the hands and feet, called Peripheral Vascular Disease (PVD), can occur earlier and the process is faster in people with diabetes mellitus than those who do not have diabetes mellitus. The pulse of the blood vessels in the leg feels weak or does not feel at all. If diabetes lasts for more than 10 years, a third of men and women may develop the disorder (Ndraha, 2014). Hyperglycaemia that occurs due to excessive carbohydrate input, reduced glucose consumption in the tissues, increased liver glucose production, long-lasting insulin defects will initiate various forms of abnormalities such as neuropathy and peripheral arterial disease (PAD) (Criqui, 2011). The presence of this PAD will reduce arterial perfusion to the lower extremities. This decrease of perfusion is usually characterized by the loss of peripheral pulsation and the presence of clinical manifestations such as claudication intermittent (pain of walking time, and improved at rest), will facilitate the development of infection, ulceration and wound healing, can even lead to gangrene which leads to amputation foot (Creager, 2012). Cross-tabulation of ABI values by gender, anti diabetic drugs consumtions, exercise, smoking history, foot therapy, and diet Cross-rabulation result of ABI of right and left extremities by sex, anti diabetic drugs consumtions, exercise, smoing history, foot therapy and diet in Table 6 Cross tabulation of ABI values in left extremity by gender, Anti Diabetic drugs consumtion, exercise, smoking history, foot therapy, and diet in Village of Kepanjen Kidul and Karangsari, Blitar City, June 2017 (32)  %  %  % Gender Male 2 16.7 2 16.7 8 66.6 Femele 7 35 7 35 6 30 Anti Diabetic Drugs Consumtion Never 3 42.9 1 14.3 3 42.9 Not a routine 4 23.5 6 35.3 7 41.2 routine 2 25 2 24 4 50 Physical exercise Never 3 42.9 1 14.3 3 42.9 Not a routine 5 26.3 5 26.3 9 47.4 routine 1 16.7 3 50 2 33.3 Terapi Kaki Yes 1 100 0 0 0 0 No 8 25.8 9 29 14 45.2 Riwayat Merokok Never 8 32 8 32 9 36 Past 1 33.3 0 0 2 66.7 Active 0 0 1 25 3 75 Diet Yes 1 11.2 4 44.4 4 43.4 No 8 34.8 5 21.7 10 44.5 Variabel ABI Left Extremity Normal Borderline Abnormal Table 6 indicates that type 2 diabetics with ABI values of the right extremity categories borderline and abnormal are female gender, abnormal values are high in diabetics who do not routinely consume anti diabetic drugs, abnormal ABI values are many in patients who do not exercise regularly, abnormal ABI values are many in patients who have never performed foot therapy, and abnormal ABI values are high in patients who do not carry out diet. DISCUSSION Description of ABI values in patients with diabetes mellitus The results of this study indicate that the ABI values of right extremity in type 2 diabetes mellitus in Village of KepanjenKidul and Karangsari in normal category are 8 peoples (25%), borderline 258 Jurnal Ners dan Kebidanan, Volume 4, Nomor 3, Desember 2017, hlm. 254–259 people with diabetes mellitus is no significant difference. Half of the respondents were male. Increased risk of PAD in men is likely due to previous smoking history. The data obtained as many as 3 respondents (9.4%) never smoked and now they have stopped smoking, and 4 respondents (12.5%) are active smokers. Cigarette smoke is known to cause vascular endothelial dysfunction, increase the concentration of fibrinogen, decrease fibrinolytic activity and increase platelet aggregation. Smokers a r e thr ee times higher r isk for inter mittent claudication and show symptoms 10 years earlier than nonsmokers. (O’Donnell et al, 2011). A tota l of 7 (41. 