Effect of Cutaneous Stimulation and Virgin Coconut Oil on Skin

Moisture in Patients with Chronic Renal Failure

Putu Intan Daryaswanti

, Elyana Asnar

and Ilya Krisnana

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Department of Physiology, Airlangga University, Surabaya, Indonesia

Keywords: Cutaneus Stimulation, Virgin Coconut Oil, VCO, Hemodialysis.

Abstract: Skin problem in patients with Chronic Kidney Failure that often appear that dry skin and most often appear

on the forearm and lower extremities. Dry skin that appears in patients undergoing hemodialysis is usually

due to atrophy of the sebaceous glands, impaired function of external secretions, and stratum corneum

hydration disturbance. The aim of this study was to explain of the combination of cutaneus stimulation and

VCO on skin moisture. Cutaneous stimulation and virgin coconut oil (VCO) was performed as a non-

pharmacological treatment option to improve skin moisture. This study used quasy experiment pre-post test

control group design, conducted between January – March 2018. A total of 52 patients undergoing

hemodialysis divided randomly into two groups. The treatment group was given cutaneous stimulation and

VCO for 4 weeks and the control group was not given cutaneous stimulation and VCO. The skin moisture

assessment was performed five times, ie pre-test at week0, week1, week2, week3 and post-test at week4

using skin moisture analyzer. Giving cutaneous stimulation and VCO effective in improving skin moisture

in patients undergoing dialysis seen from Wilcoxon test with p<0.05. Based on Friedman nonparametric test

results, there were significant differences in skin moisture value at five measurement times (pre-test, week1,

week2, week3, and post-test) p=0.000. Giving cutaneous stimulation and VCO can be used as an option to

improve skin moisture in patients undergoing hemodialysis.

1 BACKGROUND

Patients with Chronic Renal Failure (CRF) have at

least one change in their skin of 50-100% (Min et

al., 2016). One of the skin changes that occur is

pruritus where the mechanism that causes pruritus is

dry skin. Dry skin is described in most patients with

CRF and is thought to be a significant pathogenic

factor in pruritus and may increase the intensity of

itching in patients with CRF. In the study (Kolla et

al., 2012) found that 52% of patients who undergo

HD experience dry skin. Knowing early and

performing management of rapid dermatology

manifestations can reduce morbidity and improve

the quality of life of patients. Dry skin that appears

in patients with CRF who undergo hemodialysis is

usually caused due to atrophy of the sebaceous

glands, impaired function of external secretions, and

stratum corneum hydration disturbance. Dry skin in

patients with pruritic hemodialysis has lower

hydration than hemodialysis patients without

pruritus complaints (Roswati, 2013). Xerosis is a

common symptom of patients with dialysis which

occurs between 50-100%. It most often appears in

the lower extremities and forearms. It has been

reported that CRF-related pruritus is more common

and more severe in patients with xerosis. However,

patients with xerosis do not always suffer from

itching if they rehydrate and moisturize their skin

well. Thus the possibility of xerosis increases the

intensity of itch if associated with CKD-aP (Chronic

Kidney Disease-associated Pruritus) (Mettang,

2016). Skin moisture is state of moisture content of

the stratum corneum and a balance between the

evaporation of water and the ability of the skin to

retain water. Moisturizing skin can cause cracks,

allowing germs that can cause infection to enter the

body (Perry.A. Griffin., Potter, Patricia.A.,

Ostendorf, 2014). Based on the results interviews

with patients, all this time that is used to reduce dry

skin by using baby oil, olive oil, body lotion and

traditional oil sold in pharmacies. Results obtained,

moist skin only after use, a few hours later, the skin

will dry again.

338

Daryaswanti, P., Asnar, E. and Krisnana, I.

Effect of Cutaneous Stimulation and Virgin Coconut Oil on Skin Moisture in Patients with Chronic Renal Failure.

