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Difficulty: MediumPharmacological and Parenteral Therapies

A client is receiving an initial intravenous infusion of vancomycin for a severe soft tissue infection. Fifteen minutes after the infusion begins, the nurse observes that the client's face, neck, and upper chest are intensely red. The client reports feeling dizzy and severely itchy. Current vital signs reveal a blood pressure of 88/54 mmHg88/54 \text{ mmHg} and a heart rate of 118 beats/min118 \text{ beats/min}. What is the priority nursing action?

  1. Stop the intravenous vancomycin infusion completely.Answer
  2. B
    Decrease the vancomycin infusion rate by half.
  3. C
    Administer the prescribed as-needed intravenous diphenhydramine.
  4. D
    Elevate the head of the bed to a high Fowler's position.

Answer

Stop the intravenous vancomycin infusion completely.
The client is experiencing a severe vancomycin infusion reaction (historically referred to as red man syndrome) complicated by hemodynamic instability. While mild cases involving only localized flushing and itching can often be managed by slowing the infusion rate, the presence of systemic hypotension (blood pressure 88/54 mmHg88/54 \text{ mmHg}) and dizziness indicates a severe reaction or potential anaphylactic shock. The absolute priority action is to immediately stop the infusion to prevent further release of histamine and worsening shock. Only after the infusion is stopped should the nurse assess the airway, notify the healthcare provider, and administer prescribed supportive therapies such as intravenous fluids and antihistamines.

Step-by-Step Solution

1
Assess the client's clinical presentation and vital signs during the medication administration.
The client exhibits intense erythema, severe pruritus, dizziness, hypotension (88/54 mmHg88/54 \text{ mmHg}), and tachycardia (118 beats/min118 \text{ beats/min}).
Identifying these systemic signs differentiates a mild vancomycin infusion reaction from a severe reaction with hemodynamic compromise.
2
Determine the priority intervention based on the severity of the reaction.
The nurse must immediately stop the infusion.
Hypotension and dizziness indicate compromised tissue perfusion. The offending agent must be discontinued before administering rescue medications or altering the client's position.

Key Concept

Management of severe vancomycin infusion reactions and anaphylaxis
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Topics

Pharmacological and Parenteral Therapies

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