chapter 13
Skeletal Muscle Relaxants
Objectives
AFTER STUDYING THIS CHAPTER, THE STUDENT WILL BE ABLE TO:
1. Discuss common symptoms/disorders for
which skeletal muscle relaxants are used.
2. Differentiate uses and effects of selected
drugs.
Critical Thinking Scenario
John Moore was in an automobile accident 5 days ago, sustaining trauma to his back and shoulder. Although
no bones were broken, he continues to have pain and muscle spasms. His physician orders Tylox PRN for the
pain and cyclobenzaprine (Flexeril) tid for muscle spasms.
Reflect on:
 Why are two different medications ordered to manage Johns discomfort?
 What nonpharmacologic treatments can be used to promote comfort?
 What teaching needs to be done before sending John home?
SKELETAL MUSCLE RELAXANTS
S keletal muscle relaxants are used to decrease muscle spasm
or spasticity that occurs in certain neurologic and muscu-
loskeletal disorders. (Neuromuscular blocking agents used as
adjuncts to general anesthesia for surgery are discussed in
Chap. 14.)
Muscle Spasm
Muscle spasm or cramp is a sudden, involuntary, painful mus-
cle contraction that occurs with trauma or an irritant. Spasms
may involve alternating contraction and relaxation (clonic) or
sustained contraction (tonic). Muscle spasm may occur with
musculoskeletal trauma or inflammation (eg, sprains, strains,
bursitis, arthritis). It is also encountered with acute or chronic
low back pain, a common condition that is primarily a disorder
of posture.
Spasticity
Spasticity involves increased muscle tone or contraction and
stiff, awkward movements. It occurs with neurologic disorders
such as spinal cord injury and multiple sclerosis.
3. Describe nonpharmacologic interventions to
relieve muscle spasm and spasticity.
4. Apply the nursing process with clients experi-
encing muscle spasm or spasticity.
In patients with spinal cord injury, spasticity requires treat-
ment when it impairs safety, mobility, and the ability to per-
form activities of daily living (eg, self-care in hygiene, eating,
dressing, and work or recreational activities). Stimuli that pre-
cipitate spasms vary from one individual to another and may
include muscle stretching, bladder infections or stones, con-
stipation and bowel distention, or infections. Each person
needs to be assessed for personal precipitating factors, so they
can be avoided when possible. Treatment measures include
passive range-of-motion and muscle-stretching exercises and
antispasmodic medications (eg, baclofen, dantrolene).
Multiple sclerosis (MS) is a major cause of neurologic
disability among young and middle-aged adults, occurs
more often in women than in men, and has a pattern of ex-
acerbations and remissions. It is considered an autoimmune
disorder that occurs in genetically susceptible individuals,
although its cause is unknown. It involves destruction of
portions of the myelin sheath that covers nerves in the brain,
spinal cord, and optic nerve. Myelin normally insulates the
neuron from electrical activity and conducts electrical im-
pulses rapidly along nerve fibers. When myelin is destroyed
(a process called demyelination, which probably results
from inflammation), fibrotic lesions are formed and nerve
conduction is slowed or blocked around the lesions. Lesions
in various states of development (eg, acute, subacute, and
213
 214 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM
chronic) often occur at multiple sites in the CNS. Muscle
weakness and other symptoms vary according to the loca-
tion and duration of the myelin damage.
In recent years, researchers have discovered that nerve
cells can be repaired (remyelinated) if the process that dam-
aged the myelin is stopped before the oligodendrocytes (the
cells that form myelin) are destroyed. Other researchers are
trying to develop methods for enhancing nerve conduction
velocity in demyelinated nerves. For example, exposure to
cold by wearing a cooling vest or exercising in cool water
temporarily increases the rate of nerve conduction and im-
proves symptoms in some people. Avoiding environmental
heat and conditions that cause fever may also help because
an elevated body temperature slows nerve conduction and
often aggravates MS symptoms.
The person with minimal symptoms does not require treat-
ment, but should be encouraged to maintain a healthy lifestyle.
Those with more extensive symptoms should try to avoid
emotional stress, environmental temperature extremes, infec-
tions, and excessive fatigue. Physical therapy may help main-
tain muscle tone, and occupational therapy may help maintain
