diazepam Nursing Considerations & Management

 Drug Name

Generic Name : diazepam

Brand Name: Apo-Diazepam (CAN), Diastat, Diazemuls (CAN), Diazepam Intensol, Valium

Classification: Benzodiazepine, Anxiolytic, Antiepileptic, Skeletal muscle relaxant (centrally acting)

  • Pregnancy Category D
  • Controlled Substance C-IV
Dosage & Route
Dosages
  • Individualize dosage; increase dosage cautiously to avoid adverse effects.

ADULTS

Oral

  • Anxiety disorders, skeletal muscle spasm, seizure disorders: 2–10 mg bid–qid.
  • Alcohol withdrawal: 10 mg tid–qid first 24 hr; reduce to 5 mg tid–qid, as needed.

Oral sustained-release

  • Anxiety disorders: 15–30 mg/day.
  • Alcohol withdrawal: 30 mg first 24 hr; reduce to 15 mg/day as needed.

Rectal

  • 0.2 mg/kg PR; treat no more than one episode q 5 days. May give a second dose in 4–12 hr.

Parenteral

Usual dose is 2–20 mg IM or IV. Larger doses may be required for some indications (tetanus). Injection may be repeated in 1 hr.

  • Anxiety: 2–10 mg IM or IV; repeat in 3–4 hr if necessary.
  • Alcohol withdrawal: 10 mg IM or IV initially, then 5–10 mg in 3–4 hr if necessary.
  • Endoscopic procedures: 10 mg or less, up to 20 mg IV just before procedure or 5–10 mg IM 30 min prior to procedure. Reduce or omit dosage of opioids.
  • Muscle spasm: 5–10 mg IM or IV initially, then 5–10 mg in 3–4 hr if necessary.
  • Status epilepticus: 5–10 mg, preferably by slow IV. May repeat q 5–10 min up to total dose of 30 mg. If necessary, repeat therapy in 2–4 hr; other drugs are preferable for long-term control.
  • Preoperative: 10 mg IM.
  • Cardioversion: 5–15 mg IV 5–10 min before procedure.

PEDIATRIC PATIENTS

Oral

  • > 6 mo: 1–2.5 mg PO tid–qid initially. Gradually increase as needed and tolerated. Can be given rectally if needed.

Rectal

  • < 2 yr: Not recommended.
  • 2–5 yr: 0.5 mg/kg.
  • 6–11 yr: 0.3 mg/kg.
  • >12 yr: Use adult dose; may give a second dose in 4–12 hr.

Parenteral

Maximum dose of 0.25 mg/kg IV administered over 3 min; may repeat after 15–30 min. If no relief of symptoms after three doses, adjunctive therapy is recommended.

  • Tetanus (> 1 mo): 1–2 mg IM or IV slowly q 3–4 hr as necessary.
  • Tetanus (> 5 yr): 5–10 mg q 3–4 hr.
  • Status epilepticus (> 1 mo–< 5 yr): 0.2–0.5 mg slowly IV q 2–5 min up to a maximum of 5 mg.
  • Status epilepticus (> 5 yr): 1 mg IV q 2–5 min up to a maximum of 10 mg; repeat in 2–4 hr if necessary.