DOI: 10.5220/0008324903380344

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 338-344

ISBN: 978-989-758-336-0

 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reser ved

Kidney failure can cause changes in the sweat

glands and oil glands that cause the skin to lose its

natural ability to moisturize. This condition can also

be caused by changes in metabolism in chronic renal

failure, which are related to the volume of fluid from

patients undergoing dialysis.

Cutaneous stimulation is a stimulation of the skin

and underlying tissue that aims to reduce unwanted

signs and symptoms such as pain, muscle spasms,

inflammation, nausea and so on (Bullechek, Gloria;

Butcher Howard; Dechteerman, joanne; wagner,

2013). Cutaneous stimulation may include massage,

hot bath, ice packs and TENS (Transcutaneous

Electrical Nerve Stimulation). In this study using

cutaneous stimulation type of massage with stroking

technique. Massage stroking technique is the

provision of massage from proximal to distal along

the tissue at depth and speed corresponding to the

desired effect (Hollis, 1998). This technique is

chosen because it is easy to do independently by the

patient. Massage applied to dry skin certainly causes

friction and pain on the skin surface. And the

combination when given a massage that is by giving

the VCO. VCO is a pure coconut oil has antiseptic

effect and is used as an efficient skin moisturizer

(DebMandal & Mandal, 2011). VCO is a processed

product that contains fatty acids (especially uric acid

and oleic) which has the properties of softening the

skin. In addition VCO effective and used as a

moisturizer on skin so that can increase skin

hydration and accelerate skin healing and can

eliminate itching (Sukartin, 2005). The aim of this

study was to explain of the combination of cutaneus

stimulation and VCO on skin moisture.

2 METHODS

2.1 Study Design and Sample

This was a quasy experimental research with pre-

post test control group design. This research was

conducted for 4 weeks from 22 January 2018 – 21

February 2018 at Hemodialysis Room Regional

Hospital Public Buleleng, Singaraja Bali.

Calculation of sample size using Lemeshow

formula, where level of significant 5% = 1.96, power

the test 80% = 0.84 and got 24 subjects in each

group. Considering the probable loss in the sample,

the number of subjects in each group was increased

to 26. This study involved 52 patients: 26 patients

comprised the experimental group, whereas 26

patients comprised the control group.

The population in this study were patients who

underwent hemodialysis. Sampling technique in this

study was done by random sampling with inclusion

criteria: respondents did regular HD twice a week,

experienced dry skin measured using skin moisture

tool, while the exclusion criteria were patients who

did HD cito, decreased consciousness, women who

have menopause, patients with HD travelling,

patients with Hbs Ag (+) and patients with injury or

secondary infection of the skin. Random selection of

samples was perfomed. We believed that patients

undergoing dialysis in the same session could affect

each other, so we chose the control and study groups

according to their session times. Patients who met

the criteria were grouped according to the time of

their sessions. The drawing method was used to

determine which group would start the study. After

drawing, HD patients in the morning sessions were

considered the study group, whereas those in the

afternoon session were regarded as the control

group. Group study: giving cutaneous stimulation

for 30 minutes and VCO 5 ml, before patients

undergoing standard HD treatment on the skin of a

hand that is not attached to the AV Shunt. Group

control: group that did not giving stimulation

cutaneous and VCO.

2.2 Data Collection

2.2.1 Patient Information Form

The patients information form was developed by the

researchers by screening the literature. This form

consisted of 7 questions that included

sosiodemographic characteristic and duration of

hemodialysis.

2.2.2 Skin Moisture Analyzer

Skin moisture analyzer using SK-IV Digital

Moisture Monitor for Skin as especially designed

precision instrument, this product utilizes the lastest

Bioelectric Impedance Analysis (BIA) technology.

With a non-destructive measuring approach. In the

skin analyzer, has an LCD screen that serves to

display data measurements of skin moisture. This

tool has a small design and shape and portable so it

can be taken anywhere. Measurement of skin

moisture is done in a very short time is within 6

seconds and appears in the form of percentage

figures. Standard values of skin moisture in the arm

are: 0-35% meant very dry skin, 36-45% meant

normal skin and 46-100% meant moist skin.

