Transposition of the Great Arteries

Definition

Transposition of the great arteries (TGA) is a congenital heart defect in which the two main blood vessels that carry blood away from the heart – the aorta and the pulmonary artery – are switched or “transposed” in their normal positions. This results in a disruption of the normal blood flow, requiring immediate medical intervention.

Pathophysiology

In TGA, the aorta is connected to the right ventricle, while the pulmonary artery is connected to the left ventricle. This reversal of the great arteries means that deoxygenated blood is pumped back to the body, while oxygenated blood is pumped back to the lungs, leading to a life-threatening lack of oxygen circulation.

Signs and Symptoms

Newborns with TGA often exhibit cyanosis, or a bluish discoloration of the skin, due to the lack of oxygen in the blood. They may also experience difficulty breathing, poor feeding, and lethargy.

Diagnostic Tests and Differential Diagnosis

Echocardiography is the primary diagnostic tool used to confirm the presence of TGA. Other tests, such as electrocardiography and cardiac catheterization, may be used to assess the severity of the condition and rule out other potential heart defects.

Diagnosis and Treatment Approaches

Prompt diagnosis and treatment are crucial for the survival of infants with TGA. Immediate medical intervention, often within the first few days of life, is required to stabilize the patient and prepare for corrective surgery. The most common surgical approach is the arterial switch operation, which involves switching the positions of the aorta and pulmonary artery.

To read more on tinytickers.org go to https://www.tinytickers.org/2021/02/03/transposition-of-the-great-arteries-arthurs-story-2/

Conclusion

Transposition of the great arteries is a complex and life-threatening congenital heart defect that requires immediate medical attention. With advancements in diagnostic techniques and surgical interventions, the prognosis for infants with TGA has significantly improved, allowing them to lead healthy and active lives.

Understanding Lewy Body Dementia: Pathophysiology, Clinical Features, Nursing Interventions, and Treatment

Introduction: Lewy body dementia (LBD) is a complex neurodegenerative disorder characterized by the presence of abnormal protein aggregates known as Lewy bodies in the brain. This paper aims to provide an overview of the pathophysiology of LBD, imaging findings, common signs and symptoms, nursing interventions, current medical treatments, and cognition assessment testing used in clinical practice.

Pathophysiology: The underlying pathophysiology of LBD involves the accumulation of alpha-synuclein protein aggregates, known as Lewy bodies, within neurons of the brain’s cortex and subcortical structures. These Lewy bodies disrupt normal neuronal function, leading to neurotransmitter dysfunction, particularly involving dopamine and acetylcholine pathways. The degeneration of dopaminergic neurons in the substantia nigra contributes to the motor symptoms observed in LBD, while the disruption of cholinergic pathways contributes to cognitive impairment.

Imaging Results: Neuroimaging techniques such as magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT) can aid in the diagnosis of LBD. MRI may reveal structural changes in the brain, including cortical atrophy and hippocampal volume loss. SPECT imaging can show reduced dopamine transporter activity in the basal ganglia, indicative of dopaminergic dysfunction characteristic of LBD.

Signs and Symptoms: LBD presents with a constellation of symptoms, including cognitive impairment, visual hallucinations, motor symptoms resembling Parkinson’s disease, fluctuations in cognition, and autonomic dysfunction. Visual hallucinations, often vivid and detailed, are a hallmark feature of LBD and may precede cognitive decline. Motor symptoms include tremors, rigidity, bradykinesia, and postural instability, which can fluctuate in severity.

Common Cognition Assessment Testing: Cognition assessment testing is essential for diagnosing and monitoring cognitive impairment in LBD. Commonly used assessment tools include the Mini-Mental State Examination (MMSE), which evaluates orientation, memory, attention, language, and visuospatial skills. The Montreal Cognitive Assessment (MoCA) is another widely used tool that assesses various cognitive domains, including memory, attention, language, and executive function. These assessments help healthcare professionals track changes in cognitive function over time and guide treatment decisions.

Nursing Interventions: Nurses play a crucial role in the care of individuals with LBD, focusing on symptom management, safety, and support for both the patient and their caregivers. Nursing interventions may include:

  1. Monitoring for medication side effects, particularly antipsychotic medications that can worsen symptoms of LBD.
  2. Providing a safe environment to prevent falls and injuries, considering the increased risk due to motor symptoms.
  3. Implementing strategies to address fluctuating cognition, such as maintaining a consistent daily routine and minimizing environmental stimuli.
  4. Educating caregivers about the progressive nature of LBD, managing behavioral symptoms, and accessing support services.

