Transcript Pharmacology and the Nursing Process, 4th ed. Lilley/Harrington

Chapter 53
Vitamins and Minerals
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Vitamins




Organic molecules needed in small quantities for
normal metabolism and other biochemical
functions, such as growth or repair of tissue
Attach to enzymes or coenzymes and help them
activate anabolic (tissue-building) processes
Natural sources from both plants and animals
Insufficient amounts result in various
deficiencies
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Water-Soluble Vitamins





B-complex group and vitamin C
Can be dissolved in water
Easily excreted in the urine
Cannot be stored by the body in large amounts
Daily intake required to prevent deficiencies
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Fat-Soluble Vitamins




Vitamins A, D, E, K
Stored in the liver and fatty tissues
Deficiencies occur only after prolonged
deprivation from an adequate supply or from
disorders that prevent their absorption
Daily intake not required, unless one is deficient
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Vitamins: Other Issues




Nutrient megadosing
Toxic hypervitaminosis
RDAs
DRIs
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Vitamin A




Fat soluble
Vitamin A (retinol) food sources: liver, fish, dairy
products, egg yolks, dark green leafy
vegetables, and yellow-orange vegetables and
fruits
Vitamin A comes from carotenes, which are
found in plants (green and yellow vegetables
and yellow fruits)
Retinol, retinyl palmitate, and retinyl acetate
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Vitamin A: Functions



Required for growth and development of bones
and teeth (morphogenesis)
Essential for night and normal vision (rhodopsin)
Necessary for other processes



Reproduction
Integrity of mucosal and epithelial surfaces
Cholesterol and steroid synthesis
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Vitamin A: Indications

Dietary supplement


Infants and pregnant and nursing women
Deficiency states

Hyperkeratosis of the skin
 Night blindness
 Other conditions

Skin conditions


Acne, psoriasis, keratosis follicularis
isotretinoin
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Vitamin A: Toxicity

Ingestion of excessive amounts causes toxicity

Irritability, drowsiness, vertigo, delirium, vomiting,
other symptoms
 Increased intracranial pressure in infants
 Generalized peeling of the skin and erythema over
several weeks
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9
Vitamin D




Fat soluble
“Sunshine vitamin”
Responsible for proper utilization of calcium and
phosphorus
Vitamin D2 (ergocalciferol)



Plant vitamin D
Obtained through dietary sources
Vitamin D3 (cholecalciferol)

Produced in the skin by ultraviolet irradiation
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Vitamin D (cont’d)

Vitamin D2-containing foods




Fish liver oils, saltwater fish
Fortified foods: milk, orange juice, cereals
Animal livers, eggs, butter, dairy products
Endogenous synthesis in the skin
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Vitamin D: Functions


Works with parathyroid hormone to regulate
absorption of and use of calcium and
phosphorus
Necessary for normal calcification of bone and
teeth
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Vitamin D: Indications





Dietary supplement
Treatment of vitamin D deficiency
Treatment and correction of conditions related to
long-term deficiency: rickets, tetany,
osteomalacia
Prevention of osteoporosis
Other uses: treatment of osteodystrophy,
hypocalcemia, hypoparathyroidism,
pseudohypoparathyroidism, hypophosphatemia
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Vitamin D: Toxicity

Long-term ingestion of excessive amounts
causes toxicity




Hypertension, weakness, fatigue, headache
Anorexia, dry mouth, metallic taste, nausea, vomiting,
abdominal cramps
Ataxia and bone pain
Can progress to impairment of renal function and
osteoporosis if left untreated
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Forms of Vitamin D




calcifediol (Calderol)
calcitriol (Rocaltrol)
dihydrotachysterol (Hytakerol)
ergocalciferol (Drisdol)
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Vitamin E



Fat soluble
Four forms: alpha, beta, gamma, and delta
tocopherol
Dietary plant sources


Fruits, grains, fortified cereals, vegetable oils, wheat
germ, nuts
Animal sources

Eggs, chicken, meats, fish
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Vitamin E: Functions




Exact biologic function of vitamin E is unknown
Believed to act as an antioxidant
Unproved theory that vitamin E has beneficial
effects for patients with cancer, heart disease,
premenstrual syndrome, and sexual dysfunction
American Heart Association no longer
recommends the use of high-dose vitamin E to
prevent heart disease
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17
Vitamin E: Indications



