Diabetic

Neuropathy
 Outline

• Introduction of diabetic neuropathy

• Definition of diabetic neuropathy
• Classification (types ) diabetic neuropathy
• Cause and risk factor of diabetic neuropathy
• Sign and symptom of diabetic neuropathy
• Diagnose and complication of diabetic neuropathy
• Management ( nursing , medical and surgical )
• Summary
 INTRODUCTION

• DIABETES IS A CHRONIC MEDICAL CONDITION THAT OCCURS

WHEN THE BODY IS UNABLE TO PROPERLY
REGULATE BLOOD SUGAR (GLUCOSE) LEVELS. CHRONIC
METABOLIC DISORDER CHARACTERIZED BY HIGH BLOOD
GLUCOSE
• GLUCOSE IS THE BODY'S PRIMARY SOURCE OF ENERGY, AND ITS
LEVELS ARE TYPICALLY CONTROLLED BY THE HORMONE
INSULIN, WHICH IS PRODUCED BY THE PANCREAS. IN DIABETES,
EITHER THE BODY DOESN'T PRODUCE ENOUGH INSULIN, OR IT
CAN'T EFFECTIVELY USE THE INSULIN THAT IS PRODUCED,
LEADING TO HIGH BLOOD GLUCOSE LEVELS.
• INSULIN IS A HORMONE PRODUCED BY THE PANCREAS THAT
HELPS REGULATE BLOOD SUGAR.
THERE ARE TWO
MAIN TYPES OF
DIABETES
• TYPE 1 DIABETES:

• OFTEN DIAGNOSED IN CHILDHOOD

OR EARLY ADULTHOOD, TYPE 1
DIABETES IS AN AUTOIMMUNE
CONDITION WHERE THE BODY'S
IMMUNE SYSTEM ATTACKS AND
DESTROYS THE INSULIN-PRODUCING
CELLS IN THE PANCREAS. AS A
RESULT, PEOPLE WITH TYPE 1
DIABETES MUST TAKE INSULIN FOR
THE REST OF THEIR LIVES.
• IT ACCOUNTS FOR ABOUT 5-10% OF
ALL DIABETES CASES.
 TYPE 2 DIABETES

• THIS IS THE MORE COMMON FORM OF DIABETES, TYPICALLY DEVELOPING IN ADULTS, THOUGH IT IS
INCREASINGLY SEEN IN YOUNGER POPULATIONS DUE TO RISING OBESITY RATES. IN TYPE 2
DIABETES, THE BODY EITHER DOESN’T PRODUCE ENOUGH INSULIN OR BECOMES RESISTANT TO
INSULIN.
• THE BODY BECOMES RESISTANT TO INSULIN OR DOESN’T PRODUCE ENOUGH
• MOST COMMON TYPE (90–95% OF CASES)
• OFTEN LINKED TO OBESITY, PHYSICAL INACTIVITY, AND GENETICS
• IT IS PRIMARILY ASSOCIATED WITH LIFESTYLE FACTORS SUCH AS POOR DIET, LACK OF EXERCISE,
AND OBESITY. OVER TIME, THE BODY'S INABILITY TO REGULATE BLOOD SUGAR PROPERLY CAN
LEAD TO COMPLICATIONS SUCH AS HEART DISEASE, KIDNEY DAMAGE, AND NEUROPATHY.
 GESTATIONAL DIABETES:
DIABETES

• THIS TYPE OCCURS DURING PREGNANCY AND USUALLY

RESOLVES AFTER CHILDBIRTH. HOWEVER, WOMEN WHO
EXPERIENCE GESTATIONAL DIABETES ARE AT A HIGHER
RISK OF DEVELOPING TYPE 2 DIABETES LATER IN LIFE.
• COMMON SYMPTOMS
 INCREASED THIRST AND URINATION
 FATIGUE
 BLURRED VISION
 SLOW WOUND HEALING
 UNEXPLAINED WEIGHT LOSS (ESPECIALLY IN TYPE 1)
 Complications: If left uncontrolled, diabetes can
lead to serious complications, including:
Cardiovascular disease (heart attack, stroke)

Kidney damage (diabetic nephropathy)

COMPLICATION
S Nerve damage (diabetic neuropathy)