Current Medical Treatment: While there is no cure for LBD, current medical treatment aims to alleviate symptoms and improve quality of life. Pharmacological interventions may include cholinesterase inhibitors (e.g., donepezil) to enhance cholinergic function and alleviate cognitive symptoms. Additionally, medications such as levodopa may be prescribed to manage motor symptoms associated with Parkinsonism. However, caution is warranted in prescribing antipsychotic medications due to the risk of exacerbating symptoms of LBD.

Conclusion: Lewy body dementia poses significant challenges for patients, caregivers, and healthcare providers due to its diverse clinical manifestations and progressive nature. Understanding the pathophysiology, clinical features, nursing interventions, and current medical treatments is essential for delivering comprehensive care to individuals affected by LBD. Continued research efforts aimed at elucidating the underlying mechanisms of LBD and developing novel therapeutic strategies are critical to improving outcomes for patients living with this complex neurodegenerative disorder.


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Assessing for Peripheral Edema and Anasarca

Assessing for peripheral edema and anasarca, the generalized form of edema involving multiple body regions, is integral in the evaluation of cardiovascular, renal, hepatic, and systemic conditions. A systematic approach encompassing history taking, physical examination, and diagnostic investigations is essential for identifying the underlying etiology and determining appropriate management strategies.

History taking serves as the initial step in evaluating peripheral edema and anasarca, providing valuable insights into potential causative factors. Clinicians should inquire about the onset, duration, and progression of edema, as well as exacerbating or alleviating factors such as dietary intake, medication use, activity level, and positional changes. Obtaining a comprehensive medical history is crucial, including past medical conditions such as heart failure, chronic kidney disease, liver cirrhosis, venous insufficiency, or lymphatic disorders, which are common predisposing factors for fluid retention.

Physical examination plays a central role in assessing peripheral edema and anasarca, focusing on identifying the distribution, severity, and characteristics of the swelling. Clinicians should systematically inspect the extremities, abdomen, and dependent areas for signs of fluid accumulation, noting any asymmetry, pitting, erythema, warmth, or tenderness. Measurement of ankle circumference and comparison with the calf or thigh can provide objective assessment of edema severity. Additionally, assessment of jugular venous pressure, hepatojugular reflux, and auscultation for lung crackles may provide clues to underlying cardiac or pulmonary pathology contributing to fluid overload.

Differentiating between dependent edema, caused by venous insufficiency or prolonged standing, and systemic edema, indicative of fluid retention secondary to organ dysfunction, is crucial in clinical evaluation. In cases of suspected cardiac etiology, assessing for signs of heart failure such as elevated jugular venous pressure, S3 gallop, or pulmonary crackles is paramount. Renal causes of edema may manifest with hypertension, proteinuria, or electrolyte abnormalities, necessitating evaluation of renal function and urinalysis. Similarly, hepatic dysfunction leading to hypoalbuminemia and ascites may present with abdominal distension and lower extremity edema. A thorough physical examination aids in localizing the source of edema and guiding further diagnostic workup.

Diagnostic investigations complement history taking and physical examination in elucidating the underlying etiology of peripheral edema and anasarca. Laboratory studies such as complete blood count, comprehensive metabolic panel, urinalysis, and serum biomarkers (e.g., brain natriuretic peptide, liver enzymes) provide valuable information about renal, hepatic, and cardiac function. Imaging modalities including echocardiography, chest X-ray, abdominal ultrasound, and Doppler studies may be indicated to assess for structural abnormalities, fluid accumulation, or venous insufficiency. Invasive procedures such as cardiac catheterization or liver biopsy may be warranted in certain cases to further characterize underlying pathology.

In summary, the assessment of peripheral edema and anasarca requires a systematic and comprehensive approach involving history taking, physical examination, and diagnostic investigations. Clinicians must consider a broad differential diagnosis encompassing cardiovascular, renal, hepatic, and systemic etiologies to guide appropriate management and optimize patient outcomes. Early recognition and intervention are crucial in preventing complications and addressing the underlying cause of fluid retention. Collaborative multidisciplinary care involving cardiologists, nephrologists, hepatologists, and allied healthcare professionals are essential for the holistic management of patients with peripheral edema and anasarca.

Black History Month Celebrating Outstanding Black Nurses

History has shown us several outstanding black nurses who have paved the way for the strong nursing profession as it is today. I highlight several here.

Adah Belle Samuel Thoms 1870-1943

Adah Belle Samuel Thoms was born in Virginia in 1870 and moved to New York in the 1890s. She graduated from the Lincoln Hospital and Home School of Nursing, where she was named acting director one year later. She served in that position for 17 years, and because of racist policies, she was never officially named director.