Dietary supplement
Antioxidant
Treatment of deficiency

Highest risk of deficiency in premature infants
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Vitamin E: Adverse Effects

Very few acute adverse effects


GI tract
CNS effects
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Vitamin K





Fat soluble
Three types: phytonadione (vitamin K1),
menaquinone (vitamin K2), and menadione
(vitamin K3)
Body does not store large amounts of vitamin K
Vitamin K2 is synthesized by the intestinal flora
Dietary sources of K1

Green leafy vegetables (broccoli, cabbage, spinach,
kale), cheese, soybean oils
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Vitamin K: Functions


Essential for synthesis of blood coagulation
factors in the liver
Vitamin K–dependent clotting factors

factor II (prothrombin)
 factor VII (proconvertin)
 factor IX (Christmas factor)
 factor X (Stuart-Prower factor)
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Vitamin K: Indications


Dietary supplementation
Treatment of deficiency states (rare)





Antibiotic therapy
Malabsorption
Given prophylactically to newborn infants
Reverses the effects of certain anticoagulants
(warfarin)
Patient becomes unresponsive to warfarin for
approximately 1 week after vitamin K
administration
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Forms of Vitamin K


Vitamin K1 (phytonadione, AquaMEPHYTON)
Vitamin K3 (menadione)
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Water-Soluble Vitamins

Vitamin B complex

Thiamine (B1)
 Riboflavin (B2)
 Niacin (B3)
 Pantothenic acid (B5)
 Pyridoxine (B6)
 Folic acid (B9)
 Cyanocobalamin (B12)

Vitamin C

Ascorbic acid
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Water-Soluble Vitamins (cont’d)




Can dissolve in water
Excessive amounts excreted in the urine, not
stored in the body
Toxic reactions are very rare
Act as coenzymes or oxidation-reduction agents
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Vitamin B1 (Thiamine)


Water soluble
Food sources


Enriched whole grain breads and cereals, liver,
beans, yeast
Deficiencies


Beriberi
Wernicke’s encephalopathy
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Vitamin B1 (Thiamine):
Deficiencies

Beriberi


Brain lesions, polyneuropathy of peripheral nerves,
serous effusions, cardiac anatomic changes
Wernicke’s encephalopathy

Also known as cerebral beriberi
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Vitamin B1 (Thiamine):
Causes of Deficiencies







Poor diet
Extended fever
Hyperthyroidism
Liver disease
Alcoholism
Malabsorption
Pregnancy and breastfeeding
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Vitamin B1 (Thiamine):
Functions

Essential for



Carbohydrate metabolism
Many metabolic pathways, including Krebs cycle
Maintains integrity of:



Peripheral nervous system
Cardiovascular system
GI tract
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Vitamin B1 (Thiamine):
Indications

Treatment of thiamine deficiency

Beriberi
 Wernicke’s encephalopathy
 Peripheral neuritis associated with pellagra
 Neuritis of pregnancy




Metabolic disorders
Malabsorption
Management of poor appetite, ulcerative colitis,
chronic diarrhea, and cerebellar syndrome or ataxia
Oral insect repellent
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Vitamin B2 (Riboflavin)


Water soluble
Food sources

Green, leafy vegetables
 Eggs, dairy products
 Nuts, legumes
 Meats, liver
 Yeast, enriched whole-grain products
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Vitamin B2 (Riboflavin):
Causes of Deficiency


Alcoholism is a major cause
Deficiency also caused by:

Intestinal malabsorption
 Long-term infections
 Liver disease
 Malignancy
 Probenecid therapy
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Vitamin B2 (Riboflavin):
Functions





Converted into enzymes essential for tissue
respiration
Required to activate vitamin B6 (pyridoxine)
Converts tryptophan into niacin
Maintains erythrocyte integrity
Needed for normal respiratory functions
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Vitamin B2 (Riboflavin):
Deficiency

Deficiency results in:

Cutaneous, oral, and corneal changes
• Cheilosis (chapped or fissured lips)
• Seborrheic dermatitis
• Keratitis
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Vitamin B2 (Riboflavin):
Indications






