patients receiving diazepam (valium) - pearsonwps.prenhall.com/.../npf_charts/ch15/diazepam.pdf ·...

Nursing Process Focus:Patients Receiving Diazepam (Valium)

NOTE: this information is specific to the use of diazepam as a treatment for epilepsy only, notto other uses, such as anxiety.AssessmentPrior to administration:• Obtain patient’s drug history to determine

possible drug interactions and allergies,including history of anti-seizure drugtherapy and alcohol or tobacco use.

• Assess neurological status, includingLOC. Identify type and etiology of recentseizure activity.

• Assess growth and development,including age, body mass index, andpregnancy/lactation status.

• Assess skin integrity and identifylocations for venipuncture/intravenousdrug administration; insert intravenouscatheter and I.V. line if not present.

• Obtain complete health history:neurological, pulmonary, cardiac,hematologic, renal, biliary, and mentaldisorders and including laboratory values:serum anticonvulsant level, CBC, BUN,creatinine, electrolytes, PT, PTT, andliver enzymes.

Note: *Diazepam is given in response tostatus epilepticus, a medical emergency.Obtain as much key data as possible.

Potential Nursing Diagnoses• Ineffective Airway Clearance, related to

sedative effect of drug• Risk for Injury, related to sedative effect of

drug• Acute Confusion, related to drug side

effects• Risk for Impaired Skin Integrity, related to

adverse drug reaction• Disturbed Sensory Perception, related to

drug side effect• Deficient Knowledge, related to drug

action, side effects

Planning: Patient Goals and Expected OutcomesPatient will:• Maintain a patent airway and adequate tissue perfusion.• Experience the cessation of tonic-clonic seizures of status epilepticus.• Avoid serious physical injury related to status epilepticus.• Experience the return of normal consciousness and achieve stable neurological status.• Demonstrate an understanding of the drug's action by accurately describing drug effects

and precautions.Implementation

Interventions and (Rationales) Patient Education/Discharge Planning*Monitor respiratory rate and breathingpattern, as well as pulse oximetry and/orarterial blood gases.*Place an oral airway, or assist withintubation as needed. Provide suction

*Instruct patient and caregivers that keeping anopen airway and having sufficient oxygen isnecessary to prevent permanent brain damage,which may occur related to status epilepticus.

between seizures. Administer oxygen asordered. Keep resuscitative equipmentaccessible.*Monitor all vital signs, includingtemperature, cardiac output and centralvenous pressure per Intensive Care Unit orEmergency Department protocol. MonitorEKG during I.V. infusion.*Observe for severe respiratory depressionand bradycardia. (Diazepam is a CNSdepressant which affects cardiorespiratorystatus.)

• Instruct caregivers:• That status epilepticus is a life threatening

emergency and that direct IVadministration of diazepam also has riskssuch as respiratory and cardiac depressionor arrest.

• Reassure that all necessary measures arebeing taken to preserve life and neurologicfunction.

*Monitor neurological status. Observe forchanges in level of conscious. (Statusepilepticus generally causes loss ofconsciousness; patients are at risk of enteringa coma due to increased cerebral metabolicdemand.)*Observe for rebound seizures. (Diazepam isvery short-acting.)

Instruct patient/caregiver to:• Always take anti-seizure medication exactly

as prescribed.• Inform the health care provider of any other

illness; don't self-medicate with OTCmedications.

• Avoid using alcohol, tobacco andrecreational drugs.

*Monitor metabolic status. (Increasedtemperature increases metabolic demands;lactic acidosis may follow generalized motorseizures as common in status epilepticus.)*Monitor fluid and electrolyte balance andintake and output. (Electrolyte imbalancesmay precipitate status epilepticus.)

*Advise caregivers regarding variations in fluidand electrolytes which may increasesusceptibility to seizures.

*Ensure patient safety. Place patient in semi-prone position, with head turned to reducethe risk of aspiration. Use padded cot sides.Remove any restrictive clothing. Anchor IVlines per unit protocol.

Instruct patients and caregivers to:• Review standard safety precautions

regarding seizure activity.• Discuss guidelines for seizures requiring

emergency intervention and transport to ahospital.

Evaluation of Outcome CriteriaEvaluate the effectiveness of drug therapy by confirming that patient goals and expected

outcomes have been met (see “Planning”).