ability to perform activities of daily living.
Drug therapy for MS may involve several types of med-
ications for different types and stages of the disease. Acute
exacerbations are treated with corticosteroids (see Chap. 24),
interferon beta (Avonex, Betaseron) or glatiramer (Copax-
one) is given to prevent relapses, immunosuppressive drugs
(eg, methotrexate) are used to treat progressive disease, and
symptoms are treated with a variety of drugs, including anti-
depressants for depression and skeletal muscle relaxants for
spasticity.
Spasticity may be controlled with the use of baclofen,
tizanidine, or dantrolene. In some cases, decreasing spasticity
may not be desirable because clients with severe leg weakness
may require some degree of spasticity to ambulate. In cases of
severe spasticity, baclofen may be given intrathecally through
an implanted subcutaneous pump.
Mechanism of Action
All skeletal muscle relaxants except dantrolene are centrally
active drugs. Pharmacologic action is usually attributed to
general depression of the central nervous system (CNS), but
may involve blockage of nerve impulses that cause increased
muscle tone and contraction. It is unclear whether relief of
pain results from sedative effects, muscular relaxation, or a
placebo effect. In addition, although parenteral administra-
tion of some drugs (eg, diazepam, methocarbamol) relieves
pain associated with acute musculoskeletal trauma or in-
flammation, it is uncertain whether oral administration of
usual doses exerts a beneficial effect in acute or chronic dis-
orders.
Baclofen and diazepam increase the effects of gamma-
aminobutyric acid, an inhibitory neurotransmitter, and tizani-
dine inhibits motor neurons in the brain. Dantrolene is the only
skeletal muscle relaxant that acts peripherally on the muscle it-
self. It inhibits the release of calcium in skeletal muscle cells
and thereby decreases the strength of muscle contraction.
Indications for Use
Skeletal muscle relaxants are used primarily as adjuncts to
other treatment measures such as physical therapy. Occa-
sionally, parenteral agents are given to facilitate orthopedic
procedures and examinations. In spastic disorders, skeletal
muscle relaxants are indicated when spasticity causes se-
vere pain or inability to tolerate physical therapy, sit in a
wheelchair, or participate in self-care activities of daily liv-
ing (eg, eating, dressing). The drugs should not be given if
they cause excessive muscle weakness and impair rather
than facilitate mobility and function.
Dantrolene also is indicated for prevention and treatment
of malignant hyperthermia, a rare but life-threatening com-
plication of anesthesia characterized by hypercarbia, meta-
bolic acidosis, skeletal muscle rigidity, fever, and cyanosis.
For preoperative prophylaxis in people with previous
episodes of malignant hyperthermia, the drug is given orally
for 1 to 2 days before surgery. For intraoperative malignant
hyperthermia, the drug is given intravenously. After an oc-
currence during surgery, the drug is given orally for 13 days
to prevent recurrence of symptoms.
Contraindications to Use
Most skeletal muscle relaxants cause CNS depression and have
the same contraindications as other CNS depressants. They
should be used cautiously in clients with impaired renal or
hepatic function or respiratory depression, and in clients who
must be alert for activities of daily living (eg, driving a car, op-
erating potentially hazardous machinery). Orphenadrine and
cyclobenzaprine have high levels of anticholinergic activity
and therefore should be used cautiously with glaucoma, uri-
nary retention, cardiac arrhythmias, or tachycardia.
INDIVIDUAL DRUGS
Individual skeletal muscle relaxants are described below;
routes and dosages ranges are listed in Drugs at a Glance:
Skeletal Muscle Relaxants.
Baclofen (Lioresal) is used mainly to treat spasticity in
MS and spinal cord injuries. It is contraindicated in people
with hypersensitivity reactions to it and those with muscle
spasm from rheumatic disorders. It can be given orally and
intrathecally through an implanted, subcutaneous pump.
Check the pump manufacturers literature for information
about pump implantation and drug infusion techniques.
The action of oral baclofen starts in 1 hour, peaks in
2 hours, and lasts 4 to 8 hours. It is metabolized in the liver
and excreted in urine; its half-life is 3 to 4 hours. Dosage must
be reduced in clients with impaired renal function. Common
 CHAPTER 13 SKELETAL MUSCLE RELAXANTS 215