Eye problems (diabetic retinopathy, which can

lead to blindness)
Foot problems (leading to amputations in severe
cases)
.
.
 DEFINITION OF DIABETIC
NEUROPATHY
• Diabetic neuropathy IS A TYPE OF NERVE DAMAGE THAT
OCCURS AS A COMPLICATION OF DIABETES MELLITUS, RESULTING
FROM PROLONGED HIGH BLOOD GLUCOSE LEVELS. IT AFFECTS
THE PERIPHERAL NERVES, PARTICULARLY IN THE LEGS, FEET, AND
HANDS, BUT CAN ALSO IMPACT THE AUTONOMIC NERVOUS
SYSTEM, WHICH CONTROLS INTERNAL ORGANS.
• IT'S A COMMON COMPLICATION OF BOTH TYPE 1 AND TYPE 2
DIABETES, AND IT CAN MANIFEST IN SEVERAL FORMS, EACH
AFFECTING DIFFERENT AREAS OF THE BODY AND CAUSING
DISTINCT SYMPTOMS. THE PRIMARY CAUSE IS SUSTAINED HIGH
BLOOD GLUCOSE LEVELS, WHICH DAMAGE THE NERVES. OTHER
FACTORS, SUCH AS HIGH BLOOD PRESSURE, HIGH CHOLESTEROL,
SMOKING, AND ALCOHOL CONSUMPTION, CAN ALSO INCREASE
THE RISK.
 CONT..
• DIABETIC NEUROPATHY IS A TYPE OF NERVE DAMAGE CAUSED BY LONG-TERM HIGH
BLOOD SUGAR LEVELS IN PEOPLE WITH DIABETES. IT IS ONE OF THE MOST COMMON
AND SERIOUS COMPLICATIONS OF DIABETES, AFFECTING UP TO 50% OF DIABETICS
OVER TIME.
• WHAT CAUSES IT?
• CHRONICALLY HIGH BLOOD GLUCOSE LEVELS DAMAGE:
• NERVES
• SMALL BLOOD VESSELS THAT SUPPLY THE NERVES
• THIS LEADS TO NERVE DYSFUNCTION, PARTICULARLY IN THE HANDS, FEET, LEGS, AND
INTERNAL ORGANS.
CLASSIFICATION (TYPES) OF DIABETIC
NEUROPATHY
 CLASSIFICATION (TYPES) OF
DIABETIC NEUROPATHY

• 1. PERIPHERAL NEUROPATHY (DISTAL SYMMETRIC POLYNEUROPATHY)

 MOST COMMON TYPE
 AFFECTS THE FEET AND LEGS FIRST, FOLLOWED BY HANDS AND
ARMS
 SYMPTOMS:
o NUMBNESS OR REDUCED ABILITY TO FEEL PAIN OR
TEMPERATURE CHANGES
o TINGLING OR BURNING SENSATION
o SHARP PAINS OR CRAMPS
o MUSCLE WEAKNESS
o LOSS OF BALANCE AND COORDINATION
 1. High Blood Glucose

Chronic high blood sugar damages the small blood

vessels that supply nerves, especially in the extremities.
HOW 2. Nerve Degeneration
PERIPHERAL
NEUROPATHY Lack of oxygen and nutrients causes the nerves to
become inflamed, dysfunctional, or even die.
DEVELOPS IN 3. Loss of Nerve Function
DIABETES
Damaged nerves send abnormal signals, no signals, or
delayed signals to the brain.
This results in tingling, numbness, burning, and muscle
weakness.
 2. AUTONOMIC NEUROPATHY

 AFFECTS THE AUTONOMIC NERVOUS SYSTEM (CONTROLS INTERNAL ORGANS)

