病人正在進行靜脈輸注萬古黴素(Vancomycin)。輸注期間發現臉部、頸部及上半身潮紅。護理師應優先採取哪項措施?
A client is prescribed intravenous vancomycin. During the infusion, the client develops flushing of the face, neck, and upper torso. Which priority action should the nurse take?
- AStop the infusion immediately立即停止輸注
- BNotify the laboratory to check serum levels通知實驗室檢測血清濃度
- CAdminister a dose of diphenhydramine給予一劑苯海拉明
- DSlow the infusion rate✓ 正解減緩輸注速度
萬古黴素(Vancomycin)輸注引起的紅人症候群(Red Man Syndrome)是因為藥物輸注速度過快,導致組織胺(Histamine)大量釋放所致。臨床表現為臉部、頸部、胸部及背部潮紅、瘙癢與低血壓。這是藥物動力學反應而非過敏。護理處置首要為減緩輸注速率,這通常能緩解症狀。若症狀持續或嚴重,才考慮停藥或給予抗組胺藥。
Red Man Syndrome induced by vancomycin infusion is caused by a too-rapid infusion rate, leading to massive histamine release. Clinical manifestations include flushing of the face, neck, chest, and back, pruritus, and hypotension. This is a pharmacokinetic reaction, not an allergic reaction. The first nursing action is to slow the infusion rate, which usually relieves the symptoms. Only if symptoms persist or are severe should discontinuation of the drug or administration of antihistamines be considered.