Holistic care of patients with diabetic foot ulcers during the COVID-19 era: integration of Henderson's Need Theory

As of 17 July 2022, the World Health Organization (WHO) reported more than 559 million cumulative cases of COVID-19 with more than 6 million deaths globally (WHO, 2022). The rapidly changing situation has impacted healthcare delivery including diabetes care (Schofield et al, 2020); access to outpatient clinics has been limited to prevent outbreaks (Peric and Stulnig, 2020). The COVID-19 pandemic has presented challenges, particularly for patients with foot ulcer complications (Yunir et al, 2022). Furthermore, psychological issues were also found in times of pandemics including emotional distress and psychosocial disintegration (Mukhtar and Mukhtar, 2020).

These clinical manifestations pose new challenges in diabetic foot ulcer (DFU) care. Therefore, a comprehensive approach is needed to prevent the long-term effects of COVID-19 in patients with DFUs. An investigation described ‘the double triage, double buffer, and dual mode’ model and the process for treatment of DFUs in hospitals in China (Tao et al, 2020). Rogers et al (2020a) proposed a Pandemic Diabetic Foot Triage System in order to reduce complications, while Meloni et al (2020) also found that a triage pathway helps the health professional in delivering DFU care during the COVID-19 pandemic. Using an algorithm for surgical intervention prevents the negative impact of COVID-19 infection in people with diabetes (Kelahmetoglu et al, 2020). Kamal et al (2021) designed a hospital bed specifically for diabetic foot care, and there is lots of scope for health technology to be optimised in delivering care for patients with a chronic illness (such as DFUs) (Nabilla et al, 2021).

The publications discussed above described the importance of DFU care during the pandemic. However, there is limited standardisation of the best care for patients with a DFU. For instance, most studies focused on the physical aspect and fewer addressed the psychological aspects. In addition, none of the studies considered integrating nursing theory. In such situations, without the implementation of theoretical knowledge, it may lower the quality of patient care. Therefore, this article elaborates on Henderson's 14 needs in the context of DFU care during the pandemic. Using Henderson's Need Theory is appropriate as it focuses on individualised care and describes nurses' roles in assisting the individual in their daily activities, thus contributing to health and recovery (Henderson, 1966). The purpose of the study was to implement Henderson's Theory into DFU management within the COVID-19 pandemic. It is hoped that the findings serve as a basis for holistic nursing practice during the COVID-19 era.

Literature search

This review used online databases including Scopus, SAGE, SpringerLink, ProQuest, PubMed, CINAHL, and Google Scholar. The keywords were terms for 14 basic human needs in line with those identified by Henderson such as ‘breathe’, ‘eat and drink’, ‘urination and defecation’, ‘physical activities’, ‘sleep and rest’, ‘select suitable clothes-dress and undress’, ‘body temperature’, ‘keep the body clean and well-groomed and protect the integument’, ‘avoid dangers and injuring others’, ‘expressing emotions, needs, fears, or opinions’, ‘worship’, ‘work’, ‘recreation’, ‘learn, discover, or satisfy curiosity and use health facilities’. These keywords were combined with the terms ‘diabetic foot ulcer’ and ‘diabetes’.

The inclusion criteria were articles in English, articles relevant to Henderson's nursing theory, studies using quantitative and qualitative design, and articles published from 2000 to 2020. The exclusion criteria were diabetes studies not describing the concept of Henderson's nursing theory. The initial search retrieved 254 articles. After assessing the title and abstract, 150 articles were excluded. Thus, a review of the full text was conducted on 104 articles. Again, 74 articles were excluded due to failing to meet the inclusion criteria (Figure 1). A total of 30 articles were included in the final analysis (Table 1).

Henderson's 14 needs and DFU care during the COVID-19 pandemic

Virginia Avenel Henderson (1897–1996), known as ‘The First Lady of Nursing’ and ‘The Nightingale of Modern Nursing’, developed the Need Theory, which is widely implemented in nursing practice (Huitzi-Egilegor et al, 2014). The theory consists of the psychological, physiological, spiritual, and social aspects. Henderson emphasised helping the individual to maintain health or accelerate recovery (Alligood, 2013). Implementing this theory is relevant with the recent condition of the pandemic as most patients with a DFU require assistance. The theory calls attention to the importance of increasing the patient's independence so the healing progress would not be delayed. Under these circumstances, the aim of this article is to describe how Henderson's 14 basic human needs can be integrated into practice during the pandemic.