Drugs at a Glance: Skeletal Muscle Relaxants

Routes and Dosage Ranges

Generic/Trade Name Adults Children

Baclofen (Lioresal)
Carisoprodol (Soma)
Chlorphenesin (Maolate)
Cyclobenzaprine (Flexeril)
Dantrolene (Dantrium)
Diazepam (Valium)
Metaxalone (Skelaxin)
Methocarbamol (Robaxin)
Orphenadrine citrate (Norflex)
Tizanidine (Zanaflex)
PO 5 mg 3 times daily for 3 days; 10 mg 3 times <12 years: Safety not established
daily for 3 days; 15 mg 3 times daily for 3 days;
then 20 mg 3 times daily, if necessary.
Intrathecal via implanted pump: Dosage varies
widely; see manufacturers recommendations.
PO 350 mg 3 or 4 times daily, with the last dose at <12 years: Not recommended
bedtime
PO 800 mg 3 times daily until desired effect attained, Dosage not established
then 400 mg 4 times daily or less for maintenance
as needed
PO 10 mg 3 times daily. Maximal recommended <15 years: Safety and effectiveness have not been
duration, 3 weeks; maximal recommended dose, established.
60 mg daily
PO 25 mg daily initially, gradually increased weekly PO 1 mg/kg per day initially, gradually increased to a
(by increments of 50100 mg/d) to a maximal maximal dose of 3 mg/kg 4 times daily, not to ex-
dose of 400 mg daily in 4 divided doses ceed 400 mg daily
Preoperative prophylaxis of malignant hyperthermia: Same as adult
PO 48 mg/kg per day in 34 divided doses for
1 or 2 days before surgery
Intraoperative malignant hyperthermia: IV push
1 mg/kg initially, continued until symptoms are
relieved or a maximum total dose of 10 mg/kg
has been given
Postcrisis follow-up treatment: PO 48 mg/kg per day
in 4 divided doses for 13 days
PO 210 mg 3 or 4 times daily PO 0.120.8 mg/kg per day in 3 or 4 divided doses
IM, IV 510 mg repeated in 34 hours if necessary IM, IV 0.040.2 mg/kg in a single dose, not to ex-
ceed 0.6 mg/kg within an 8-h period
PO 800 mg 3 or 4 times daily >12 years: Same as adults
<12 years: Safety and effectiveness have not been
established
PO 1.52 g 4 times daily for 4872 hours, reduced Safety and effectiveness have not been established
to 1.0 g 4 times daily for maintenance except for treatment of tetanus (IV 15 mg/kg
IM 500 mg q8h every 6 hours as indicated)
IV 13 g daily at a rate not to exceed 300 mg/min
(3 mL of 10% injection). Do not give IV more than
3 days.
PO 100 mg twice daily Not recommended
IM, IV 60 mg twice daily
PO 4 mg q68h initially, increased gradually if Safety and effectiveness have not been established
needed. Maximum of 3 doses and 36 mg in 24 h

IM, intramuscular; IV, intravenous; PO, oral.