Dietary supplement
Treatment of deficiency
Microcytic anemia
Acne
Migraine headaches
Many other uses
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Vitamin B2 (Riboflavin):
Adverse Effects


No adverse or toxic effects
Large doses will discolor urine to a yelloworange
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Vitamin B3 (Niacin)


Water soluble
Food sources



Beans, turkey, tuna, liver, yeast
Enriched whole-grain breads and cereals, wheat
germ
Also synthesized from tryptophan (an essential
amino acid obtained from protein digestion)
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Vitamin B3 (Niacin):
Functions



Once ingested, converted to nicotinamide
Nicotinamide is converted to two coenzymes
These enzymes are required for:


Glycogenolysis, tissue respiration
Lipid, protein, and purine metabolism
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Vitamin B3 (Niacin):
Indications


Prevention and treatment of pellagra
Antihyperlipidemic drug

Lowers serum cholesterol and triglyceride levels by
reducing VLDL synthesis
 Doses required for this effect are higher than those
required for its nutritional and metabolic effects
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Vitamin B3 (Niacin):
Deficiency

Pellagra: niacin deficiency

Mental: various psychotic symptoms
 Neurologic: neurasthenic syndrome
 Cutaneous: crusting, erythema
 Inflammation of mucous membranes: oral, vaginal,
and urethral lesions; glossitis
 GI: diarrhea or bloody diarrhea
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Vitamin B3 (Niacin):
Adverse Effects

Adverse effects seen when higher doses are
used in the treatment of hyperlipidemia

Flushing
 Pruritus
 GI distress
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Classroom Response Question
A patient is taking isoniazid for tuberculosis. The
nurse anticipates supplementation with which
vitamin for the prevention of drug-induced neuritis?
A. Vitamin C (ascorbic acid)
B. Vitamin B6 (pyroxidine)
C. Vitamin K (AquaMEPHYTON)
D. Vitamin E (d-alpha tocopherol)
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Vitamin B6 (Pyridoxine)


Water soluble
Sources

Whole grains, wheat germ, yeast
 Fish, organ meats, poultry, meats, eggs
 Peanuts, nuts, vegetables, bananas
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Vitamin B6 (Pyridoxine) (cont’d)

Composed of three compounds



Pyridoxine
Pyridoxal
Pyridoxamine
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Vitamin B6 (Pyridoxine):
Function

Necessary for many metabolic functions



Protein, lipid, and carbohydrate utilization
Conversion of tryptophan to niacin
Necessary for integrity of peripheral nerves,
skin, mucous membranes, hematopoietic system
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Vitamin B6 (Pyridoxine): Deficiency

Signs and symptoms

Sideroblastic anemia
 Neurologic disturbances
 Seborrheic dermatitis
 Cheilosis (chapped, fissured lips)
 Glossitis, stomatitis
 Epileptiform convulsions
 Hypochromic microcytic anemia
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Vitamin B6 (Pyridoxine):
Causes of Deficiency




Inadequate intake
Poor absorption
Uremia, alcoholism, cirrhosis, hyperthyroidism,
malabsorption, heart failure
Drug induced (isoniazid, hydralazine, others)
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Vitamin B6 (Pyridoxine):
Indications




Prevent and treat vitamin B6 deficiency
Seizures that are unresponsive to usual therapy
Morning sickness during pregnancy
Various metabolic disorders may respond to
pyridoxine therapy
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Vitamin B6 (Pyridoxine):
Toxicity

Toxic effects occur with large doses, especially
neurotoxicity
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Vitamin B12 (Cyanocobalamin)



Water soluble
Synthesized by microorganisms present in the
body
Food sources



Liver, kidney, fish, shellfish, poultry, milk
Eggs, blue cheese, fortified cereals
Contained in minimal amounts in plants
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Vitamin B12
(Cyanocobalamin): Function


Present as two different coenzymes
Required for many metabolic pathways

Fat and carbohydrate metabolism
 Protein synthesis
 Growth, cell replication
 Hematopoiesis
 Nucleoprotein and myelin synthesis
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Vitamin B12
(Cyanocobalamin): Deficiency


The most common manifestation of untreated
cyanocobalamin deficiency is pernicious anemia
Deficiency leads to:

