Impaired peripheral neurovascular function: a middle-range theory for assessing people with diabetes – an integrative reviewAbstract
Objective To construct a middle-range theory for the “Impaired Peripheral Neurovascular Function” nursing diagnosis in diabetic patients.
Methods The theory was constructed in six stages: defining the approach to theory construction; defining the conceptual models to be included; defining the main concepts; constructing a pictogram; formulating propositions; and establishing causal relationships and evidence for practice.
Results The theory incorporated 14 etiological factors and 16 clinical indicators. Additionally, six associated conditions from risk diagnosis in NANDA International were homologated for theory construction. A pictogram was developed, and eight propositions for etiological factors and five for clinical indicators were formulated to verify causal relationships and evidence for practice.
Conclusion This study led to the development of a middle-range theory for the “Impaired Peripheral Neurovascular Function” nursing diagnosis in patients with diabetes, incorporating etiological factors, clinical indicators, a pictogram, and causal relationships among concepts.
Keywords:
Diabetes mellitus; Diabetic angiopathy; Diabetic neuropathies; Etiology; Signs and symptoms
Resumo
Objetivo Construir uma teoria de médio alcance para o diagnóstico de enfermagem “Função Neurovascular Periférica Prejudicada” em pacientes diabéticos.
Métodos A teoria foi construída em seis etapas: definição da abordagem para construção teórica; definição dos modelos conceituais a serem incluídos; definição dos principais conceitos; elaboração de um pictograma; formulação de proposições; e estabelecimento de relações causais e evidências para a prática.
Resultados A teoria incorporou 14 fatores etiológicos e 16 indicadores clínicos. Além disso, seis condições associadas do diagnóstico de risco da NANDA International foram homologadas para a construção teórica. Um pictograma foi desenvolvido, e oito proposições para fatores etiológicos e cinco para indicadores clínicos foram formuladas para verificar relações causais e evidências para a prática.
Conclusão Este estudo levou ao desenvolvimento de uma teoria de médio alcance para o diagnóstico de enfermagem “Função Neurovascular Periférica Prejudicada” em pacientes com diabetes, incorporando fatores etiológicos, indicadores clínicos, um pictograma e relações causais entre os conceitos.
Descritores:
Diabetes mellitus; Angiopatias diabéticas; Neuropatias diabéticas; Etiologia; Sinais e sintomas
Resumen
Objetivo Elaborar una teoría de alcance medio para el diagnóstico de enfermería “Función neurovascular periférica alterada” en pacientes diabéticos.
Métodos La teoría se construyó en seis etapas: definición del enfoque para la construcción teórica, definición de los modelos conceptuales que se incluirían, definición de los conceptos principales, elaboración de un pictograma, formulación de proposiciones y establecimiento de relaciones causales y evidencias para la práctica.
Resultados La teoría incorporó 14 factores etiológicos y 16 indicadores clínicos. Además, se homologaron seis condiciones asociadas al diagnóstico de riesgo de NANDA International para la construcción teórica. Se elaboró un pictograma y se formularon ocho proposiciones para los factores etiológicos y cinco para los indicadores clínicos con el fin de verificar las relaciones causales y las evidencias para la práctica.
Conclusión Este estudio condujo al desarrollo de una teoría de alcance medio para el diagnóstico de enfermería “Función neurovascular periférica alterada” en pacientes con diabetes, que incorporó factores etiológicos, indicadores clínicos, un pictograma y relaciones causales entre los conceptos.
Descriptores:
Diabetes mellitus Angiopatías diabéticas; Neuropatías diabéticas; Etiología; Signos y síntomas
Introduction
Diabetes mellitus (DM) is a metabolic disease caused by genetic, environmental, socioeconomic, and demographic factors. The International Diabetes Federation classifies DM as one of the fastest-growing diseases of this century. Over the past three decades, the number of individuals with DM has quadrupled worldwide, projected to reach 643 million by 2030 and 783 million by 2045.(1) Prolonged exposure to a hyperglycemic environment damage both macrovascular and microvascular systems, contributing to complications such as myocardial infarction, stroke, peripheral arterial disease, nephropathy, retinopathy, and diabetic neuropathy.(2)
Peripheral neuropathy is one of the most common complications of DM, defined as signs and symptoms of peripheral nerve dysfunction affecting motor and sensory nerves in the peripheral nervous system.(3) It is a major cause of chronic pain, which can progress to loss of sensation in the lower extremities.(4) The consequences of neuropathy can be severe, including foot ulcers, major amputations, falls, intracranial injuries, and reduced quality of life.(5)
Among the nursing diagnoses associated with this phenomenon, NANDA International includes the “Risk for Peripheral Neurovascular Dysfunction” diagnosis within Domain 11 (Safety and Protection), Class 2 (Physical Injury). This is a risk-focused diagnosis defined as “at risk for alteration in circulation, sensation, and movement of an extremity”.(6) However, the construction of a problem-focused diagnostic structure makes this study particularly innovative first, because such a diagnosis does not currently exist within the nursing taxonomy, and second, because one of the key components of this diagnostic approach includes related factors, which can be directly and independently addressed by nursing professionals.