During her lifetime, she fought for the rights of Black women to serve in the military, which led to the U.S. Army Nurse Corps. She helped start the National Association of Colored Graduate Nurses. The organization was disbanded in 1950 when Thoms won the fight to integrate nurses into the American Nurses Association (ANA) and the U.S. Armed Forces.

Bernardine Lacey 1932-2021

Bernardine Lacey, Ed.D., graduated as the first Black student at Georgetown University in 1969 from the registered nurse to bachelor of science (RN-to-BSN) program. She was the founding dean of Western Michigan University School of Nursing in 1994 and served in that position for five years.

Lacey held leadership roles at several organizations and in 2014 was honored by the American Academy of Nursing as one of four Living Legends that year. Lacey was featured in “‘You Don’t Have Any Business Being This Good’: An Oral History Interview with Bernardine Lacey” published in the American Journal of Nursing in August 2020. The oral history included the mark that racism left on her and her professional growth in the many leadership roles she held. Lacey died on March 26, 2021.

Beverly Malone 1943-

Beverly Malone, Ph.D., is a healthcare leader, innovator, and champion for nurses. She is the CEO of the National League of Nursing and a past president of the American Nurses Association. Malone has been a vocal advocate for nurses to ensure culturally competent care for diverse patient populations. She has worked in education, administration, policy, and clinical practice in psychiatric nursing.

She also served as deputy assistant secretary for health in the U.S. Department of Health and Human Services. Her global achievements include being the first Black general secretary of the Royal College of Nursing, the United Kingdom’s (UK) largest professional union of nurses. She served as a member of the U.K. delegation to the World Health Assembly and has the distinguished honor of having her portrait at the National Portrait Gallery in London.

Malone is active on Twitter and LinkedIn.

Ernest J. Grant 1954-

Ernest Grant, Ph.D., is an internationally known burn-care and fire-safety expert with over 30 years of nursing experience. He has been a prolific speaker and conducted many burn-care education courses for the U.S. military as they prepared for deployment to Iraq and Afghanistan. He was inducted into the American Academy of Nursing as a fellow in 2014 and is the first man to serve as president of the American Nurses Association. He also volunteered at Ground Zero after September 11, 2001, at the Burn Center at New York-Presbyterian Hospital.

Grant lives in Chapel Hill, North Carolina, and he actively posts on LinkedIn and Twitter. He was interviewed by the North Carolina African American Heritage Commission during Black History Month in 2021. Grant started his career as a licensed practical nurse at a local community college before advancing his nursing career and eventually graduating with his doctor of philosophy from the University of North Carolina at Greensboro in 2015.

Stephan Davis 1969-

Stephan Davis, DNP, is a healthcare executive, leader, and educator. He has worked at hospitals, insurance companies, and is now the clinical assistant professor at Georgia State University. He teaches classes in leadership, policy, community health, and management. He is also on the board of directors for the Georgia Nurses Association and an inaugural member of the leadership committee of the American College of Healthcare Executives LGBTQ forum.

Davis earned his doctor of nursing practice at Yale School of Nursing and a master’s in health system administration from Georgetown University. He is board certified as an advanced nurse executive and has other national certifications in finance, education, and healthcare quality. Davis is active on LinkedIn and Twitter, where he identifies himself as the founder and principal of ILLUMINANT.

Sojourner Truth 1797-1883

Sojourner Truth was an African American abolitionist who lived from 1797-1883. She was born into enslavement in New York as one of 10 or 12 children. During enslavement, she was also a nurse. After being freed from enslavement, she worked for the National Freedman’s Relief Association in D.C. where she advocated on behalf of nursing education and formal training programs.

In 1849 she began public speaking, working hard for Black and women’s rights. In 1864 she met Abraham Lincoln at the White House. She was best known and remembered for her speech on racial inequalities delivered in 1851 at the Ohio Women’s Rights Convention.

Harriet Tubman, 1822-1913

Harriet Tubman, photo courtesy of the Library of Congress

Many of us are familiar with the name Harriet Tubman, a formerly enslaved woman who was instrumental in leading slaves to freedom as a conductor on the Underground Railroad. Tubman served the Union Army during the Civil War, and while many of us are familiar with her story, her service as a nurse is often overlooked.

In 1862, Tubman served as a nurse in Beaufort, South Carolina, and was appointed matron of a hospital in Fort Monroe in Virginia where she cared for sick and wounded Black soldiers. Unfortunately, Tubman did not receive pay or pension as a nurse during the Civil War.

