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Difficulty: MediumPharmacological and Parenteral Therapies

A client hospitalized with severe cellulitis requires scheduled doses of intravenous vancomycin. The client has an active, continuous heparin drip running via a dedicated single-lumen peripheral catheter. Which of the following nursing actions are necessary for safe administration and monitoring? Select all that apply.

  1. Administer the medication over a minimum of 60 minutes to reduce the risk of severe hypotension.Answer
  2. B
    Connect the vancomycin as a secondary piggyback infusion directly into the continuous heparin line.
  3. Assess the client for a sudden onset of severe flushing and a macular rash on the upper body.Answer
  4. Review the client's serum creatinine and blood urea nitrogen (BUN) laboratory results regularly.Answer
  5. E
    Delegate the ongoing assessment of the peripheral intravenous insertion site to the unlicensed assistive personnel (UAP).
  6. F
    Program the intravenous pump to deliver the 250 mL250\text{ mL} vancomycin solution at a rate of 500 mL/hr500\text{ mL/hr} to complete the dose in 30 minutes30\text{ minutes}.

Answer

The correct actions include administering the medication over at least 60 minutes, assessing for signs of flushing and rash (Red Man Syndrome), and monitoring serum creatinine and BUN levels.
Vancomycin is a potent antibiotic with known risks of nephrotoxicity, ototoxicity, and infusion-related reactions. It is essential to monitor renal function markers (BUN and creatinine) to prevent kidney damage. The medication must be infused slowly over at least 60 minutes to prevent Red Man Syndrome, which presents as intense flushing, erythema, and pruritus of the face, neck, and upper torso. The nurse must actively assess for this reaction during the infusion.

Step-by-Step Solution

1
Evaluate the medication's administration guidelines and known adverse effects.
Identified that vancomycin requires slow infusion (minimum 60 minutes) and can cause Red Man Syndrome and nephrotoxicity.
Understanding the pharmacokinetic profile of high-alert medications prevents severe infusion reactions and end-organ damage.
2
Assess the compatibility of vancomycin with the client's current intravenous therapy.
Determined that vancomycin and heparin are physically incompatible.
Preventing drug precipitation in the IV line avoids potential emboli and loss of venous access.
3
Determine appropriate delegation of care for the infusion site.
Recognized that IV site assessment cannot be delegated to unlicensed assistive personnel.
Clinical judgment and evaluation are exclusively the responsibility of the registered nurse.

Key Concept

Safe administration of high-alert parenteral medications requires assessing IV compatibility, monitoring for specific toxicities, and adhering to strict infusion rate limits.
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Topics

Pharmacological and Parenteral Therapies

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