Independent interventions that nursing professionals can implement, which are considered cross-cutting in light of the etiological factors reported in literature interventions such as patient education, prescribed exercise, exercise promotion, dietary prescriptions, and behavior modification, have been identified. These nurse-led interventions have demonstrated effectiveness in improving anthropometric outcomes, promoting adherence to healthy dietary habits and physical activity, reducing complications associated with the human response under study, and ultimately enhancing patients’ quality of life.(7)
Furthermore, the existing risk diagnosis in NANDA-I taxonomy currently lacks any level of evidence supporting its validity. If no further development is achieved to reach level 2.1 (conceptual level), it will be removed in the next edition. Additionally, the development of this theory will contribute to the advancement of nursing science by supporting the development of clinical reasoning, evidence-based decision-making, and its application and expansion across research, academic, and clinical settings.
To address this gap, some scholars suggest nursing diagnosis validity methods such as using a middle-range theory (MRT), which is defined as a set of interrelated ideas focusing on a particular dimension of nursing knowledge, encompassing a limited number of concepts and propositions, described at a specific and concrete level, and directly related to research and practice.(8) Thus, by constructing an MRT, this study will develop a theoretical gradient to identify the ‘Peripheral Neurovascular Dysfunction” diagnosis etiological elements and clinical characteristics and establish causal relationships that explain the occurrence of this human response.(8)
Methods
A theoretical-causal validity study that enabled the construction of an MRT for the “Impaired Peripheral Neurovascular Function” (IPNF) nursing diagnosis in the context of patients with DM, based on an integrative literature review. This process follows the model proposed by Lopes, Silva, and Herdman, adapted from Roy, and is divided into six stages: defining the approach for theory construction; selecting the conceptual models to be included; identifying the main concepts; constructing a pictogram; formulating propositions; and establishing causal relationships and evidence for practice.(8,9) Each stage is described below.
Defining the approach to theory construction
An MRT was developed through the analysis of elements that constitute the IPNF phenomenon, such as essential attributes, clinical antecedents, and consequences. To fulfill the MRT, three models were applied: the diagnostic validity model based on a theoretical-causal approach; the clinical-epidemiological model through diagnostic testing; and the clinical reasoning model grounded in a causality framework. These models were integrated through shared concepts, enabling the identification of the diagnostic structure and the establishment of causal relationships among the concepts involved in the human response under study.(8,10)
To formulate the guiding research question, the PCC strategy was adapted to the study context, where P refers to the population (patients diagnosed with DM), C to the concept (IPNF), and C to the context (etiological factors and clinical manifestations).(11) Based on this, the research question was defined as follows: What are the etiological factors and clinical manifestations of IPNF in diabetic patients?
In response to this question, a literature search was conducted in the following databases: LILACS, Scopus, WoS, and PubMed. The descriptors were selected from the DeCS/MeSH health sciences thesauri, and included Nursing Diagnosis, Diabetes, Etiology, Causality, Signs and Symptoms, Risk Factors, Diabetic Complications, Angiopathy, and Diabetic Neuropathy. Boolean operators AND and OR were used to combine the search terms. See search strategies in chart 1.
Primary and secondary studies addressing the IPNF concept in diabetic patients receiving care in any clinical setting, regardless of age, sex, ethnicity, or comorbidities were included. No restrictions were placed on the time period or language. Letters to the editor and opinion articles were excluded.
To ensure article selection quality and minimize selection bias, at least two independent reviewers assessed all studies. The decision to include or exclude a study was made based on a review of titles and abstracts. In cases of disagreement between the two reviewers, a third reviewer was consulted to reach a resolution.
