Xavier University — Ateneo de Cagayan

College of Nursing
A.Y 2021-2022

Concept Map on Cognitive Disorders

In Partial Fulfillment of the Requirements for

NCM 116 - LEC

Submitted by:

Acut, Louella B.
Banaag, Ma. Venus Caress T.
Banza, Khrisna Nymph P.
Bontuyan, Chien Lai R.
Cubillas, Franczhes A.
Datu-Ramos, Dimapuno T.
Ebio, Dynn M.
Go, Clarke Nathaniel Sean E.
Jomuad, Ariel Jr. L.
Laid, Althia Crizza J.
Langeras, Howard S.
BSN 3 - NC (Group 1)

Submitted to:

Mrs. Jesusa C. Gabule

February 18, 2022

 CONCEPT MAP
Google Drive Link:
https://drive.google.com/file/d/1c4WvpQtDkqjNX5NqGMhTdgcyDoPccX8u/view

NEUROLOGICAL AUTOIMMUNE DISORDERS AND NEUROPATHIES

Bell’s Palsy

Bell’s Palsy, also termed idiopathic facial paralysis (IFP), is the most common cause
of unilateral facial paralysis. It is one of the most common neurologic disorders of the cranial
nerves. The cause of Bell Palsy is not known. It is thought that it may be due to
inflammation that is directed by the body's immune system against the nerve controlling
movement of the face. The predisposing factors of this disorder include Guillain-Barré
syndrome, people who are 15-45 years of age, and pregnancy. The precipitating factors
include diabetes, hypertension, infection especially after viral infection with Herpes simplex
virus, injury, myasthenia gravis, multiple sclerosis, obesity, pre-eclampsia, lyme disease,
sarcoidosis, and toxins.

In Bell’s Palsy, there is a unilateral inflammation of the seventh cranial nerve (facial
nerve) in response to an infection. As a result, there is an increased pressure within the
Fallopian canal. The nerve becomes compressed to the point of damage where blood and
oxygen supply then becomes occluded. This leads to the ischemic necrosis of the nerve,
ultimately paralyzing the facial muscles. Facial distortion and decreased lacrimation occurs
and the patient experiences painful sensations in the face, behind the ear, and in the eye.

There are several clinical manifestations of the disease. This include posterior
auricular pain, decreased tearing, hyperacusis, taste disturbances, otalgia, weakness of
the facial muscles, poor eyelid closure, aching of the ear or mastoid, tingling or numbness
of the cheek or mouth, epiphora, ocular pain, blurred vision, and flattening of forehead and
nasolabial fold on the side affected by palsy. In addition, when the patient’s eyebrows raise,
the palsy-affected side of the forehead remains flat and when the patient smiles, the face
becomes distorted and lateralizes to the side opposite the palsy. If the disease is not
treated, complications may occur such as irreversible damage to the facial nerve, abnormal
regrowth of nerve fibers, resulting in involuntary contraction of certain muscles when trying
to move others (synkinesis), and partial or complete blindness of the eye that won't close
due to excessive dryness and scratching of the cornea.
 There are diagnostic tests that can help diagnose bell palsy. In otologic examination,
pneumatic otoscopy and tuning fork examination, particularly if evidence of acute or chronic
otitis media. Another is the ocular examination where the patient is often unable to
completely close eye on the affected side. Oral examination is also important because in
bell palsy, the patient’s taste and salivation are often affected. In addition, all cranial nerves,
sensory and motor testing, and cerebellar testing are also important to diagnose bell palsy.
Impaired physical mobility and disturbed thought processes are some of the nursing
diagnoses in bell palsy.

Nursing management focuses on preventing the patient from any kinds of injury. To
prevent injury, the eye should be covered with a protective shield at night. Moisturizing eye
drops during the day and eye ointment at bedtime may help prevent injury. It is also
important to educate the patient to close the paralyzed eyelid manually before going to
sleep. Wraparound sunglasses or goggles may be worn during the day to decrease
evaporation from the eye. After the sensitivity of the nerve to touch decreases and the
patient can tolerate touching the face, the nurse can suggest massaging the face several
times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises may be
performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold
and drafts is avoided.

