Diabetic neuropathy is a peripheral nervous system pathology caused by diabetes mellitus (DM). Its development correlates to the duration of DM and the patient’s compliance with lifestyle modifications and therapeutic modalities to control their serum glucose level. Obesity, smoking, excessive alcohol consumption, hypertension, elevated triglyceride levels, and preexisting heart disease increase the risk of developing diabetic neuropathy.
Even though the exact etiology of diabetic neuropathy is unknown, uncontrolled high blood sugar leads to microvascular damage causing poor oxygen and nutrient delivery to the nerves. Distal sensory and autonomic fiber damage may progress until there is a gradual loss of sensation in the skin and tissues.
Peripheral neuropathy is very common in patients with diabetes. The peripheral nerves are affected, with complaints of burning, tingling, and numbness in the lower legs and feet.
Autonomic neuropathy damages internal organs such as the heart, digestive system, sexual organs, sweat glands, and more. Patients may experience changes in bowel habits, sexual dysfunction, nausea and vomiting, and low blood pressure.
Focal neuropathy affects one nerve at a time, most often in the hand, chest, or leg. Entrapped nerves, such as with carpal tunnel syndrome, are the most common focal neuropathy.
Patient history may be used as a solid basis for detecting diabetic neuropathy. Doctors may also recommend electromyography and nerve conduction studies if severe or rapidly progressive symptoms or motor weakness exist.
Nursing Process
Nurses should conduct frequent assessments of symptoms to prevent diabetic foot ulcers because patients with diabetes mellitus have poor wound-healing ability. Their high risk for injury due to the lack of protective sensation makes them vulnerable to lower extremity compromise, local to systemic infection, septicemia, and death. Nurses can help patients prevent this complication with frequent education on medication adherence, diet, and lifestyle modifications.
Nursing Care Plans Related to Diabetic Neuropathy
Unstable Blood Glucose
Uncontrolled glucose levels increase the incidence of complications.
Nursing Diagnosis: Unstable Blood Glucose
Related to:
- Insufficient adherence to diabetes management
- Inadequate blood glucose monitoring
- Deficient knowledge of the disease process
- Changes in weight
- Change in activity level
- Stress
As evidenced by:
- Frequent urination
- Increased thirst
- Tingling sensation/numbness in feet
- Headache
- Dizziness
Expected outcomes:
- Patient will maintain glucose levels at or below 125 mg/dL.
- Patient will verbalize a plan for modifying their lifestyle to prevent variations in glucose levels.
- Patient will verbalize their medication regimen for controlling diabetes mellitus.
Assessment:
1.Assess the patient’s knowledge of their disease process.
Assessing the patient’s understanding of diabetes and its treatment will help the nurse determine where barriers and gaps in knowledge lie to prevent unstable glucose levels.
2. Monitor for signs and symptoms of hypoglycemia/hyperglycemia.
Signs of hypoglycemia include changes in the level of consciousness, cool and clammy skin, tachycardia, headache, lightheadedness, anxiety, and hunger. Symptoms of hyperglycemia include increased thirst, polyuria, blurred vision, and recurrent infections. Uncontrolled glucose levels increase the risk of diabetic neuropathy.
Interventions:
1. Perform blood glucose testing.
Patients with diabetes will have individualized goals for glucose control, but most glucose levels should be below <125 mg/dL. Consistently high glucose levels damage blood vessels and nerves.
2. Conduct meal planning with the patient and family.
Diet is a crucial component of diabetes management. Complex carbohydrates are recommended as they help maintain glucose levels, lower cholesterol, and ensure satiety. Carbohydrate intake must be balanced and calculated according to the patient’s specific needs. Involving the family will promote a sense of involvement, especially if they prepare the patient’s meals.
3. Administer hypoglycemic medications.
The core management of DM lies primarily in the appropriate pharmacologic therapies necessary for each patient. Physicians may prescribe the following antidiabetic medications:
- Sulfonylureas (glipizide, gliclazide, glimepiride):
These medications inhibit the K-ATP channel, causing an influx of calcium and insulin release. - Meglitinides (repaglinide and nateglinide):
They work similarly to sulfonylureas by inducing insulin secretion from the pancreas. - Biguanides (metformin):
Metformin is the first-line agent for patients with type 2 DM. It acts by decreasing glucose production in the liver, decreasing intestinal absorption, and increasing insulin sensitivity. - Thiazolidinediones (rosiglitazone, pioglitazone):
These drugs increase insulin sensitivity and peripheral uptake of insulin. It also stimulates fatty acid oxidation, which leads to an increase in the number of insulin-sensitive adipocytes. - α-Glucosidase inhibitors (acarbose, miglitol, voglibose):
They competitively inhibit alpha-glucosidase enzymes, which convert complex carbohydrates into simple absorbable carbohydrates. - DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin):
They inhibit dipeptidyl peptidase 4 (DPP-4), causing a decrease in glucagon release and an increase in glucose-dependent insulin release. - SGLT2 inhibitors (dapagliflozin and canagliflozin):
They inhibit glucose reabsorption in the proximal tubules of renal glomeruli by inhibiting sodium-glucose cotransporter 2 (SGLT-2). - Insulin:
Injectable insulin helps with the uptake of glucose to be used for energy and for storage in the liver as glycogen.