Effect of Cutaneous Stimulation and Virgin Coconut Oil on Skin Moisture in Patients with Chronic Renal Failure

339

2.3 Process

2.3.1 Study Group

In the study group, the first patient information form

and measure the skin’s moisture level before patients

undergoing HD treatment. In practice, giving

cutaneous stimulation in this case massage is given

for 30 minutes with stroking technique, and when

giving massage followed by giving VCO as much as

5 ml. 10 ml bottle given 5 ml VCO given each

intervention. Intervention is given twice a day, ie

morning before HD treatment and night before going

to bed. Patients taking part in the study were patients

with regular HD twice a week. At the first session of

the first week, the patient was provided with 5

bottles (25 ml) of VCO to the house until the second

HD session of the first week, the patient was again

provided with 7 bottles (35 ml) for the house. Then

when the first HD session in the second week is

given back and forth for four weeks. At the

beginning of administration, perform allergic tests

on the back of the hand for 10 minutes, by applying

a small amount of VCO, if the patient feels itchy or

sore, there is a possibility that the patient is allergic,

and the patient is not included as a research sample.

VCO should not be given on the hands of the AV

shunt and on the hands that are having an open

wound.

Patients in the study group performed skin

moisture measurements every week. Measurements

were made five times, ie pre-test in the zero week,

first week, second week, third week, and post-test in

the fourth week.

2.3.2 Control Group

In the control group, the first patient information

form and measure the skin’s moisture level patients

undergoing HD treatment. Education about the

research procedure was provided to the patients.

Provide VCO and cutaneous stimulation guides at

the end after doing post-test. Skin moisture

measurements were made twice in the first sessions

of HD in the fifth week. Then the patient is given

one bottle of VCO as much as 300 ml.

2.4 Virgin Coconut Oil (VCO) Practice

VCO provided by students majoring in Traditional

Medicine, Airlangga University. VCO is made from

selected coconut is old coconut. Oil is made without

heating. VCO is packed in clear 10 ml plastic bottles

(for study group) and 300 ml (for control group),

tightly sealed so that it does not spill easily. Clear

colored oil, not rancid and smells typical of coconut

oil.

2.5 Data Analysis

The statistical analyses were performed with SPSS.

Average and percentage were used for analysis of

descriptive features. Normal distribution of the data

was tested by Shapiro-Wilk test. The two groups

were compared via Wilcoxon test and Independent t-

test. To evaluate more than two variance, the

Friedman test is used.

2.6 Ethical Considerations

This study has gained approval of ethical eligibility

from Ethical Commision of Health Research at

Nursing Faculty of Universitas Airlangga number

609-KEPK on 4

January 2018. Written consent was

obtained from all centers. The aim of the study was

explained to the participants, and informed consent

forms the participants were collected.

3 RESULTS

Fithty four selected for eligibility with simple

random sampling, 2 patients were dropped out

because passing away before post test, leaving a

final study sample of 52 patients, who were assigned

to intervention group (n=26) and control group

(n=26).

Based on table 1 shows the characteristics of

respondent by age, gender, education, occupation,

and duration of hemodyalisis. Most respondents

were 30-45 years old (38.5%), male sex (69.2%),

had level of education in high school (42.3%), did

not work (19.2%), and undergoing HD less than five

years (75%). Based on homogeneity test, it was

found that the characteristic of age, education and

occupation showed homogeneous (p>0.05).

Dry skin occurred in both group, all of

respondents both the intervention group and control

group obtained dry skin. After given intervention

has increased the skin moisture level to normal as

much 11 (42.3%) and 9 (34.6%) skin becomes

moist. However, there are 6 patients (23%) are still

at very dry skin level, but skin’s moisture value has

increased slightly.

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

340

Table 1: Characteristics and demographic.

