http://nurseslabs.com/category/nursing-care-plans/page/2/

Fever is among the most common symptom usually seen in infections and can often be a cause for concern for apprehensive parents. In children, a fever can appear quite suddenly and resolve just as quickly although significantly high temperatures may be recorded during the episode. Although a fever may be a sign of the body’s natural defenses against an infection, there are times when a fever can occur without any clear indication of an infection. High fevers may lead to fits (convulsions), often indicating a need for immediate medical intervention.

What are febrile convulsions?

A febrile convulsion is a seizure in young children caused by a sharp rise in body temperature (fever). Febrile convulsions otherwise called febrile seizures (fever seizures) or febrile fits (fever fits) can cause a lot of concern among parents because of its sudden onset and frightening nature.. A convulsion triggered by sudden fever is usually harmless and normally does not indicate a long term or ongoing problem like epilepsy. It is important to note that episodes such as these occur in relation to a rapid rise in temperature, & is not related to the duration of the fever or the degree of temperature.

What causes of fever seizures?

As previously mentioned, most fever fits occur as a result of a sudden rise in body temperature but it may also develop as the fever is declining.

Usually, the fevers that trigger febrile convulsions are caused by an infection in the infant’s body, such as middle ear infections, or other bacterial or viral infections of the nose & throat. A less common, but more serious cause of such fevers is an infection of the child’s brain & spinal cord, such as meningitis. The risk of fever seizures can also increase after some common childhood immunizations.

What are the symptoms of febrile fits?

A child experiencing a febrile convulsion may display the following signs and symptoms:

A fever, usually higher than 38.9 C Loss of consciousness

Jerking of the arms & legs

Eyes rolled back in the head

Difficulty breathing

Vomiting & urinating

Crying or moaning

Seizure: “A clinical event in which there is a sudden disturbance of neurological function in association with an abnormal or excessive neuronal discharge.” (Lissauer, 2002).

A febrile convulsion is a seizure occurring in a child aged from six months to five years, precipitated by a fever arising from infection outside the nervous system in a child who is otherwise neurologically normal. Febrile convulsions have long been

recognised, but only in recent years more fully understood. Hippocrates, writing in the 4th century BC, described such a convulsion, clearly differentiating it from rigors and breath holding attacks. He noted that both generalised and partial seizures can occur, and realised that there was a strong association with age, high fever and a precipitating infection. (Great Ormond Street Hospital for Children NHS Trust).

  Febrile convulsions are a common paediatric presentation to A&E departments,

occurring in about 3% of children between the ages of six months and five years. The seizure usually occurs early on in a viral infection when the temperature is rising rapidly, and typically lasts less than five minutes. It is the abrupt rise in temperature rather than the high level that is important. The seizures are tonic or tonic-clonic, with loss of consciousness and muscular rigidity forming the tonic stage. This may be preceded by a frightened cry from the child. Cessation of respiratory movements and incontinence of urine and faeces may occur during this stage, which lasts about 30 seconds. The clonic stage that follows is characterised by repetitive movements of the limbs and face.

Management of the fitting febrile child:

Clothing should be removed and the child covered with a sheet.The child should be placed on its side, or prone with its head to one side, since vomiting with aspiration is a hazard.Rectal diazepam is the drug of choice, producing an effective blood concentration of anticonvulsant within ten minutes.All children with a first febrile convulsion should be admitted to hospital to a) exclude meningitis and b) educate the parents.A urine specimen should be taken to exclude infection, and a blood glucose level should be taken.A lumbar puncture may be performed if the child is less than eighteen months old  shows signs of meningitis or sepsis.

Treatment of the febrile child: Fever should be treated to promote the comfort of the child and to prevent dehydration. Paracetamol is the preferred anti-pyretic and fluid levels should be maintained. Ibuprofen can be given if the fever does not respond to paracetamol.Rectal diazepam should be administered as soon as possible after the start of the convulsion, and should not be given after the convulsion has stopped.     Information should be supplied by the hospital to parents, explaining the nature of

febrile convulsions, including information about the prevalence and prognosis. Parents should be instructed on the management of fever, the management of a convulsion and the administration of rectal diazepam. Finally, they should be reassured. During further febrile illnesses, parents should be advised to keep the childs temperature low, by removing warm clothing, tepid sponging and giving an antipyretic (paracetamol or ibuprofen) such as Calpol. Parents of children with an increased risk of seizure recurrence should be supplied with rectal diazepam to administer for any further seizure lasting more than five minutes. Parents should receive written as well as verbal advice on the first aid management of a further convulsion. Following convulsion, a doctor should always be consulted in order to determine that the cause is simply a viral infection, and not something more serious such as meningitis.