After reviewing the titles and abstracts, the selected articles were analyzed in full text to ensure compliance with eligibility criteria. Data extraction focused on identifying elements that contribute to understanding and structuring the IPNF diagnostic construct and its associated aspects. Additionally, risk factors and conditions currently described in existing risk diagnosis within NANDA-I taxonomy will be considered for developing the MRT.
Defining the main concepts
To develop an MRT, three main concepts were utilized: neurovascular function, which serves as the conceptual core of the diagnosis; clinical antecedents, which predispose the occurrence of the human response; and consequences, which represent the clinical manifestations of the diagnosis observed in patients with DM. Two researchers independently participated in the identification of these concepts by reviewing the full text of the articles included in the sample. The diagnostic elements (related factors, defining characteristics, and associated conditions) outlined in NANDA-I taxonomy, along with new elements obtained from the literature review, were incorporated into the MRT structure.(8)
Constructing a pictogram
To enhance the understanding of the primary concepts of the MRT for IPNF, a pictogram was developed to facilitate the interpretation of the main concepts identified in the literature review. This diagram graphically explains the interrelationships between antecedents, the phenomenon under study, and clinical manifestations from the perspective of a nursing diagnosis, as a product of clinical reasoning. The Ishikawa diagram was used to visually represent the relationships among key concepts of the IPNF diagnosis, including etiology and clinical indicators. Etiological factors were categorized based on Lopes and Silva’s causal hierarchy—precipitating, disabling, predisposing, and reinforcing factors. The NANDA-I structure for problem-focused diagnoses—related factors, associated conditions, and at-risk populations—was also integrated into the diagram.(10)
Formulating propositions
Based on the findings from the literature review, these were divided into propositions related to etiological factors and propositions associated with clinical indicators, with the aim of constructing explanatory relationships for the concepts linked to the MRT of the IPNF diagnosis. These propositions form the foundation for building causal relationships that predict the phenomenon under study.
Establishing causal relationships and evidence for practice
The Lopes, Silva, and Herdman model 2017 was employed to define causal models for explaining causal relationships. This model describes six types of causal organization (linear, trigger, domino effect, butterfly effect, quantum leap, and sufficient causes), which enabled the analysis of the relationships between the elements of the phenomenon under study in the context of nursing practice, facilitating a better understanding of the IPNF diagnosis.(8)
Results
The literature search identified 434 scientific articles across four different databases: LILACS (131), Scopus (86), WoS (136), and PubMed (80). A total of 18 duplicate articles were excluded using the Rayyan software. Subsequently, the titles and abstracts of 416 articles were reviewed to identify antecedent and consequent elements related to the phenomenon under study, leading to the exclusion of 378 articles that were unrelated to peripheral neurovascular dysfunction. For the second phase of full-text review, 38 articles were retained, and eligibility criteria were applied, resulting in the exclusion of eight articles for the reasons detailed in figure 1. Finally, the sample consisted of a total of 30 articles used for the extraction of concepts.
Definition of main concepts
After literature review, IPNF antecedents and consequences were identified. Fourteen etiological factors were found: six precipitating, four predisposing, and four reinforcing factors, with no disabling factors. Additionally, NANDA-I’s axiological structure revealed five related factors, three at-risk populations, and six associated conditions. Related factors included poor glycemic control, obesity, dyslipidemia, smoking, and vitamin D deficiency, as shown in chart 2. NANDA-I risk diagnosis includes seven risk factors and eleven associated conditions. After review, six conditions (atherosclerosis, DM, infection, vascular obstruction, wounds) were found consistent with the literature; basically, associated conditions were the same as those reported by the empirical findings from the literature review on diabetic patients, contributing to the MRT. The remaining conditions were excluded as nonspecific to the study population.
Classification of concepts related to human response, impairment of peripheral neurovascular function
Constructing a pictogram
For the theory organization, four types of causal relationships were identified from the literature and categorized according to Lopes and Silva as follows: precipitating factors (DM duration > 10 years, metabolic syndrome, peripheral arterial disease, hypertension, oxidative stress, and obesity); predisposing factors (age > 60 years, male sex, height, and smoking); and reinforcing factors (poor glycemic control, subclinical inflammation, dyslipidemia, and vitamin D deficiency). No findings were identified for disabling factors.(10)
Formulating propositions
Antecedent concepts were classified into precipitating factors (initiating the causal chain), predisposing factors (increasing susceptibility), disabling factors (hindering recovery), and reinforcing factors (amplifying existing conditions) to establish a causal hierarchy (Figure 2).(10)
Cause-effect diagram of etiological factors of impaired peripheral neurovascular function
Note: *Associated conditions; **Population at risk; ***Related factors. Precipitating factors: Represent factors that initiate the causal chain. Predisposing factors: Lead to increased susceptibility to nursing diagnosis. Incapacitating factors: Interfere with recovery or health promotion. Reinforcing factors: Amplify the effect of an existing clinical condition.