Breathe normally

Henderson emphasised the importance of the respiratory system for the body's metabolism (Current Nursing, 2020). Breathing is a gas exchange process distributing oxygen followed by removing carbon dioxide from the body (Patwa and Shah, 2015). COVID-19 causes breathing problems such as pneumonia leading to acute respiratory distress syndrome (ARDS) (Gibson et al, 2020). A systematic review by Hasan et al (2020) highlighted that ARDS is the leading cause of fatality in patients with COVID-19 infection. Nurses need to refer the patients to the emergency department for advanced management (Deitrick et al, 2020). For example, respiratory intervention will be the first-line strategy to prevent fatality (Gattinoni et al, 2020). Patients with diabetes may be at increased risk of developing pneumonia (Bader et al, 2016). The pneumonia severity index is helpful to calculate the probability of morbidity and mortality (Chalmers et al, 2010). Assessing the breath pattern or rhythm and delivering oxygen therapy where needed can reduce respiratory symptoms. In addition, community nurses are in a key position to promote respiratory health via their access to individuals and families (McHugh et al, 2009). Awareness of Hamman's syndrome is very important as the patient may present with chest or neck pain and shortness of breath. This syndrome is likely underdiagnosed as the main symptom is shortness of breath, which is attributed to Kussmaul's breathing (Pain et al, 2017).

Eat and drink adequately

Henderson highlighted the importance of a balanced diet (Gonzalo, 2022). It is well known that malnutrition increases the chance of viral infections. Social isolation during the pandemic resulted in more severe effects on nutritional status (Visser et al, 2020). It is recommended that patients have a routine consultation with nutritionists regarding maintaining a good nutritional status (Banerjee et al, 2020). In addition, patients with COVID-19 infection who are malnourished are at a high risk of mortality (Handu et al, 2021). Therefore, the nurse should bear in mind the nutrition aspect of care by recommending an adequate intake of dietary protein, essential fatty acids, fibre, and micronutrients such as vitamins B12, C, D, zinc, folate, and selenium (Mahluji et al, 2021). Nutritional intervention should be a part of regular care in patients with diabetes (Basiri et al, 2020). Engaging family support will optimise nutrition in patients with diabetes, particularly important during the pandemic (Fernández-Quintela et al, 2020; Horikawa et al, 2020).

At the other extreme, obesity has been highlighted as a risk factor for severe illness and hospitalisation with COVID-19 (Centers for Disease Control and Prevention, 2022). Obesity is thought to impair immune function, altering cell-mediated immune responses and leukocyte counts (Ganeshan and Chawla, 2014). This also has implications for patients with DFU – Harris et al (2019) found that very obese patients hospitalised with a DFU and infection were at higher risk of sepsis than patients who were less overweight.

Urination and defecation

Henderson explained that individuals should eliminate body waste (Current Nursing, 2020; Gonzalo, 2022). Urination and defecation are body mechanisms to eliminate solid, semisolid, or liquid waste material (Pellatt, 2007; Sands and Layton, 2009). Nurses should evaluate the gastrointestinal symptoms related to COVID-19 infection. A study documented that SARS-CoV-2 leads to diarrhoea (Villapol, 2020). However, symptoms of diarrhoea could be easily overlooked by health professionals in hospital or community practice (Xiao et al, 2020). Nurses will need to deliver interventions including fluid therapy, self-management, patient education, and follow-up care (Cong et al, 2018; Prasad et al, 2020). In addition, outpatient care management and gastroenterology consultations are also important (D'Amico et al, 2020).