In the book “Harriet: The Moses of Her People,” author Sarah H. Bradford wrote this of Tubman: “She nursed our soldiers in the hospitals, and knew how, when they were dying by numbers of some malignant disease, with cunning skill to extract from roots and herbs, which grew near the source of the disease, the healing draught, which allayed the fever and restored numbers to health.”

Despite her service, Tubman was denied a nurse’s pension, even after the petitioning of then U.S. Secretary of State William H. Seward. The only monetary acknowledgment she received for her service was through her widow’s pension based on her husband’s service in the Civil War, which was increased from $8 to $20 a month in consideration of her personal services to the country.

Estelle Massey Osborne, 1901-1981

Estelle Massey Osborne, photo courtesy of the New York University Rory Meyers College of Nursing

Estelle Osborne attended nursing school in St. Louis at a time when only 14 of the 1,300 nursing schools in the country admitted Black students. During this time, the American Nursing Association refused membership to Black nurses. Osborne studied at St. Louis City Hospital, which later became known as the Homer G. Phillips Hospital. This hospital was the largest exclusively Black, city-operated general hospital in the world and at the time served more than 70,000 people.

Over the next few years, Osborne earned several accolades, including being the first Black nurse to receive the Julius Rosenwald Fund Scholarship and the first Black nurse to earn a master’s degree, receiving a Master of Arts from Columbia University Teachers College in New York City.

She then became a researcher for the Rosenwald Fund, where she studied rural life in the deep South, with a focus on ways to improve health education in rural Black communities. Following a five-year period as president of the National Association of Colored Graduate Nurses, Osborne returned to the Homer G. Phillips Hospital as its first Black superintendent of nurses, as well as the first Black female director of the hospital’s nursing school.

In 1943, to address a shortage of nurses both in the U.S. and overseas in the military, Congress enacted the Bolton Act, which appropriated $160 million in federal funding to nursing schools across the country. Osborne played a key role in ensuring funds from the Bolton Act benefited Black nurses. She would go on to serve in several prominent national leadership positions and helped pave the way for generations of Black nurses.

Mary Eliza Mahoney, 1845-1926

Mary Eliza Mahoney, photo courtesy of the National Women’s History Museum

Mary Mahoney is the first Black nurse to graduate from nursing school and receive a professional nursing license in the U.S. Born in 1845 in Boston to freed slaves, she studied at Phillips School in her hometown, which in 1855, became one of the first integrated schools in the country.

As a teenager, Mahoney began working at the New England Hospital for Women and Children, where she worked for 15 years in a variety of roles, including as a nurse’s aide. In 1878, a 33-year-old Mahoney was admitted to the hospital’s nursing school. It was a demanding program and few who began their studies graduated, though in 1879, Mahoney completed the program and became the first African American in the country to earn a professional nursing license.

Following her training, she continued a 40-year-career in the profession. In 1896, she joined the Nurses Associated Alumnae of the United States and Canada, the precursor to the American Nurses Association. Upon her retirement, she continued to fight for women’s rights and was among the first women who registered to vote in Boston following the ratification of the 19th Amendment.

As we take just a glimpse into the lives of these distinguished leaders in nursing, it is important for us to recognize and reflect upon their important contributions.

Having that Difficult Conversation with Patients or Colleagues

pink flower on a collage background

Beautiful Dalia

There are always times when we need to have a difficult conversation. Perhaps it is with a friend, peer, colleague, or patient. The topic continuously varies. Many of us humans, who I’m referring to, may dread difficult conversations or conflict. We often learned to avoid difficult conversations as we grew up, probably because these conversations were not dealt with well by our parents or peers. Learning to deal with difficult conversations systematically can help everyone be better communicators and convey the message more positively. Remember, the principles of a positive discussion are the same.

Mary Jean is a coworker who has been coming to work late several times a week over the past month. You need to talk with her about coming to work on time.

Benjamin is a patient who has a terminal illness and wants to go to Hospice. His family disagrees and wants him to receive all treatment. You need to mediate a conversation between Benjamin and his family.

The Right State of Mind

Both examples are of possible problematic situations. So, how should you proceed? Let’s discuss some steps first to get in the right state of mind. It is essential to practice scenarios like this, not in person or out loud; practice in your head as you get ready for bed and relax for the evening. Practice all possible outcomes, from the worst possible to the best possible, and everything in between. Next, keep your state of mind positive. Whenever you practice scenarios, picture yourself calm, positive, and effective when communicating.

It would help if you held every conversation with empathy and compassion. Show the person you care about them and anything they are going through. You share compassion and empathy by listening carefully, being authentic, and genuinely caring.