Neurologic damage
 Megaloblastic anemia

Deficiency states caused by:

Malabsorption
 Poor dietary intake (vegetarians)
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Vitamin B12 (Cyanocobalamin):
Oral Absorption


Oral absorption of vitamin B12 (extrinsic factor)
requires presence of the intrinsic factor
The intrinsic factor is a glycoprotein secreted
from the gastric parietal cells
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Classroom Response Question
Which vitamin does the nurse expect to be ordered
for a patient diagnosed with Wernicke’s
encephalopathy?
A. Vitamin B1 (thiamine)
B. Vitamin B6 (pyroxidine)
C. Vitamin B9 (folic acid)
D. Vitamin B12 (cyanocolbalamin)
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Vitamin C (Ascorbic Acid)


Water soluble
Natural sources

Citrus fruits and juices, strawberries
 Tomatoes, potatoes
 Broccoli, spinach, Brussels sprouts
 Cabbage, green peppers
 Liver

Can also be synthesized
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Vitamin C (Ascorbic Acid):
Functions


Acts in oxidation-reduction reactions
Required for several metabolic activities

Collagen synthesis
 Maintenance of connective tissue
 Tissue repair
 Maintenance of bone, teeth, and capillaries
 Folic acid metabolism
 Erythropoiesis
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Vitamin C (Ascorbic Acid):
Functions (cont’d)


Enhances absorption of iron
Required for the synthesis of:

Lipids
 Proteins
 Steroids


Aids in cellular respiration
Aids in resistance to infections
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Vitamin C (Ascorbic Acid):
Deficiency

Prolonged deficiency results in scurvy

Gingivitis and bleeding gums
 Loss of teeth
 Anemia
 Subcutaneous hemorrhage
 Bone lesions
 Delayed healing of soft tissues and bones
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Vitamin C (Ascorbic Acid):
Indications




Dietary supplement
Prevention and treatment of scurvy
Urinary acidifier
Most large controlled studies have shown that
ascorbic acid has little or no value as a
prophylactic for the common cold
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Vitamin C (Ascorbic Acid):
Megadoses

Megadoses may cause:



Nausea, vomiting, headache, abdominal cramps
Acidified urine, with possible stone formation
Discontinuing megadoses may result in scurvylike symptoms
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Classroom Response Question
The nurse identifies which vitamin as most often
indicated for the prevention and treatment of vision
alterations?
A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D
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Minerals



Inorganic elements or salts
Bind with enzymes or other organic molecules
Help to regulate many bodily functions
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Minerals (cont’d)




Building blocks for many body structures
Required for intracellular and extracellular body
fluid electrolytes
Macrominerals
Microminerals, or trace elements
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Calcium





Most abundant mineral element in the body
Accounts for 2% of body weight
Highest concentration in bones and teeth
Efficient absorption requires adequate amounts
of vitamin D
Calcium requirements high for

Growing children
 Women who are pregnant or breastfeeding
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Calcium: Food Sources

Found in many foods

Especially milk and dairy products
 Fortified cereals
 Calcium-fortified orange juice
 Sardines, salmon
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Calcium: Function

Essential for normal maintenance and function
of



Nervous, muscular, skeletal systems
Cell membrane and capillary permeability
Catalyst in many enzymatic reactions
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Calcium: Function (cont’d)

Essential in many physiologic processes




Transmission of nerve impulses
Contraction of cardiac, smooth, and skeletal muscles
Renal function, respiration, and blood coagulation
Several other functions
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Calcium Deficiency

Calcium deficiency: hypocalcemia

Infantile rickets
 Adult osteomalacia
 Osteoporosis
 Many other conditions associated with calcium
deficiency
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Calcium: Causes of Deficiency




Inadequate intake of calcium or vitamin D
Hypoparathyroidism
Malabsorption syndrome
Many other causes
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Calcium: Indications







Achlorhydria
Alkalosis
Chronic diarrhea
Hyperphosphatemia
Hypoparathyroidism
Menopause
Pancreatitis






Pregnancy and
lactation
Premenstrual
syndrome
Renal failure
Sprue
Steatorrhea
Vitamin D deficiency
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Calcium: Indications (cont)






