CLORAZEPATE DIPOTASSIUM

Drug Name

Generic Name : clorazepate dipotassium

Brand Name:  Apo-Clorazepate (CAN), Novo-Clopate (CAN), Tranxene-SD, Tranxene-SD Half Strength, Tranxene-T-tab

Classification: Benzodiazepine, Anxiolytic, Antiepileptic

Pregnancy Category D 
Controlled Substance C-IV

Dosage & Route

Individualize dosage; increase dosage gradually to avoid adverse effects. Drug is available only in oral forms.

Adults 

Anxiety: Usual dose is 30 mg/day PO in divided doses tid; adjust gradually within the range of 15–60 mg/day; also may be given as a single daily dose hs with a maximum starting dose of 15 mg. For maintenance, give the 22.5-mg PO tablet in a single daily dose as an alternate form for patients stabilized on 7.5 mg PO tid; do not use to initiate therapy; the 11.25-mg tablet may be given as a single daily dose.

Adjunct to antiepileptic medication: Maximum initial dose is 7.5 mg PO tid. Increase dosage by no more than 7.5 mg every wk, do not exceed 90 mg/day.

Acute alcohol withdrawal: Day 1: 30 mg PO initially, then 30–60 mg in divided doses. Day 2: 45–90 mg PO in divided doses. Day 3: 22.5–45 mg PO in divided doses. Day 4: 15–30 mg PO in divided doses. Thereafter, gradually reduce dose to 7.5–15 mg/day PO, and stop as soon as condition is stable.

Pediatric Patients 

Adjunct to antiepileptic medication:

·        12 yr: Use adult dosage.

·        9–12 yr: Maximum initial dose is 7.5 mg PO bid; increase dosage by no more than 7.5 mg every wk, and do not exceed 60 mg/day.

·        < 9 yr: Not recommended.

Geriatric Patients or Patients with Debilitating Disease 

Anxiety: Initially, 7.5–15 mg/day PO in divided doses. Adjust as needed and tolerated.

Therapeutic actions 

Exact mechanisms not understood; benzodiazepines potentiate the effects of GABA, an inhibitory neurotransmitter; anxiolytic effects occur at doses well below those necessary to cause sedation, ataxia.

Indications 

Management of anxiety disorders or for short-term relief of symptoms of anxiety

Symptomatic relief of acute alcohol withdrawal

Adjunctive therapy for partial seizures

Adverse effects 

Drowsiness, muscular hypotonia, anterograde amnesia, tremor, GI upsets.

Contraindications 

Contraindicated with hypersensitivity to benzodiazepines; psychoses; acute narrow-angle glaucoma; shock; coma; acute alcoholic intoxication with depression of vital signs; pregnancy (risk of congenital malformations, neonatal withdrawal syndrome); labor and delivery (“floppy infant” syndrome); lactation (infants tend to become lethargic and lose weight).

Use cautiously with impaired liver or renal function, debilitation; elderly patients.

Nursing considerations

CLINICAL ALERT! Name confusion has occurred between clorazepate and clofibrate; use caution.

Assessment 

History: Hypersensitivity to benzodiazepines; psychoses; acute narrow-angle glaucoma; shock; coma; acute alcoholic intoxication; pregnancy; lactation; impaired liver or renal function; debilitation

Physical: Skin color, lesions; T; orientation, reflexes, affect, ophthalmologic examination; P, BP; R, adventitious sounds; liver evaluation, abdominal examination, bowel sounds, normal output; CBC, LFTs, renal function tests

Interventions 

WARNING: Taper dosage gradually after long-term therapy, especially in epileptics.

Arrange for patients with epilepsy to wear medical alert identification, indicating disease and medication usage.

Teaching points 

·        Take drug exactly as prescribed; do not stop taking drug (long-term therapy) without consulting your health care provider.

·        Avoid alcohol, sleep-inducing, or over-the-counter drugs.

·        Avoid pregnancy while taking this drug; using barrier contraceptives is advised. If you become pregnant, do not stop the drug; contact your health care provider.

·        You may experience these side effects: Drowsiness, dizziness (may be transient; avoid driving a car or engaging in other dangerous activities); GI upset (take with food); fatigue; depression; dreams; crying; nervousness; depression, emotional changes; bed-wetting, urinary incontinence.

·        Report severe dizziness, weakness, drowsiness that persists, rash or skin lesions, difficulty voiding, palpitations, swelling in the extremities.

