A client receiving IV vancomycin develops flushing of the face and neck and itching during the infusion. Which action should the nurse take?
1Stop the infusion and administer intramuscular epinephrine to treat anaphylaxis.
2Administer diphenhydramine and resume the infusion at the same rate.
3Document the reaction as an expected side effect and continue the infusion.
4Stop or slow the infusion according to policy and notify the provider.✓ Correct answer
Explanation
Flushing and itching during vancomycin infusion may indicate an infusion-related reaction. The nurse should stop or slow the infusion according to policy, assess the client, and notify the provider. Rapid infusion can worsen the reaction.
Clinical Judgment Medication reactions require stopping the source and assessing the client.
Memory Tip Vancomycin flushing: slow or stop, then report.
Clinical Practice GuideVancomycin should be infused at an appropriate rate and clients should be monitored for infusion reactions and allergy symptoms.
CautionDo not confuse an infusion reaction with a reason to push the medication faster.
Vancomycin — An antibiotic used for selected serious gram-positive infections.
Infusion Reaction — A reaction related to the rate or process of IV medication administration.
Pruritus — Itching that can occur with allergic or infusion-related reactions.