A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?

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Red man syndrome (RMS) is a condition that can occur with rapid IV vancomycin administration. It is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest. Muscle pain, spasms, dyspnea, and hypotension may also occur. RMS is usually a rate-related infusion reaction and not an allergic reaction. It can be reduced by infusing vancomycin over a minimum of 60 minutes. It can be difficult to differentiate severe RMS from anaphylaxis as flushing and hypotension can occur in both conditions. However, hives, angioedema (lip swelling), wheezing, and respiratory distress are more suggestive of anaphylaxis. The client exhibiting signs and symptoms suggestive of anaphylaxis should have the vancomycin infusion stopped immediately and be treated with intramuscular (IM) epinephrine. The infusion must not be restarted if anaphylaxis is suspected. A slowed infusion rate or pre-medications will not prevent a future anaphylactic response. (Option A) Muscle pain and spasms may be symptoms of RMS. The nurse should also assess for other medications the client may be taking that could cause these symptoms (ie, statins). (Option B) Flushing and pruritus may also be symptoms of RMS. The nurse should further assess the client's airway for possible anaphylaxis. (Option C) Low blood pressure (BP) can have many causes, RMS being one of them. If low BP is due to RMS, stopping or reducing the rate of vancomycin (depending on severity) would solve this. If low BP is due to anaphylaxis, IM epinephrine must be given in addition to stopping the vancomycin infusion. Educational objective: The development of hives, angioedema, wheezing, and respiratory distress in a client receiving IV vancomycin indicates anaphylaxis. The infusion must be stopped immediately and IM epinephrine administered. RMS is a rate-related infusion reaction to IV vancomycin that is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest.

A Client Just Diagnosed with Methicillin-Resistant Staphylococcus Aureus Septic Arthritis