Peripheral neuropathy arises from damage to the peripheral nerves, which are located outside the brain and spinal cord. This damage disrupts nerve signaling, leading to a range of symptoms including weakness, numbness, and pain, predominantly experienced in the hands and feet. The impact of peripheral neuropathy can extend beyond the extremities, affecting vital bodily functions like digestion and urination.
Understanding Peripheral Neuropathy
Peripheral neuropathy is not a single disease, but rather a condition resulting from nerve damage. Various factors can trigger this damage, including:
- Diabetes Mellitus: High blood sugar levels over time can injure nerves.
- Chronic Alcoholism: Excessive alcohol consumption is toxic to nerve tissues.
- Autoimmune Diseases: Conditions like rheumatoid arthritis and lupus can cause inflammation that damages nerves.
- Nutritional Deficiencies: Lack of essential vitamins, especially B vitamins, can lead to nerve damage.
- Infections: Certain bacterial or viral infections, such as Lyme disease and shingles, can affect nerves.
- Chemotherapy Drugs: Some chemotherapy agents are known to cause peripheral neuropathy as a side effect.
- Malignancy: Tumors can press on nerves or cause paraneoplastic syndromes that affect nerve function.
- Hypothyroidism: An underactive thyroid can sometimes lead to peripheral nerve damage.
- Trauma: Physical injury, such as fractures or compression, can directly damage nerves.
The symptoms of peripheral neuropathy are diverse and depend on the type of nerves affected:
Motor Symptoms: These relate to muscle control and movement.
- Muscle Weakness: Difficulty in lifting objects, walking, or performing fine motor skills.
- Paralysis: In severe cases, loss of muscle function.
- Uncontrolled Muscle Movements: Twitching, cramps, or spasms.
Sensory Symptoms: These involve sensations and feeling.
- Tingling: Pins and needles sensation, often in the hands and feet.
- Numbness: Reduced or complete loss of sensation, making it difficult to feel touch, temperature, or pain.
- Pain: Can range from sharp, stabbing pain to burning, throbbing, or aching pain.
- Loss of Balance: Difficulty maintaining equilibrium, especially when walking.
Autonomic Symptoms: These affect involuntary bodily functions.
- Orthostatic Hypotension: Dizziness or lightheadedness upon standing due to a drop in blood pressure.
- Tachycardia: Abnormally fast heart rate.
- Sweating: Excessive or decreased sweating.
- Bowel and Bladder Difficulties: Constipation, diarrhea, incontinence, or urinary retention.
- Sexual Dysfunction: Erectile dysfunction in men, vaginal dryness in women.
- Blurred Vision: Problems with vision due to nerve damage affecting eye muscles.
Diagnosis of peripheral neuropathy typically involves a combination of:
- Neurological Exams: Assessing reflexes, muscle strength, sensation, and coordination.
- Blood Tests: To identify underlying conditions like diabetes, vitamin deficiencies, or autoimmune diseases.
- Electromyography (EMG): To evaluate the electrical activity of muscles and nerves.
- Imaging Tests: MRI or CT scans to look for tumors, nerve compression, or other structural issues.
Image of a neurological examination being performed on a patient’s foot to assess peripheral neuropathy symptoms.
The Nursing Process for Peripheral Neuropathy
Nursing care for patients with peripheral neuropathy focuses on several key goals:
- Symptom Management: Alleviating the disruptive symptoms, particularly pain and sensory disturbances.
- Safety Maintenance: Preventing injuries due to impaired sensation and motor function.
- Underlying Cause Management: Collaborating with the medical team to address the root cause of the neuropathy.
- Patient Education: Empowering patients with knowledge about their condition, treatment options, and self-management strategies.
Nurses play a critical role in managing peripheral neuropathy through comprehensive assessment, planning, implementation, and evaluation of care. Nursing diagnoses are crucial for guiding this process and ensuring patient-centered care.
Nursing Care Plans for Peripheral Neuropathy
Nursing care plans are structured frameworks that help nurses prioritize care and interventions based on identified nursing diagnoses. For peripheral neuropathy, common nursing diagnoses include:
Chronic Pain
Nerve damage is a primary cause of chronic pain in peripheral neuropathy, leading to persistent and unpleasant sensory experiences.