 CAN AFFECT:
o CARDIOVASCULAR SYSTEM: RESTING TACHYCARDIA, ORTHOSTATIC HYPOTENSION
o GASTROINTESTINAL TRACT: GASTROPARESIS, CONSTIPATION, DIARRHEA
o ) GENITOURINARY SYSTEM: BLADDER DYSFUNCTION, ERECTILE DYSFUNCTION
o SWEAT GLANDS: ALTERED SWEATING (ANHIDROSIS OR HYPERHIDROSIS
.
.
 AUTONOMIC NEUROPATHY IN THE
GENITOURINARY SYSTEM
• . BLADDER DYSFUNCTION (DIABETIC CYSTOPATHY)
• 🔹 NORMAL PHYSIOLOGY
• PARASYMPATHETIC NERVES (S2–S4) STIMULATE THE DETRUSOR MUSCLE TO
CONTRACT (EMPTY BLADDER).
• SYMPATHETIC NERVES (T11–L2) CONTROL BLADDER RELAXATION AND INTERNAL
SPHINCTER TONE.
• SOMATIC NERVES (PUDENDAL NERVE) CONTROL THE EXTERNAL SPHINCTER
(VOLUNTARY CONTROL).
 IN DIABETIC AUTONOMIC NEUROPATHY
• HIGH BLOOD SUGAR → NERVE DAMAGE (ESPECIALLY TO PARASYMPATHETIC NERVES)
• DETRUSOR UNDERACTIVITY → BLADDER DOESN'T CONTRACT WELL
• DECREASED SENSATION → PATIENT DOESN’T FEEL A FULL BLADDER
• URINE RETENTION → BLADDER OVERDISTENDS, BECOMES FLACCID
• CAN LEAD TO:
• INCOMPLETE EMPTYING
• URINARY TRACT INFECTIONS (UTIS)
• OVERFLOW INCONTINENCE
 3. PROXIMAL NEUROPATHY
(DIABETIC AMYOTROPHY)

 ALSO CALLED DIABETIC LUMBOSACRAL RADICULOPLEXUS

NEUROPATHY
 AFFECTS NERVES IN THE THIGHS, HIPS, BUTTOCKS, OR LEGS
 USUALLY OCCURS ON ONE SIDE AND MAY IMPROVE OVER
TIME
 SYMPTOMS:
o SUDDEN SEVERE PAIN IN HIP, THIGH, OR BUTTOCK
o MUSCLE WEAKNESS AND ATROPHY
o DIFFICULTY RISING FROM A SEATED POSITION
 MECHANISM OF ACTION: HOW DIABETES
CAUSES PROXIMAL NEUROPATHY

• 🔹 1. CHRONIC HYPERGLYCEMIA
• PERSISTENT HIGH BLOOD GLUCOSE CAUSES:
• MICROVASCULAR INJURY (TO THE BLOOD SUPPLY OF NERVES)
• OXIDATIVE STRESS
• INFLAMMATORY DAMAGE TO NERVES
• 🔹 2. ISCHEMIC NERVE INJURY
• NERVE INFARCTION (LACK OF OXYGEN) MAY OCCUR IN THE LUMBOSACRAL PLEXUS — A NETWORK OF NERVES IN THE LOWER SPINE THAT
SUPPLIES THE LEGS.
• THIS LEADS TO:
• AXONAL DEGENERATION (NERVE FIBERS DIE)
• WALLERIAN DEGENERATION (DOWNSTREAM NERVE BREAKDOWN)
• 🔹 3. MOTOR AND SENSORY DEFICITS
• THE DAMAGE PRIMARILY AFFECTS MOTOR NERVES, LEADING TO MUSCLE WEAKNESS AND ATROPHY.
• SENSORY NERVES MAY ALSO BE INVOLVED, CAUSING PAIN AND NUMBNESS.
 4. FOCAL NEUROPATHY
(MONONEUROPATHY)

 AFFECTS A SINGLE NERVE OR NERVE GROUP, OFTEN IN THE HEAD,

TORSO, OR LEG
 COMES ON SUDDENLY AND IS USUALLY TEMPORARY
 COMMON FORMS:
o CRANIAL NEUROPATHIES (E.G., CN III PALSY CAUSING DIPLOPIA)
o RADIAL, ULNAR, OR PERONEAL NERVE PALSIES
 SYMPTOMS:
o SUDDEN WEAKNESS OR PAIN IN A SPECIFIC NERVE DISTRIBUTION
o DOUBLE VISION, BELL’S PALSY, OR LOCALIZED PAIN (E.G., CHEST
OR ABDOMEN)
 CAUSES AND RISK FACTORS OF DIABETIC NEUROPATHY

The primary cause of diabetic neuropathy is prolonged

hyperglycemia (high blood sugar), which leads to:
• Metabolic damage to nerves:
• High glucose alters nerve metabolism and impairs nerve signal
transmission.
• Accumulation of sorbitol and fructose in nerves causes oxidative stress and
cell damage.
• Vascular damage:
• High glucose damages small blood vessels that supply nerves (vasa
nervorum), leading to nerve ischemia.
• Inflammatory processes:
• Chronic inflammation due to diabetes may contribute to nerve injury.
• Autoimmune factors:
• In some cases, the immune system may attack peripheral nerves.
⚠FACTORS
Poor blood sugar control

• The most significant risk factor.

