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Difficulty: HardPharmacological Therapies

Fifteen minutes after a registered nurse (RN) initiates an intravenous (IV) vancomycin infusion for a client with a severe soft tissue infection, the practical nurse (PN) responds to the client's call light. The client states, "My face and chest feel like they are burning and itching." The PN observes profound erythema over the client's face, neck, and upper torso. The client's blood pressure is 122/78 mmHg122/78\text{ mmHg}, and respirations are unlabored at 16 breaths/min16\text{ breaths/min}. Which action should the PN take first?

  1. A
    Inform the client that this is an expected reaction to the medication and offer a cool washcloth to soothe the skin.
  2. B
    Recalculate the intravenous drip rate to determine if the medication is infusing too rapidly.
  3. Stop the vancomycin infusion immediately and notify the RN.Answer
  4. D
    Scan the client's identification band and check the electronic health record for undocumented drug allergies.

Answer

The immediate priority action is to stop the vancomycin infusion and notify the registered nurse.
The client is exhibiting signs of Red Man Syndrome, a rate-dependent infusion reaction to vancomycin characterized by intense flushing, erythema, and itching of the face, neck, and upper torso. Although the client's vital signs are currently stable, the immediate priority is to stop the infusion to prevent further histamine release, which could lead to severe hypotension. The practical nurse (PN) must then immediately notify the registered nurse (RN) to assess the client and determine the next steps, which typically involve administering an antihistamine and restarting the infusion at a significantly slower rate.

Step-by-Step Solution

1
Assess the client's clinical presentation and vital signs.
The client has intense flushing and itching of the upper body, but stable blood pressure and unlabored respirations.
To differentiate between true anaphylaxis (which typically involves respiratory distress or severe hypotension) and a rate-related infusion reaction.
2
Identify the complication.
The findings indicate Red Man Syndrome, an adverse reaction caused by rapid infusion of vancomycin.
Recognizing the specific adverse effect dictates the appropriate nursing intervention.
3
Determine the priority nursing intervention within the PN scope of practice.
The PN must stop the infusion immediately.
Removing the causative agent prevents the reaction from progressing to severe hypotension or shock. The PN has the authority and responsibility to stop a harmful infusion.
4
Escalate the situation.
Notify the RN immediately.
The RN is required to perform a comprehensive assessment, notify the provider if necessary, and manage the restart of the infusion at a slower rate.

Key Concept

Vancomycin Infusion Reactions (Red Man Syndrome)
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Topics

Pharmacological Therapies

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