Medical management in bell palsy includes corticosteroid therapy (specifically

prednisone) may be prescribed to reduce inflammation and edema. This reduces vascular
compression and permits restoration of blood circulation to the nerve. Antivirals such as
Acyclovir (Zovirax) and Valacyclovir (Valtrex) may also be prescribed. To control facial pain,
analgesic agents are prescribed. Electrical simulation may be applied to the face to prevent
muscle atrophy. For surgical management, this includes decompression surgery. Cosmetic
or reconstructive surgery is rare, to reduce deformities and correct damage.

Peripheral Neuropathies

Peripheral neuropathy is a result of damage to the nerves located outside of the

brain and spinal cord (peripheral nerves), often causes weakness, numbness and pain,
usually in the hands and feet. It can also affect other areas and body functions including
digestion, urination and circulation.
 Peripheral neuropathy can result from traumatic injuries, infections, metabolic
problems, inherited causes and exposure to toxins. The predisposing factors of this disease
are age, heredity and race. On the contrary, the precipitating factors are Diabetes, High
Blood pressure, High Cholesterol, Obesity, Trauma, Autoimmune disorders, and Alcoholism.

There are two types of peripheral neuropathies. Acute and Chronic Neuropathies.
The disease process of acute neuropathies starts with an immune attack on the nerves
which leads to infection. The individual would highly experience symptoms and as these
symptoms worsen this would eventually resolve slowly.On the other hand, the disease
process of chronic neuropathies starts with the symptoms then relief followed relapse,
plateau or may worsen which will then lead to a complication due to the existing disorder.

The affected sites are the extremities and muscles. The signs and symptoms of
peripheral neuropathies are the following: gradual onset of numbness, prickling or tingling in
your feet or hands, which can spread upward into your legs and arms; sharp, jabbing,
throbbing or burning pain; extreme sensitivity to touch; pain during activities that shouldn't
cause pain, such as pain in your feet when putting weight on them or when they're under a
blanket, lack of coordination and falling, muscle weakness, feeling as if you're wearing
gloves or socks when you're not, and paralysis if motor nerves are affected. When
peripheral neuropathies are left untreated, this may lead to burns and skin injuries, infection
or falls.

Peripheral neuropathies are usually examined with the use of the following
diagnostic procedures: history and physical exam, neurologic exam, blood work and
imaging tests, genetic testing, electrodiagnostic assessment (EDX), nerve conduction study
(NCS), needle electromyography (EMG), and tissue biopsies.

There are different nursing diagnosis that can be used in this disease and this
include: Impaired physical mobility related to sensory perceptual impairment become weak
and dizzy during movements in bed, Risk for impaired Skin integrity, Risk for falls related to
altered sensory perception and numbness in lower abdomen and the nursing management
for these include educating the patient on the proper nutrition as well as educating the
clients on healthy living habits.

The medical management also includes the following: mechanical aids, occupational
therapy, medication, and physical therapy. While the surgical management include both the
nerve decompression surgery and peripheral neuropathy surgery.
 DEGENERATIVE NEUROLOGIC DISORDERS

Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis, or ALS, is a progressive nervous system disease that

affects nerve cells in the brain and spinal cord, causing loss of muscle control. ALS is often
called Lou Gehrig's disease, after the baseball player who was diagnosed with it. It's
possible that it's because of SOD1 and C9orf72 are the most common genetic causes for
ALS. However, as described above, additional genes are associated with the disease.
ALS1, associated with a mutation in SOD1 (superoxide dismutase 1) gene. Its predisposing
factor are heredity, age most common between the ages of 40 and the mid-60s, before the
age of 65, slightly more men than women develop ALS, and genetics. The precipitating
factors include smoking, menopause, and environmental toxin exposure.