 

Definition

Febrile seizures are convulsions of sudden onset due to abnormal electrical activity in the brain that is caused by fever. Fever is a condition in which body temperature is elevated above normal (generally above 100.4°F [38°C]).

Description

Febrile seizures were first distinguished from epileptic seizures in the twentieth century. The National Institutes of Health defined febrile seizures in 1980 as "an event in infancy or childhood usually occurring between three months and five years of age, associated with fever, but without evidence of intracranial infection or defined cause."

There are three major subtypes of febrile seizures. The simple febrile seizure accounts for 70 to 75 percent of febrile seizures and is one in which the affected child is age six months to five years and has no history or evidence of neurological abnormalities, the seizure is generalized (affects multiple parts of the brain), and lasts less than 15 minutes, and the fever is not caused by brain illness such as meningitis or encephalitis. The complex febrile seizure shares similar characteristics with the exception that the seizure lasts longer than 15 minutes or is local (affects a localized part of the brain), or multiple seizures take place and accounts for about 20 to 25 percent of all febrile seizures. Lastly, about 5 percent of febrile seizures are diagnosed as symptomatic, in cases in which the child has a history or evidence of neurological abnormality.

The seizure activity itself is generally characterized as clonic (consisting of rhythmic jerking movements of the arms and/or legs), or tonic-clonic (commencing with a stiffening of the body followed by a clonic phase).

Demographics

Fever is the most common cause of seizures in children, occurring in 2 to 5 percent of children from six months to five years of age. First onset usually occurs by two years of age, with the risk decreasing after age three; most children stop having febrile seizures by the age of five or six. Male children have been shown to have a higher incidence of febrile seizures. The majority of children who experience a febrile seizure will only have one in their lifetime; approximately 33 percent will go on to have more than one.

Causes and Symptoms

Under normal circumstances, information is transmitted in the brain by means of electrical discharges from brain cells. A seizure occurs when the normal electrical patterns of the brain become disrupted. A febrile seizure is caused by fever, most commonly a high fever that has risen quickly. The average fever temperature in which febrile seizures take place is 104°F (40°C). Conversely, a healthy person's body temperature fluctuates between 97°F (36.1°C) and 100°F (37.8°C).

Fevers are caused in most cases by viral or bacterial infections, such as otitis media (ear infection), upper respiratory infection, pharyngitis (throat infection), pneumonia, chickenpox, and urinary tract infection. Other conditions can induce a fever, including allergic reactions, ingestion of toxins, teething, autoimmune disease, trauma, cancer, excessive sun exposure, or certain drugs. In some cases no cause of the fever can be determined.

Febrile seizures generally last between one and ten minutes. A child experiencing a febrile seizure may exhibit some or all of the following behaviors:

stiff body twitching or jerking of the extremities or face

rolled-back eyes

unconsciousness

inability to talk

problems breathing

involuntary urination or defecation

vomiting

confusion, sleepiness, or irritability after the seizure

Approximately one third of children who have had a febrile seizure will experience recurrent seizures. Several risk factors are associated with recurrent febrile seizures; children who exhibit all four are at a 70 percent chance of developing recurrent seizures, while those who have none of the risk factors have only a 20 percent chance. The risk factors include:

family history of febrile seizures young age of the child (i.e. less than 18 months of age)

seizure occurs soon after or with onset of fever

seizure-associated fever is relatively low

Causes

The direct cause of a febrile seizure is not known; however, it is normally precipitated by a recent upper respiratory infection or gastroenteritis. A febrile seizure is the effect of a sudden rise in temperature (>39°C/102°F) rather than a fever that has been present for a prolonged length of time.[1]

Febrile seizures represent the meeting point between a low seizure threshold (genetically and age-determined; some children have a greater tendency to have seizures under certain circumstances) and a trigger, which is fever. The genetic causes of febrile seizures are still being researched. Some mutations that cause a neuronal hyperexcitability (and could be responsible for febrile seizures) have already been discovered.

When to Call the Doctor

A healthcare provider should be contacted after a febrile seizure. A visit to the emergency room is warranted if the accompanying fever is greater than 103°F (39.4°C) in a child older than three months or 100.5°F (38°C) in an infant of three months or younger or if the seizure is the child's first. Emergency medical personnel (telephone 911) should be called if a febrile seizure lasts more than five minutes; if the child stops breathing; if the child's skin

starts to turn blue; or if the fever is greater than 105.8°F (41°C), a condition called hyperpyrexia.

