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Make sure to tune in to the Unbiased Signs podcast to get all your questions answered. Well, hello there, I'm Nurse Mo, and this is the Straight A Nursing Podcast, where I teach nursing concepts and share tips on how to thrive in school and beyond that at the bedside. So today we are diving into peripheral neuropathy, a very, very common condition. I can't even count how many times I've had a patient with peripheral neuropathy and I learned a ton by putting this episode together for you. So let's start off with three stat facts.
Number one, peripheral neuropathy is the primary cause of amputations in the United States, resulting in nearly one amputation every five and a half minutes. Number two, there are more than 100 types of peripheral neuropathy, and symptoms vary depending on the type of nerve that is damaged, be it a sensory nerve, motor nerve, or autonomic nerve. And stat fact number three, about 2.4% of the population is affected by peripheral neuropathy, and the incidence increases to up to 8% in older populations.
It's definitely common and affects a lot of your patients. So peripheral neuropathy is a condition in which the distal nerves of the hands and the feet are damaged and unable to transmit messages correctly. And this results in numbness and 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. And in fact, tight blood glucose control in type 1 diabetes has shown to reduce an individual's risk of diabetic neuropathy by 78%.
So while neuropathy can be idiopathic and have no known cause, some common causes in addition to diabetes include trauma. Physical injury can stretch, compress, crush, or even detach nerves, leading to neuropathy. It can also be due to infection. A wide range of viral and bacterial infections can cause neuropathy, such as Lyme disease, shingles, and hepatitis B or C. And then there's autoimmune disease, conditions including rheumatoid arthritis, Guillain-Barre, Ray.
vasculitis, and chronic inflammatory demyelinating polyneuropathy can all cause, you guessed it, neuropathy. Tumors can compress nerves, which limit their function and can lead to neuropathy, and toxic substances that can cause neuropathy include arsenic exposure, lead, and organic solvents. What about medications? Many medications can cause peripheral neuropathy as an adverse effect. Common culprits include chemotherapeutic agents, amiodarone, statins, some antibiotics, hydroxychloroquine, phenytoin, and lithium.
What about bone marrow disorders? This is one that I definitely had no idea about until I started putting this lesson together, but patients with myeloma, lymphoma, and amyloidosis are at higher risk for developing neuropathy. And then there are nutritional deficiencies.
B vitamins, copper, vitamin E, thymine, 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. So these patients may have neuropathy.
And then hypothyroidism, left untreated. Severe hypothyroidism can cause peripheral neuropathy due to excess fluid and edema, putting pressure on nerves. Lastly, we have inherited conditions. Hereditary neuropathies such as Charcot-Marie-Tooth disease affects the peripheral nervous system and can be really debilitating for individuals.
So what are the complications of peripheral neuropathy? We talked about a lot of different causes. Now let's look at some complications. The key ones are injury, infection, falls, pain, and disability. So injuries can occur more readily.
Because the nerves are not able to transmit signals that let the brain know that 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 really big and important complication of this condition. It's also vital to note that neuropathy can cause lifelong pain, decreased quality of life, and decreased ability to perform ADLs. So 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.
So let's dive in. We start with the letter L, which stands for look. How does the patient look?
Essentially, what are their signs and symptoms? 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 like really, really cold or 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 their feet, for example, you may want to tent the bedding so it doesn't cause pain. Even something as simple as sheets touching their feet could be painful. And then when the feet are affected, some patients experience loss of balance or coordination, and again, are at high risk for falls.
So that would be the key symptoms and signs of someone with peripheral neuropathy. The next letter in the LATTE method is an A, and that stands for assessment. How are we going to assess our patient. So key assessments for a patient with peripheral neuropathy include, first of all, assessing the hands and feet for sensation to touch, to heat, and to cold. If the patient has a lack of sensation, they are much, much more prone to injury.