ALS affects the motor cortex and when the motor neuron cells die as a result the
muscle fibers that they supply undergo atrophic changes and neuronal degeneration occur
in both the upper and lower motor neuron systems.Which will lead to the theory held by
researchers is that over excitation of nerve cells by the neurotransmitter glutamate leads to
cell injury and neuronal degeneration. ALS has numerous clinical symptoms. This includes
difficulty walking or doing normal daily activities, tripping and falling, weakness in your legs,
feet or ankles, hand weakness or clumsiness, slurred speech or trouble swallowing, muscle
cramps and twitching in your arms, shoulders and tongue, inappropriate crying, laughing or
yawning, cognitive and behavioral changes. If not managed, complications may develop
breathing problems, speaking problems, eating problems, dementia.

There are certain diagnostic tests that might assist in the diagnosis like
electromyogram (EMG) wherein bnormalities in muscles seen in an EMG can help doctors
diagnose or rule out ALS. An EMG can also help guide your exercise therapy, nerve
conduction study it studies measurement of your nerves' ability to send impulses to muscles
in different areas of your body, MRI which can reveal spinal cord tumors, herniated disks in
your neck or other conditions that might be causing your symptoms, blood and urine tests.
spinal tap (lumbar puncture), and muscle biopsy. Nursing diagnosis for ALS are as follow
Impaired mobility related to muscle wasting, weakness, and spasticity, Impaired
communication related to impairment of the muscles of speech, High risk for aspiration
related to impaired muscles of swallowing and Ineffective breathing pattern related to
impaired muscles of breathing

The various nursing diagnoses that can be used in this disease, which include
Impaired mobility related to muscle wasting, weakness, and spasticity, Impaired
communication related to impairment of the muscles of speech, High risk for aspiration
related to impaired muscles of swallowing, Ineffective breathing pattern related to impaired
muscles of breathing, Potential for injury related to impaired physical mobility and alteration
in comfort. All should be managed by assessing patients' readiness to learn and explaining
what ALS is by informing details in layman's terms, as well as encouraging open-ended
questions to assess client lifestyle and behavior that would help in the management of ALS.

Nursing management provides intellectual stimulating activities, such as client and

family teaching in promoting client and family coping. It provides experiences that would
enable the client to retain his/her mental abilities and avoid cognitive deficits. Providing
client and family teaching promotes coping as the client and his family would deal with
measures that would enhance body image Maximizing functional abilities such as
preventing further complications of immobility, providing self-care and maximizing effective
communication as a management is an important nursing management. Always ensure and
adequate nutrition is given to the patient and monitor respiratory complications by ensuring
proper measure in maintaining adequate airway, ensuring measures that would ensure gas
exchanges such as oxygen therapy and ventilator assistance and measures in preventing
respiratory infection.

Medical management in ALS would include breathing care; as the client's muscles
weaken, he or she will have more difficulty breathing. Doctors may perform regular
breathing tests and provide devices to help with breathing at night. Low-impact exercises,
for example, can help maintain cardiovascular fitness, muscle strength, and range of motion
for as long as possible. Occupational therapy helps you maintain your independence
despite hand and arm weakness. Dressing, grooming, eating, and bathing can all be made
easier with adaptive equipment. A speech therapist can teach you adaptive techniques to
improve the clarity of your speech. Speech therapists can also assist in the exploration of
alternative modes of communication, such as an alphabet board or pen and paper. The
team will collaborate with the client and family members to ensure that he or she is eating
foods that are easier to swallow and meet the nutritional requirements. The client may
eventually require a feeding tube. A psychological and social report includes a social worker
who can assist the client with financial issues, insurance, and obtaining and paying for
necessary equipment and devices. Psychologists, social workers, and other professionals
may offer emotional support to the client and their families.