Diagnosis

A key focus of diagnostic tests will be to determine the underlying cause of the fever. A comprehensive medical history including the fever's duration and course, other symptoms the child is experiencing, prior or current medical conditions, recent vaccinations or exposure to communicable diseases, and the child's current behaviors may point to the fever's origin. A temperature below 100.4°F (38°C) suggests another cause for the seizure. The caregiver who was present with the child while he or she was having the seizure will be asked questions relating to the child's behaviors in an attempt to determine the type of seizure.

Physicians may administer tests to rule out conditions other than fever that could have caused the seizure, such as epilepsy, meningitis, or encephalitis. Children who suffer from recurrent febrile seizures are not diagnosed with epilepsy, a seizure disorder that is not caused by fever. In the case of children under 18 months of age, a lumbar puncture (spinal tap) may be recommended to rule out meningitis because symptoms are often lacking or subtle in children of that age. Because of the benign nature of the simple febrile seizure, tests such as computed tomography (CT) scans, magnetic resonance imaging (MRI), or electroencephalogram (EEG) are not usually recommended.

Treatment

During a seizure parents or caregivers need to remain calm and take steps to make sure the child remains safe. During the period after the seizure the child may be disoriented and/or sleepy (called the postictal state), but quick recovery from this state is normal, and medical treatment is not normally needed.

During a Seizure

If a parent or caregiver observes a child having a seizure, there are a number of measures that should be taken to ensure the child's safety. These include:

staying calm laying the child on his or her side or front to prevent vomited matter from being

aspirated into the lungs

loosening any tight clothing or items that could constrict breathing

marking the start and end time of the seizure

clearing the surrounding area of unsafe items

attending to the child for the duration of the seizure

clearing the child's airway if it becomes obstructed with vomited material or other objects

Parents or caregivers should not attempt to stop the seizure or slap or shake the child in attempt to wake him/her. The child may move around during the seizure, and parents should not try to hold the child down. If the child vomits, a suction bulb can be used to help clear the airway.

After a Seizure

A healthcare professional should be called immediately after the seizure in the event that further treatment or tests are required. Hospitalization is not normally required unless the child is suffering from a serious infection or illness or the seizure itself was abnormally long. Parents or caregivers may be instructed to take certain measures at home to reduce the child's fever, such as administering fever-reducing drugs (called antipyretics) such as acetaminophen (Tylenol) or ibuprofen (Advil). There is, however, no evidence that shows fever-reducing therapies reduce the risk of another febrile seizure occurring. If the child is suffering from a bacterial infection that is the cause of the fever, he or she may be placed on antibiotics.

Treating the Fever

The treatment of pediatric fever varies according to the age of the child and the fever's cause, if known. Physicians recommend that newborns less than four weeks of age with fever be admitted to the hospital and administered antibiotics until a complete workup can be done to rule out bacterial infection or other serious illness. The same is recommended for infants ages four to 12 weeks if they appear ill. Infants of this age who otherwise appear well can often be managed on an outpatient basis with antipyretics and antibiotics in the case of bacterial infection.

For children ages three months and older, the course of treatment depends on the extent and cause of the fever. Most fevers and associated conditions can be managed on an outpatient basis. Low-grade fevers often do not need to be treated in otherwise healthy children. Antipyretics may be suggested to lower a fever and make the child more comfortable but will not affect the course of an underlying infectious disease. Aspirin should not be given to a child or adolescent with a fever since this drug has been linked to an increased risk of the serious condition called Reye's syndrome. Antibiotics may be administered if the child has a known or suspected bacterial infection.

Alternative Treatment

There are some outpatient treatments that parents or caregivers may administer to reduce their febrile child's discomfort, although there is no evidence that indicates such treatments reduce the risk of febrile seizures. These include dressing the child lightly, applying cold washcloths to the face and neck, providing plenty of fluids to avoid dehydration, and giving the child a lukewarm bath or sponging the child in lukewarm water.