You can touch them with your hand. You can poke them with something sharp. You can get a heel warmer.
and use that for heat. You can put ice in a glove and use that for cold. We do that all the time in the recovery room when we are assessing people after they have an epidural or spinal block. So you could do those same techniques to assess for sensation in someone with neuropathy. Really, really important to assess the feet especially, but basically any part of the body that's affected by neuropathy, especially the feet though.
You're looking for wounds. These can often go unnoticed because, again, the individual has a lack of sensation. The nerves are not transmitting the pain signals accurately. You also want to assess the patient's gait, making note of balance or coordination issues. That could lead to a fall.
If they're having difficulty with gait, maybe they would benefit from a physical therapy consult. Assess the patient's ability to perform their ADLs. Neuropathy in the hands. may make getting dressed, writing, or opening packages of food difficult.
Neuropathy in the feet can significantly affect mobility. You also want to conduct a thorough assessment of the patient's pain. You may want to utilize a standard assessment tool or framework such as OLD CARTS.
So O stands for onset, asking, when did this pain begin? Is it new pain for you or is it chronic pain? Most of the time, a patient with peripheral neuropathy is going to say it's chronic, unless, of course, it just started. L is for location. Where does it hurt?
For peripheral neuropathy, it's going to be the hands or the feet or both. D is for duration, asking the patient, is the pain constant or does it come and go? Most likely with peripheral neuropathy, the pain is always there. C stands for characteristics, asking the patient, can you describe the pain? Neuropathic pain is often described as shooting, pins and needles, burning, cramping, tingling, or like electrical shocks.
A stands for 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 stands for relieving factors. What makes the pain better? We'll talk about potential treatments in just a moment.
And then T is for treatments. Asking the patient, what treatments are you currently utilizing or have you used in the past? Some resources also signify the T to represent temporal patterns.
If using this component, you're asking the patient, have you noticed any patterns to when this pain occurs? For example, is it worse in cold temperatures? Is it worse at night? Is it worse when you're more stressed?
Whatever that may be. And then S stands for severity. How severe is the pain? Ask the patient to rate it on a 0 to 10 scale if they're able to self-report. The patient who experiences pain with peripheral neuropathy will likely describe the pain as extremely intense and disabling.
Next, we'll dive into the letter T, which stands for tests. What tests are conducted for a patient with peripheral neuropathy? But first, a quick break.
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So looking at the tests for a patient with peripheral neuropathy, it's typically diagnosed through a thorough assessment of the patient's symptoms, a 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 a ultrasound. So peripheral nerve ultrasound can show injured and compressed nerves. Another test is electromyography or 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 very small wire or pin acts like an antenna and picks up electrical activity of the muscle, which is displayed on a screen. Data is collected when the muscle's at rest and during a muscle contraction. There are also tests called nerve conduction studies.
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 electrical shock is delivered and this electrical shock activates the nerve. The MD evaluates the speed, size, and consistency of the nerve response and any associated muscle twitches.
The patient may also undergo a biopsy. So 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.
The test I saw mentioned most often was a skin biopsy, which looks at those little tiny nerves. And then blood tests. Blood tests may be conducted to evaluate potential conditions that can contribute to peripheral neuropathy, such as diabetes or nutritional deficiencies.
The next letter in the LATTE method is a T, which stands for treatments. 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 improvements by maintaining optimal blood glucose levels.
Pharmacologic treatments include medications for pain, medications for seizure, and depression, as well as topical treatments. Note that neuropathic pain typically doesn't respond to traditional analgesics, so they are not often utilized. So first we have anti-seizure medications.
Three commonly used medications in this class are pregabalin, gabapentin, and tegritol. It is thought that these medications block the transmission of pain signals. Common adverse effects include drowsiness and dizziness. And then we have 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 used medication in this class is duloxetine, which is an SSNRI, Selective Serotonin and Norepinephrine Reuptake Inhibitor. This medication can cause nausea, anxiety, and insomnia. Another commonly utilized antidepressant is the TCA or tricyclic antidepressant amitriptyline, which can cause suicidal ideation and dangerous arrhythmias. And then there are topical medications.