Propositions for etiological factors
The occurrence of chronic diseases such as DM, hypertension, and peripheral arterial disease can precipitate peripheral neurovascular function deterioration through the activation of various pathophysiological mechanisms that affect the vascular and nervous systems. The chronicity of certain conditions, such as DM lasting over 10 years, can impair nerve conduction and blood flow due to sustained elevated glucose levels, potentially precipitating peripheral neurovascular function deterioration. Age >60 years and male sex may increase susceptibility to the IPNF diagnosis due to the progressive decline in neurological functions. Likewise, height may predispose individuals to the expression of the diagnosis due to the length-dependent pattern of nerve fiber involvement at the axonal level. The development of obesity may lead to endothelial dysfunction, which in turn can trigger microangiopathies with small nerve fiber dysfunction. This is considered a factor that initiates the causal chain of IPNF. Behavioral factors such as smoking increase susceptibility to the diagnosis, acting as an independent risk factor due to endothelial damage, activation of inflammatory processes, and thrombosis formation. Poor control of clinical parameters, such as glycemic control, dyslipidemia, and subclinical inflammation, amplifies the phenomenon under study by exacerbating microcirculation deterioration and peripheral nerve function impairment. Low levels of oxidative stress markers such as nitric oxide cause greater oxidative DNA damage in individuals with type 2 DM, leading to difficulties in the relaxation processes of smooth muscle in vascular walls. This is therefore considered a precipitating factor for IPNF. Vitamin D deficiency is considered a factor that amplifies the effect of IPNF, as one of its roles includes stimulating the production of nerve growth factor, which exerts a neuroprotective effect.
Propositions for clinical indicators
The peripheral vascular flow reduction caused by mechanical, environmental factors and/or comorbidities affects the nervous system, leading to paresthesia, loss of protective sensation, burning sensations, numbness, and cramps. Nervous system involvement due to pathophysiological factors such as hyperglycemia associated with DM lasting more than 10 years can result in deformities of the lower limbs (claw or hammer toes), skin changes (dry, cracked, or shiny skin, reduced moisture), atrophy of small muscles, and lower limb weakness as severe motor manifestations of the phenomenon under study. Peripheral arterial disease and smoking compromise the nervous system and microvasculature, leading to peripheral neurovascular dysfunction through infectious processes, lower limb ulceration, and even amputation. Blood glucose instability altered skin microcirculation, and reduced nerve fiber density may be the genesis of pain, allodynia, and hyperesthesia in the context of IPNF. The development of atheromatosis due to factors such as peripheral arterial disease, age over 60 years, and metabolic syndrome manifests as clinical signs and symptoms such as an Ankle-Brachial Index<0.9 or >1.1 and claudication, which are consequences that define peripheral neurovascular dysfunction.
Discussion
The MRT is composed of 14 etiological factors and 16 clinical indicators. As expected, clinical indicators are strongly associated with IPNF, and the literature highlights these indicators as the most frequently observed in patients with DM.