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Bloom's Taxonomy of Learning Domains

Bloom's Taxonomy was created in 1956 under the leadership of educational psychologist Dr Benjamin Bloom in order to promote higher forms of thinking in education, such as analyzing and evaluating concepts, processes, procedures, and principles, rather than just remembering facts (rote learning). It is most often used when designing educational, training, and learning processes.

The Three Domains of Learning

The committee identified three domains of educational activities or learning (Bloom, et al. 1956):

·      Cognitive: mental skills (knowledge)

·      Affective: growth in feelings or emotional areas (attitude or self)

·      Psychomotor: manual or physical skills (skills)

Since the work was produced by higher education, the words tend to be a little bigger than we normally use. Domains may be thought of as categories. Instructional designers, trainers, and educators often refer to these three categories as KSA (Knowledge [cognitive], Skills [psychomotor], and Attitudes [affective]). This taxonomy of learning behaviors may be thought of as “the goals of the learning process.” That is, after a learning episode, the learner should have acquired a new skill, knowledge, and/or attitude.

While the committee produced an elaborate compilation for the cognitive and affective domains, they omitted the psychomotor domain. Their explanation for this oversight was that they have little experience in teaching manual skills within the college level. However, there have been at least three psychomotor models created by other researchers.

Their compilation divides the three domains into subdivisions, starting from the simplest cognitive process or behavior to the most complex. The divisions outlined are not absolutes and there are other systems or hierarchies that have been devised, such as the Structure of Observed Learning Outcome (SOLO). However, Bloom's taxonomy is easily understood and is probably the most widely applied one in use today.

Cognitive Domain

The cognitive domain involves knowledge and the development of intellectual skills (Bloom, 1956). This includes the recall or recognition of specific facts, procedural patterns, and concepts that serve in the development of intellectual abilities and skills. There are six major categories of cognitive an processes, starting from the simplest to the most complex (see the table below for an in-depth coverage of each category):

·        Knowledge

·        Comprehension

·        Application

·        Analysis

·        Synthesis

·        Evaluation

The categories can be thought of as degrees of difficulties. That is, the first ones must normally be mastered before the next one can take place.

Table of The Cognitive Domain (original)

Category	Example, Key Words (verbs), and Technologies for Learning (activities)
Knowledge: Recall data or information.	Examples: Recite a policy. Quote prices from memory to a customer. Know the safety rules. Define a term. Key Words: arranges, defines, describes, identifies, knows, labels, lists, matches, names, outlines, recalls, recognizes, reproduces, selects, states Technologies: bookmarking, flash cards, Internet search, reading
Comprehension: Understand the meaning, translation, interpolation, and interpretation of instructions and problems. State a problem in one's own words.	Examples: Rewrites the principles of test writing. Explain in one's own words the steps for performing a complex task. Translates an equation into a computer spreadsheet. Key Words: comprehends, converts, diagrams, defends, distinguishes, estimates, explains, extends, generalizes, gives an example, infers, interprets, paraphrases, predicts, rewrites, summarizes, translates Technologies: create an analogy, participating in cooperative learning, taking notes, story telling
Application: Use a concept in a new situation or unprompted use of an abstraction. Applies what was learned in the classroom into novel situations in the work place.	Examples: Use a manual to calculate an employee's vacation time. Apply laws of statistics to evaluate the reliability of a written test. Key Words: applies, changes, computes, constructs, demonstrates, discovers, manipulates, modifies, operates, predicts, prepares, produces, relates, shows, solves, uses Technologies: collaborative learning, create a process, material good, etc.), blog, practice
Analysis: Separates material or concepts into component parts so that its organizational structure may be understood. Distinguishes between facts and inferences.	Examples: Troubleshoot a piece of equipment by using logical deduction. Recognize logical fallacies in reasoning. Gathers information from a department and selects the required tasks for training. Key Words: analyzes, breaks down, compares, contrasts, diagrams, deconstructs, differentiates, discriminates, distinguishes, identifies, illustrates, infers, outlines, relates, selects, separates Technologies: fishbowls, debating, questioning what happened, run a test
Synthesis: Builds a structure or pattern from diverse elements. Put parts together to form a whole, with emphasis on creating a new meaning or structure.	Examples: Write a company operations or process manual. Design a machine to perform a specific task. Integrates training from several sources to solve a problem. Revises and process to improve the outcome. Key Words: categorizes, combines, compiles, composes, creates, devises, designs, explains, generates, modifies, organizes, plans, rearranges, reconstructs, relates, reorganizes, revises, rewrites, summarizes, tells, writes Technologies: essay, networking
Evaluation: Make judgments about the value of ideas or materials.	Examples: Select the most effective solution. Hire the most qualified candidate. Explain and justify a new budget. Key Words: appraises, compares, concludes, contrasts, criticizes, critiques, defends, describes, discriminates, evaluates, explains, interprets, justifies, relates, summarizes, supports Technologies: survey, blogging