Characteristic

Intervention

Control

val

Age (years)

30-45

46-55

56-65

53.8

23.1

42.3

34.6

0.1

Mean Age

47.73±7.68

50.85±7.58

Gender

Male

Female

53.8

46.2

84.6

15.4

0.0

Education

Not schooling

Primary

Secondary

High School

Collage

3.8

23.1

19.2

42.3

11.5

19.2

42.3

19.2

0.3

Occupation

Not Working

Working

38.4

61.6

19.2

80.8

0.1

HD Duration

0 – 5 years

6-10 years

>10 years

61.5

30.8

7.7

88.5

11.5

0.0

Mean HD

Duration

4.76±3.13

2.40±1.76

Table 2: Incidence of skin moisture in intervention and

control group (pre test-post test).

Stage of skin

moisture

Intervention

Control

Skin moisture before intervention (pre test)

Dry skin

Normal

Moisture

100

Skin moisture after intervention (post test)

Dry skin

Normal

Moisture

42.3

34.6

100

Table 3: Result Wilcoxon and Independent t test.

Group

Skin Moisture

value

Pre test

Post test

Intervention

Control

20.31±4.84

21.96±5.89

41.08±5.95

21.12±4.44

0.000

0.557

Independent t test p: 0.000

Table 3 shows, that effectivity of cutaneous

stimulation and vco on skin moisture, each group

was tested by Wilcoxon statistic analysis, because

the result of Shapiro Wilk data not normally test, the

normal data distribution (p<0.05). Based on the

results of the test showed that the results obtained

significant in the treatment group (p<0.05), whereas

in the control group showed no significant result

(p>0.05).

After testing on each group, the next test is to

know the difference of effectivity of cutaneous

stimulation and VCO in the intervention and control

group. The used Independent t-test because the

distribution of the difference data between pre and

post both treatments is normally distributed

(p>0.05).

Table 4: Result Independent t-test.

Groups

Mean

Standar

Deviasi

value

Intervention

20.77

6.641

0.000

Control

-0.85

4.722

Table 5: Distribution of mean and standar deviasi of skin

moisture scores of the participants in treatment group

according to measurement time (Friedman Test).

Measurement time

Study griup (n=26)

p value

week 0

week 1

week 2

week 3

week 4

20.69 ± 5.98

24.88 ± 6.21

27.92 ± 5.78

32.35 ± 5.67

41.46 ± 6.51

0.000

Table 6: Result post hoct test of Friedman test.

Weeks

Week1

Week2

Week3

Week4

0.000

The results in table 4 show that there is a

significant difference (p<0.05) in the treatment

group compared with the control group.

Giving cutaneous stimulation and VCO is given

for four weeks. And the skin moisture measurement

is done 5 times, that is pre test in the first week,

second week, third week, fourth week and post test

in the fifth week. To test the result of skin moisture

measurements on a weekly basis the measurements

in the group given cutaneous stimulation

intervention and VCO using Anova Repeated

Measure test. However, since the residual value of

the data distribution group is not normally

distributed, it uses the Friedman test. Table 5 shows

a significant relationship between the differences in

mean skin moisture score in the first week and the

fifth week in the treatment group.

The groups that differed significantly on the

friedman test, using the post hoc test by performing

the Wilcoxon Signed Rank Test. there was a

significant difference in skin moisture value between

Effect of Cutaneous Stimulation and Virgin Coconut Oil on Skin Moisture in Patients with Chronic Renal Failure

341

week 0 value with first week (0.000), second week

(0.000), third week (0.000) and fourth week (0.000).

4 DISCUSSION

The results of this study showed that all patients had

dry skin (100%). Ankudowicz et al, in patients

treated with hemodialysis because of CRF, various

skin lesions were detected, the most common

symptomps were skin dryness and pruritus

(observed in 63% of patients) (A. Ankudowicz,

Król, & Dębska-Ślizień, 2016). Giving cutaneous

stimulation and VCO can improve skin moisture in

patients with CRF who undergo hemodialysis tend

to have dry skin. Dry skin that appears in patients

dialysis is usually due to retention of vitamin A

which causes decreased function of the kidneys to

secrete some body substances. This vitamin A

accumulates in the subcutaneous tissue of the skin.