Physical activities

Henderson emphasised the importance of moving and maintaining desirable posture (Current Nursing, 2020; Gonzalo, 2022). Most people have been subject to stay-at-home orders, which may potentially reduce their physical activities. As a result, there was an increase in sedentary behaviour and more unhealthy food consumption (Marçal et al, 2020), meaning the risk of getting type 2 diabetes will also increase (Kishimoto et al, 2021). To overcome this, wound care nurses should encourage the patients to increase their level of physical activity at home. The American Diabetes Association recommends physical activity for at least 150 minutes a week (Wake, 2020). In addition, engaging in physical activities for 30 minutes a day is also important to improve the immune system (Isrofah et al, 2017). For example, non-weight-bearing exercise should be involved as part of the management plan for patients with diabetic foot ulcers (Tran and Haley, 2021).

Sleep and rest

Henderson encourages achieving adequate sleep and rest (Current Nursing, 2020; Gonzalo, 2022). The risks of circadian disruptions and sleep-wake disorder have been increased in patients with diabetes during the COVID-19 pandemic. This is due to the impairment of melatonin production, immune system response, and glucose metabolism in those who have been infected with the coronavirus (Alimoradi et al, 2021). For many people, the pandemic situation itself leads to anxiety and sleep problems (Yu et al, 2020; Morin and Carrier, 2021). If a patient has less sleep this will cause memory problems (Chaput et al, 2018; Tucker et al, 2020). Therefore, nurses need to help the patient with DFU in finding effective coping strategies Wound care nurses should use instruments to assess memory problems, for example the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA) (Siru et al, 2021). With the use of effective programmes to overcome psychological distress, the incidence of sleep problems can be reduced in the clinical or community setting. Monitoring and advising strategies to maintain adequate sleep quality and duration is required (Barone et al, 2020). Sleep fragmentation has been found to be a predictor of poor wound healing and Chen et al (2021) suggested using polysomnography to evaluate sleep disorders and risk-stratify wound healing in patients with DFUs. They also acknowledged that wearable devices and smartphone applications might be more widely available alternatives for screening/assessing sleep quality, but the validation of these methods needs to be considered.

Select suitable clothes, dress and undress

Henderson explained the use of suitable clothes for patients (Current Nursing, 2020; Gonzalo, 2022). During the COVID-19 pandemic, patients with DFUs (eg with severe symptoms) are also encouraged to change their clothes to minimise infection and to increase comfort. The daily caregiver may help the patient, particularly those unable to change their own clothes unaided, or need help with the selection of suitable clothing that fits comfortably over wound dressings and allows ease of access to change dressings. Unfortunately, studies focusing on this aspect are limited, so it needs further investigation.

Body temperature

Henderson recommends maintaining body temperature within the normal range (Current Nursing, 2020; Gonzalo, 2022). Fever is a symptom of infection including COVID-19 infection (Zhang et al, 2020). If the patient experiences a fever, it may lead to dehydration requiring intravenous fluids. Therefore, community nurses need to provide interventions such as supplying adequate hydration, medication, blood glucose assessment, and insulin injections (Wang et al, 2020). Nurses need to understand temperature regulation and the febrile response to provide comprehensive nursing care. Consequently, monitoring temperature and assessing for other signs and symptoms of infection are also crucial for patients with a DFU – in a pandemic situation, a high temperature may be attributed to COVID-19 but could equally be a sign of complications with the ulcer. Comprehensive documentation is needed to improve the recognition and treatment of fever. To promote this, electronic medical records can be integrated with documentation prompts or relevant tools (Thompson and Kagan, 2011).

Keep the body clean and well-groomed and protect the integumentary system

Henderson encourages keeping the patient's body clean and well-groomed, protecting the integumentary system (Current Nursing, 2020; Gonzalo, 2022). This parameter refers to the implementation of self-care during the pandemic. During the pandemic, self-care in patients with DFUs has been a great struggle due to the impact of quarantine, social distancing, containments, and lockdown (Mukona and Zvinavashe, 2020; Bala et al, 2021). Bala et al (2021) found that patients in India with diabetes, who had problems with access to medical appointments compared with before the pandemic, were not performing foot checks daily as they needed to. In the UK, telemedicine has played a significant part in monitoring active diabetic foot disease during lockdowns (Stafford, 2020).

Wound-care nurses should optimise the role of caregivers, implement self-care management education, and use telemedicine for consultation purposes (Gupta et al, 2020). Evidence suggests that routine application of skin care using gentle cleansers and moisturisers improves skin barrier dysfunction and helps in preventing complications in patients with diabetes (Kirsner et al, 2019).