GERIATRIC PATIENTS OR PATIENTS WITH DEBILITATING DISEASE

  • 2–2.5 mg PO daily–bid or 2–5 mg parenteral initially; reduce rectal dose. Gradually increase as needed and tolerated; use cautiously.
Therapeutic actions
  • Diazepam is a long-acting benzodiazepine with anticonvulsant, anxiolytic, sedative, muscle relaxant and amnestic properties. It increases neuronal membrane permeability to chloride ions by binding to stereospecific benzodiazepine receptors on the postsynaptic GABA neuron within the CNS and enhancing the GABA inhibitory effects resulting in hyperpolarisation and stabilisation.
Indications
  • Management of anxiety disorders or for short-term relief of symptoms of anxiety
  • Acute alcohol withdrawal; may be useful in symptomatic relief of acute agitation, tremor, delirium tremens, hallucinosis
  • Muscle relaxant: Adjunct for relief of reflex skeletal muscle spasm due to local pathology (inflammation of muscles or joints) or secondary to trauma; spasticity caused by upper motoneuron disorders (cerebral palsy and paraplegia); athetosis, stiff-man syndrome
  • Parenteral: Treatment of tetanus
  • Antiepileptic: Adjunct in status epilepticus and severe recurrent convulsive seizures (parenteral); adjunct in seizure disorders (oral)
  • Preoperative (parenteral): Relief of anxiety and tension and to lessen recall in patients prior to surgical procedures, cardioversion, and endoscopic procedures
  • Rectal: Management of selected, refractory patients with epilepsy who require intermittent use to control bouts of increased seizure activity
  • Unlabeled use: Treatment of panic attacks
Adverse effects
  • Psychological and physical dependence with withdrawal syndrome; fatigue, drowsiness, sedation, ataxia, vertigo, confusion, depression, GI disturbances, changes in salivation, amnesia, jaundice, paradoxical excitation, elevated liver enzyme values; muscle weakness, visual disturbances, headache, slurring of speech and dysarthria; mental changes; incontinence, constipation; hypotension, tachycardia; changes in libido; pain and thrombophloebitis at Inj site (IV).
  • Potentially Fatal: Respiratory and CNS depression; coma.
Contraindications
  • Hypersensitivity; preexisting CNS depression or coma, respiratory depression; acute pulmonary insufficiency or sleep apnoea; severe hepatic impairment; acute narrow angle glaucoma; children < 6 mth; pregnancy and lactation.
Nursing considerations
Assessment
  • History: Hypersensitivity to benzodiazepines; psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication; elderly or debilitated patients; impaired liver or renal function; pregnancy, lactation
  • Physical: Weight; skin color, lesions; orientation, affect, reflexes, sensory nerve function, ophthalmologic examination; P, BP; R, adventitious sounds; bowel sounds, normal output, liver evaluation; normal output; LFTs, renal function tests, CBC
Interventions
  • WARNING: Do not administer intra-arterially; may produce arteriospasm, gangrene.
  • Change from IV therapy to oral therapy as soon as possible.
  • Do not use small veins (dorsum of hand or wrist) for IV injection.
  • Reduce dose of opioid analgesics with IV diazepam; dose should be reduced by at least one-third or eliminated.
  • Carefully monitor P, BP, respiration during IV administration.
  • WARNING: Maintain patients receiving parenteral benzodiazepines in bed for 3 hr; do not permit ambulatory patients to operate a vehicle following an injection.
  • Monitor EEG in patients treated for status epilepticus; seizures may recur after initial control, presumably because of short duration of drug effect.
  • Monitor liver and renal function, CBC during long-term therapy.
  • Taper dosage gradually after long-term therapy, especially in epileptic patients.
  • Arrange for epileptic patients to wear medical alert ID indicating that they are epileptics taking this medication.
  • Discuss risk of fetal abnormalities with patients desiring to become pregnant.
Teaching points
  • Take this drug exactly as prescribed. Do not stop taking this drug (long-term therapy, antiepileptic therapy) without consulting your health care provider.
  • Caregiver should learn to assess seizures, administer rectal form, and monitor patient.
  • Use of barrier contraceptives is advised while using this drug; if you become or wish to become pregnant, consult with your health care provider.
  • It is advisable to wear a medical alert ID indicating your diagnosis and treatment (as antiepileptic).
  • You may experience these side effects: Drowsiness, dizziness (may lessen; avoid driving or engaging in other dangerous activities); GI upset (take drug with food); dreams, difficulty concentrating, fatigue, nervousness, crying (reversible).
  • Report severe dizziness, weakness, drowsiness that persists, rash or skin lesions, palpitations, swelling of the ankles, visual or hearing disturbances, difficulty voiding.