— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人在輸注萬古黴素（Vancomycin）時出現臉部與頸部潮紅、低血壓及搔癢，護理師應優先做什麼？
A client is prescribed intravenous vancomycin. During the infusion, the client develops flushing, hypotension, and pruritus of the face and neck. What is the priority action?
- AStop the infusion immediately✓ 正解立即停止輸注
- BSlow the infusion rate減慢輸注速率
- CNotify the rapid response team通知快速反應小組
- DAdminister a PRN dose of diphenhydramine給予 PRN 劑量的苯海拉明
— Explanation · 中文詳解 —
此症狀為萬古黴素輸注太快引起的「紅人症候群（Red Man Syndrome）」。應先停止輸注以終止過敏原進入，隨後依醫囑降低速度重新給予。雖然此反應多與輸注速度有關，但若出現低血壓，停止給藥是保護循環穩定的第一步。
These symptoms represent Red Man Syndrome caused by rapid vancomycin infusion. The infusion should be stopped first to halt entry of the offending agent, after which it can be restarted at a slower rate per provider order. Although this reaction is mostly related to infusion rate, when hypotension occurs, stopping the medication is the first step to preserve circulatory stability.
✦ 台美臨床差異
美台臨床處理紅人症候群之護理常規皆相同，以暫停並減速為主。