Nursing Diagnosis: Chronic Pain
Related Factors:
- Impaired Sensation
- Physical Trauma
- Nerve Injury
Evidenced By:
- Patient’s self-report of pain intensity, quality, and location.
- Guarding behaviors (protecting painful areas).
- Facial grimacing or other pain expressions.
- Restlessness or irritability.
Expected Outcomes:
- Patient will report a reduction in pain intensity using a pain scale (e.g., from 7/10 to 4/10).
- Patient will demonstrate improved comfort, evidenced by relaxed posture and improved sleep patterns.
- Patient will verbalize and utilize effective pain management strategies.
Nursing Assessments:
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Pain Assessment: Elicit a detailed description of the pain from the patient, including onset, location, duration, characteristics (burning, stabbing, tingling), aggravating and relieving factors, and pain intensity using a standardized pain scale. Neuropathic pain can manifest in diverse ways, affecting single or multiple nerves, and patients may describe unusual pain triggers such as light touch or temperature changes.
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Nonverbal Pain Cues: Observe for nonverbal indicators of pain, especially in patients who have difficulty communicating verbally. These cues can include changes in facial expression (grimacing, furrowed brow), body movements (restlessness, guarding), vital sign changes (increased heart rate, blood pressure), and vocalizations (moaning, crying).
Nursing Interventions:
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Topical Medications Education: Educate the patient about over-the-counter topical pain relievers like capsaicin cream and lidocaine patches. These medications can provide localized pain relief with minimal systemic side effects by desensitizing nerve endings or numbing the area.
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Pharmacological Pain Management: Administer prescribed pain medications as ordered, which may include NSAIDs, opioids, anti-seizure medications (e.g., gabapentin, pregabalin), and tricyclic antidepressants (e.g., amitriptyline). These medications work through different mechanisms to modulate nerve pain signals. Anti-seizure and antidepressant medications are often effective for neuropathic pain by altering nerve excitability and neurotransmitter levels.
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Transcutaneous Electrical Nerve Stimulation (TENS): Instruct the patient on the use of a TENS unit. TENS units deliver mild electrical currents to the affected area, which can interfere with pain signals and stimulate the release of endorphins, providing pain relief.
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Surgical Intervention Preparation: Prepare the patient for potential surgical interventions if pain is caused by nerve compression from tumors, injuries, or other structural issues. Surgery aims to relieve pressure on the affected nerves, thereby reducing pain.
Image of a patient receiving TENS therapy for pain relief in their leg due to peripheral neuropathy.
Disturbed Sensory Perception (Touch)
Peripheral neuropathy disrupts normal nerve signaling, leading to altered sensory experiences, including diminished, distorted, or absent responses to stimuli.
Nursing Diagnosis: Disturbed Sensory Perception (Touch)
Related Factors:
- Impaired Sensation
- Altered Circulation
Evidenced By:
- Hyperesthesia (increased sensitivity to touch)
- Tingling sensations (paresthesia)
- Numbness (hypoesthesia or anesthesia)
- Muscle weakness
- Twitching
Expected Outcomes:
- Patient will demonstrate awareness of sensory deficits and implement compensatory strategies.
- Patient will remain free from injury related to altered sensory perception.
Nursing Assessments:
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Sensory and Motor Function Assessment: Conduct a thorough assessment of sensory function, including light touch, pain, temperature, vibration, and proprioception (position sense). Assess motor function, including muscle strength, reflexes, and coordination. These assessments help identify the extent and nature of sensory and motor impairments caused by neuropathy.
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Etiology Identification: Investigate and document factors that contribute to the development of peripheral neuropathy, such as diabetes, alcohol abuse, autoimmune disorders, vascular disease, vitamin deficiencies, and exposure to neurotoxic substances. Identifying underlying causes is crucial for guiding treatment and preventative measures.
Nursing Interventions:
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Occupational and Physical Therapy Collaboration: Refer the patient to occupational and physical therapists for specialized rehabilitation. Therapists can develop personalized exercise programs, recommend assistive devices, and teach adaptive strategies to manage sensory and motor deficits.
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Safety Education: Educate the patient and family about safety precautions to prevent injury due to sensory loss. Emphasize the importance of checking water temperature before bathing, inspecting feet daily for injuries, and using assistive devices to prevent falls and burns.