2%) r espondents with abnormal ABI values on right extremity were respondents with non-routine categories consuming anti diabetic drugs, as did the left limb. Number of respondents with abnormal ABI score on right exercise non-exercise routine as many as 8 (42.1%) respondents, while abnormal ABI score on left extremity in non-routine respondents exercised as many as 9 (47.4%) respondents. The number of respondents with abnormal ABI values on the right extremity who had never performed foot therapy were 13 (41.9%) respondents. While respondents with abnormal ABI values on the left extremity who never performed foot therapy as much as 14 (45.2%) respondents. Number of respondents with abnormal ABI value on right extremity who did not implement diabetes diet as many as 9 (39.2%) respondents. While a number of respondents with abnormal ABI value on left extremity that did not implement diet of diabetes mellitus counted 10 (44.5%) of respondents. Approximately 70% of cases of foot ulcers are the main causes of Chronic Vein Insufficiency (CVI), and about 20% to 25% with arterial or mixed diseases (Nelson and Bradley, 2003; Brayant& Nix 2007). Risk factors for venous blood disorders in patients with diabetes mellitus include age over 50 years, more women than men, heart problems, obesity, and others (Scemons&Elston, 2009). Key str a tegies for consider ing venous insufficiency a nd hyper tension, ther a py, management; Additional actions. For body health, pharmacological agents, and routine leg elevation (Brayant& Nix 2007) CONCLUSIONS AND SUGGESTIONS Conclusion The result of the research have shown that the most of the respondents who have been done ABI examination results are abnormal on the left and right extremities. Additional data showed that some respondents did not adhere to diet, did not do foot therapy, did not exercise regulary, and did not routinely consume diabetic drugs. Suggestion Based on the research that has been done, obtained ABI examination results in people with diabetes mellitus mostly in the category of borderline and abnormal. Some factors that may affect the results include lack of adherence in the diet, not exercise routine, never do foot therapy, and not r outinely in consuming a nti dia betic dr ugs. Therefore, for nurse specially nurse Specialist of Medical Nursing of Surgical and Wound Care is expected to conduct comprehensive study in order to formulate a comprehensive action plan which of course to overcome the problem that happened in diabetesmellitus. REFERENCE Boulton AJ. et al.2008. Comprehensive Foot Examina- tion andRisk Assessment. Diabetes Care. 31: 1679- 85. Brayant, RA. & Nix, DP. 2007. Acute & Chronic Wounds. Current Management Concepts. Third Edition. United States of America: Mosby Elsevier. Brownrigg JR. et al. 2012. The Association of Ulceration of The Foot With Cardiovascular and All-Cause Mortality in Patients with Diabetes: A Meta- Analysis. Diabetalogia. 55 (11): 2906-12. Carville, K. 2007. Wound Care Manual. 5th Edition. Western Australia: Silver Chain Foundation. Creager, M.A. 2012. Peripheral Artery Disease a Text Book of Cardiovascular Medicine. 9th ed. Phila- delphia, USA: Elsevier Saunders. pp 1338-56 Criqui, MH., 2011. Peripheral Arterial-Disease-Epide- miological Aspects.Vasc Med. 6: 3–7. Migliacci, R. et al. 2008. Ankle-Brachial Index Measured By Palpation For The Diagnosis Of Peripheral Arterial Disease. Fam Pract. 25:228–232 Ndraha , S. 2014. Di abe tes Mel itus Tipe 2 dan Tatalaksana Terkini. Midicinus Vol. 27, No. 2. O’Donnell ME., et al. 2011. Optimal Management Of Peripheral Arterial Disease For The Non Specialist.Ulster Med J. ; 80(1): 33–41. 259Fata, Overview of Ankle Brachial Index (ABI) Values... Perkeni. 2015. Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia. Jakarta: Perkeni Potier, L., et al. 2011. Use and Utility of Akle Brachial Index in Patients with Diabetes. Eur J Vasc Endovasc Surg. 41(1): 110-16. Prompers, L. et al. 2008. Resource Utilisation and Cost Associated with The Treatment of Diabetic Foot Ulcers. Diabetologia. 51: 1826 – 34. Smeltzer, et al. 2010. Brunner &Suddarth’s Textbook of Medical Surgical Nursing. 12th ed. Philadelphia: Lippincott, 1197. WOCN Wound Commite. 2012. Ankle Brachial Index. Quick Reference Guide for Clinicians. J Wound Ostomy Continence Nurs. 39(2S): S21-S29.