These include creams and patches that contain lidocaine or capsaicin. Other treatments include plasma exchange, IV immune globulin, and steroids. These therapies may be utilized if the underlying cause is not known.
cause of peripheral neuropathy is an autoimmune condition. And then there are a bunch of non-pharmacologic therapies that can be utilized. So first is physical therapy. Physical therapy 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. Along with that, we have 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, so if the patient has difficulty getting dressed, those things could help significantly. Surgery could be another treatment option. If the cause of the 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. And then acupuncture. This treatment helps re-stimulate damaged nerve fibers and improve blood flow, and may even help with nerve preservation and regeneration.
The patient may have a TENS unit. TENS stands for Transcutaneous Electrical Nerve Stimulation. And with this unit, low-intensity electrical impulses are generated through electrodes. And this impulse disrupts pain signals, and inhibits pain transmission.
Another really interesting therapy is scrambler therapy. It's a non-invasive therapy option that modifies pain pathways by stimulating specific nociceptors to produce non-painful information that is often perceived as an itch, a vibration, pressure, tingling, or even a massage. Though not specifically for neuropathic pain, but I did find this study to be very interesting.
A study showed that out of 11 patients with chronic cancer pain, nine were able to stop using prescribed analgesics after just five sessions of scrambler therapy. So the goal of scrambler therapy is to eliminate pain not only during the treatment sessions, but to provide long-lasting pain relief. The typical schedule is 10 to 12 daily treatments provided over a two-week period, and that is excluding some days off for the weekend.
It's important to note that anti-seizure medications can decrease scrambler therapy effectiveness due to their interference with action potentials. So patients will typically be weaned off these medications. prior to or during scrambler therapy treatment. The patient may get a 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 just above the buttocks. 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 spinal cord stimulator therapy include a tingling or fluttering sensation, while others do not.
And then there's biofeedback therapy. Biofeedback utilizes monitoring devices to track involuntary body responses. such as heart rate or 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. And then hypnosis.
Studies suggest that hypnosis can play a key role as part of an integrative treatment approach and enhance the efficacy of other therapies. And then another that is really interesting is 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.
And then 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 and important measure that helps preserve skin integrity. And the last letter in the LATTE method is E for educate.
How do we educate our patients or families? Since one of the key treatments for neuropathy is to address that underlying cause whenever possible, it's imperative patients understand the importance of managing their underlying condition, such as diabetes. 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 when taking antidepressants, so teach the patient to seek urgent medical care 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 between 120 to 125 degrees. 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 your patients with neuropathy of the feet to inspect their feet daily, wear closed toed 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, but I would say cycling could put them at risk for injury if they're doing it outdoors, maybe cycling on a stationary bicycle.
You want to 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 slipping.
thick rugs and other trip hazards, installing nightlights, and ensuring pathways from bed to bathroom are clear. You also want to teach patients and families to call their physician if the pain and numbness worsen, if they have loss of function or their function worsens, and if their medication simply is not improving symptoms. And of course, if the medication is causing worrisome adverse reactions. So there you have it, your quick guide to peripheral neuropathy. Before we close out, let's take a quick minute for a listener shout out.
This one goes to Krista. Krista says, Nurse Mo, after listening to countless nursing podcasts, you are my favorite. Your podcasts are informative and definitely not boring.
With the help of your podcast and book, I was truly able to thrive in my first semester of nursing. Thank you for your time, dedication, motivation, and support. You are making a difference. Krista, thank you so much for taking time to share that feedback. And I'm so glad that the podcast has helped you and that the book Nursing School Thrive Guide has helped you and that you're thriving in the first semester of your nursing program.
By now, maybe you've graduated. I don't know. If you have, I'd love to hear from you. Send me an email and let me know how you're doing.
All right, so I will see you. Back here next week, we are going to be diving into gestational diabetes. So I definitely want to see you back here for that.
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