adverse effects include drowsiness, dizziness, confusion, con-
stipation, fatigue, headache, hypotension, insomnia, nausea,
and weakness. When discontinued, dosage should be tapered
and the drug withdrawn over 1 to 2 weeks.
Carisoprodol (Soma) is used to relieve discomfort from
acute, painful, musculoskeletal disorders. It is not recom-
mended for long-term use and, if used long term or in high
doses, it can cause physical dependence (ie, symptoms of with-
drawal if stopped abruptly). The drug is contraindicated in
clients with intermittent porphyria, a rare metabolic disorder
characterized by acute abdominal pain and neurologic symp-
toms. Oral drug acts within 30 minutes, peaks in 1 to 2 hours
and lasts 4 to 6 hours. It is metabolized in the liver and has a
half-life of 8 hours. Common adverse effects include drowsi-
ness, dizziness, and impaired motor coordination.
Chlorphenesin (Maolate) is used to relieve discomfort
from acute, painful, musculoskeletal disorders. Oral drug ef-
fects peak in 1 to 3 hours and last 8 to 12 hours; half-life is
3.5 hours. The drug is metabolized in the liver and excreted
in urine. Common adverse effects are drowsiness, dizziness,
confusion, nausea.
Cyclobenzaprine (Flexeril) has the same indication for use
as carisoprodol and chlorphenesin, above. It is contraindicated
in clients with cardiovascular disorders (eg, recent myocardial
infarction, dysrhythmias, heart block) or hyperthyroidism.
Oral drug acts in 1 hour, peaks in 4 to 6 hours and lasts 12 to
 216 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM
24 hours; half-life is 1 to 3 days. Duration of use should not
exceed 3 weeks. Common adverse effects are drowsiness,
dizziness, and anticholinergic effects (eg, dry mouth, consti-
pation, urinary retention, tachycardia).
Dantrolene (Dantrium) acts directly on skeletal muscle to
inhibit muscle contraction. It is used to relieve spasticity in
neurologic disorders (eg, multiple sclerosis, spinal cord in-
jury) and to prevent or treat malignant hyperthermia, a rare
but life-threatening complication of anesthesia characterized
by hypercarbia, metabolic acidosis, skeletal muscle rigidity,
fever, and cyanosis. For preoperative prophylaxis in people
with previous episodes of malignant hyperthermia, the drug is
given orally for 1 to 2 days before surgery. For intraoperative
malignant hyperthermia, the drug is given intravenously. After
an occurrence during surgery, the drug is given orally for 1 to
3 days to prevent recurrence of symptoms.
Oral drug acts slowly, peaks in 4 to 6 hours and lasts 8 to
10 hours. IV drug acts rapidly, peaks in about 5 hours and
lasts 6 to 8 hours. Common adverse effects include drowsi-
ness, dizziness, diarrhea, and fatigue. The most serious ad-
verse effect is potentially fatal hepatitis, with jaundice and
other symptoms that usually occur within 1 month of starting
drug therapy. Liver function tests should be monitored peri-
odically in all clients receiving dantrolene. These adverse
effects do not occur with short-term use of IV drug for malig-
nant hyperthermia.
Metaxalone (Skelaxin) is used to relieve discomfort from
acute, painful, musculoskeletal disorders. It is contraindi-
cated in clients with anemias or severe renal or hepatic im-
pairment. Oral drug acts within 60 minutes, peaks in 2 hours
and lasts 4 to 6 hours. It has a half life of 2 to 3 hours, is me-
tabolized in the liver, and is excreted in urine. Common ad-
verse effects include drowsiness, dizziness, and nausea;
hepatotoxicity and hemolytic anemia may also occur. Liver
function should be monitored during therapy.
Methocarbamol (Robaxin) is used to relieve discomfort
from acute, painful, musculoskeletal disorders; it may also be
used to treat tetanus. Parenteral drug is contraindicated in
clients with renal impairment because the solution contains
polyethylene glycol. Oral drug acts within 30 minutes and
peaks in 2 hours; parenteral drug acts rapidly but peak and du-
ration of action are unknown. The drug has a half life of 1 to
2 hours, is metabolized in the liver, and is excreted in urine
and feces. Common adverse effects with oral drug include
drowsiness, dizziness, nausea, and urticaria; effects with in-
jected drug also include fainting, incoordination, and hypo-
tension. The drug may also discolor urine to a green, brown, or
black. This is considered a harmless effect, but clients should
be informed about it.
Orphenadrine (Norflex) is used to relieve discomfort
from acute, painful, musculoskeletal disorders. Because of its
strong anticholinergic effects, the drug is contraindicated in
glaucoma, duodenal obstruction, prostatic hypertrophy, blad-
der neck obstruction, and myasthenia gravis. It should be used
cautiously in clients with cardiovascular disease (eg, heart
failure, coronary insufficiency, dysrhythmias) and renal or he-
patic impairment. The action of both oral and parenteral drug
Nursing Notes: Apply Your Knowledge
Sarah Johnson is experiencing severe muscle spasms. Her physi-
cian orders Valium 50 mg to be given IV stat. Your stock supply
has 10 mg Valium in 2-cc vial. Discuss how you will safely
administer this medication.
peaks in 2 hours and lasts 4 to 6 hours. The drug has a half-
life of 14 hours, is metabolized in the liver, and is excreted in
urine and feces. Common adverse effects include drowsiness,
dizziness, constipation, dry mouth, nausea, tachycardia, and
urinary retention.
Tizanidine (Zanaflex) is an alpha2 adrenergic agonist,
similar to clonidine, that is used to treat spasticity in clients
with multiple sclerosis, spinal cord injury, or brain trauma.
It should be used cautiously with renal or hepatic impair-
ment and hypotension. It is given orally and its action starts
within 30 to 60 minutes, peaks in 1 to 2 hours, and lasts 3 to
4 hours. Its half-life is 3 to 4 hours; it is metabolized in the
liver and excreted in urine. Common adverse effects include
drowsiness, dizziness, constipation, dry mouth, and hypo-
tension. Hypotension may be significant and occur at usual
doses. It may also cause psychotic symptoms, including
hallucinations.
Nursing Process
Assessment
Assess for muscle spasm and spasticity.
With muscle spasm, assess for:
Pain. This is a prominent symptom of muscle spasm and
is usually aggravated by movement. Try to determine the
location as specifically as possible, as well as the inten-
sity, duration, and precipitating factors (eg, traumatic in-
jury, strenuous exercise).
Accompanying signs and symptoms, such as bruises
(ecchymoses), edema, or signs of inflammation (red-
ness, heat, edema, tenderness to touch)
With spasticity, assess for pain and impaired functional
ability in self-care (eg, eating, dressing). In addition, severe
spasticity interferes with ambulation and other movement
as well as exercises to maintain joint and muscle mobility.
Nursing Diagnoses
Pain related to muscle spasm
Impaired Physical Mobility related to spasm and pain
Bathing/Hygiene Self-Care Deficit related to spasm and
pain
Deficient Knowledge: Nondrug measures to relieve mus-
cle spasm, pain, and spasticity and safe usage of skeletal
muscle relaxants