RISK • Chronic hyperglycemia increases the likelihood and severity of nerve damage.

Duration of diabetes

• The longer a person has diabetes, the higher the risk (especially >10 years).

FOR Type of diabetes

DIABETIC • More common and severe in Type 2 diabetes, though also occurs in Type 1.

NEUROPAT
Age

• Risk increases with age.

HY High blood pressure (Hypertension)

• Damages blood vessels supplying nerves.

High cholesterol and triglycerides

• Contribute to vascular disease and nerve damage.

 CONT..

Obesity • Associated with insulin resistance and worsens glycemic control.

• Both contribute to vascular and nerve damage.

Smoking and alcohol use • Alcohol also has a direct neurotoxic effect.

Kidney disease • Uremic toxins from kidney failure can worsen nerve damage.

Genetics
Some individuals may have a
genetic predisposition to
neuropathy.
 SIGN AND
SYMPTOM OF
DIABETIC
NEUROPATHY
 CONT..

• NUMBNESS, TINGLING, OR BURNING SENSATIONS

IN THE HANDS OR FEET
• PAIN IN THE HANDS, FEET, OR LEGS
• MUSCLE WEAKNESS OR WASTING
• DIFFICULTY WITH COORDINATION WHEN WALKING
• SENSITIVITY TO TOUCH OR LOSS OF SENSE OF
TOUCH
• BURNING SENSATION IN FEET, ESPECIALLY AT
NIGHT
• BLOATING OR FULLNESS
DIAGNOSIS OF DIABETIC NEUROPATHY
 DIAGNOSIS OF DIABETIC NEUROPATHY

• DIAGNOSING DIABETIC NEUROPATHY INVOLVES A COMBINATION OF CLINICAL EVALUATION, PATIENT HISTORY, AND
DIAGNOSTIC TESTS. HERE'S HOW IT IS TYPICALLY DONE:
• 1. MEDICAL HISTORY AND SYMPTOMS

 DURATION AND CONTROL OF DIABETES

 SYMPTOMS SUCH AS:

o NUMBNESS OR TINGLING IN THE FEET OR HANDS
o BURNING OR STABBING PAIN
o MUSCLE WEAKNESS
o DIZZINESS OR FAINTING
o DIGESTIVE OR URINARY ISSUES
• 2. PHYSICAL EXAMINATION

 MONOFILAMENT TEST (USING A NYLON FIBER TO TEST PRESSURE SENSATION)

 VIBRATION PERCEPTION TEST (TUNING FORK)

 CONT..

• 3. NERVE CONDUCTION STUDIES / ELECTROMYOGRAPHY (EMG)

 MEASURES ELECTRICAL ACTIVITY OF NERVES AND MUSCLES
 DETECTS NERVE DAMAGE
• 4. QUANTITATIVE SENSORY TESTING
 MEASURES RESPONSE TO PRESSURE, VIBRATION, AND TEMPERATURE
• 5. AUTONOMIC TESTING (FOR AUTONOMIC NEUROPATHY)
 HEART RATE VARIABILITY
 BLOOD PRESSURE CHANGES WITH POSTURE
 SWEAT TESTING
COMPLICATIONS OF DIABETIC NEUROPATHY
 COMPLICATIONS OF DIABETIC NEUROPATHY

If not managed properly, diabetic neuropathy can lead to serious complications:

1. Foot Complications
• Loss of sensation → unnoticed injuries
• Ulcers and infections
• Charcot joint (progressive foot deformity)
• Amputation (due to poor healing or severe infection)
2. Autonomic Neuropathy
• Cardiovascular: silent heart attacks, orthostatic hypotension
• Gastrointestinal: gastroparesis, constipation, diarrhea
• Genitourinary: erectile dysfunction, bladder dysfunction
• Sudomotor: abnormal sweating
3. Peripheral Neuropathy
• Painful neuropathy (burning, stabbing pain)
• Balance issues → risk of falls
 Tight glycemic control

