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Vitamins

Vitamins: Two Categories

Fat Soluble Vitamins

Fat soluble vitamins are A, D, E and K . They are metabolized slowly; can be stored in fatty tissue, and liver, and muscle in significant amounts and excreted in the urine, at a slow rate.

Vitamin A• Contraindications: Hypervitaminosis A, pregnancy

(Massive dose)• S/Es: HA, fatigue, drowsiness, irritability,

anorexia, vomiting, diarrhea, dry skin, visual change

• ADE: Evident only with toxicity: leukopenia, aplastic anemia, papilledema, increased intracranial pressure, hypervitaminosis A, bulging fontanelles in infants, jaundice

Vitamin D ( Calciferol)• Vitamin D has a major role in regulating calcium

and phosphorous metabolism and is needed for calcium absorption from intestines.

• Excess vitamin D ingestion (> 40, 000 international units) results in hypervitaminosis D and may cause hypercalcemia( an elevated serum calcium level).

• Anorexia, nausea and vomiting are early symptoms of vitamin D toxicity.

Vitamin E• Has antioxidant properties that protect cellular components from being oxidized and

red blood cells from hemolysis.

• It has been reported that taking 400-800 international units of vitamin E per day reduces the number of nonfatal myocardial infarctions(MIs) and taking 200 unites for several years can reduces the risk of coronary artery disease(CAD)

• S/Es: large doses of vitamin E may include fatigue, weakness, nausea, GI upset, headache, and breast tenderness.

• Vitamin E prolongs the prothrombin time (PT) and patient taking Warfarin should have their PT monitored closely. Iron and Vitamin E shouldn't be taken together because iron interferes with the body's absorption and use of vitamin E.

• Use Vitamin E: Cautiously in: Anemia due to iron deficiency, vitamin K deficiency (May increase risk of bleeding)

Vitamin K

• Is used as antidote for oral anticoagulant overdose and to prevent and treat the hypoprothrombinemia of vitamin K deficiencies.

Water Soluble Vitamins • Water soluble Vitamins are the B-complex

vitamins and vitamin C. Theses group of vitamins are not very toxic unless taken in excessive amount.

Vitamin B complex • Four of the vitamin B-complex members are

vitamin B1 ( thiamine), vitamin B2( riboflavin), vitamin B3( Nicotinic acid, or niacin) and vitamin B6 ( Pyridoxine)

Vitamin B12 (Cobalamin)

• Functions as a building block of nucleic acids and to form red blood cells. And also it facilitates functioning of nervous system.

• Vitamin B12 is stored in the liver and it can take 2 to 3 years for stored vitamin B12 to be depleted and a deficient noticed.

• Contraindicated in: hypersensitivity• S/Es: Headache, dizziness, memory impairment,

restlessness, chest pain. Tachycardia, diarrhea, abdominal discomfort, dusphagia, pain at injection (IM site)

• Use cautiously in: Hereditary optic nerve atrophy (accelerates nerve damage); uremia, folic acid deficiency

Vitamin C• Is used to prevent and treat vitamin C deficiency (Scurvy);

to increase wound healing, for burns. Preserves integrity of blood vessels. It is a water soluble vitamin, thus essential for collagen formation and tissue repair (bones, skin, blood vessels). Synthesis of lipids, protein, and carnithine

• Contraindications(caution): Renal calculi, gout, anemia, sickle cell, sideroblastic and thalassemia

• S/Es: Oral: Nausea, vomiting, diarrhea, heartburn, headache Parenteral: Flushing, headache, dizziness, soreness at injection site

• ADE: Kidney stones, crystalluria, hyperuricemia, hemolytic anemia with clients with G6PD

• Life threatening: Sickle cell crisis, seep vein thrombosis

Nursing Process: Assessment• Check client for vitamin deficiency before start or

therapy and regularly there after. Explore such areas as inadequate nutrient intake, debilitating disease and GI disorders.