Adult osteomalacia
Hypoparathyroidism
Infantile rickets or tetany
Muscle cramps
Osteoporosis
Renal insufficiency
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Calcium: Toxicity

Hypercalcemia may occur with therapy

Anorexia
 Nausea
 Vomiting
 Constipation

Severe hypercalcemia can cause:



Cardiac irregularities
Delirium
Coma
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Calcium: Drug Interactions
Chelation
 Calcium salts will bind (chelate) with
tetracyclines to produce an insoluble complex
 If hypercalcemia is present in patients taking
digoxin, serious cardiac dysrhythmias can occur
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Magnesium



One of the principal cations of intracellular fluid
Essential for enzyme systems associated with
energy metabolism
Required for:


Nerve physiology
Muscle contraction
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Magnesium (cont’d)

Dietary sources




Green, leafy vegetables
Meats, seafood, milk, cheese, yogurt
Bran cereal, nuts
Required in higher amounts for those with diets
high in protein-rich foods, calcium, and
phosphorus
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Magnesium:Causes of Deficiency

Hypomagnesemia

Malabsorption
 Alcoholism
 Long-term IV feedings
 Diuretics
 Metabolic disorders (hyperthyroidism, diabetic
ketoacidosis)
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Magnesium: Indications


Nutritional supplement
Treatment of magnesium deficiency

Anticonvulsant in magnesium deficiency
 Preeclampsia and eclampsia
 Tocolytic drug for inhibition of uterine contractions in
premature labor
 Pediatric acute nephropathy
 Cardiac dysrhythmias
 Short-term treatment of constipation
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Magnesium: Adverse Effects

Adverse effects caused by hypermagnesemia

Tendon reflex loss
 Difficult bowel movements
 CNS depression
 Respiratory distress
 Heart block
 Hypothermia
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Phosphorus

Widely distributed in foods

Milk
 Yogurt
 Cheese
 Peas
 Meat
 Fish
 Eggs

Dietary deficiency is rare
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Phosphorus Deficiency

Deficiency caused by nondietary causes

Malabsorption
 Extensive diarrhea or vomiting
 Hyperthyroidism
 Long-term use of aluminum or calcium antacids
 Hepatic disease
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Phosphorus: Functions



Required precursor for the synthesis of essential
body chemicals
Building block for body structures
Required for the synthesis of:

Nucleic acid
 ADP
 AMP
 ATP
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Phosphorus: Functions (cont’d)



Responsible for cellular energy transfer
Necessary for the development and
maintenance of the skeletal system and teeth
Several other functions
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Phosphorus: Indications


Treatment of deficiency states
Dietary supplement
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Phosphorus: Adverse Effects






Diarrhea
Nausea and vomiting
Other GI disturbances
Confusion
Weakness
Breathing difficulties
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Zinc




Trace element
Essential in metabolic reactions of proteins and
carbohydrates
Important for normal tissue growth and repair,
especially wound repair
Found in

Red meats, liver, oysters, milk products, eggs, beans,
nuts, whole grains, fortified cereals, certain seafoods
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Classroom Response Question
The nurse identifies which food as high in zinc?
A. Dark green, leafy vegetables
B. Yeast
C. Peas
D. Oysters
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Nursing Implications




Assess nutritional status
Assess baseline lab values (H&H, WBC, RBC,
protein, albumin levels)
Assess history and medication history
Assess for contraindications
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Classroom Response Question
The nurse is providing education about the use of vitamins
and minerals at a community health center. One of the
participants who is a vegetarian asks if he is at risk for any
deficiencies. The nurse identifies which deficiency of which
substance as the most common nutritional deficiency in
vegetarians?
A. Vitamin K
B. Magnesium
C. Vitamin B12
D. Calcium
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Nursing Implications (cont’d)


Follow specific guidelines for administration,
especially if parenteral
Provide nutritional counseling about necessary
foods to include in the diet
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Nursing Implications (cont’d)

Monitor for therapeutic responses


Will vary for each vitamin and mineral
Monitor for adverse effects
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Classroom Response Question
Which substance does the nurse identify as useful
in the treatment of hyperlipidemia?
A. Vitamin K
B. Magnesium
C. Vitamin B3 (Niacin)
D. Calcium
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