Peripheral neuropathy is a condition in which the distal nerves of the hands and feet are damaged and unable to transmit messages correctly, resulting in numbness, tingling, weakness and pain. The most common cause is diabetes, with more than half of all individuals with diabetes eventually developing a form of neuropathy. While the exact cause of diabetic neuropathy is unknown, nerve damage is related to persistently elevated blood glucose levels. In fact, tight blood glucose control in Type 1 diabetes has shown to reduce an individual’s risk of diabetic neuropathy by 78%. 

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While neuropathy can be idiopathic and have no known cause, some known causes include: 

  • Trauma – Physical injury can stretch, compress, crush or even detach nerves, leading to neuropathy. 
  • Infection – A wide range of viral and bacterial infections can cause neuropathy, such as Lyme disease, shingles, and hepatitis B and C.
  • Autoimmune disease – Conditions include rheumatoid arthritis, Guillain-Barre, vasculitis, and chronic inflammatory demyelinating polyneuropathy.
  • Tumors – Tumors can compress nerves, which limits their function
  • Toxins – Toxic substances that can cause neuropathy include arsenic, lead and organic solvents.
  • Medications – Many medications can cause peripheral neuropathy. Common culprits include chemotherapeutic agents, amiodarone, statins, some antibiotics, hydroxychloroquine, phenytoin, and lithium.
  • Bone marrow disorders – Patients with myeloma, lymphoma, and amyloidosis are at higher risk for developing neuropathy.
  • Nutritional deficiencyB vitamins, copper, vitamin E, thiamine, folate and other nutrients are essential for optimal nerve function. Note that patients with malabsorption disorders or alcoholism are at high risk for nutritional deficiencies.
  • Hypothyroidism – Left untreated, severe hypothyroidism can cause peripheral neuropathy due to excess fluid putting pressure on nerves.
  • Inherited conditions – Hereditary neuropathies such as Charcot-Marie-Tooth disease affect the peripheral nervous system.

What are the complications of peripheral neuropathy?

The key complications of peripheral neuropathy are injury, infection, falls, pain and disability. 

Injuries can occur more readily because the nerves are not able to transmit signals that let the brain know danger is present. Injuries can occur from things like heat, extreme cold, pressure, and sharp objects. If a wound does occur, then infection can go unnoticed simply because the pain typically associated with infection may not be noticed. Even simple wounds can lead to systemic infection and even sepsis.

Additionally, because neuropathy in the feet can affect one’s gait and balance, falls are another complication of this condition. It’s also important to note that neuropathy can cause lifelong pain, decreased quality of life, and decreased ability to perform ADLs.

Now that you have an understanding of peripheral neuropathy, let’s dive into the nursing implications using the Straight A Nursing LATTE Method. This method provides a framework for focusing on the key things a nurse needs to know. Keep reading to see it in action!

L: How does the patient LOOK?

The most prevalent symptoms of peripheral neuropathy are muscle weakness, numbness, tingling, and pain of the affected extremities. Other signs and symptoms include cramping pain and the inability to feel extreme temperatures (cold and heat). Some patients experience allodynia which is pain due to stimulation that normally would not provoke pain such as light touch. If your patient has peripheral neuropathy of the feet, you may want to tent the bedding so it doesn’t cause pain.

When the feet are affected, some patients experience loss of balance or coordination and are at high risk for falls.

A: How do you ASSESS the patient?

Key assessments for a patient with peripheral neuropathy include:

  • Assess the hands and feet for sensation to touch, heat, and cold. If the patient has a lack of sensation, they are much more prone to injury.
  • Assess the feet for wounds, which often go unnoticed by the individual, due to a lack of sensation.
  • Assess the patient’s gait, making note of balance or coordination issues that could lead to a fall.
  • Assess the patient’s ability to perform ADLs. Neuropathy in the hands may make getting dressed, writing or opening packages of food difficult. Neuropathy in the feet can significantly affect mobility.
  • Perform a thorough assessment of the patient’s pain. You may want to utilize a standard assessment such as OLDCARTS:
    • O (Onset): When did this pain start? Is it new or chronic?
    • L (Location): Where does it hurt?
    • D (Duration): Is the pain constant or does it come and go?
    • C (Characteristics): Can you describe the pain? Neuropathic pain is often described as shooting, pins and needles, burning, cramping, tingling or like “electrical shocks.” 
    • A (Aggravating factors): What makes the pain worse? A patient with peripheral neuropathy may state that walking or having the bed sheets touch their feet makes the pain worse.
    • R (Relieving factors): What makes the pain better? 
    • T (Treatment): What treatments are you currently utilizing or have used in the past? Some resources signify the T to represent “temporal patterns.” If using this component, ask the patient, “Have you noticed any patterns to when this pain occurs? For example, is it worse in cold temperatures or at night?
    • S (Severity): How severe is the pain on a 0 to 10 scale? The patient who experiences pain with peripheral neuropathy will likely describe the pain as extremely intense and disabling.