Hence, among the etiological factors of impaired neurovascular function, DM stands out, which, when combined with hypertension, can lead to chronic complications such as neuropathy and peripheral vascular disease, contributing to foot ulcers and potential lower limb amputations. In people with DM, disease duration and hyperglycemia are linked to peripheral neuropathy, with each 1% increase in HbA1c raising the risk of microvascular complications.(12)
Hyperglycemia alters ion transport in neural pathways, impairing nerve conduction and blood flow.(28) Age over 60 is an independent risk factor for diabetic polyneuropathy, with its prevalence increasing progressively with age.(12) Height also plays a role due to the length-dependent nature of the disease; taller individuals, with longer nerve fibers, are more susceptible to nerve damage.(12,14)
Dyslipidemia reduces the density of myelinated fibers, contributing to diabetic polyneuropathy and peripheral neurovascular dysfunction.(12) Obesity may trigger microvascular diseases like neuropathy through endothelial dysfunction. Obese individuals often show small nerve fiber dysfunction, with impaired pain perception and reduced vasodilation.(12,37) Dyslipidemia also leads to progressive nerve fiber loss via lipotoxicity from free fatty acids.(20)
Metabolic syndrome, comprising hyperlipidemia, hypertension, obesity, and insulin resistance, is a risk factor for neurovascular dysfunction, often presenting as distal sensory changes or burning pain.(22) Smoking increases oxidative stress, impairs insulin signaling, and promotes advanced glycation end products, linking it to vascular diseases. This can manifest as claudication, abnormal Ankle-Brachial Index, ulcers, infections, and potential amputations.(38)
Vitamin D plays a crucial role in promoting the secretion of nerve growth factor. Nerve growth factor is a target-derived protein that regulates the phenotype and sensitivity of nociceptive fibers. Its deficiency can lead to the development of small fiber clinical diabetic neuropathy, manifesting as burning, electric shock-like pains in the feet and legs, and contact hypersensitivity.(27)
Finally, microvascular complications are associated with poor glycemic control and, consequently, with the onset of peripheral neuropathy. The proposed etiopathogenic mechanisms include increased non-enzymatic glycation of structural nerve proteins or vascular changes with endoneural hypoxia due to microangiopathy.(13)
For nurses, understanding the diagnosis antecedents and consequences is a key tool for developing clinical reasoning in identifying the human response. This knowledge enables the implementation of autonomous interventions aimed at mitigating complications associated with the diagnosis and improving quality of life.
Among clinical indicators, peripheral neuropathy is the most common type of neuropathy, affecting about 50% of people with DM. It involves motor and sensory nerves, with early changes in unmyelinated “C” fibers, leading to distal sensitivity loss, pain, hypersensitivity, and allodynia, primarily due to axonal degeneration.(18)
Symmetrical diabetic peripheral neuropathy typically starts with sensory symptoms in the toes, progressing proximally in a stocking-like pattern. In advanced cases, it affects the hands, causing muscle atrophy and limb weakness.(19) Sensory loss may go unnoticed until a foot ulcer appears. About one-third of affected individuals report unpleasant symptoms in the lower limbs, including tingling, burning, stabbing pain, allodynia, or sensations like swollen feet or cold legs. Some describe walking as if on stones or hot sand.(19)
Many also experience neuropathic pain, often worse at night, disrupting sleep and causing fatigue. In this context, chronic pain may lead to depression and anxiety.(36) Furthermore, the mechanisms of diabetic neuropathic pain are not fully clear but may involve altered sodium and calcium channels, neuropeptide changes, sympathetic sprouting, axonal degeneration, small fiber damage, blood glucose fluctuations, reduced intraepidermal nerve fiber density, and autonomic dysfunction.(36)
Finally, the clinical indicators of the phenomenon under study can be identified by nursing professionals during patient interview and physical examination. This facilitates evidence-based decision making and the development of a care plan aligned with the individual needs of a person receiving care. Although a variety of clinical indicators have been described, some such as tingling, pain, and loss of protective sensation are more frequently reported in the literature.
This study presents certain limitations regarding the scope of the proposed MRT. Since it was developed specifically for adult patients with DM, caution should be exercised when considering its use in other pathologies or stages of life. In such cases, the supporting literature should be broadened and adapted to fit the specific clinical or population context.
Conclusion
The methodology used to construct the theoretical foundation for the IPNF diagnosis enabled the identification of 14 etiological factors and 16 clinical indicators, as well as the establishment of causal relationships among concepts, contributing to the discipline development and providing nurses with tools for evidence-based clinical judgment. Based on the literature review, eight propositions for etiological factors and five for clinical indicators of the IPNF diagnosis were formulated. Finally, the validity of nursing diagnoses through more robust methodologies, such as the construction of an MRT, provides a solid foundation for developing evidence levels for diagnostic validity, essential for subsequent validity phases.
Acknowledgements
This study is part of the doctoral thesis of the first author within the Doctoral Program in Nursing at the Federal University of Ceará, Brazil. I sincerely thank my advisor for their guidance in making this article a reality and for the invaluable contributions from the discipline of critical analysis of nursing theories. This study did not receive funding for its execution.
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Data availability:
The survey data are available in the article.
Edited by
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Editora Associada:
Camila Takao Lopes (https://orcid.org/0000-0002-6243-6497) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brasil
The survey data are available in the article.