Risk for Injury: Dizziness, sedation related to CNS
depression
Planning/Goals
The client will:
Experience relief of pain and spasm
Experience improved motor function
Increase self-care abilities in activities of daily living
Take medications as instructed
Use nondrug measures appropriately
Be safeguarded when sedated from drug therapy
Interventions
Use adjunctive measures for muscle spasm and spasticity:
Physical therapy (massage, moist heat, exercises)
Bed rest for acute muscle spasm
Relaxation techniques
Correct posture and lifting techniques (eg, stooping rather
than bending to lift objects, holding heavy objects close
to the body, not lifting excessive amounts of weight)
Regular exercise and use of warm-up exercises. Strenuous
exercise performed on an occasional basis (eg, weekly or
monthly) is more likely to cause acute muscle spasm.
Evaluation
Interview and observe for relief of symptoms.
Interview and observe regarding correct usage of med-
ications and nondrug therapeutic measures.
PRINCIPLES OF THERAPY
Goal of Treatment
The goal of treatment is to relieve pain, muscle spasm, and
muscle spasticity without impairing the ability to perform
self-care activities of daily living.
CLIENT TEACHING GUIDELINES
Skeletal Muscle Relaxants
General Considerations
Use nondrug measures, such as exercises and applica-
tions of heat and cold, to decrease muscle spasm and
spasticity.
Avoid activities that require mental alertness or physical
coordination (eg, driving an automobile, operating poten-
tially dangerous machinery) if drowsy from medication.
Do not take other drugs without the physicians knowledge,
including nonprescription drugs. The major risk occurs with
concurrent use of alcohol, antihistamines, sleeping aids,
or other drugs that cause drowsiness.
CHAPTER 13 SKELETAL MUSCLE RELAXANTS 217
Drug Selection
Choice of a skeletal muscle relaxant depends mainly on the
disorder being treated:
1. For acute muscle spasm and pain, an oral or parenteral
drug may be given. The drugs cause sedation and other
adverse effects and are recommended for short-term
use. Cyclobenzaprine should not be used longer than
3 weeks.
2. Parenteral agents are preferred for orthopedic proce-
dures because they have greater sedative and pain-
relieving effects.
3. Baclofen (Lioresal) is approved for treatment of spas-
ticity in people with multiple sclerosis. It is variably ef-
fective, and its clinical usefulness may be limited by
adverse reactions.
4. None of the skeletal muscle relaxants has been estab-
lished as safe for use during pregnancy and lactation.
5. For children, the choice of drug should be limited to
those with established pediatric dosages.
Use in Children
For most of the drugs, safety and effectiveness for use in chil-
dren 12 years of age and younger have not been established.
The drugs should be used only when clearly indicated, for
short periods, when close supervision is available for moni-
toring drug effects (especially sedation), and when mobility
and alertness are not required.
Use in Older Adults
Any CNS depressant or sedating drugs should be used cau-
tiously in older adults. Risks of falls, mental confusion, and
other adverse effects are higher because of impaired drug
metabolism and excretion.
Avoid herbal preparations that cause drowsiness or
sleep, including kava and valerian.
Self-Administration
Take the drugs with milk or food, to avoid nausea and
stomach irritation.
Do not stop drugs abruptly. Dosage should be decreased
gradually, especially with baclofen (Lioresal), carisoprodol
(Soma), and cyclobenzaprine (Flexeril). Suddenly stopping
baclofen may cause hallucinations; stopping the other
drugs may cause fatigue, headache, and nausea.
 218 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM

Use in Renal Impairment and periodically during treatment. If liver damage occurs, the
drugs should be stopped. The drugs should not be given to
The drugs should be used cautiously in clients with renal clients with preexisting liver disease.
impairment; dosage of baclofen must be reduced.

Use in Hepatic Impairment
Dantrolene may cause potentially fatal hepatitis, with jaun-
dice and other symptoms that usually occur within 1 month
of starting drug therapy. Liver function tests should be mon-
itored periodically in all clients receiving dantrolene.
Metaxalone and tizanidine can cause liver damage. Thus,
liver function should be assessed before starting either drug
Home Care
The home care nurse is likely to be involved with the use of
baclofen, dantrolene, or tizanidine in chronic spastic disorders.
Clients may need continued assessment of drug effects, moni-
toring of functional abilities, assistance in arranging blood tests
of liver function, and other care. Caregivers may need instruc-
tion about nonpharmacologic interventions to help prevent or
relieve spasticity.

NURSING
ACTIONS Skeletal Muscle Relaxants

NURSING ACTIONS RATIONALE/EXPLANATION

1. Administer accurately
a. Give baclofen, chlorphenesin, metaxalone with milk or
food.
b. Do not mix parenteral diazepam in a syringe with any other
drugs.
c. Inject intravenous (IV) diazepam directly into a vein or the
injection site nearest the vein (during continuous IV infusions)
at a rate of approximately 2 mg/min.
d. Avoid extravasation with IV diazepam, and inject intra-
muscular (IM) diazepam deeply into a gluteal muscle.
e. With IV methocarbamol, inject or infuse slowly.
f. With IV methocarbamol, have the client lie down during
and at least 15 minutes after administration.
g. Avoid extravasation with IV methocarbamol, and give IM
methocarbamol deeply into a gluteal muscle. (Dividing the
dose and giving two injections is preferred.)
2. Observe for therapeutic effects
a. When the drug is given for acute muscle spasm, observe for:
(1) Decreased pain and tenderness
To decrease gastrointestinal distress
Diazepam is physically incompatible with other drugs.
Diazepam may cause a precipitate if diluted. Avoid contact with
IV solutions as much as possible. A slow rate of injection mini-
mizes the risks of respiratory depression and apnea.
To prevent or reduce tissue irritation
Rapid administration may cause bradycardia, hypotension, and
dizziness.
To minimize orthostatic hypotension and other adverse drug effects
Parenteral methocarbamol is a hypertonic solution that is very ir-
ritating to tissues. Thrombophlebitis may occur at IV injection
sites, and sloughing of tissue may occur at sites of extravasation
or IM injections.
Therapeutic effects usually occur within 30 minutes after IV injec-
tion of diazepam or methocarbamol.

