Venlafaxine is a selective serotonin-norepinephrine reuptake inhibitor (SNRI) used in the palliative care setting for concurrent treatment of depressive disorders and neuropathic pain. (Neuropathic chronic pain is often resistance to standard opioid therapy and is best treated with a secondary amine tricyclic antidepressant (nortriptyline, desipramine), a selective serotonin or norepinephrine reuptake inhibitor (SSNRI) (venlafaxine, duloxetine), or a calcium channel alpha2 delta lignd (anticonvulsants) (gabapentin or pregabalin).
In the United States there are three SNRIs that have been approved by the FDA: venlafaxine (Effexor and Effexor XR), desvenlafaxine (Pristiq), and duloxetine (Symbalta). Venlafaxine and duloxetine both block the serotonin and norepinephrine transporters, thereby inhibiting and availability to bind with the postsynaptic receptors. At lower doses, venlafazine predominantly affects serotonin reuptak, contributing to greater anxiety reduction more so than depressive symptom reduction. Duloxetine, however, appears to be a more potent and equal serotonin and norepinephrine reuptake inhibitor than venlafaxine is. These drugs are rapidly absorbed after oral intake and metabolized extensively in the liver. Time needed to reach maximum plasma concentration is 2 hours for both venlafaxine and duloxetine. Venlafaxine has a half-life of 5 hours and the active metabolite is 11 hours. Steady state is achieve in 3 to 4 days. Duloxetine has a half-life of 12 hours, reaching steady state in 3 days. Both drugs are excreted mostly in urine.
The most common side effects with both venlafaxine and duloxetine include headache, somnolence, dizziness, insomnia, nervousness, nausea, dry mouth, constipation, and abnormal ejaculation. Appetite and weight decreases may occur. At higher doses, both drugs may contribute to elevated blood pressure. No specific serum level monitoring is available for either of these drugs. With duloxetine, liver function should be monitoered once weekly, once monthly, biannually, and finally annually. All patients taking antidepressants need to be carefully monitored for suicidal risk as well as activation of hypomanic or manic symptoms.
Considered to be the largest organ system in the human body, our skin protects our internal organs and structures. The skin layers include the epidermis, dermis, and subcutaneous tissue. Although skin is only 1 to 2 mm thick, it contains 15% of the total weight for an adult and acts as the first line of defense against invading microorganisms.
Providing protection for the underlying tissues and organs.
Receptors in the skin sense pain, pressure, and temperature changes.
Skin also plays a role in fluid balance, temperature regulation, and the synthesis of vitamin D.
The subcutaneous fatty layer acts as a cushion and stores fat for energy.
Alteration in skin integrity:
Age – As a person ages, physiological changes inherent to the aging process occur, such as reduced elasticity, loss of skin turgor, and decreased vascularity. Changes also occur in the cells at the junction of the dermis and epidermis, which may result in skin tearing more easily in elderly. Patients with a terminal illness pose a unique risk of alternations in skin integrity, and one aspect gaining attention includes the concept that skin injuries for these patient may be unavoidable and related to dying process.
Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease. Motor neurons are affected in certain patterns, such as cervical, thoracic, lumbar, and bulbar (facial) regions. Although initial presentations can vary, eventually upper and lower motor neurons are lost in the two types of ALS: familial and sporadic.
About 6000 people in the U.S. are diagnosed with ALS yearly. A French physician, Jean Charcot, identified ALS in 1869; initially, the disease was called “Charcot Disease.” However, in 1939, when the famous baseball player Lou Gehrig was diagnosed with ALS, it became known as “Lou Gehrig’s Disease”. It is estimated that more than 20,000 Americans live with ALS at any given time. Today, patients usually live 2 to 5 years after diagnosis, but progression of the disease is different in each person. It is common for patients to have remissions, lasting weeks to months, when there is little or no loss of function.
The American Association of Critical Care Nurse’s therapeutic communication tool “NURSE” is an empathy tool when having emotional conversations to help guide the conversation to convey empathy and to elicit more information:
Elisabeth Kubler-Ross Model describes five stages in which the dying patient moves through denial, anger, bargaining, depression, and acceptance.
The first stage of the process of grieving and preparing for death is denial. This may initially manifest as shock or speechlessness. It is common to believe a mistake in the prognosis has been made due to inaccurate test results, having not attempted the correct treatment, or deficits in knowledge of their provider.