Drug Study: diazepam

Adverse effects
• CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy, fatigue, light-headedness, disorientation, restlessness, confusion, crying, delirium, headache, slurred speech, dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness, difficulty in concentration, vivid dreams, psychomotor retardation, extrapyramidal symptoms; mild paradoxical excitatory reactions, during first 2 wk of treatment, visual and auditory disturbances, diplopia, nystagmus, depressed hearing, nasal congestion
• CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension, palpitations, edema
• Dependence: Drug dependence with withdrawal syndrome when drug is discontinued (common with abrupt discontinuation of higher dosage used for longer than 4 mo); IV diazepam: 1.7% incidence of fatalities; oral benzodiazepines ingested alone; no well-documented fatal overdoses
• Dermatologic: Urticaria, pruritus, skin rash, dermatitis
• GI: Constipation; diarrhea, dry mouth; salivation; nausea; anorexia; vomiting; difficulty in swallowing; gastric disorders; elevations of blood enzymes—LDH, alkaline phosphatase, AST, ALT; hepatic dysfunction; jaundice
• GU: Incontinence, urinary retention, changes in libido, menstrual irregularities
• Hematologic: Decreased hematocrit, blood dyscrasias
• Other: Phlebitis and thrombosis at IV injection sites, hiccups, fever, diaphoresis, paresthesias, muscular disturbances, gynecomastia; pain, burning, and redness after IM injection

Interactions
Drug-drug
• Increased CNS depression with alcohol, omeprazole
• Increased pharmacologic effects of diazepam if combined with cimetidine, disulfiram, hormonal contraceptives
• Decreased effects of diazepam with theophyllines, ranitidine

Nursing considerations
Assessment
• History: Hypersensitivity to benzodiazepines; psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication; elderly or debilitated patients; impaired liver or kidney 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; liver and kidney 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 kidney 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.
• 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.


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