Avoid dangers and injuring others

Henderson highlighted avoiding dangers and preventing injuring others in daily activities (Current Nursing, 2020; Gonzalo, 2021). It has been recommended that patients with a DFU should remain at home to reduce the chances of COVID-19 infection. A study explained that patients with diabetes are immunocompromised and at higher risk of viral infection (Zhou et al, 2018). As a result, wound-care nurses should provide strategies to prevent infection with coronavirus. For example, providing online consultation on foot care and diabetes care at home, routine assessment, and follow-up care. In addition, preventing the patient from walking barefoot as it may increase the risk factor for diabetic foot disease. Thus, public health messages should strongly advise patients to use footwear in their daily activities (Hirpha et al, 2020).

Expressing emotions, needs, fears, or opinions

Henderson emphasised that patients express emotions, fears, needs, and opinions in their life (Current Nursing, 2020; Gonzalo, 2022). Patients with diabetes may have psychosocial issues due to worrying about getting the right food, insulin, and other medication, and accessing usual care (eg foot care) (Hillson, 2020; Joensen et al, 2020). Moreover, the prevalence of significant post-traumatic stress symptoms related to COVID-19 was 96.2%; such people need psycho-educational services (Bo et al, 2021). Thus, an integrated multidisciplinary approach is needed to manage psychological issues during the pandemic. Community nurses need to collaborate with mental health specialists for psychological care optimisation. For instance, mental health screening, telepsychiatry, dietary changes, physical exercises, health education, self-monitoring, and blood glucose control (Singhai et al, 2020). In addition, behaviour change intervention is also important for individuals with diabetes to improve foot self-management (Paton et al, 2021).

Worship

Henderson advocated respect for the patient's religious and spiritual beliefs related to healing (Current Nursing, 2020; Gonzalo, 2022). Patients with diabetes often experience challenges including dependence on nursing care, loss of a job, family problems, and social issues (de Wit et al, 2020). Adherence to a set of beliefs, values, and practices may be of importance to patients with DFUs and their families. It is therefore essential that nurses acquire a basic knowledge of the most common religions to deliver holistic care that meets the patients' needs. Furthermore, religious beliefs may have implications for diet, dress, and medication. Even though this condition leads to complex treatment, there is also a need for spiritual and psychological care (Kalra et al, 2018). Nurses are urged to check the details of their patients' religious practices and not to make assumptions. In addition, a study confirmed that patients with higher religiosity had significantly better glycaemic control (How et al, 2011). Therefore, community nurses are required to integrate spiritual care into their nursing, to help prevent adverse psychological outcomes (Subrata, 2020). For example, showing reverence for religious differences, keeping an open mind, showing respect for the individuality of the patient and assuming nothing.

Work

Henderson highlighted the benefits of work in giving people a sense of accomplishment (Current Nursing, 2020; Gonzalo, 2022). In terms of DFU care, work may increase stress levels when the patient needs to visit the hospital during working hours. In addition, nurses may give advice as follows: discussion with the patient's manager related to flexible working time, asking for support from colleagues, making a plan to go to a healthcare facility for a general check-up, and joining education courses (Diabetes UK, 2021). However, studies describing this aspect are limited in the literature.

Recreation

Henderson recommended playing or participating in various forms of recreation (Current Nursing, 2020; Gonzalo, 2022). As is well known, recreation activities are part of a coping strategy in times of high stress, particularly for patients with DFUs, who have a higher chance of having psychological issues (Fejfarová et al, 2014; Szilágyi et al, 2019). Also, engaging with the natural environment is an important contributor to their sense of identity, belonging, and community (Slater et al, 2020). Where there are high numbers of cases of COVID-19, these activities should be restricted to reduce the spread of the virus. However, community nurses need to stay connected with the group of patients. For instance, delivering motivation to find satisfying activities at home to reduce psychological stress. A systematic review by Pai et al (2012) highlighted that moderate physical leisure time activities for 60 minutes every week are effective in improving glycaemic control in patients with type 2 diabetes.