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Foot Care Education: Provide comprehensive education on proper foot care, especially for patients with diabetes. This includes daily foot inspection, washing and drying feet carefully, moisturizing dry skin (avoiding between toes), wearing proper footwear, and seeking regular podiatric care.
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Assistive Device Encouragement: Encourage the use of appropriate assistive devices such as canes, walkers, wheelchairs, and braces to enhance mobility and prevent falls. Assistive devices can compensate for muscle weakness, balance problems, and sensory loss, improving safety and independence.
Impaired Physical Mobility
Peripheral neuropathy can significantly impact physical mobility due to pain, muscle weakness, numbness, and impaired balance.
Nursing Diagnosis: Impaired Physical Mobility
Related Factors:
- Disease Process (Peripheral Neuropathy)
- Decreased Muscle Strength
- Physical Deconditioning
- Pain
- Numbness
- Peripheral Nerve Damage
Evidenced By:
- Uncoordinated movements
- Loss of sensation affecting movement
- Loss of balance
- Reluctance to initiate movement
Expected Outcomes:
- Patient will demonstrate progressive improvement in mobility, such as increased walking distance or improved ability to perform daily activities.
- Patient will report reduced pain during movement.
- Patient will effectively utilize assistive devices to enhance mobility.
Nursing Assessments:
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Functional Mobility Assessment: Assess the patient’s current level of functional mobility, including range of motion, gait, balance, and ability to perform activities of daily living (ADLs). This assessment provides a baseline for monitoring progress and tailoring interventions.
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Symptom Impact Assessment: Determine the specific symptoms that are most significantly limiting the patient’s mobility, such as pain, weakness, numbness, or fear of falling. Understanding the primary mobility barriers helps in developing targeted interventions.
Nursing Interventions:
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Pain Medication Administration: Administer prescribed pain medications, particularly before activity or exercise sessions, to improve comfort and participation. Medications like gabapentin, pregabalin, or amitriptyline can effectively manage neuropathic pain, allowing for greater participation in physical therapy and exercise.
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Assistive Device Education: Educate the patient on the correct and safe use of prescribed assistive devices, such as canes, walkers, or braces. Proper use of assistive devices maximizes their benefit and minimizes the risk of injury.
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Proper Footwear Guidance: Advise patients, especially those with foot neuropathy, to wear well-fitting, supportive footwear or shoe inserts. Proper footwear can improve stability, reduce discomfort, and prevent foot injuries during ambulation.
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Stretching and Strengthening Exercises: Assist with or instruct the patient in performing stretching and strengthening exercises as recommended by physical therapy. Exercises tailored to peripheral neuropathy, including aerobic activities, balance training, and specific stretches, can improve muscle strength, flexibility, and overall mobility.
Image illustrating exercises for peripheral neuropathy, including calf stretches and balance exercises.
Ineffective Tissue Perfusion
Certain causes of peripheral neuropathy, such as diabetes, can impair blood flow to the peripheral nerves, leading to ineffective tissue perfusion.
Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral)
Related Factors:
- Diabetes Mellitus
- Infection
- Malignancy
- Trauma/Injury
- Kidney Disease
Evidenced By:
- Decreased or absent peripheral pulses
- Altered motor function
- Capillary refill time greater than 3 seconds
- Delayed wound healing in extremities
- Extremity edema
- Extremity pain (intermittent claudication)
- Pallor or cyanosis
- Skin temperature changes (coolness)
- Paresthesias (numbness, tingling)
- Altered sensations
Expected Outcomes:
- Patient will demonstrate improved peripheral tissue perfusion, evidenced by palpable peripheral pulses, warm and dry skin, and normal capillary refill time.
- Patient will accurately differentiate between sharp and dull sensations in the lower extremities.
- Patient will verbalize strategies to improve circulation.
Nursing Assessments:
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Peripheral Vascular Assessment: Regularly assess and monitor peripheral pulses (dorsalis pedis, posterior tibial) and capillary refill time bilaterally. Decreased or absent pulses and prolonged capillary refill indicate impaired arterial blood flow and potential ischemia.
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Skin Assessment: Assess skin color, temperature, and condition of the extremities. Pallor, mottling, coolness to touch, and dryness can indicate poor circulation.