Medical management in ALS is not recognized as a potential amyotrophic lateral

sclerosis (ALS) risk factor that could alter the onset or course of the disease. But some tests
are conducted with special considerations such as the Electromyogram (EMG) as a needle
electrode is inserted into numerous muscles through your skin by your doctor. The test
assesses your muscles' electrical activity, Spinal tap or Lumbar puncture uses a tiny needle,
a sample of your spinal fluid is taken for laboratory testing, and lastly Muscle biopsy may be
performed if your doctor suspects you have a muscle illness rather than ALS.

Muscular Dystrophies

Muscular dystrophy is a group of incurable muscle disorders characterized by

progressive weakening and wasting of the skeletal or voluntary muscles. In muscular
dystrophy, abnormal genes (mutations) interfere with the production of proteins needed to
form healthy muscle. The estimated prevalence of Duchenne and Becker muscular
dystrophy (DBMD) was 1 in every 7,250 males aged 5 – 24 years. People who are at risk of
developing this disease include clients with familiar history of any muscular dystrophy,
younger males aged 5 to 24 years, and clients who have poor nutritional intake or
underweight.

The disease is caused by a defective gene on the 23rd, or X, chromosome that

results in the failure of the body to produce a functional muscle protein called dystrophin.
Most females who carry the genetic defect are unaffected, but they have a 50 percent
probability of passing the disease to each of their sons.

Some of its early symptoms occur between the ages of two and six, include a
waddling gait, frequent falling, difficulty in getting up from a lying or sitting position,
enlargement of the calf muscles, inability to raise the knees, and disappearance of a normal
knee or ankle jerk. These symptoms become more obvious as the child ages. Muscle
wasting progresses upward from the legs, and the arms are eventually affected. Ultimately,
muscle wasting affects the muscles of the diaphragm, and breathing becomes shallow.
Life-threatening pulmonary infections or respiratory failure usually occurs before the age of
20. Thus, severe scoliosis, pneumonia, and cardiac and respiratory failure may occur.

Genetic testing can reliably detect the Duchenne gene in female carriers and in
affected male fetuses.This type of testing looks for a large mutation of the dystrophin (DMD)
gene. Blood testing may show High levels of serum creatine kinase, serum aldolase, and
myoglobin may all signal the need for further testing to confirm or rule out muscular
dystrophy. Electromyography (EMG) is also effective in diagnosing this disease. It measures
the muscle’s electrical activity using an electrode needle that enters your muscle. Moreover,
the Neurological physical exam also helps to rule out nervous system disorders and
identifies the state of muscle strength and reflexes. And lastly, Cardiac testing identifies
heart problems that sometimes occur with muscular dystrophy. Imaging tests.

The 3 nursing priorities may include Ineffective breathing patterns related to

deformity of thorax secondary to severe scoliosis. Impaired skin integrity related to
immobility. Risk for injury and falls related to muscle weakness. Thus the nurses must
encourage the patient to engage in physical activities as tolerated to prevent or slow down
the muscular dystrophy. Assist the patient when mobilizing and ensure that the side rails are
up to ensure the client’s safety. Ensure that the patient and significant others are involved in
decision making including end-of-life decisions. Educate the family to monitor the patient
for respiratory problems and cardiac concerns. Encourage the siblings of the patient to have
genetic counseling for early detection and management.

Doctors may administer medications such as; Eteplirsen (Exondys 51), Golodirsen
(Vyondys 53), Viltolarsen (Viltepso), Casimersen (Amondys 45), and Deflazacort (Emflaza)
according to the patient’s condition. Collaborating with therapeutic exercise programs to
prevent muscle tightness and contracture would also help the client maintain his/her daily
routine activities. And Introducing the patient to an orthotastic jacket that supports the spine
would also be helpful in terms of preventing scoliosis and maintaining balance and posture.

Soft tissue release surgery is a surgical measure in which it involves making an

incision in affected muscles, tendons, or ligaments to release them from the joints, allowing
people with muscular dystrophy to move more freely and comfortably.
The third part of the Degenerative neurological disorder which is known to be “degenerative
Disk disease”
Degenerative Disk Disease

Degenerative disk disease is when your spinal disks wears down. Spinal disks are
rubbery cushions between your vertebrae (bones in your spinal column). They act as shock
absorbers and help you move, bend and twist comfortably. Everyone’s spinal disks
degenerate over time and is a normal part of aging.

