— 藥理與非經腸給藥 · HARD · SATA —
護理師正在給予病人靜脈滴注萬古黴素（Vancomycin），哪些護理介入是正確的？（選所有適合的）
A nurse is administering IV Vancomycin to a client. Which nursing interventions are appropriate? (Select all that apply.)
- AInfuse the medication slowly over at least 60 minutes✓ 正解至少以 60 分鐘緩慢輸注藥物
- BMonitor for flushing, rash, or hypotension during infusion✓ 正解輸注期間監測潮紅、皮疹或低血壓
- CCheck trough levels before the next scheduled dose✓ 正解在下次預定劑量前檢查谷濃度
- DAdminister the drug rapidly to achieve peak levels快速給藥以達到峰值濃度
- EAssess the infusion site for signs of phlebitis✓ 正解評估注射部位是否有靜脈炎跡象
— Explanation · 中文詳解 —
萬古黴素若輸注過快，會導致紅人症候群（Red Man Syndrome），表現為臉部、頸部紅腫及血壓降低，因此必須慢速輸注（至少 60 分鐘）。需監測血中谷濃度（Trough level）以調整劑量，並觀察靜脈炎風險。
Slow infusion over at least 60 minutes prevents Red Man Syndrome, characterized by flushing and hypotension. Monitoring for these signs during administration is essential for early detection of infusion-related reactions. Trough levels must be checked to ensure therapeutic efficacy while avoiding toxicity, and the infusion site should be assessed for phlebitis since vancomycin is a vesicant.
✦ 台美臨床差異
兩地皆重視藥物濃度監測與輸注速度控制，以減少毒性。