• Obtain 24 and 48 hour diet history analysis

Nursing process: Interventions •   Administer vitamins with food to promote absorption• Store drug in light - resistant container• Administer IM primarily for clients unable to take by

PO route( eg., GI malabsorption syndrome)• Recognize need for vitamin E supplements for infants

receiving vitamin A to avoid risk of hemolytic anemia.• Monitor for vitamin A therapeutic serum levels ( 80 to

300 international unites/ ML)

Nursing process: Teaching• Instruct client to take prescribed amount of drug• Inform clients to read vitamin labels to determine which vitamin is most appropriate

for them.• Instruct client to consult with health care provider/ pharmacist regarding interactions

with prescription and OTC medications• Discourage client from taking megavitamins over a long period unless these are

prescribed for specific purpose by health care provider.• Inform client that missing vitamins for 1 or 2 days is not a cause of concern, because

deficiencies do not occur for sometime.• Advice clients to check expiration dates on vitamins containers before purchasing

them.• Instruct client to avoid taking mineral oil with vitamin A on a regular basis, because it

interferes with vitamin E absorption. If needed take mineral oil at bed time.• Explain to client that there is no scientific evidence that megadoses of vitamin C

( ascorbic acid) will cure a cold.• Alert client not to take megadose of vitamin C with aspirin or sulfonamides because

crystals may form in the kidneys and urine.• Instruct client to avoid excessive intake of alcoholic beverages. Alcohol can cause

vitamin B – complex deficiencies.

Nursing process: Diet

• Advice client to eat well balanced diet, and inform client that vitamin supplements are not needed if the person is healthy and receives the proper nutrition on a regular basis.

• Instruct client about foods rich in vitamin A, including whole milk, butter, eggs, leafy green and yellow vegetables, fruits and liver.

Nursing process: SE/ADE’s• Instruct client that nausea, vomiting, headache,

loss of hair, and cracked lips (symptoms of hypervitaminosis A) should be reported to the health care provider. Early symptoms of hypervitaminosis D are anorexia, nausea and vomiting.

Herbs

Herbs• Herbs are a plant or plant parts used for its

medicinal qualities. • Herbs were the originals medicines used

throughout the world and are still used today for therapeutic effects.

• Herbs can help promote health, but when mixed with some certain medications they can be contraindicated or even cause toxicity.

Client Responsibility• Because of the risks of mixing herbal remedies

and medications, It is the responsibility of the client

• To consult with the health care provider before taking any herbal preparation

• Report any herbal preparations taken to the health care provider

• Inform health care providers of any allergy or sensitivity to any herbal products

Dietary Supplement Health And Education Act of 1994

• This act made regulations for herbal preparations • Made herbs marketed with dosages• Physiologic effects can be noted, but cant make

claims about preventing or curing conditions • Herbs need a disclaimer that indicates it is NOT

approve by the U.S. Food and Drug administration and not meant to be used as a drug.

Types of Herbal Preparations• Dried: fresh herbs that have their moisture

removed by the sun• Extracts: certain isolated components of the herb• Oils: soaking herb in olive or vegetable oil then

heated• Salves: crushing herb and mixing it in a

petroleum jelly base• Teas: steeping fresh or dried herbs in boiling

water• Syrups: adding sweetener to herb then cooking it

Commonly Used Herbs

Aloe Vera

The juice is used for minor sun burns and insect bites. If ingested, it can be used as a laxative. But can cause increased menstrual flow. • Side Effects: arrhythmias, edemas, neuropathies,

and hematuria.• Contraindicated in: pregnant or lactating women

and children under the age of 12. • Drug Interactions in cardiac glycosides,

antiarrthymics, corticosteroids, and thiazide diuretics.

Ginko (Ginkgo Biloba)• Antioxidant, peripheal vasodilation, and increased

blood flow to CNS. Reduces platelet aggregation.• Uses: Allergic rhinitis, Alzheimer’s disease,

anxiety/stress, dementia, tinnitus, impotence, and poor cirulation.

Ginko Continued…• Avoid use in pregnancy, lactation, children, and

with MAOI’s. • Drug Interactions: Caution with prescription

anticoagulants. May increase Blood pressure with thiazide diuretics. Must discontinue two weeks before surgery.

• Other Herbal Contraindications: Ginger, Garlic, or feverfew.

• Side Effects/ ADE’s: mild headache, mild gastric distress

• Toxicity: vomiting, diarrhea, dermatitis, irritability.

St. John’s Wort

St. John’s Wort• AKA: “Herbal Prozac” because of its use as a

“tonic” for the nervous system.

• Uses: Mood swings, mild to moderate depression, anxiety, and sleep disorders.

St. John’s Wort Continued…

• When taken with prescription antidepressants, adverse effect of suicidal ideations.

• Side effects/ Adverse effects: skin photosensitivity, headache, GI upset, dry mouth, dizziness, confusion.

• Interactions: avoid with pregnancy, lactation, prescription antidepressants, MAOI’s, indinavir, children <2 years.