PREVENTION Foot care and regular exams

AND
MANAGEMENT
Pain management (e.g., pregabalin,
duloxetine, TCAs)

Lifestyle modifications: smoking

cessation, exercise, proper diet
 DIABETIC NEUROPATHY MANAGEMENT

1. Nursing Management

Focuses on symptom relief, patient education, and prevention of

complications.
• Patient Education
• Importance of blood glucose control
• Foot care: daily inspection, proper footwear
• Recognizing signs of infection or injury
• Monitoring
• Regular foot assessments
• Monitoring pain levels and response to treatment
• Supportive Care
• Promote mobility and prevent falls
• Encourage balanced diet and hydration
• Assist with medication compliance and lifestyle changes
• Psychosocial Support
• Address depression or anxiety related to chronic pain
 2. MEDICAL MANAGEMENT

Aims to slow disease progression, relieve symptoms, and prevent

complications.
• Glycemic Control
• Tight blood sugar control (insulin or oral hypoglycemics)
• Pharmacological Treatment
Pain management
• First-line: Pregabalin, duloxetine, amitriptyline
• Others: Gabapentin, capsaicin cream, tramadol (short-term)
Autonomic symptoms:
• Gastroparesis: Metoclopramide or erythromycin
• Orthostatic hypotension: Midodrine, fludrocortisone
• Bladder dysfunction: Scheduled voiding, anticholinergics
Nutritional Supplements

Alpha-lipoic acid, vitamin B12 (especially if deficient

 Used in select cases for severe
complications or structural
issues.
• Foot Ulcers/Infections
• Debridement
3. SURGICAL • Drainage of abscesses
MANAGEME • Amputation in advanced or non-
NT healing infections
• Charcot Foot
• Surgical correction or reconstruction in
severe deformities
• Nerve Decompression Surgery (rare)
• For localized nerve entrapments
causing pain or weakness
 Type Affected Area Symptoms
Numbness, burning,
Peripheral Hands, legs, feet
tingling, pain
SUMMARY Digestive problems,
OF DIABETIC Autonomic Internal organs bladder issues, sexual
NEUROPATH dysfunction

Y: Focal Single nerve

Sudden weakness or
pain (e.g., in eye or
thigh)
Weakness, pain in legs,
Proximal Thighs, hips difficulty rising from
sitting
 SYMPTOMS:
CAUSES AND RISK FACTORS
• POOR BLOOD SUGAR CONTROL. • NUMBNESS OR REDUCED ABILITY TO FEEL PAIN
OR TEMPERATURE.
• DURATION OF DIABETES. • BURNING OR TINGLING SENSATIONS.

• KIDNEY DISEASE. • SHARP PAINS OR CRAMPS.

• MUSCLE WEAKNESS.
• OBESITY.
• LOSS OF REFLEXES.
• SMOKING. • PROBLEMS WITH BALANCE AND COORDINATION.
 AUTHORITATIVE SOURCES

1.ABSTRACT. [DIABETIC NEUROPATHY: A POSITION STATEMENT BY THE AMERICAN DIABETES ASSOCIATION]

2.PRACTICE ESSENTIALS. [DIABETIC NEUROPATHY - MEDSCAPE]
3.INTRODUCTION. [DIABETIC NEUROPATHY: A POSITION STATEMENT BY THE AMERICAN DIABETES ASSOCIATION]
4.DA DIABETIC NEUROPATHY – POSITION STATEMENT, DIABETES CARE, 2017 JAN. DIABETES.ORG.UK
5.NIDDK OVERVIEW: “WHAT IS DIABETIC NEUROPATHY?” (LAST REVIEWED FEB 2018)
6.MAYO CLINIC STAFF ARTICLES ON SYMPTOMS AND CAUSES (APR 2022) AKAMAI.MAYOCLINIC.ORG
7.CURRENT PAIN AND HEADACHE REPORTS, JUNE 2024, PATHOPHYSIOLOGY-FOCUSED
8.VERY WELL HEALTH ARTICLES ON DIAGNOSIS AND TREATMENT (2022)
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