This excessive vitamin causes the atrophy of

sebaceous glands and sweat glands that make skin

dry and itchy (Melastuti, Erna., Setyaningrum,

2016). Xerosis is a skin disorder number two after

pruritus. Skin xerosis is a frequent complication in

hemodialysis patients. It can be seen in CRF before

HD, but a significant rise in its frequency is found

after the start of dialysis (Masmoudi, Darouiche,

Salah, Hmida, & Turki, 2014). Dry skin conditions,

triggering the itching of the skin. If this condition

persists there will be pruritus. Before pruritus

occurs, making the skin moist is very important. In

addition to improving patient comfort can also

improve the quality of life patients. The results

showed that the combination of cutaneous

stimulation and VCO significantly gave good

results. Patients say more moist and less itchy skin,

making patients more comfortable.

Cutaneous stimulation in the form of massage, in

addition to providing a sense of relaxation in the

skin, also helps the VCO more quickly absorbed into

the skin. The massage is given in the type of

stroking, which provides massage from the proximal

to distal direction along the tissue at depth and speed

corresponding to the required effect, but the

direction of stroking may vary to provide greater

comfort (Hollis, 1998). Massage is oriented to the

superficial region, so it can stimulate the receptors

that exist on the skin. One of the physiological

effects of massage is its ability to increase local

blood and lymphatic flow, improve nutritional

status, facilitate removal of toxins released by

wounded tissue and speed healing (Hollis, 1998).

Increase blood flow and lymph nodes may occur as a

result of direct mechanical displacement, as well as

the neural reflex response of blood and lymph

channels. In addition, vasodilator release, such as

histamine from mast cells, is associated with

increased local blood flow. Massage that is done can

provide relaxation to the muscles so that the blood

vessels dilate. Under these conditions, can lower

levels of cortisol, epineprin and norepineprin (Unal

& Balci Akpinar, 2016). Other physiological effects,

massage can increase the secretions of sweat glands

and sebaceous glands. Massage mechanically has the

ability to change the texture and consistency of the

skin if doing repeatedly and prolonged, the skin will

be more elastic (Hollis, 1998).

Most of patients had increased skin moisture

(94%) after giving VCO, 6% did not increase

significantly, but showed slight improvement. A

total of 17 people after being given intervention

have not been at the skin level to be moist. As many

as 11 people who were previously at the dry skin

level became normal skin, there was an increase of

approximately 20 points. While as many as 6 people

remain in dry skin condition although there is an

increase in value in quantity. This is because the

skin moisture value at pre test is at very low value

(<21%), so to achieve the normal value required a

considerable increase of points. The increase in the

value of six people is approximately 15 points. The

skin condition of each patient is certainly not always

the same, some factors that cause the patient to

remain in dry skin condition after four weeks of

intervention due to atrophy of the sebaceous glands

associated with decreased lipid surfaces that cause

dehydration of the stratum corneum (Masmoudi et

al., 2014). In addition to the duration of patients

undergoing HD also may affect skin moisture due to

the decline in the glans with abnormal functions

associated with hypervitaminosis A when patients

undergoing dialysis (Anna Ankudowicz, Król,

Dębska Ślizień, & Czernych, 2018); (Robles-

Mendez, Vazquez-Martinez, & Ocampo-Candiani,

2015). Therese et al, observed in atopic dermatitis

patients, the results are an increase in stauts, whereas

formerly atopic patients of severe dermatitis after

being given VCO intervention, became atopic of

moderate dermatitis (Evangelista, Casintahan, &

Villafuerte, 2014). Noor et al study showed 24.8%

increase in skin moisture for lotions with VCO-SLPs

compared with 12.7% increase in skin moisture in

regular lotion use for duration of use twice daily for

28 days. The use of lotions with VCO-SLPs has

igher moisture retention and this could be due to the

high occlusion factor of smaller particles.

