Diclofenac

 Drug Name

Generic Name : diclofenac, diclofenac potassium, diclofenac sodium

Brand Name: Cataflam, Novo-Difenac-k (CAN), Voltaren Rapide (CAN), Novo-Difenac (CAN), Novo-Difenac SR (CAN), Nu-Diclo (CAN), Solaraze, Voltaren, Voltaren nu-Diclo SR (CAN), Ophtha (CAN), Voltaren-XR

Classification: Anti-inflammatory, NSAID

Pregnancy Category B

Dosage & Route

ADULTS

Oral

• Pain, including dysmenorrhea: 50 mg tid PO; initial dose of 100 mg may help some patients (Cataflam).
• Osteoarthritis: 100–150 mg/day PO in divided doses (Voltaren); 50 mg bid–tid PO (Cataflam).
• Rheumatoid arthritis: 150–200 mg/day PO in divided doses (Voltaren); 50 mg bid–tid PO (Cataflam).
• Ankylosing spondylitis: 100–125 mg/day PO. Give as 25 mg qid, with an extra 25-mg dose hs (Voltaren); 25 mg qid PO with an additional 25 mg at bedtime if needed (Cataflam).

Topical

• Actinic keratosis: Cover lesion with gel and smooth into skin; do not cover with dressings or cosmetics (Solaraze).

Ophthalmic

• 1 drop to affected eye qid starting 24 hr after surgery for 2 wk.

PEDIATRIC PATIENTS

• Safety and efficacy not established.

Therapeutic actions

• Diclofenac has potent anti-inflammatory, analgesic and antipyretic actions. It inhibits the enzyme, cyclooxygenase, thus resulting in reduced synthesis of prostaglandin precursors.

Indications

• Acute or long-term treatment of mild to moderate pain, including dysmenorrhea
• Rheumatoid arthritis
• Osteoarthritis
• Ankylosing spondylitis
• Treatment of actinic keratosis in conjunction with sun avoidance
• Ophthalmic: Postoperative inflammation from cataract extraction

Adverse effects

• GI disturbances; headache, dizziness, rash; GI bleeding, peptic ulceration; abnormalities of kidney function. Pain and tissue damage at Inj site (IM); local irritation (rectal); transient burning and stinging (ophthalmic).

• Potentially Fatal: Stevens-Johnson syndrome, exfoliative dermatitis, toxic epidermal necrolysis.

Contraindications

• Active peptic ulcer; hypersensitivity to diclofenac or other NSAIDs. Treatment of perioperative pain in CABG surgery. 3rd trimester of pregnancy. Topical: Not to be applied onto damaged or nonintact skin.

Nursing considerations

Assessment

• History: Renal impairment; impaired hearing; allergies; hepatic, CV, and GI conditions; lactation, pregnancy
• Physical: Skin color and lesions; orientation, reflexes, ophthalmologic and audiometric evaluation, peripheral sensation; P, edema; R, adventitious sounds; liver evaluation; CBC, clotting times, renal function tests, LFTs, serum electrolytes, stool guaiac

Interventions

• BLACK BOX WARNING: Be aware that patient may be at increased risk for CV events, GI bleed, renal insufficiency; monitor accordingly.
• Administer drug with food or after meals if GI upset occurs.
• Arrange for periodic ophthalmologic examination during long-term therapy.
• WARNING: Institute emergency procedures if overdose occurs (gastric lavage, induction of emesis, supportive therapy).

Teaching points

• Take drug with food or meals if GI upset occurs.
• Take only the prescribed dosage.
• You may experience these side effects: Dizziness, drowsiness (avoid driving or using dangerous machinery while using this drug).
• Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers, changes in vision; black, tarry stools.

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Constipation

 Definition

Constipation, costiveness, or irregularity, is a condition of the digestive system in which a person experiences hard feces that are difficult to expel.

• This usually happens because the colon absorbs too much water from the food. If the food moves through the gastro-intestinal tract too slowly, the colon may absorb too much water, resulting in feces that are dry and hard.
• Defecation may be extremely painful, and in severe cases (fecal impaction) lead to symptoms of bowel obstruction.

Causes of constipation:

• may be dietary
• hormonal
• anatomical a side effect of medications (e.g. some opiates)
• or an illness or disorder.

Clinical Manifestations

• Fewer than three bowel movements per week, abdominal distention, and pain and pressure
• Decreased appetite, headache, fatigue, indigestion, sensation of incomplete emptying
• Straining at stool; elimination of small volume of hard, dry stool
• Complications such as hypertension, hemorrhoids and fissures, fecal impaction, and megacolon

Assessment and Diagnostic Methods

• Diagnosis is based on history, physical examination, possibly a barium enema or sigmoidoscopy, stool for occult blood, anorectal manometry (pressure studies), defecography, and colonic transit studies.
• Newer tests such as pelvic floor MRI may identify occult pelvic floor defects.