Prognosis

The risk of complications associated with febrile seizures is very low. Some of the complications that may occur are:

biting the tongue choking on items that were in the mouth at the start of the seizure

injury from falling down

aspirating fluid or vomit into the lungs

developing recurrent febrile seizures

developing recurrent seizures unrelated to fever (epilepsy)

complications related the underlying cause of the fever

Children who have had a febrile seizure are at an increased risk of having another; approximately one third of febrile seizure cases become recurrent. The risk of recurrent seizures decreases with age: infants younger than 12 months have a 50 percent chance of having a second seizure, while children over the age of 12 months have a 30 percent chance. The risk of a child going on to develop epilepsy is slightly increased at approximately 2–5 percent, compared to 1 percent for the general population; such a risk is increased in children who have a history of neurological abnormalities such as cerebral palsy or developmental delays and in children whose seizures recur or are prolonged. Research has shown that febrile seizures do not affect a child's intelligence level or achievement in school.

Prevention

In some cases, a febrile seizure may be the first indication that a child is ill. Prevention is, therefore, not always possible. While the use of anticonvulsants such as Phenobarbital or Valproate has been shown to prevent recurrent febrile seizures, these drugs are associated with significant side effects such as adverse behaviors, allergic reaction, and organ injury, and have not been shown to benefit simple febrile seizures. Only rarely is anticonvulsant therapy recommended for a child with febrile seizures because of the generally benign nature of the seizures and the risk of side effects from the drugs. In some cases oral diazepam (Valium) can be administered at the first sign of fever to reduce the risk of febrile seizures; about two-thirds of children who receive this drug experience side effects such as sleepiness and loss of coordination. The majority of children who have had a febrile seizure do not need drug therapy. Parents may be directed to administer over-the-counter antipyretics at the first sign of fever.

Parental Concerns

A febrile seizure can be a frightening experience for both the child and his or her parents. It is important that parents be educated about the low risk of simple febrile seizures and the measures that can be taken to ensure their child's safety during and after a seizure.

Types

There are two types of febrile seizures.

A simple febrile seizure is one in which the seizure lasts less than 15 minutes (usually much less than this), does not recur in 24 hours, and involves the entire body (classically a generalized tonic-clonic seizure).

A complex febrile seizure is characterized by longer duration, recurrence, or focus on only part of the body.

The simple seizure represents the majority of cases and is considered to be less of a cause for concern than the complex.[citation needed]

Simple febrile seizures do not cause permanent brain injury; do not tend to recur frequently (children tend to outgrow them); and do not make the development of adult epilepsy significantly more likely (about 3–5%), compared with the general public (1%) Template:Shinnar S, Glauser TA: Febrile Seizures. J Child Neurol 17S:S44, 2002. Children with [1] febrile convulsions are more likely to suffer from afebrile epileptic attacks in the future if they have a complex febrile seizure, a family history of afebrile convulsions in first-

degree relatives (a parent or sibling), or a preconvulsion history of abnormal neurological signs or developmental delay. Similarly, the prognosis after a simple febrile seizure is excellent, whereas an increased risk of death has been shown for complex febrile seizures, partly related to underlying conditions.[4]

Symptoms

During simple febrile seizures, the body will become stiff and the arms and legs will begin twitching. The patient loses consciousness, although their eyes remain open. Breathing can be irregular. They may become incontinent (wet or soil themselves); they may also vomit or have increased secretions (foam at the mouth). The seizure normally lasts for less than five minutes.[5]

Treatment

The vast majority of patients do not require treatment for either their acute presentation with a seizure or for recurrences. The best way to manage is to control the temperature with acetaminophen (Paracetamol) or by sponging. When anticonvulsant therapy is judged by a doctor to be indicated, anticonvulsants can be prescribed. Sodium valproate or clonazepam are active against febrile seizures, with sodium valproate showing superiority over clonazepam

1 Hyperthermia

Benign Febrile Convulsion is a convulsion triggered by a rise in body temperature. Fever is not an illness and is an important part of the body’s defense against infection. Antigens or microorganisms cause inflammation and the release of pyrogens which is a substance that induces fever.

Assessment Nursing Diagnosis

Planning Nursing Interventions

Rationale Expected Outcome

Subjective:

Ө

Objective:

the patient manifested:

> febrile temp = 39°C

>flushed skin and warm to touch

> convulsion

> RR = 34

Hyperthermia

Short term:

After 4 hours of nursing interventions, the patient’s temperature will decrease from 39°C to normal range of 36.5°C to 37°C.

Long Term:

After 2 days of nursing interventions, the patient will be able to be

>Assess underlying condition and body temperature.

>Monitor and recorded vital signs.

>Remove unnecessary clothing that could only aggravate heat.

