Final answer:
Appropriate nursing measures when administering intravenous vancomycin include monitoring serum creatinine levels, advising the patient about possible flushed feeling or itching, instructing the patient to report any dizziness or ear fullness, and reporting and holding the drug on a trough level of 24 mcg/mL to prevent toxicity.
Step-by-step explanation:
The appropriate nursing measures when administering intravenous vancomycin (Vancocin) to a patient who has had gastrointestinal surgery are:
- Monitoring serum creatinine levels to assess kidney function as vancomycin can be nephrotoxic, especially if the patient is receiving it for a prolonged period or if there are pre-existing kidney issues.
- Warning the patient that a flushed feeling or facial itching may occur, which are common side effects of vancomycin, a phenomenon known as ‘red man syndrome’.
- Instructing the patient to report dizziness or a feeling of fullness in the ears, as these could be signs of ototoxicity, which is a less common but serious side effect of vancomycin.
- Reporting a trough drug level of 24 mcg/mL and holding the drug, as this level suggests potential toxicity. Typically, vancomycin trough levels should be between 10-20 mcg/mL, depending on the infection type and the patient's individual characteristics
Restricting fluids is not typically part of the protocol for vancomycin administration, as staying hydrated may actually help prevent nephrotoxicity. Reporting a trough level of 11 mcg/mL does not typically necessitate holding the medication unless advised by specific hospital protocols or the patient's physician. It is important to monitor and adjust the dosing of vancomycin based on trough levels and renal function to ensure therapeutic efficacy while avoiding toxicity.