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Sensory Function Assessment: Evaluate sensory function, particularly the ability to differentiate between sharp and dull sensations in the lower legs and feet. Impaired sensation can be an early sign of tissue perfusion problems and increases the risk of injury.
Nursing Interventions:
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Ambulation Encouragement: Encourage and assist the patient to ambulate as tolerated. Walking promotes blood flow to the extremities, improves collateral circulation, and enhances tissue perfusion.
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Range of Motion Exercises: Encourage active or passive range of motion exercises of the extremities. Exercise improves blood flow, reduces venous stasis, and promotes overall circulation.
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Clothing and Compression Stockings Education: Advise the patient to wear nonrestrictive clothing to avoid constricting blood flow. Educate on the appropriate use of compression stockings if indicated for edema or poor circulation, following physician orders. Compression stockings can improve venous return and reduce edema, while avoiding tight clothing promotes unimpeded circulation.
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Underlying Condition Management Adherence: Emphasize the importance of adhering to the treatment plan for underlying conditions, such as diabetes, hypertension, or kidney disease. Effective management of these conditions is crucial for improving overall health and preventing further vascular complications that contribute to peripheral neuropathy.
Risk for Impaired Skin Integrity
Numbness and impaired sensation in peripheral neuropathy increase the risk of skin injury due to reduced awareness of pressure, temperature extremes, and trauma.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related Factors:
- Impaired Sensation
- Impaired Circulation
Evidenced By:
- (Risk diagnoses are not evidenced by actual signs and symptoms but by risk factors. The focus is on prevention.)
Expected Outcomes:
- Patient will maintain intact skin throughout the course of care.
- Patient will demonstrate preventative behaviors and techniques to protect skin integrity and prevent breakdown.
Nursing Assessments:
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Skin Inspection: Inspect the skin, particularly the feet and pressure points, for any signs of redness, breaks in the skin, blisters, or discoloration during each shift and with position changes. Early detection of skin changes allows for prompt intervention to prevent further breakdown.
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Hydration and Fluid Intake Monitoring: Monitor fluid intake and assess hydration status of the skin and mucous membranes. Dehydration or fluid overload can compromise skin integrity and increase the risk of breakdown.
Nursing Interventions:
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Gentle Skin Care: Provide gentle skin care, avoiding harsh soaps, scrubs, or rough washcloths. Use mild cleansers and pat skin dry. Apply moisturizing lotions or ointments to prevent dryness and cracking, especially to feet and hands. Gentle skin care maintains skin barrier function and prevents irritation.
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Injury Prevention Measures: Implement measures to prevent unintentional injuries. Advise using cool, moist compresses for itching instead of scratching. Keep fingernails short and smooth. Consider recommending gloves during sleep to prevent scratching. Preventing injury is paramount in patients with impaired sensation who may not feel pain or pressure until damage is significant.
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Frequent Repositioning and Pressure Relief: Reposition the patient frequently, especially if mobility is limited. Pad bony prominences with pillows or specialized cushions. Use pressure-relieving mattresses and heel/elbow protectors to minimize pressure on vulnerable areas. Frequent repositioning and pressure relief distribute weight and prevent prolonged pressure on tissues, reducing the risk of pressure ulcers.
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Pressure-Relieving Mattresses: Utilize foam or pressure-relieving mattresses to minimize sustained pressure on tissues. These mattresses redistribute weight and reduce pressure concentration on bony prominences, improving tissue perfusion and preventing ischemia.
Conclusion
Nursing Diagnosis Peripheral Neuropathy is essential for providing targeted and effective care. By understanding the various nursing diagnoses associated with peripheral neuropathy and implementing appropriate care plans, nurses can significantly improve patient outcomes, enhance quality of life, and promote safety. Focusing on pain management, sensory and motor function, tissue perfusion, and skin integrity allows for a holistic approach to care, addressing the multifaceted challenges posed by peripheral neuropathy.
References
- 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.
- Hammi C, Yeung B. Neuropathy. [Updated 2022 Oct 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542220/
- Jameson, L.J., et al. (2018). Harrison’s principles of internal medicine. (20th ed.). McGraw Hill.
- Marchettini, P., Lacerenza, M., Mauri, E., & Marangoni, C. (2006). Painful peripheral neuropathies. Current neuropharmacology, 4(3), 175–181. https://doi.org/10.2174/157015906778019536