Medical Management

• Treatment should target the underlying cause of constipation and aim to prevent recurrence, including education, bowel habit training, increased fiber and fluid intake, and judicious use of laxatives.
• Discontinue laxative abuse; increase fluid intake; include fiber in diet; try biofeedback, exercise routine to strengthen abdominal muscles.
• If laxative is necessary, use bulk-forming agents, saline and osmotic agents, lubricants, stimulants, or fecal softeners.
• Specific medication therapy to increase intrinsic motor function (eg, cholinergics, cholinesterase inhibitors, or prokinetic agents).

Nursing Management

Assessment

Use tact and respect with patient when talking about bowel habits and obtaining health history.

Note the following:

• Onset and duration of constipation, current and past elimination patterns, patient’s expectation of normal bowel elimination, and lifestyle information (eg, exercise and activity level, occupation, food and fluid intake, and stress level).
• Past medical and surgical history, current medications, history of laxative or enema use.
• Report of any of the following: rectal pressure or fullness, abdominal pain, straining at defecation, and flatulence.
• Sets specific goals for teaching; goals for the patient include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications.

Nursing Care Plan

Nursing Diagnosis

• Constipation

May be related to

• Functional Recent environmental changes; habitual denial or ignoring of urge to defecate; insufficient physical activity; irregular defecation habits; inadequate toileting, abdominal muscle weakness
  
• Psychological Depression; emotional stress; mental confusion
  
• Pharmacological Antilipemic agents; laxative overdose; calcium carbonate; aluminum-containing antacids; nonsteroidal antiinflammatory agents; opiates; anticholinergics; diuretics; iron salts; phenothiazides; sedatives; sympathomimetics; bismuth salts; antidepressants; calcium channel blockers
  
• Mechanical Rectal abscess or ulcer; pregnancy; rectal anal fissures; tumors; megacolon (Hirschsprung’s disease); electrolyte imbalance; rectal prolapse; prostate enlargement; neurological impairment; rectal anal stricture; rectocele; postsurgical obstruction; hemorrhoids; obesity
  
• Physiological Poor eating habits; decreased motility of gastrointestinal tract; inadequate dentition or oral hygiene; insufficient fiber intake; insufficient fluid intake; change in usual foods and eating patterns; dehydration

Desired Outcomes

• Maintains passage of soft, formed stool every 1 to 3 days without straining
• States relief from discomfort of constipation
• Identifies measures that prevent or treat constipation

Nursing Interventions

• Observe usual pattern of defecation including time of day, amount and frequency of stool, consistency of stool, history of bowel habits or laxative use; diet including fluid intake; exercise patterns; personal remedies for constipation; obstetrical/gynecological history; surgeries; alterations in perianal sensation; present bowel regimen.
  • Rationale: There often are multiple reasons for constipation; the first step is assessment of usual patterns of bowel elimination.
• Have the client or family keep a diary of bowel habits including time of day; usual stimulus; consistency, amount, and frequency of stool; fluid consumption; and use of any aids to defecation.
  • Rationale: A diary of bowel habits is valuable in treatment of constipation.
• Review client’s current medications.
  • Rationale: Many medications affect normal bowel function, including opiates, antidepressants, antihypertensives, anticholinergics, diuretics, anticonvulsants, antacids containing aluminum, iron supplements, and muscle relaxants.
• Palpate for abdominal distention, percuss for dullness, and auscultate bowel sounds.
  • Rationale: In clients with constipation the abdomen is often distended with a palpable colon.
• Check for impaction; perform digital removal per physician’s order. If impaction is present, use cleansing regimen until you obtain a very soft stool. If using an enema, the client must be able to bodily retain the fluid. If the client has poor sphincter tone, use a cone tip irrigating bag to assist the client in retaining the fluids.
  • Rationale: This also decreases the amount of fluid necessary for cleansing.
• Provide privacy for defecation. Assist the client to the bathroom and close the door if possible.
  • Rationale: Bowel elimination is a very private act, and a lack of privacy can contribute to constipation.
• Encourage fiber intake of 25 g/day for adults. Emphasize foods such as fresh fruits, beans, vegetables, and bran cereals. Add fiber to diet gradually.
  • Rationale: Fiber helps prevent constipation by giving stool bulk. Add fiber to diet gradually because a sudden increase can cause bloating, gas, and diarrhea. A daily fiber intake of 25 g can increase frequency of stools in clients with constipation. Dietary supplements of fiber in the form of bran or wheat fiber are helpful for women experiencing constipation with pregnancy.
• Encourage a fluid intake of 1.5 to 2 L/day (6 to 8 glasses of liquids per day). If oral intake is low, gradually increase fluid intake. Fluid intake must be within the cardiac and renal reserve.
  • Rationale: Adequate fluid intake is necessary to prevent hard, dry stools. Increasing fluid intake to 1.5 to 2 L/day along with fiber intake of 25 g can significantly increase frequency of stools in clients with constipation.
• Encourage client to be out of bed as soon as possible, and to own activities of daily living (ADLs) as able. Encourage exercises such as turning and changing positions in bed, lifting their hips off the bed, doing range of motion exercises, alternating lifting each knee to the chest, doing wheelchair lifts, doing waist twists, stretching arms away from body, and pulling in the abdomen while taking deep breaths.
  • Rationale: Activity, even minimal, increases peristalsis, which is necessary to prevent constipation.
• At each meal, sprinkle bran over client’s food as allowed by client and prescribed diet. Ensure that client receives adequate fluid (1500 ml/day) along with bran.
  • Rationale: The number of bowel movements is increased and the use of laxatives is decreased in a client who eats wheat bran. A study done on institutionalized elderly male clients with chronic constipation demonstrated that with bran use, clients were able to discontinue use of oral laxatives.
• Initiate a regular schedule for defecation, using the client’s normal evacuation time whenever possible. Offer hot coffee, hot lemon water, or prune juice before breakfast, or while sitting on the toilet if necessary. An optimal time for many individuals is 30 minutes after breakfast because of the gastrocolic reflex.
  • Rationale: A schedule gives the client a sense of control, but more importantly it promotes evacuation before drying of stool and constipation occur. Hot liquids can stimulate peristasis and result in defecation.
• Emphasize to the client the necessary ingredients for a normal bowel regimen (e.g., fluid, fiber, activity, and regular schedule for defecation). Help client onto bedside commode or toilet with client’s hips flexed and feet flat. Have client deep breathe through mouth to encourage relaxation of the pelvic floor muscle and use the abdominal muscles to help evacuation.
• Provide laxatives, suppositories, and enemas as needed and as ordered only; establish a client goal of eliminating their use. Avoid soapsuds enemas, or use a low concentration of castile soap only. Use of laxatives should be avoided.
  • Rationale: Soapsuds enemas can cause damage to the colonic mucosa. The use of a soapsuds enema was shown to increase stool output as compared with tap water enemas in preoperative liver transplant patients; amount of mucosal irritation was unknown.
• For the stable neurological client, consider use of a bowel routine of Therevac enema or suppositories every other day, or performing digital stimulation with physician’s permission. For persistent constipation, refer to physician for evaluation.
  • Rationale: Use of the Therevac SB mini-enema was found to cut time needed for bowel care by as much as one hour or more as compared with use of suppositories.

