Diabetic Peripheral Neuropathy: A Case Study

An attending physician statement completed by Dr. Peter Chweyah (Internal Medicine), dated 06/16/2016, indicated that the claimant presented with complaints of lower extremity weakness, neuropathy, weight loss, acute renal failure, and gout, as well as anemia. Objective findings showed an extreme weakness of the legs and pain in the feet. He also had diabetes mellitus type 2, chronic kidney disease, and hypertension. It was noted that the claimant was totally disabled from 05/30/2017 through 06/15/2017 and 05/23/2017 - 05/26/2017 secondary to gout.

DPN has been defined as "the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes"

Specifically inquire about exercise for type, frequency and duration and any complaints of physical limitation for exercise. Equally important, perform a visual inspection of the foot and shoes, coupled with an inquiry as to history of neuropathy or its symptoms, and presence or history of foot ulcerations. As a result, this portion of the exam offers an opportunity for education regarding proper foot care and type of shoes suitable for the diabetic patient. Of great concern, neuropathy development is directly linked to glycemic control and presents as the leading cause for disability due to foot ulceration, amputation gait disturbances and fall related injuries in diabetic patients (Juster-Switlyk, & Smith, 2016). ADA 2017 standards require completion of a comprehensive foot examination and inspection, to include palpation of dorsalis pedis and posterior tibial pulses, assessment for the presence/absence of patellar and Achilles reflexes and determination of proprioception, vibration, and monofilament

• Severe Diabetics with advanced atherosclerosis (peripheral vascular disease documented ABI (ankle brachial index >2) or carotid artery atherosclerosis with narrowing more than 50 percent on carotid artery

Diabetic neuropathy is a nerve disorders caused by diabetes. Symptoms include pain, tingling, or numbness, loss of feeling in hands, arms, feet, and legs. Nerve problems can occur in every organ system. Diabetic neuropathies appears more common in people who have problems controlling their blood glucose, those with high levels of blood fat, high blood pressure and obese (Porth, 2015). Metabolic factors include high blood glucose, abnormal blood fat levels, and low insulin levels. Neurovascular factors are associated to damage to the blood vessels that carry oxygen and nutrients to nerves (Porth, 2015). Autoimmune factors that cause inflammation in nerves. Mechanical injury to nerves, for example, carpal tunnel syndrome (Porth, 2015). Inherited

Diabetes insipidus is a condition where the release or response to the pituitary hormone vasopressin is not able to operate correctly. This results in large amounts of urine and it’s accompanied by dehydration and excessive thirst. Diabetes mellitus is a long lasting condition where the body does not make enough insulin to respond to the blood sugar levels that are taking place. This results in an abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine. It is the most common of the two. Diabetes insipidus is a kidney disorder, does not cause a rise in blood sugar levels, and does not release glucose in the urine. While diabetes mellitus is a pancreatic disorder, causes a rise in blood sugar levels, and releases

Tina rates her pain at a 7/10 on the verbal pain scale. This a critical finding because, Tina is s diabetic and her symptoms are consistent with the characteristics of an infection. As a diabetic Tina is at a greater risk for infection, slow wound healing and can lead to the need for amputation of the limb (Brunner & Suddarth, 2012). Tina’s non-compliance with the Diabetes medication (Metformin), poor nutritional status (BMI 31), and poor health maintenance, combined with her family history, gender, and increasing age place Tina at significantly higher risks for developing

Patient is 71-year-old white right-handed white female who presents with her sister for evaluation of peripheral neuropathy. She states that it started about a year and a half ago in her toes and has slowly increased to involve her soles of her feet and the dorsum and now the lower one third of her calves bilaterally. There is occasional problems with edema in her lower extremities, but this has come later. The severity of the numbness changes if she walks for a long period of time, at which point it gets more numb. She currently is not having any burning or jabbing pain. She does not have the symptoms in her hands or in her torso. She does have hypothyroidism, but she is on medication. She is obese with problems with fasting glucose and hyperglycemia. Her hemoglobin A1C went from 4 to slightly over 5 over the course of the last year, but she has not been given the diagnosis of diabetes. She has no other medical risk factors for developing the peripheral neuropathy. She is unable to give any further history, except on detailed questioning, she does not have any problems with ambulation in the dark or on uneven surfaces and has not had any falls.