  • Compassion is showing concern for someone who is suffering.
  • Compassion leads to an action to help others.
  • Compassion inspires positive feelings.
  • Empathetic persons feel the emotions of others.
  • Empathy leads to understanding.

Practice these over and over before the difficult conversation and even anytime you anticipate a difficult conversation. It does not matter who the conversation is supposed to be with, practice. Practice the right way to say something. Practice the unexpected as well as the expected. Don’t give yourself a script; follow a different script each time you practice. Use other words each time so that you are prepared for different scenarios and can adapt to anything that comes your way. This technique is called Guided Imagery and is extremely useful.

Breathing

Practice basic principles of mindful breathing. Mindful breathing is a form of meditation you can do when practicing different scenarios at bedtime or during other quiet periods. First, get in a relaxed pose. Any position that you are comfortable in will work. Take a slow, deep breath in, then release and exhale slowly until all air is out of your lungs. Do not take a break in between each breath. Practice this for 10 minutes for about a week, then move on to 20 minutes. Do remember that you can stop at any time. Feel yourself, be calm, be relaxed. Notice any areas where you are tense, and relax those muscles. As you breathe, tune into your breath and feel your breath move in and out. Feel yourself relax.

Now that you have practiced a bit, you will be more ready for the expected and the unexpected. You will be more prepared for that difficult conversation than ever. Now, let us move toward a systematic way to respond to someone and how to be relaxed and compassionate while you are responding.

The Systematic Approach

Start with an opening comment or question. Show empathy while you are at it. If you are delivering terrible news, a death, for example, you should try to ensure that they have someone to be with them or drive them to where they need to go. You might say

  • “I’m concerned about your attendance lately. Is everything okay at home?”
  • “I’ve asked you here today to talk about Benjamin’s wishes for his care.”
  • “It is nice to see you today; how have things been with you and your family lately.”
  • “Tell me what you know about Benjamin’s health.”

Take Time to Understand Their Perspective

You do not have to answer right away. Take several breaths, relax, and consider their perspective or issues. It is okay to say I’m so sorry that this happened to you. or that you are going through this. If they begin to cry, give them space and acknowledge the distress before moving on. Remember to deliver the news in a calm, compassionate manner. Do not try to convey the other person’s sympathy by saying things like I feel wrong about this, or This is hard for me to do.

Explain the Change in Their Behavior You Expect to See

Work-Related Issue

Explain the issue that you are having and what changes you expect to see. Do so compassionately and calmly. You cannot fix the situation for them, but you can provide suggestions if they would like suggestions. But first, ask them what they think the solution is. If they cannot come up with a solution, ask them if they would like you to provide suggestions. If they say no, respect their wishes.

Healthcare Issue

If you are discussing a medical issue with patients or family members, describe the issue at hand and how that issue impacts the patient and family. Explain medical words or procedures and give timelines when necessary. It is important to be nonjudgmental, reflective, and compassionate. Provide teaching materials if that helps. Use I statements or allow the patient to use I statements. Mediate situations where the patient needs to tell their family how they feel and what they want. Be there to support the patient in those instances. Then, give them a bit of a break to process. Just listen.

End the Session

To end these conversations, paraphrase the problem and the plan to move forward. If no plan was established, then ask them to reflect and get back to you. Give them a specific timeline of when you expect to hear from them. Be encouraging, calm, and empathetic. Then, follow up with them at the right time to complete the circle.

References

Bigelow, S., Medzon, R., Siegel, M., & Jin, R. (2024). Difficult Conversations: Outcomes of Emergency Department Nurse-Directed Goals-of-Care Discussions. Journal of Palliative Care, 39(1), 3–12. https://doi.org/10.1177/08258597221149402

Hannans, J., & Nevins, C. (2024). Using Mixed Reality to Practice Difficult Conversations. Clinical Simulation in Nursing, 86, N.PAG. https://doi-org.proxy.mul.missouri.edu/10.1016/j.ecns.2023.101472

King, C., & Williams, B. (2021). Enabling difficult conversations in the Australian health sector. Australian Journal of Advanced Nursing, 38(3), 5–13. https://doi-org.proxy.mul.missouri.edu/10.37464/2020.383.310

Sulistio, M. S., Chen, C. L., Eleazu, I., Godfrey, S., Abraham, R. A., & Toft, L. E. B. (2023). Personal Actions to Create a Culture of Inclusion: Navigating Difficult Conversations With Medical Colleagues. Annals of Internal Medicine, 176(11), 1520–1525. https://doi-org.proxy.mul.missouri.edu/10.7326/M23-1374