This disease does not have any causative agent, but one of the major causes of this
disease are trauma or major injuries directly towards the spinal cords. One of the most
known predisposing factors that should be noted with this disease is first, a patient who has
family history related to musculoskeletal disorders, Gender: males are known to acquire
this disease due to the heavy activities that men usually do that contributes to severe
straining of the spinal cord. Other factors are genetic mutations in which there are some
babies who are born with disk that do not have fluid in the spine, this is called dry out.
Lastly, Age: 50 years old and above are exposed to this disease as muscle tissues
dissipate as we age, so as the fluids that present in the spine.

In addition, there are also precipitating factors such as injuries, strain on lumbar
disk such as doing sport, obesity or being overweight as it is not healthy for a human to
have more fat tissues than fluids. The affected sites for this disease are the three main parts
of the spine such as the cervical, thoracic (which happens rarely), and lastly lumbar.
Furthermore the disease process can be summarized as follows:

● Aging/trauma → Degeneration of hydrophilic proteoglycans (a type of protein in which

hich provides hydration and swelling pressure to the tissue enabling it to withstand
compressional forces) in the nucleus present in the spinal disk → Dehydration of
water → less shock-absorbing capacity → Tear of the annulus fibrosus → spinal disc
ruptures → pt will feel symptoms

When the patient has already been diagnosed with the disease using the following
diagnostic findings: MRI scan has become the most used diagnostic tool of choice for
localizing even small disk protrusions, particularly for lumbar spine disease. Neurologic
examination is carried out to determine whether reflex, sensory, or motor impairment from
root compression is present and to provide a baseline for future assessment. Lastly,
Electromyography may be used to localize the specific spinal nerve roots involved. Some
possible nursing diagnoses should then be made such as Impaired physical mobility related
to pain (cervical pain, thoracic pain, or lumbar pain), Acute pain related to physical
pain/trauma , and Disturbed sensory perception related to Destruction of sensory tracts.

The clinical manifestations/Signs and symptoms that should be assessed by the

nurses are the constant pain depending on the location, pain that is worse when sitting, pain
that gets worse when bending, lifting or twisting, numbness and tingling in the extremities,
and weakness in the leg muscles. If it will not be cured in its early stage there are also
complications that will occur such as Herniated disc, loss of bladder or bowel control,
weakness or tingling in one or both legs, and pain in one or both legs.

Nursing management to address the acute pain includes assessing the intensity,
description, location, radiation of pain, changes in sensation. Instructing the patient on how
to use a rating scale (0–10), review expected manifestations and changes in the intensity of
pain, encourage patient to assume a position of comfort if indicated, demonstrate and
encourage the use of relaxation skills like deep breathing, visualization, Work closely with
the physical therapy department, and lastly assist with activity and progressive ambulation.

Medical management for this disease includes administration of tylenol or NSAIDs

as prescribed by the physician (pain relief medication). Also Facet rhizotomy which is a
radiofrequency current that deadens the nerves around the facet joint, preventing pain
signals from reaching the brain.

There are several surgical management that can be done with the patient who has
degenerative disk disease but the major procedure that usually done to the patient is the
procedure known as discectomy with fusion: fusion of the vertebral spinous process with a
bone graft (from iliac crest or bone bank); the object of spinal fusion is to bridge over the
defective disk to stabilize the spine and reduce the rate of recurrence, and Laminectomy
the removal of the bone between the spinal process and facet pedicle junction to expose
the neural elements in the spinal canal (Hickey, 2009); this allows the surgeon to inspect the
spinal canal, identify and remove pathologic tissue, and relieve compression of the cord and
roots.
 Herniation of a cervical intervertebral disk

Cervical disc herniation is the result of the displacement of the nucleus pulposus of
the intervertebral disk due to the tearing of its outer lining. It is usually caused by disk
degeneration over time or trauma to the area.

