Diabetic Neuropathy Approximately 60% of Diabetics will develop a form of neuropathy despite tight glucose control on or after 5 years

of diagnosis. The occurrence increases to 90% with lack of tight glucose control on or after 5 years of diagnosis. Diabetic Neuropathy may occur in three types of peripheral nerves: Sensory Motor Autonomic Neuropathy can be symmetrical or asymmetrical in nature, and may also affect a single joint or multiple joints. The most common form of neuropathy is symmetrical in nature. The location of neuropathy can occur anywhere along the path of the given nerve; e.g. proximal versus distal. Distal neuropathy is the most common. The most common form of neuropathy involves the lower extremities / feet. Common forms and signs and symptoms of neuropathies include the following Sensory nerves: numbness, tingling, pain, loss of proprioception and vibration Motor nerves: loss of muscle mass, loss of motor function, foot drop Autonomic Nerves: Stomach Intestines Bladder Sexual Organs o bloating, nausea, vomiting o diarrhea, constipation o urinary incontinence, urinary tract infections o erectile dysfunction, vaginal dryness

If diabetic neuropathies of the lower extremities / feet is present, chances are other forms of neuropathy already exist. Consider the following examples when the patient presents with peripheral neuropathy of the feet: the patient complained of bloating and vomiting after eating, gastroparesis could possible be the culprit; the patient has frequent bouts of urinary tract infection, and overflow incontinence, neurogenic bladder could be the possible culprit.

The common problems encountered with diabetic neuropathy of the lower extremities / feet include the following: Skin changes due to the nerves inability to produce oil and lack of moisture control, dryness and flakiness being the most common Calluses are easily formed usually due to improper footwear or an abnormal gait. Calluses need to be addressed because if allowed to deteriorate they will form an open sore. Podiatric services is a vital intervention for calluses. Poor circulation usually demonstrates proximal to distal cooling of the lower extremities. This is a potential problem because a patient may try to warm the feet with water that is too hot or wear socks that may promote falls. We know what poor circulation does to normal wound healing, usually doubling the normal healing process timeframe. Smoking is a huge problem too if poor circulation already exists, usually tripling the normal healing process timeframe. Intermittent claudication is a usual phenomenon.

There is a high correlation with smoking and non-traumatic amputations in the diabetic population. Ulcer formation is a big problem associated with diabetic neuropathy of the lower extremities / feet. Improper care of the web spaces (wetness due to improper drying or using oils and lotions), calluses, abnormal pressure areas on parts of the feet (improper footwear), or traumatic lesions like stepping on a small pebble or sharp objects (usually due to not wearing appropriate footwear). Amputations of toes, the metatarsal area, and/or foot, leads to increased vulnerability to falls due to imbalance and/or impaired mobility. Nailbeds are usually dystrophic (thickened) and mycotic (fungus usually causing yellowing of the nail.) Proper care of nails is essential to preventing ulcerations of surrounding tissue and infections of the nailbeds.

The American Diabetic Association recommends inspecting the feet daily by the patient/caregiver. It is prudent for us to address assessment of the lower extremities if nursing is providing daily skilled nursing visits for insulin administration and/or finger-stick blood sugar analysis. It could be as simple as asking the patient if he/she has pain or numbness, evaluating that proper footwear is present, and assessing proper muscle strength and ambulation of the lower extremities / feet as they see the patient walk. With this in mind, I created the modified integumentary system and possible options for the nurse to choose, relative to assessment parameters that are normally associated with daily nursing interventions. I stayed away from acute situations like moderate to severe pain or burning, ulcers, infections, vomiting, diarrhea, or incontinence because these should be addressed through appropriate NDPs, as they are not normal variations associated with assessment findings of neuropathy. It is also noted that tingling, pain and prickling like sensations may not always be a negative outcome, or evidence of deterioration. Consider this example: The patient has complete numbness, no pain and bilateral foot drop. Vitamin B12 injections are started along with physical therapy. As nerves regenerate at approximately an inch per month, the patient starts developing prickling sensations, and some intermittent pain sensations. In this situation this is a good outcome. Controlling the pain is still important but can controlled with appropriate medications.