>Promote adequate rest

>To obtain baseline date.

>To note for progress and evaluate effects of hyperthermia.

>To decrease or totally diminish pain.

>Reduces metabolic

Short term:

The patient’s temperature shall have decreased from 39°C to normal range of 36.5°C to 37°C.

Long Term:

The patient shall have been able to be free of complications and

bpm

the  patient may manifest:

> high fever

> weakness

free of complications and maintain core temperature within normal range.

periods.

>Provide TSB

>Advise to increase fluid intake.

>Loosen clothing.

>Administer IV fluids at prescribed rate. Monitor regulation rate frequently.

>Administer antipyretics as ordered.

demands or oxygen.

>To promote surface cooling.

>To help decrease body temperature.

>To provide proper ventilation and promote release of heat through evaporation.

>To promote fluid management.

> Antipyretics lower core temperature.

maintain core temperature within normal range.

2 Imbalanced Nutrition

The nutritional requirements of the human body reflect the nutritional intake necessary to maintain optimal body function and to meet the body’s daily energy needs. Malnutrition (literally, “bad nutrition”) is defined as “inadequate nutrition,” and while most people interpret this as undernutrition, falling short of daily nutritional requirements. The etiology of malnutrition includes factors such as poor food availability and preparation, recurrent infections, and lack of nutritional education.

Assessment Nursing Diagnosis

Planning Nursing Interventions

Rationale Expected Outcome

Subjective:

Ө

Objective:

the patient manifested:

Imbalance Nutrition: Less than the body requirement related to economical factors.

Short term:

After 4 hours of nursing interventions, the patient’s will identify measures to promote nutrition and

>Review patient’s records.

>Assess underlying condition.

>discuss eating habits and encourage diet

>To obtain baseline data.

>To determine specific interventions.

>To achieve

Short term:

The patient shall have identified measures to promote nutrition and follow the treatment

> body weakness

> weight of 7.9kg

> loss of appetite

> poor muscle tone

the  patient may manifest:

> abnormal laboratory studies

> pallor

follow the treatment regimen

Long Term:

After 2 days of nursing interventions, the will demonstrate behaviours or lifestyle changes to regain appropriate weight.

for age.

> Note total daily intake includes patterns and time of eating.

>Consult physician for further assessment and recommendation regarding food preferences and nutritional support.

health needs of the patient with the proper food diet for his disease.

>To reveal change that should be made in the client’s dietary intake.

>For greater understanding and further assessment of specific food.

regimen.

Long Term:

The patient shall have demonstrated behaviours or lifestyle changes to regain appropriate weight.

3 Ineffective Tissue Perfusion

The circulation to the tissues is not getting enough oxygen or nourishment. Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level.

Assessment Nursing Diagnosis

Planning Nursing Interventions

Rationale Expected Outcome

Subjective:

Ө

Objective:

The patient manifested:

Ineffective tissue perfusion realated to decreased Hgb concentration in blood as evidenced

Short term:

After 4 hours of nursing intervention, the patient will demonstrate behaviour lifestyle

> Establish rapport.

> Monitor VS.

> Determine factors related to individual

> To gain patient and S.O.’s trust and promote cooperation.

> To monitor patients

Short term:

The patient shall have demonstrated behaviour lifestyle change.

>Body temperature changes.

>Skin discoloration

The patient may manifest:

> Anemia

by low Hgb count in CBC result

changes to improve circulation.

Long term:

After 2 days of nursing intervention, the patient’s S.O. will verbalize understanding of the condition.

situation.

> Evaluate for signs of infection especially when immune system is compromised.

> Discuss individual risk factors.

> Elevate head of bed at night.

> Discuss the importance of a healthy diet..

status.

> To gain information regarding the condition.

>To observe for possible risk factors.

> This information would be necessary for the client’s S.O.

> To increase gravitational blood flow.

>To promote a healthy diet to help increase RBC synthesis and Hgb count for faster recovery.

Long term:

The patient’s S.O. shall have verbalized understanding of the condition.