Not sure what to focus on when studying? Download the FREE LATTE method template

T: What TESTS are conducted for a patient with peripheral neuropathy?

Peripheral neuropathy is diagnosed through assessment of the patient’s symptoms, a thorough medical history, clinical exams and lab tests. The MD will assess the patient’s muscle strength and reflexes as well as sensitivity to temperature, light touch, position, and vibration. Specific diagnostic tests include: 

  • Ultrasound – Peripheral nerve ultrasound can show injured and compressed nerves.
  • Electromyography (EMG) – An EMG evaluates how well nerves and muscles work together by looking at the electrical activity of a muscle both at rest and during contraction. In this test, the physician places a very small wire into the specific muscle being evaluated. This pin acts like an antenna and picks up electrical activity of the muscle which is displayed on a screen. Data is collected at rest and during a muscle contraction.
  • Nerve conduction studies (NCS) – This test measures the speed at which an electrical impulse travels through a nerve and how much of that impulse is transmitted. In this test, the physician places sensors on the skin and a small electric shock is delivered, which activates the nerve. The MD evaluates the speed, size, and consistency of the nerve response and any associated muscle twitches.
  • Biopsy – Biopsies of nerve, skin or muscle may be utilized to examine nervous and muscle tissue. Muscle biopsies are typically utilized when other diagnostic tests have not provided a clear diagnosis.
  • Blood tests – Blood tests may be conducted to evaluate potential conditions that can contribute to peripheral neuropathy such as diabetes or nutritional deficiencies.

T: What TREATMENTS will be provided?

The main treatment goal for patients with peripheral neuropathy is to address the underlying cause if one is present. For example, a patient with neuropathy due to a vitamin deficiency may benefit greatly from nutritional supplementation. Or, a patient with diabetic peripheral neuropathy can see improvement by maintaining optimal blood glucose levels.

Pharmacologic treatments include medications for pain, seizures and depression, as well as topical treatments. Note that neuropathic pain doesn’t typically respond to traditional analgesics, so they are not often utilized. 

  • Anti-seizure medications – Three commonly used medications in this class are pregabalin, gabapentin and tegretol. It is thought that these medications block the transmission of pain signals. Common adverse effects include drowsiness and dizziness.
  • Antidepressants – Antidepressants have been shown to decrease pain in peripheral neuropathy, though the reason why this occurs is not fully understood. An accepted theory is that antidepressants affect neurotransmitter levels, and some neurotransmitters reduce pain signals. A commonly utilized medication in this class is the SSNRI duloxetine, which can cause nausea, anxiety and insomnia. Another commonly utilized antidepressant is the TCA amitriptyline, which can cause suicidal ideation and dangerous arrhythmias.
  • Topical – Topical medications include creams and patches that contain lidocaine or capsaicin.
  • Plasma exchange, IV immune globulin and steroids – These therapies may be utilized if the underlying cause of peripheral neuropathy is an autoimmune condition.

Nonpharmacologic therapies include: 