For the predisposing factors, age increases the risk of cervical intervertebral disk
herniation because a disk can be more prone to herniating due to wear and tear. Over time
as we get older, the amount of water in disks decrease. Less water in the disks means they
can become less flexible. In older people, they can rupture with less force. The injury is
prevalent in older age with 35-55 year olds being at most risk. Being female also increases
the likeliness of getting a herniated disk as women account for more than 60% of cases.
Lastly, genetics is allso a predisposing factor as herniated disks can run in families. For the
precipitating factors, a spine injury and doing strenuous and repetitive activities that cause
strain may lead to cervical disk herniation. Some examples of these activities include sports
and lifting.

A combination of the predisposing factors and trauma, strain, or injury to the cervical
spine will lead to the tearing of the ligament and posterior capsule of cervical disk. With this,
the nucleus pulposus extrudes, indicating a herniation. The nucleus pulposus can compress
the nerve root and vascular supply may be compromised. This leads to inflammatory
changes in the nerve root. In some cases, the spinal cord may be compressed too leading
to more neurological symptoms. Cervical disc herniations most commonly occur between
C5-C6 and C6-C7 vertebral bodies. This will cause symptoms at C6 and C7, respectively.

Signs and symptoms of cervical disk herniation include pain and stiffness in the
neck, the top of shoulders, and scapulae; paresthesia and numbness of upper extremities;
weakness in a hand or arm; loss of balance and coordination; and stumbling or awkward
walking. When left untreated or prolonged, this may lead to nerve injury, infection, spinal
cord infarction, and lesions due to cervical disk degeneration.
 For the diagnostic tests, a physical & neurological examination is usually performed.
Some of their purposes include finding the source of pain, ruling out other disorders, and
assessing the client’s range of motion. Then, a cervical MRI us done to confirm the
diagnosis.

The possible nursing diagnoses for client’s with Herniation of a cervical intervertebral
disk are acute pain related to nerve compression and muscle spasm, impaired physical
mobility related to pain, anxiety related to ineffective coping, deficient knowledge related to
lack of information about prognosis, and risk for trauma related to temporary weakness.

Nursing interventions to address these problems include assessing complaints of

pain, location, intensity, and precipitating factors; encouraging use of relaxation techniques
such as guided imagery, visualization, and deep-breathing exercises; positioning the patient
comfortably on a firm mattress, as indicated; instructing patient to maintain bed rest and
immobilize cervical spine; providing cervical isometric exercises once patient is free of pain,
as indicated; applying hot, moist compress to the back of the neck to increase blood flow to
muscles and help patient relax, as indicated; providing skin care and assess skin under
collar or brace once removed or changed; and providing accurate information about
diagnosis, treatment, and restrictions.

Medical management of the injury includes immobilization of cervical spine by a

cervical collar, cervical traction, or a brace. Medications are then administered depending
on their need. Analgesic agents can be administered such as NSAIDs, propoxyphene
(Darvon), oxycodone (Tylox), hydrocodone (Vicodin) to relieve pain. Sedatives can be given
to control anxiety as needed. Administration of muscle relaxants are done to interrupt
muscle spasm and promote comfort. Medications for these include cyclobenzaprine,
methocarbamol, and metaxalone. Lastly, administration of NSAIDS (aspirin, ibuprofen,
naproxen) or corticosteroids can be done to treat inflammation in affected nerve roots and
tissues.

For the surgical management, a surgical excision of the herniated disk may be
necessary if there is a significant neurologic deficit, progression of the deficit, evidence of
cord compression, or pain that either worsens or fails to improve. Moreover, cervical
diskectomy, with or without fusion may be performed to alleviate symptoms. Miscrosurgery
such as endoscopic microdiskectomy can also be performed in selected patients through a
small incision using magnification techniques.

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