problems, and alterations in the function of the sweat glands (NIDDK, 2018a). Heart and Blood Vessel Impact of Autonomic Neuropathy Damage to the nerves of the cardiovascular system adversely affects the body’s ability to adjust blood pressure and heart rate. This can lead to orthostatic hypotension, dizziness, lightheadedness, or fainting. Damage to the nerves that control heart rate can lead to tachycardia instead of normal increases and decreases in heart rate in response to body functions, stress, and physical activity (NIDDK, 2018a). Patients must be taught to avoid changing position too quickly, especially from a lying to a sitting or standing position. Wearing elastic stockings may be helpful, and physical therapy can be useful when dealing with muscle weakness or loss of coordination. Heart healthy interventions such as smoking cessation, lipid management, blood pressure control, exercise, and diet may help to decrease the development or progression of heart and blood vessel autonomic neuropathy (NIDDK, 2018a). Digestive System Autonomic Neuropathy. Following are common symptoms of digestive autonomic neuropathy (NIDDK, 2018a): ● Bloating ● Diarrhea ● Constipation ● Difficulty swallowing ● Feeling full after eating only a small amount of food ● Loss of appetite ● Nausea ● Vomiting ● Fecal incontinence Treatments include dietary changes and medications to treat symptoms of constipation, diarrhea, fecal incontinence, and gastroesophageal reflux (NIDDK, 2018a). Urinary Tract Involvement Nerve damage can cause incomplete emptying of the bladder and increase the likelihood of urinary tract infections. Patients may also experience incontinence and increased urination at night (NIDDK, 2018a). Focal diabetic neuropathy Focal diabetic neuropathy can appear suddenly. It affects specific nerves most often in the head, torso, or leg (NIDDK, 2018b). Focal diabetic neuropathy may cause the following problems Diabetic retinopathy Diabetic retinopathy is the most common diabetic eye disease and a leading cause of blindness in American adults. Initially, diabetic retinopathy may not cause any symptoms or only mild vision disturbances. However, the complication can eventually result in blindness (Mayo Clinic, 2021b; National Eye Institute, 2019). The American Diabetes Association (2021i) recommends that to slow progression of diabetic retinopathy, patients should optimize glycemic control, blood pressure, and serum lipid control. Diabetic retinopathy has four stages (Dansinger, 2021c): (NIDDK, 2018b): ● Double vision ● Aching behind one eye ● Bell’s palsy (paralysis on one side of the face) ● Difficulty focusing the eyes 1. Mild non-proliferative retinopathy: Microaneurysms occur, which are small areas of balloon-like swelling in the blood vessels of the retina. 2. Moderate non-proliferative retinopathy: Some blood vessels that provide nourishment to the retina are blocked. 3. Severe non-proliferative retinopathy: More and more blood vessels are blocked. Several areas of the retina are deprived of their blood supply, and they transmit messages to the body to grow new, additional blood vessels to supply nourishment.
Patients are encouraged to drink plenty of fluids to help prevent infections. Because they may not be able to sense when their bladders are full, patients may implement a regular schedule of voiding such as every four hours (NIDDK, 2018a). Sexual Organs Involvement Autonomic neuropathy can gradually decrease sexual response in men and women even though sex drive may be unchanged. Men may be unable to have or unable to maintain an erection or have dry or reduced ejaculations. Women may have difficulty becoming aroused or achieving orgasm or experience a decrease in vaginal lubrication that can lead to painful intercourse (NIDDK, 2018a). Treatment of erectile dysfunction in men begins with testing to rule out hormonal causes. To treat erectile dysfunction caused by neuropathy, medications that increase blood flow to the penis may be prescribed. Some medications are oral; others are injected into the penis or inserted into the urethra at the tip of the penis. Other interventions include the use of mechanical vacuum devices to increase blood flow to the penis or surgical implantation of an inflatable or semirigid device in the penis (Dansinger, 2021b; Ignatavicius et al., 2018; NIDDK, 2018a). For women, the use of vaginal lubricants, estrogen creams, suppositories, and rings or medications to help reduce symptoms and facilitate arousal may be prescribed (Dansinger, 2021b; Ignatavicius et al., 2018; NIDDK, 2018a). Self-Assessment Quiz Question #9
When counseling patients about autonomic diabetic neuropathy, healthcare professionals must know that: a. The impact on heart and blood vessels can lead to orthostatic hypotension or fainting. b. This type of neuropathy has no impact on sexual functioning. c. It is important to limit fluid intake. d. The use of elastic stockings is contraindicated.
Focal diabetic neuropathy is unpredictable as well as being painful and is seen most often in older patients with focal neuropathy who tend to develop nerve compressions, also called entrapment syndromes. Carpal tunnel syndrome, which causes numbness and tingling of the hand and sometimes muscle weakness and pain, is a common example of such compression. Other nerves that are vulnerable to entrapment may cause pain on the outside of the shin or the inside of the foot (NIDDK, 2018b). 4. Proliferative retinopathy: New blood vessels grow in an attempt to nourish the retina. This condition is referred to as proliferative retinopathy. These new blood vessels are fragile and abnormal and grow along the retina and along the surface of the clear vitreous gel that fills the inside of the eye. Because the walls of the abnormal vessels are so thin and fragile, they leak blood causing severe vision loss and even blindness. It is rare to have signs and symptoms of the disease during early stages of diabetic retinopathy. However, as the disease progresses, symptoms may include the following Mayo Clinic, 2021b; National Eye Institute, 2019): ● Spots or dark strings floating in the visual field (commonly referred to as floaters) ● Blurred vision ● Dark or empty areas in vision ● Vision loss ● Problems with color perception
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