Geriatric

• Explain the importance of fiber intake, fluid intake, and activity for soft, formed stool.
  • Rationale: Fiber intake, fluid intake, and activity are often decreased in elderly clients. Increasing fiber and fluids can effectively prevent constipation in the elderly.
• Determine client’s perception of normal bowel elimination; promote adherence to a regular schedule.
  • Rationale: Misconceptions regarding the frequency of bowel movements can lead to anxiety and overuse of laxatives.
• Explain Valsalva’s maneuver and the reason it should be avoided.
  • Rationale: Valsalva’s maneuver can cause bradycardia and even death in cardiac patients.
• Respond quickly to client’s call for help with toileting.
• Avoid regular use of enemas in the elderly.
  • Rationale: Enemas can cause fluid and electrolyte imbalances ( and damage to the colonic mucosa.
• Use opioids cautiously.
  • Rationale: If ordered, use stool softeners and bran mixtures to prevent constipation. Use of opioids can cause constipation.
• Position client on toilet or commode and place a small footstool under the feet.
  • Rationale: Placing a small footstool under the feet increases intraabdominal pressure and makes defecation easier for an elderly client with weak abdominal muscles.

Home Care Interventions

• Put client in bathroom to toilet when possible.
  • Rationale: Bowel elimination is a very private act, and a lack of privacy can contribute to constipation.
• Carefully monitor bowel patterns of clients under pain management with opioids. Introduce a bowel management program at first sign of constipation.
  • Rationale: Constipation is a major problem for terminally ill or hospice clients who may need very high doses of opioids for pain management.
• When using a bowel program, establish a pattern that is very regular and allows client to be part of family unit.
  • Rationale: Regularity of program promotes psychological and/or physiological “readiness” to evacuate. Families of home care clients often cannot proceed with normal daily activities until bowel programs are complete.

Client/Family Teaching Nursing care plans For Constipation

• Instruct client on normal bowel function and the necessity of fluid, fiber, and activity in a bowel program.
• Encourage client to heed defecation warning signs and develop a regular schedule of defecation by using a stimulus such as a warm drink or prune juice.
  • Rationale: Most cases of constipation are mechanical and result from habitual neglect of impulses that signal appropriate time for defecation. This results in accumulation of a large, dry fecal mass.
• Encourage client to avoid long-term use of laxatives and enemas and to gradually withdraw from their use if used regularly.
• If not contraindicated, teach client how to do bent-leg sit-ups to increase abdominal tone; also encourage client to contract abdominal muscles frequently throughout the day.
  • Rationale: Help client develop a daily exercise program to increase peristalsis.

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Diazepam

 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.

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