  • Physical therapy – PT can address muscle weakness and balance issues, making it easier for the individual to perform ADLs and ambulate safely. Assistive devices may be utilized such as a walker or braces for the hands or feet.
  • Occupational therapy – An occupational therapist can help patients determine which adaptive devices will be most beneficial as well as how to use them. Examples include zipper pulls and buttoners.
  • Surgery – If the cause of neuropathy is due to compression on the nerves (such as with carpal tunnel syndrome or a tumor), surgery may be utilized to relieve the pressure.
  • Acupuncture – Acupuncture helps re-stimulate damaged nerve fibers and improve blood flow, and may even help with nerve preservation and regeneration.
  • Transcutaneous electrical nerve stimulation (TENS) – Low-intensity electrical impulses are generated through electrodes, thereby disrupting pain signals and inhibiting pain transmission.
  • Scrambler Therapy – This noninvasive therapy option modifies pain pathways by stimulating specific nociceptors to produce nonpainful information that is often perceived as an itch, vibration, pressure, tingling or even a massage. One study showed that out of 11 patients with chronic cancer pain, 9 were able to stop using prescribed analgesics after just five sessions of scrambler therapy. The goal of Scrambler Therapy is to eliminate pain not only during treatment, but to provide long-lasting pain relief. The typical schedule is 10 to 12 daily treatments provided over a 2-week period (with two days off for the weekend). It’s important to note that antiseizure medications can decrease ST effectiveness due to their interference with action potentials, so patients will typically be weaned off these medications prior to or during ST treatment.
  • Spinal cord stimulator  – A surgically implanted spinal cord stimulator relieves pain by sending low levels of electrical stimulation directly into the spinal cord. The patient will have a small generator that resembles a pacemaker also implanted, typically near the abdomen or upper buttock. A remote device allows the patient to adjust the level of stimulation and turn it on or off as needed. Note that a spinal cord stimulator doesn’t remove the pain, it simply changes the way it is perceived by the brain. Some forms of SCS therapy induce a tingling or fluttering sensation while others do not.
  • Biofeedback therapy – Biofeedback utilizes monitoring devices to track involuntary body responses such as heart rate and blood pressure, which increase when painful stimulation is felt. A trained therapist instructs the individual how to use relaxation techniques to control the body’s involuntary responses, thereby reducing the pain associated with neuropathy.
  • Hypnosis – Studies suggest that hypnosis can play a key role as part of an integrative treatment approach and enhance the efficacy of other therapies.
  • Moxibustion: This is an Eastern remedy that is often used in conjunction with acupuncture to treat diabetic peripheral neuropathy. Moxibustion (also known as “moxa”) involves burning ground mugwort, which is utilized to warm specific points along the body and stimulate blood flow. Patients treated with this method have reported significant improvements in pain. 

Nursing-related treatments include careful and frequent repositioning to prevent pressure ulcers, since the patient may not be able to feel the pain associated with increased pressure. Additionally, ensuring skin is clean and dry is a vital measure that helps preserve skin integrity.

E: How do you EDUCATE the patient/family?

Since one of the key treatments for neuropathy is to address the underlying cause whenever possible, it’s imperative patients understand the importance of managing their underlying condition. 

As always, ensure patients understand each of their medications and that if antidepressants are prescribed, they could take several weeks to have an effect. Additionally, some patients experience suicidal ideation while taking antidepressants, so teach the patient to call 911 immediately if this occurs.

It’s also important to teach the patient about safety since a lack of sensation can lead to injury. Teach patients to be especially aware of their surroundings and to check for potential injuries regularly. Educate patients on the risk of burns with hot water and encourage them to lower the temperature setting on the water heater to 120-125 degrees F. Also teach patients to measure the temperature of hot beverages with a thermometer prior to drinking, as they may not notice the increased temperature by feel.

Other important elements to include in your teaching are: 

  • Teach patients with neuropathy of the feet to inspect their feet daily, wear closed-toe shoes and to always wear clean, dry socks.
  • Encourage the patient to exercise regularly, and to choose low-impact activities that don’t cause pain or put them at risk for injury. Examples include Tai Chi, yoga, swimming, walking and cycling.
  • Encourage the patient to talk with their physician regarding whether or not it is safe for them to drive a vehicle. Severe neuropathy of the hands or feet can make driving unsafe.
  • Teach the patient strategies to avoid falls at home such as removing slippery or thick rugs and other trip hazards, installing nightlights, and ensuring pathways from bed to bathroom are clear.
  • Teach patients/families to call their MD if the pain/numbness worsen, loss of function worsens, if the medication doesn’t help improve symptoms, or if the medication causes worrisome adverse reactions.

Want to dive deeper into diabetes, the most common cause of peripheral neuropathy? Learn more here.

Take this topic on the go by tuning in to episode 316 of the Straight A Nursing podcast. Listen from any podcast platform, or straight from the website here.

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The information, including but not limited to, audio, video, text, and graphics contained on this website are for educational purposes only. No content on this website is intended to guide nursing practice and does not supersede any individual healthcare provider’s scope of practice or any nursing school curriculum. Additionally, no content on this website is intended to be a substitute for professional medical advice, diagnosis or treatment.

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