(2) Increased mobility

(3) Increased ability to participate in activities of daily
living
b. When the drug is given for spasticity in chronic neurologic
disorders, observe for:
(1) Increased ability to maintain posture and balance
(2) Increased ability for self-care (eg, eating and dressing)
(3) Increased tolerance for physical therapy and exercises

(continued )

NURSING ACTIONS
3. Observe for adverse effects
a. With centrally active agents, observe for:
(1) Drowsiness and dizziness
(2) Blurred vision, lethargy, flushing
(3) Nausea, vomiting, abdominal distress, constipation or
diarrhea, ataxia, areflexia, flaccid paralysis, respiratory
depression, tachycardia, hypotension
(4) Hypersensitivityskin rash, pruritus
(5) Psychological or physical dependence with diazepam
and other antianxiety agents
b. With a peripherally active agent (dantrolene), observe for:
(1) Drowsiness, fatigue, lethargy, weakness, nausea, vom-
iting
(2) Headache, anorexia, nervousness
(3) Hepatotoxicity
4. Observe for drug interactions
a. Drugs that increase effects of skeletal muscle relaxants:
(1) Central nervous system (CNS) depressants (alcohol,
antianxiety agents, antidepressants, antihistamines, anti-
psychotic drugs, sedative-hypnotics)
(2) Monoamine oxidase inhibitors
(3) Antihypertensive agents
Nursing Notes: Apply Your Knowledge
Answer: Check this order with the physician. Normal IV Valium
dosage is 510 mg every 34 hours. A 50-mg dose is unsafe and
should not be given. Any time you have to administer 10 cc IV
push you should question whether the dose is appropriate.
Review and Application Exercises
1. How do skeletal muscle relaxants act to relieve spasm and
pain?
2. What are the indications for the use of skeletal muscle
relaxants?
CHAPTER 13 SKELETAL MUSCLE RELAXANTS 219
RATIONALE/EXPLANATION
These are the most common adverse effects.
These effects occur more often with IV administration of drugs.
They are usually transient.
These effects are most likely to occur with large oral doses.
The drug should be discontinued if hypersensitivity reactions
occur. Serious allergic reactions (eg, anaphylaxis) are rare.
Most likely to occur with long-term use of large doses
Adverse effects are usually transient.
These effects are the most common.
Less common effects
This potentially serious adverse effect is most likely to occur in
people older than 35 years of age who have taken the drug 60 days
or longer. Women over age 35 years who take estrogens have the
highest risk. Hepatotoxicity can be prevented or minimized by ad-
ministering the lowest effective dose, monitoring liver enzymes
(aspartate aminotransferase and alanine aminotransferase) during
therapy, and discontinuing the drug if no beneficial effects occur
within 45 days.
Additive CNS depression with increased risks of excessive seda-
tion and respiratory depression or apnea
May potentiate effects by inhibiting metabolism of muscle relaxants
Increased hypotension, especially with tizanidine
3. What are the contraindications to the use of these
drugs?
4. What are the major adverse effects of these drugs, and
how can they be minimized?
5. What are some nonpharmacologic interventions to use
instead of or along with the drugs?
SELECTED REFERENCES
Drug facts and comparisons. (Updated monthly). St. Louis: Facts and
Comparisons.
Porth, C. M. & Curtis, R. L. (2002). Alterations in motor function.
In C. M. Porth, Pathophysiology: Concepts of altered health states, 6th ed.,
pp. 11231157. Philadelphia: Lippincott Williams & Wilkins.
Richert, J. R. (2000). Demyelinating diseases. In H. D. Humes (Ed.), Kelleys
Textbook of internal medicine, 4th ed., pp. 29122915. Philadelphia:
Lippincott Williams & Wilkins.