Moisturizing lotion containing VCO with 0.608 μm

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

342

show a better way of working that is by extending

the effects of moisture on the skin. This effect can be

caused by a smaller particle size that allows the

particles to be maintained in the stratum corneum

layer. The most important criterion for moisturizers

is to prevent water loss from the skin and keep the

moisture of stratum corneum skin about 20-35% or

more. In addition to increasing skin hydration, VCO

can also improve skin elasticity. There was an

increase in skin elasticity by 2.60% from day 0 and

day 28 compared to using moisturizers could be an

increase of 0.76% after 28 days. This may be due to

higher skin hydration and decreased transpidermal

water loss (Noor, Norhayati Mohamed., Aziz, Azila

Abd., Sarmidi, Mohamad Roji., Aziz, 2013).

When the VCO is applied to the skin, the VCO

not only coats the skin, but also penetrates the skin.

VCO has saturated fat and contains 62% Medium

Chain Fatty Acids (MCFAs). When applied to the

skin, MCFAs react with the lipase of the skin flora

and convert it into free fatty acids, which penetrate

the dermis. In addition, VCO has been shown to

destroy free radicals, compounds that can cause skin

disorders. The antioxidant capacity of VCO can be

caused by phenolic compounds such as ferulic acids

and p-coumaric acids (Evangelista et al., 2014).

VCO is applied to the skin, in addition to coating the

skin, cover and protect by slowing transpidermal

water loss and increase hydration in the stratum

corneum and upper layer of dermis, this makes the

skin moist (Verallo-Rowell, Dillague, & Syah-

Tjundawan, 2008).

The use of traditional coconut oil as a lotion has

been done in many parts of the world. Coconut oil is

shown to have an antiseptic effect and is used as a

safe skin moisturizer (DebMandal & Mandal, 2011).

In addition to cheap, coconut oil is also easy to

obtain and easy to make.

4.1 Limitations

This study has some limitation. Limitations of this

study are that researcher can not control well during

the implementation of home interventions.

Respondents only provided an observation sheet and

reminded via SMS or telp. Researcher rely on the

results of an observation sheet that has been filled

with the patient or patient’s family.

5 CONCLUSIONS

Based on the test results of the treatment, obtained

significant results on the treatment of cutaneous

stimulation and VCO. That the provision of

cutaneous stimulaton and VCO can effectively

improve skin moisture and can be used as a non-

pharmacological therapy option to improve skin

moisture. In addition VCO is easy to obtain, cheap

and easy to make.

REFERENCES

Ankudowicz, A., Król, E., & Dębska-Ślizień, A. (2016).

Do Patients With End-Stage Chronic Renal Failure

Treated With the Use of Hemodialysis Have Healthy

Skin? Evaluation of Skin Lesions and Basic Education

About Risk Factors for Skin Cancer in This Patient

Population. Transplantation Proceedings, 48(5),

1435–1438.

https://doi.org/10.1016/j.transproceed.2016.03.004

Ankudowicz, A., Król, E., Dębska Ślizień, A., &

Czernych, R. (2018). The risk of skin diseases in

maintenance hemodialysis. Transplantation

Proceedings.

https://doi.org/10.1016/J.TRANSPROCEED.2018.02.

133

Bullechek, Gloria; Butcher Howard; Dechteerman, joanne;

wagner, C. (2013). Nursing Intervention Classification

(NIC).

DebMandal, M., & Mandal, S. (2011). Coconut (Cocos

nucifera L.: Arecaceae): In health promotion and

disease prevention. Asian Pacific Journal of Tropical

Medicine, 4(3), 241–247.

https://doi.org/10.1016/S1995-7645(11)60078-3

Evangelista, M., Casintahan, F., & Villafuerte, L. (2014).