4. Educate about the management of diabetes at home.
Since some possible reasons why patients have unstable glucose control include poor adherence and inadequate glucose monitoring, nurses must firmly instill in them the importance of adherence. Subsequently, compliance could be facilitated by providing adequate knowledge to patients about their disease condition and management.
Risk for Impaired Skin Integrity
Loss of protective sensation and alterations in tissue perfusion and oxygenation brought by hyperglycemia make the patient vulnerable to tissue damage.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related to:
- Decreased blood and nutrients to tissues secondary to DM
- Imbalanced nutrition
- Obesity or emaciation
- Mechanical trauma secondary to alterations in protective sensation
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will maintain intact skin integrity.
- Patient will verbalize understanding of diabetic neuropathy, including its risk factors and possible complications.
- Patient will demonstrate lifestyle changes to prevent poor skin integrity.
Assessment:
1. Assess blood supply and sensation of the affected area, especially the feet.
Feet are the most distal parts vulnerable to poor wound healing due to impaired tissue perfusion brought on by diabetes mellitus and loss of sensation from neuropathy.
2. Identify causes of risks for impaired skin integrity.
Along with DM, poor physical conditioning, impaired mobility, age, inability to perform self-care, and other chronic conditions may increase the risk of impaired skin integrity.
Interventions:
1. Provide or encourage optimum nutrition.
Adequate nutrition ensures better tissue health, and proper hydration minimizes fluid loss in the cells and improves circulation.
2. Recommend routine podiatry visits.
Patients with diabetic neuropathy may require visits to a podiatrist who is trained to inspect the feet as well as safely trim toenails.
3. Instruct on proper care of extremities.
Feet are the most vulnerable parts to experience impaired skin integrity as these are the areas that are last to be perfused. Advise not to manipulate or engage in activities that may harm the feet (e.g., pedicures, walking barefoot, wearing tight-fitting shoes).
4. Protect the patient from any environmental hazards.
Patients with diabetic neuropathy have decreased sensation to detect hazardous objects that may injure the tissues. They may have reduced sensation to heat/cold and sharp objects that can lead to injury.
Risk for Infection
The patient with DM and neuropathy has an increased risk of acquiring disease-causing pathogenic microorganisms due to their disease process and alterations in skin integrity.
Nursing Diagnosis: Risk for Infection
Related to:
- Alteration in skin integrity
- Compromised physical health secondary to DM
- Immunosuppression
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will remain free from any infection.
- Patient will demonstrate techniques and lifestyle changes to prevent infection.
Assessment:
1. Monitor for signs of infection or inflammation.
Immediate identification of local signs of infection and inflammation, such as erythema, swelling, pain, loss of function, and warmth, prevents progression to any systemic disease.
2. Monitor vital signs.
Vital signs are quick objective measurements of a person’s physical health. Hyperthermia, tachycardia, and tachypnea may indicate inflammatory or infectious processes.
3. Assess lab values.
Closely monitor the WBC, wound cultures, and CRP levels for signs of infection and inflammation.
Interventions:
1. Maintain an aseptic technique for any procedure.
Maintaining aseptic techniques in conducting procedures such as wound care reduces the risk of cross-contamination and the introduction of pathogens.
2. Obtain specimens for culture and sensitivities, as indicated.
Identifying the causative agent helps select the appropriate antibiotic therapy for the patient.
3. Administer antibiotics as appropriate.
Administering antibiotics as prescribed destroys the pathologic agent and prevents the development of resistance.
4. Instruct the patient and family on proper handwashing.
Handwashing is the simplest, most effective way to prevent infection.
5. Educate on wound healing.
DM reduces the body’s ability to heal itself. Instruct on extra precautions to prevent infection if the patient undergoes a surgical procedure or wound care.
References
- Bodman MA, Varacallo M. Peripheral Diabetic Neuropathy. [Updated 2022 Sep 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK442009/
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice. (14th ed.). Lippincott Williams & Wilkins.
- Doenges, M. E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. (10th ed.). F.A. Davis.
- Ganesan K, Rana MBM, Sultan S. Oral Hypoglycemic Medications. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482386/
- Jameson, L.J., et al. (2018). Harrison’s principles of internal medicine. (20th ed.). McGraw Hill.