Bloom's Revised Taxonomy

Lorin Anderson, a former student of Bloom, and David Krathwohl revisited the cognitive domain in the mid-nineties and made some changes, with perhaps the three most prominent ones being (Anderson, Krathwohl, Airasian, Cruikshank, Mayer, Pintrich, Raths, Wittrock, 2000):

·     changing the names in the six categories from noun to verb forms

·     rearranging them as shown in the chart below

·     creating a processes and levels of knowledge matrix

The chart shown below compares the original taxonomy with the revised one:

This new taxonomy reflects a more active form of thinking and is perhaps more accurate. The new version of Bloom's Taxonomy, with examples and keywords is shown below,

Table of the Revised Cognitive Domain

Category	Examples, key words (verbs), and technologies for learning (activities)
Remembering: Recall or retrieve previous learned information.	Examples: Recite a policy. Quote prices from memory to a customer. Recite the safety rules. Key Words: defines, describes, identifies, knows, labels, lists, matches, names, outlines, recalls, recognizes, reproduces, selects, states Technologies: book marking, flash cards, rote learning based on repetition, reading
Understanding: Comprehending the meaning, translation, interpolation, and interpretation of instructions and problems. State a problem in one's own words.	Examples: Rewrite the principles of test writing. Explain in one's own words the steps for performing a complex task. Translate an equation into a computer spreadsheet. Key Words: comprehends, converts, defends, distinguishes, estimates, explains, extends, generalizes, gives an example, infers, interprets, paraphrases, predicts, rewrites, summarizes, translates Technologies: create an analogy, participating in cooperative learning, taking notes, storytelling, Internet search
Applying: Use a concept in a new situation or unprompted use of an abstraction. Applies what was learned in the classroom into novel situations in the work place.	Examples: Use a manual to calculate an employee's vacation time. Apply laws of statistics to evaluate the reliability of a written test. Key Words: applies, changes, computes, constructs, demonstrates, discovers, manipulates, modifies, operates, predicts, prepares, produces, relates, shows, solves, uses Technologies: collaborative learning, create a process, blog, practice
Analyzing: Separates material or concepts into component parts so that its organizational structure may be understood. Distinguishes between facts and inferences.	Examples: Troubleshoot a piece of equipment by using logical deduction. Recognize logical fallacies in reasoning. Gathers information from a department and selects the required tasks for training. Key Words: analyzes, breaks down, compares, contrasts, diagrams, deconstructs, differentiates, discriminates, distinguishes, identifies, illustrates, infers, outlines, relates, selects, separates Technologies: Fishbowls, debating, questioning what happened, run a test
Evaluating: Make judgments about the value of ideas or materials.	Examples: Select the most effective solution. Hire the most qualified candidate. Explain and justify a new budget. Key Words: appraises, compares, concludes, contrasts, criticizes, critiques, defends, describes, discriminates, evaluates, explains, interprets, justifies, relates, summarizes, supports Technologies: survey, blogging
Creating: Builds a structure or pattern from diverse elements. Put parts together to form a whole, with emphasis on creating a new meaning or structure.	Examples: Write a company operations or process manual. Design a machine to perform a specific task. Integrates training from several sources to solve a problem. Revises and process to improve the outcome. Key Words: categorizes, combines, compiles, composes, creates, devises, designs, explains, generates, modifies, organizes, plans, rearranges, reconstructs, relates, reorganizes, revises, rewrites, summarizes, tells, writes Technologies: Create a new model, write an essay, network with others

Affective Domain

The affective domain is one of three domains in Bloom's Taxonomy, with the other two being the cognitive and psychomotor (Bloom, et al., 1956).