4 Risk for Infection

The immune system is the body’s defense against bacteria, viruses, and other foreign organisms or harmful chemicals.  It is very complex and it has to work properly to protect us from the harmful bacteria and other organisms in the environment which may infect our body.  If the immune system is compromised, it can affect the normal production of WBC from the bone marrow.  If there is an increase in number of WBC, therefore it may increase the possibility to increase infection

Assessment Nursing Diagnosis

Planning Nursing Interventions

Rationale Expected Outcome

S = Ø Risk for Short Term: >Establish good >To gain Short Term:

O = the patient manifested:

>body weakness

>fatigue

>poor muscle tone

=The patient may manifest:

>elevated body temperature

>Hgb = 112

>WBC = 22.9

>RBC = 3.97

>HCT = 0.34

>Platelet count = 234

(spread) of infection After 3 hours of

nursing interventions, the patient will verbalize understanding of ways on how to prevent spread of infection.

Long Term:

After 1week of nursing interventions, the patient will be free from infections and further complications

working relationship with the client and S.O.

>Monitor and record vital signs

> Determine pt’s individual strength

>Provide peaceful environment

>Provide adequate rest and sleep.

>Emphasize importance of hand washing

>Provide safety measures

>Monitor I & O

>Check IV and Regulate IVF

>Advice pt to increase oral fluid intake when allowed

their trust and cooperation

>For comparative baseline data

>To know when to assist client

>To promote optimum level of functioning

>To prevent fatigue and conserve energy

>.to prevent occurrence of further infections

>To prevent falls and injuries

>To note for imbalances

>To ensure proper hydration

> To replace fluid electrolyte loss

After 3 hours of nursing interventions, the patient shall have verbalized understanding of ways on how to prevent spread of infection.

Long Term:

After 1week of nursing interventions, the patient shall have been free from infections and further complications.

5 Risk for Injury

A seizure or convulsion is the visible sign of a problem in the electrical system that controls your brain. A single seizure can have many causes, such as a high fever and lack of oxygen. Hemoglobin is a protein in red blood cells that carries oxygen. Therefore, Low levels of hemoglobin in the human body may reult to seizure. During episodes of convulsion, patients are prone to injuries since they may strike different objects due to uncontrollable muscle spasms.

Assessment Nursing Diagnosis

Planning Nursing Interventions

Rationale Expected Outcome

Subjective:

Ө

Objective:

the patient may manifest the following:

>Fever

>Convulsion

>Low

>Low Hgb Level = 112

Risk for injury related to possible convulsion.

Short term:

After 4 hours of nursing interventions, the SO will modify environment as indicated to enhance safety.

Long term:

After 2 days of nursing interventions, the SO will verbalize understanding of individual factors that contribute to possibility of injury.

>establish rapport

>monitor and record Vital Signs

> ascertain knwlge of safety needs/ injury prevention

> note clients gender, age, developmnt stage, decision makng ability, level of cognition/competence

>provide health care within a culture of safety

> identify interventions/safety devices

> discuss importance of self monitoring of conditions/ emotions

> To gain patient’s trust

>To obtain baseline data

> to prevent injuries in home, community, and work setting

>affects client’s ability to protect self/others and influence choice of interventions/ teachings

>to prevent errors resulting in client injury, promote client safety and model  safety behaviors for client/SO

>to promote safe physical environment and individual safety

>it can contribute to occurence of injury

Short term:

The SO shall have modified environment as indicated to enhance safety.

Long term:

The SO shall have verbalized understanding of individual factors that contribute to possibility of injury.

Diazepam

Generic Name: diazepam

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

Pregnancy Category D

Controlled Substance C-IV

Drug classes: Benzodiazepine Anxiolytic

Antiepileptic

Skeletal muscle relaxant (centrally acting)

Therapeutic actions

Exact mechanisms of action not understood; acts mainly at the limbic system and reticular formation; may act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation; potentiates the effects of GABA, an inhibitory neurotransmitter; anxiolytic effectsf GABA, an inhibitory neurotransmitter; anxiolytic effects occur at doses well below those necessary to cause sedation, ataxia; has little effect on cortical function.

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

Contraindications and cautions

Contraindicated with hypersensitivity to benzodiazepines; psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication; pregnancy (cleft lip or palate, inguinal hernia, cardiac defects, microcephaly, pyloric stenosis when used in first trimester; neonatal withdrawal syndrome reported in newborns); lactation.

Use cautiously with elderly or debilitated patients; impaired liver or renal function; and in patients with a history of substance abuse.

Available forms

Tablets—2, 5, 10 mg; SR capsule—15 mg; oral solution—1 mg/mL, 5 mg/5 mL; rectal pediatric gel—2.5, 5, 10 mg; rectal adult gel—10, 15, 20 mg; injection—5 mg/mL

Dosages

Individualize dosage; increase dosage cautiously to avoid adverse effects.

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.

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.