The Total Neuropathy Score (TNS), initially was used to assess diabetic neuropathy, utilizes objective criterion, such as pin prick, with a subjective account of all neuropathic areas including sensory, autonomic and motor (Curcio, 2016). However, it is too time consuming for nurses to use routinely (Curcio, 2016). The Total Neuropathy Score – clinical version (TNSc) was recommended for broader use (Curcio, 2016). This abbreviated version which was developed is more sensitive than other tools including the NCI-CTCAE (Curcio, 2016). In a systematic review by Haryani et al. (2017) similar conclusions were realized. They analyzed nineteen studies and twenty CIPN assessment tools and determined that both the FACT/GOG-Ntx and TNSc were recommended (Haryani et al., 2017). Further, since CIPN is more subjective than objective in nature, utilizing the FACT/GOG—Ntx first, followed by a provider validation using the TNSc is suggested (Haryani et al., 2017).

Nerve damage from diabetes is called diabetic neuropathy. About half of all people with diabetes have some form of nerve damage. It is more common in those who have had the disease for a number of years and can lead to many kinds of problems.If you keep your blood glucose levels on target, you may help prevent or delay nerve damage. If you already have nerve damage, this will help prevent or delay further damage (ADA,2016). I've encountered patients that describe the feeling as pins and needles, and that their feet are constantly cold. There isn't medication to cure the nerve damage that causes neuropathy, however certain mediction can be precribed by your physician that will help with the symptoms. Increased blood glucose levels damages blood

Diabetes affects virtually every aspect of the body and poorly controlled diabetes increases the risk for diabetes related complications. Patients diagnosed with mental illness are at an increased risk to develop diabetes complications as a result of poor self-care management (Green, Gazmarian, Rask, & Druss, 2010). Dickerson et al (2011) found that patients diagnosed with bipolar disorder tend to have a more sedentary life, poor dietary intake, be obese, smoke and have an increased risk for alcohol and illicit drug abuse. Each of these factors contribute to poor glycemic control, which contributes to the development of diabetic peripheral neuropathy. Up to 50% of patients diagnosed with diabetes have some form of diabetic neuropathy. Diabetic neuropathy presents in the form of sensory neuropathy, motor neuropathy or autonomic neuropathy. Sensory neuropathy may also be called polyneuropathy due to the number of different nerve centers affected by damage. Over time elevated glucose levels lead to extensive damage to the blood vessels that supply nerves to numerous sites in the body. Continued assault upon nerves can lead to permanent nerve damage, resulting in pain to affected areas and increased risk of injury, which can lead to amputation (Diabetes UK, n.d.).

Normalizing blood glucose levels is the first step in managing diabetic peripheral neuropathy. In fact, diabetic peripheral neuropathy is best prevented by a tight control of blood glucose levels. This is achieved by careful monitoring, dietary modifications, exercise, and the use of medications or insulin. Newer treatments to slow down the progress of or to reverse neuropathy are still under study.

The diabetic foot should be inspected carefully on regular basis is one of the easiest, least expensive and most effective activities that prevent the foot problems. The patients with high risk of getting DFU should be identified and assess the neurological and vascular deficits. The heal care personnel must carry out careful physical examination and foot examination and appropriate history collection to avoid unnecessary amputations. (Armstrong, 2000).

Foot problems are a big risk in diabetics therefore diabetic patients must constantly monitor their feet or face severe consequences, including amputation. With a diabetic foot, a wound as small as a blister from wearing a shoe that's too tight can cause a lot of damage. Because diabetes decreases blood flow, injuries are slow to heal as new blood often doesn’t flow freely to the injury. When wounds do not heal in a timely fashion, they are at risk for infection meaning that infections in the feet of diabetic patients spread quickly. If you have diabetes, you should inspect your feet every day. Look for puncture wounds, bruises, pressure areas, redness, warmth, blisters, ulcers, scratches,

Patients with diabetic neuropathy generally ended up with wounds, since they have reduced ability to feel pain and temperature. The problem that the guideline addresses is “patients with lower-extremity neuropathic disease (LEND) with or at risk for wounds” (National Guideline Clearinghouse, 2012, para. 1). The purpose of the guideline is to “support clinical practice by providing consistent, research-based information with the goal of improved cost-effective patient outcomes as well as to stimulate increased wound research” (National Guideline Clearinghouse, 2012, para. 9). This paper will present a summary of the quantitative and the qualitative article, gaps between guideline and practice; also,