The affective domain (Krathwohl, Bloom, Masia, 1973) includes the manner in which we deal with things emotionally, such as feelings, values, appreciation, enthusiasms, motivations, and attitudes. The five major categories are listed from the simplest behavior to the most complex:

Category	Example and Key Words (verbs)
Receiving Phenomena: Awareness, willingness to hear, selected attention.	Examples: Listen to others with respect. Listen for and remember the name of newly introduced people. Key Words: acknowledge, asks, attentive, courteous, dutiful, follows, gives, listens, understands
Responds to Phenomena: Active participation on the part of the learners. Attend and react to a particular phenomenon. Learning outcomes may emphasize compliance in responding, willingness to respond, or satisfaction in responding (motivation).	Examples: Participates in class discussions. Gives a presentation. Questions new ideals, concepts, models, etc. in order to fully understand them. Know the safety rules and practice them. Key Words: answers, assists, aids, complies, conforms, discusses, greets, helps, labels, performs, presents, tells
Valuing: The worth or value a person attaches to a particular object, phenomenon, or behavior. This ranges from simple acceptance to the more complex state of commitment. Valuing is based on the internalization of a set of specified values, while clues to these values are expressed in the learner's overt behavior and are often identifiable.	Examples: Demonstrates belief in the democratic process. Is sensitive towards individual and cultural differences (value diversity). Shows the ability to solve problems. Proposes a plan to social improvement and follows through with commitment. Informs management on matters that one feels strongly about. Key Words: appreciates, cherish, treasure, demonstrates, initiates, invites, joins, justifies, proposes, respect, shares
Organization: Organizes values into priorities by contrasting different values, resolving conflicts between them, and creating an unique value system. The emphasis is on comparing, relating, and synthesizing values.	Examples: Recognizes the need for balance between freedom and responsible behavior. Explains the role of systematic planning in solving problems. Accepts professional ethical standards. Creates a life plan in harmony with abilities, interests, and beliefs. Prioritizes time effectively to meet the needs of the organization, family, and self. Key Words: compares, relates, synthesizes
Internalizes Values(characterization): Has a value system that controls their behavior. The behavior is pervasive, consistent, predictable, and most important characteristic of the learner. Instructional objectives are concerned with the student's general patterns of adjustment (personal, social, emotional).	Examples: Shows self-reliance when working independently. Cooperates in group activities (displays teamwork). Uses an objective approach in problem solving. Displays a professional commitment to ethical  practice on a daily basis. Revises judgments and changes behavior in light of new evidence. Values people for what they are, not how they look. Key Words: acts, discriminates, displays, influences, modifies, performs, qualifies, questions, revises, serves, solves, verifies

Psychomotor Domain

The psychomotor domain (Simpson, 1972) includes physical movement, coordination, and use of the motor-skill areas. Development of these skills requires practice and is measured in terms of speed, precision, distance, procedures, or techniques in execution. Thus, psychomotor skills rage from manual tasks, such as digging a ditch or washing a car, to more complex tasks, such as operating a complex piece of machinery or dancing.

The seven major categories are listed from the simplest behavior to the most complex:

Category	Example and Key Words (verbs)
Perception (awareness): The ability to use sensory cues to guide motor activity.  This ranges from sensory stimulation, through cue selection, to translation.	Examples:  Detects non-verbal communication cues. Estimate where a ball will land after it is thrown and then moving to the correct location to catch the ball. Adjusts heat of stove to correct temperature by smell and taste of food. Adjusts the height of the forks on a forklift by comparing where the forks are in relation to the pallet. Key Words: chooses, describes, detects, differentiates, distinguishes, identifies, isolates, relates, selects.
Set: Readiness to act. It includes mental, physical, and emotional sets. These three sets are dispositions that predetermine a person's response to different situations (sometimes called mindsets).	Examples:  Knows and acts upon a sequence of steps in a manufacturing process. Recognize one's abilities and limitations. Shows desire to learn a new process (motivation). NOTE: This subdivision of Psychomotor is closely related with the “Responding to phenomena” subdivision of the Affective domain. Key Words: begins, displays, explains, moves, proceeds, reacts, shows, states, volunteers.
Guided Response: The early stages in learning a complex skill that includes imitation and trial and error. Adequacy of performance is achieved by practicing.	Examples:  Performs a mathematical equation as demonstrated. Follows instructions to build a model. Responds hand-signals of instructor while learning to operate a forklift. Key Words: copies, traces, follows, react, reproduce, responds
Mechanism (basic proficiency): This is the intermediate stage in learning a complex skill. Learned responses have become habitual and the movements can be performed with some confidence and proficiency.	Examples:  Use a personal computer. Repair a leaking faucet. Drive a car. Key Words: assembles, calibrates, constructs, dismantles, displays, fastens, fixes, grinds, heats, manipulates, measures, mends, mixes, organizes, sketches.
Complex Overt Response (Expert): The skillful performance of motor acts that involve complex movement patterns. Proficiency is indicated by a quick, accurate, and highly coordinated performance, requiring a minimum of energy. This category includes performing without hesitation, and automatic performance. For example, players are often utter sounds of satisfaction or expletives as soon as they hit a tennis ball or throw a football, because they can tell by the feel of the act what the result will produce.	Examples:  Maneuvers a car into a tight parallel parking spot. Operates a computer quickly and accurately. Displays competence while playing the piano. Key Words: assembles, builds, calibrates, constructs, dismantles, displays, fastens, fixes, grinds, heats, manipulates, measures, mends, mixes, organizes, sketches. NOTE: The Key Words are the same as Mechanism, but will have adverbs or adjectives that indicate that the performance is quicker, better, more accurate, etc.
Adaptation: Skills are well developed and the individual can modify movement patterns to fit special requirements.	Examples:  Responds effectively to unexpected experiences.  Modifies instruction to meet the needs of the learners. Perform a task with a machine that it was not originally intended to do (machine is not damaged and there is no danger in performing the new task). Key Words: adapts, alters, changes, rearranges, reorganizes, revises, varies.
Origination: Creating new movement patterns to fit a particular situation or specific problem. Learning outcomes emphasize creativity based upon highly developed skills.	Examples:  Constructs a new theory. Develops a new and comprehensive training programming. Creates a new gymnastic routine. Key Words: arranges, builds, combines, composes, constructs, creates, designs, initiate, makes, originates.

Other Psychomotor Domain Taxonomies

As mentioned earlier, the committee did not produce a compilation for the psychomotor domain model, but others have. The one discussed above is by Simpson (1972). There are two other popular versions by Dave (1970) and Harrow (1972):

Dave (1975):

Category	Example and Key Words (verbs)
Imitation — Observing and patterning behavior after someone else. Performance may be of low quality.	Examples: Copying a work of art. Performing a skill while observing a demonstrator. Key Words: copy, follow, mimic, repeat, replicate, reproduce, trace
Manipulation — Being able to perform certain actions by memory or following instructions.	Examples: Being able to perform a skill on one's own after taking lessons or reading about it. Follows instructions to build a model. Key Words: act, build, execute, perform
Precision — Refining, becoming more exact. Performing a skill within a high degree of precision	Examples:  Working and reworking something, so it will be “just right.” Perform a skill or task without assistance. Demonstrate a task to a beginner. Key Words: calibrate, demonstrate, master, perfectionism
Articulation — Coordinating and adapting a series of actions to achieve harmony and internal consistency.	Examples: Combining a series of skills to produce a video that involves music, drama, color, sound, etc. Combining a series of skills or activities to meet a novel requirement. Key Words: adapt, constructs, combine, creates, customize, modifies, formulate
Naturalization — Mastering a high level performance until it become second-nature or natural, without needing to think much about it.	Examples:  Maneuvers a car into a tight parallel parking spot. Operates a computer quickly and accurately. Displays competence while playing the piano. Michael Jordan playing basketball or Nancy Lopez hitting a golf ball. Key Words: create, design, develop, invent, manage, naturally

Harrow (1972):

Category	Example and Key Words (verbs)
Reflex Movements — Reactions that are not learned, such as a involuntary reaction	Examples:  instinctive response Key Words: react, respond
Fundamental Movements — Basic movements such as walking, or grasping.	Examples:  perform a simple task Key Words: grasp an object, throw a ball, walk
Perceptual Abilities — Response to stimuli such as visual, auditory, kinesthetic, or tactile discrimination.	Examples:  track a moving object, recognize a pattern Key Words: catch a ball, draw or write
Physical Abilities (fitness) — Stamina that must be developed for further development such as strength and agility.	Examples:  gain strength, run a marathon Key Words: agility, endurance, strength
Skilled movements — Advanced learned movements as one would find in sports or acting.	Examples:  Using an advanced series of integrated movements, perform a role in a stage play or play in a set of series in a sports game. Key Words: adapt, constructs, creates, modifies
Nondiscursive communication— Use effective body language, such as gestures and facial expressions.	Examples:  Express one's self by using movements and gestures Key Words: arrange, compose, interpretation

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