The effect of topical virgin coconut oil on scorad,

transepidermal water loss and skin capacitance in mild

to moderate pediatric atopic dermatitis: A randomized,

double-blind clinical trial. International Journal of

Dermatology, 53(4), 100–108.

https://doi.org/10.1111/ijd.12339

Hollis, M. (1998). Margaret Hollis, Elisabeth Jones-

Massage for Therapists (1998)(1).pdf (Second Edi).

Oxford: Blackwell Science.

Kolla, P. K., Desai, M., Pathapati, R. M., Mastan Valli, B.,

Pentyala, S., Madhusudhan Reddy, G., & Vijaya

Mohan Rao, A. (2012). Cutaneous Manifestations in

Patients with Chronic Kidney Disease on Maintenance

Hemodialysis. ISRN Dermatology, 2012, 1–4.

https://doi.org/10.5402/2012/679619

Masmoudi, A., Darouiche, M. H., Salah, H. Ben, Hmida,

M. Ben, & Turki, H. (2014). Cutaneous Abnormalities

in Patients with End Stage Renal Failure on Chronic

Hemodialysis. A Study Of 458 Patients. J Dermatol,

86–94.

Melastuti, Erna., Setyaningrum, D. . (2016). Effectiveness

of providing Virgin Coconut Oil (VCO) towards

pruritus reduction: Study on patients with chronic

kidney disease undergoing hemodialysis. In Global

Nursing Challenges in The Free Trade Era (pp. 281–

285). Surabaya.

Effect of Cutaneous Stimulation and Virgin Coconut Oil on Skin Moisture in Patients with Chronic Renal Failure

343

Mettang. (2016). Pruritus. London: Springer.

Min, J. W., Kim, S. H., Kim, Y. O., Jin, D. C., Song, H.

C., Choi, E. J., … Kim, Y. K. (2016). Comparison of

uremic pruritus between patients undergoing

hemodialysis and peritoneal dialysis. Kidney Research

and Clinical Practice, 35(2), 107–113.

https://doi.org/10.1016/j.krcp.2016.02.002

Noor, Norhayati Mohamed., Aziz, Azila Abd., Sarmidi,

Mohamad Roji., Aziz, R. (2013). The Effect of Virgin

Coconut Oil loaded Solid Lipid Particles (VCO-SLPs)

on skin hydration amd skin elasticity. Jurnal

Teknologi, 62(1), 39–43.

Perry.A. Griffin., Potter, Patricia.A., Ostendorf, W. R.

(2014). Clinical Nursing Skills & Technique (Eighth

Edi). Canada: Elsevier Inc.

Robles-Mendez, J. C., Vazquez-Martinez, O., & Ocampo-

Candiani, J. (2015). Skin manifestations of chronic

kidney disease. Actas Dermo-Sifiliográficas (English

Edition), 106(8), 609–622.

https://doi.org/10.1016/j.adengl.2015.09.001

Roswati. (2013). Pruritus pada pasien Hemodialysis.

Cermin Dunia Kedokteran, 40(4), 260–264.

Sukartin, K. & S. (2005). Gempur Penyakit dengan VCO.

Jakarta: PT. AgroMedia Pustaka.

Unal, K. S., & Balci Akpinar, R. (2016). The effect of foot

reflexology and back massage on hemodialysis

patients’ fatigue and sleep quality. Complementary

Therapies in Clinical Practice, 24, 139–144.

https://doi.org/10.1016/j.ctcp.2016.06.004

Verallo-Rowell, V. M., Dillague, K. M., & Syah-

Tjundawan, B. S. (2008). Novel antibacterial and

emollient effects of coconut and virgin olive oils in

adult atopic dermatitis. Dermatitis : Contact, Atopic,

Occupational, Drug, 19(6), 308–315.

https://doi.org/10.2310/6620.2008.08052

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

344