Learn, discover, or satisfy curiosity and use health facilities

Henderson brings attention to learning, discovering, or satisfying curiosity and use of healthcare facilities (Current Nursing, 2020; Gonzalo, 2022). During the COVID-19 era, patients with DFU should make optimal use of healthcare facilities to control symptoms and prevent complications such as limb amputations. However, there is evidence that the use of health services has decreased since the beginning of the COVID-19 pandemic (Health Foundation, 2022). Thus, implementing telemedicine will help in delivering DFU care. Technology can be used to supplement healthcare provider diabetes care by providing both educational and motivational support. Education can be provided using technology, allowing patients to learn new practices and routines related to diabetes management. Technology can support daily diabetes self-management activities including blood glucose monitoring, exercising, healthy eating, taking medication, monitoring for complications, and problem-solving (Hunt, 2015). However, studies focusing on the learning, discovering, or satisfying aspects of Henderson's Need Theory are limited in the literature.

Discussion

Henderson's nursing theory highlighted that nursing practice should emphasise the patient's independence as the highest priority. Since DFUs require regular visits to healthcare services, the goal of management has already changed to preventing wound complications along with hospitalisation (Rogers et al, 2020b). The nurse may assist in accomplishing the 14 patient needs so the healing progress will not be delayed after any hospitalisation (Nayeri et al, 2020). By considering the increased prevalence of DFUs and COVID-19 infection, the International Diabetes Federation (IDF) recommends improving the quality of diabetes care worldwide (Hussain and Boulton, 2020). As is well known, a DFU requires a specific approach, involving a combination of nurses and other health professionals. Ongoing care is still needed during the COVID-19 pandemic, for example, using telemedicine. However, this is difficult as delivering care for patients with a DFU requires ‘hands-on’ management (Boulton, 2021). In addition, patients with hard-to-heal wounds are treated in virtual hospitals and clinics. The pandemic was a challenging situation in which to deliver DFU care because of the following: protection of vulnerable patients and shielding principles, decreased capacity for clinics and hospital admissions, staff shortages and staff-related sickness among specialists, patient-related challenges, reduced allied health professional input, vascular service, transport and logistical difficulties (Jaly et al, 2020).

The Need Theory model has three assumptions: nurses care for the patient until the patient can care for themselves; nurses will devote themselves to the patient; and nurses should have a higher education at the college level (Petripin, 2020). The assumptions also apply during the COVID-19 pandemic. The assumptions can be achieved by optimising the role of nurses in DFU care, both in clinical and community settings. For instance, through collaboration with different professionals and educating the caregiver in DFU care. However, several parameters still need to be integrated into nursing research, including ‘select suitable clothes-dress and undress’, ‘learning, discovering, or satisfying’, and ‘work’.

Recently, the concept of a ‘Wound Center Without Walls’ (WCWW) become a model for delivering DFU care in times of pandemic (Rogers et al, 2020b). It describes an algorithm of care for wound patients (eg DFUs) based on triage category and setting. For DFU care optimisation, the concept of WCWW can be integrated into Henderson's 14 needs. During the pandemic, wound-care nurses' and other health professionals' roles have adapted to communicating with patients, families, and home health services in preparing the best care (Rogers et al, 2020b). The nurse can enhance patients' independence and that of their families by providing foot care education.

Conclusion

The article has discussed the implementation of Henderson's Need Theory and the 14 basic needs outlined in this in DFU care during the pandemic. Wound-care nurses should provide comprehensive strategies, including online consultation, follow-up care and screening for DFU complications. Also, an integrated multidisciplinary approach is urgently needed for a cohesive and high-quality approach to care of patients with DFUs. Further studies will be needed in order to translate this evidence into clinical nursing practice.

KEY POINTS

• The prevalence of COVID-19 infection is increasing worldwide
• Integrating Henderson's 14 needs theory into diabetic foot ulcer (DFU) care during a pandemic will help community nurses care for patients
• Nurses, patients and families should work in together to achieve the best possible DFU care during COVID-19

CPD reflective questions

• What are the main points of DFU care that can be implemented during a pandemic?
• Evaluate the achievement of Henderson's 14 needs in patients in your community nursing practice
• How would you establish collaborative working with other healthcare professionals during a pandemic?