• Drug interactions: decreased effect of digoxin, use with amphetamines, trazodone may cause serotonin syndrome.

• Interferes with absorption of other minerals.

Echinacea

Echinacea (Purple coneflower)• Is used to enhance the immune system, and for

an antipyretic, antifungal (topical) and antibacterial.

• Increases leukocytes, spleen cells, and activating granulocytes.

• Leaf preparation: used for respiratory and urinary tract infections.

• Root extract: for flu-like symptoms

Echinacea Side Effects/ Adverse Effects and Contraindications

• Temporary tingling of tongue.• cross-sensitivity in clients allergic to daisy

(flower) family• GI upset• Diarrhea• Contraindicated in: immunosuppressants

(corticosteroids). Persons with systemic disease of immune system (HIV, AIDS, TB)

Nursing ProcessAssessment

• Obtain patient’s baseline info about herbal use and OTC drug use

• Include dosage, frequency, side effects

Nursing ProcessDiagnoses

• Knowledge, deficient about therapeutic regimen related to use of herbal products

Planning• Herbal Therapy• Prescription and OTC drugs• Interaction between herbal therapy, prescription,

and OTC drugs

Nursing ProcessInterventions

• Check client’s response to herbal therapy• Monitor response to prescrip. And OTC drug

therapy• Consult dietician and other specialists necessary• Continue same brand of herbal therapy; notify

health care provider if considering change brands/ preparations

Nursing Process

Client Teaching• Explain rationale• Encourage client to read labels and heed

recommended info• Inform client of storage conditions

Diet• Teach about food that diminish/enhance the

action of herb• Foods to avoid

Nursing ProcessEvaluation

• Evaluate effectiveness of herbal remedies for alleviating symptoms.

• Evaluate client’s use of resources

Minerals

Iron• Vital for hemoglobin regeneration• 60% of the iron in the body is found in

hemoglobin• Normal diet = 5 to 20 mg per day• Found in liver, lean meats, egg yolks, dried

beans, green vegetables, and fruit• Foods and antacids slow absorption of iron and

Vitamin C increases iron absorption• More iron is needed when pregnant, but during

the first trimester megadoses are contraindicated because of its possible teratogenic effects

Iron• Dose for infants and children 6 months to 2 years

is 1.5 mg/kg• Adults is 50 mg/day • Iron toxicity is a serious cause of poisoning in

children

Copper• Needed for the formation of RBC’s and connective

tissues• Cofactor of many enzymes and its function in the

production of the neurotransmitters norepinephrine and dopamine

• Excess levels may be associated with Wilson’s disease

• Prolonged deficiency may result in anemia• Abnormal blood and skin changes caused by

deficiency include a decrease in WBC count, glucose intolerance, and a decrease in skin and hair pigmentation. Mental retardation may also occur in the young

Copper• RDA for copper is 1.5 to 3 mg/day• Most adults only consume about 1mg/day• Foods rich in copper: shellfish, liver, nuts, seeds,

legumes, and cocoa

Zinc• Important to many enzymatic reactions and is

essential for normal growth and tissue repair, wound healing, and taste and smell

• Some believe it can alleviate symptoms of the common cold and shorten its duration

• Intranasal zinc preparations may cause permanent loss of smell

Zinc• Up to 200 mg/day can be taken• RDA for an adult is 12 to 19 mg/day• Foods rich in zinc: beef, lamb, eggs, and leafy and

root vegetables• More than 150 mg may cause a copper deficiency

Chromium• Said to be helpful in control of Type 2 Diabetes• Thought to help normalize blood glucose by

increasing effects of insulin on the cells• No RDA • 50 to 200 mcg/day is considered within the

normal range • Foods rich in chromium: meats, whole-grain

cereals, and brewer’s yeast

Selenium• Cofactor for an antioxidant enzyme that protects

protein and nucleic acids from oxidative damage• Works with Vitamin E• Thought to have an anticarcinogenic effect, and

doses lower than 200 mcg may reduce the risk of lung, prostate, and colorectal cancer

• Excess doses greater than 200 mcg may cause weakness, a loss of hair, dermatitis, nausea, diarrhea, and abdominal pain, and may also be a garlic-like odor from the skin and breath

Selenium• RDA is 40 to 75 mcg (lower dose for women and

higher for men)• Foods rich in selenium: meats, seafood, eggs, and

dairy products

Iron Assessment• Obtain a drug history of current drugs and herbs

client is taking.• Obtain a history of anemia or health problems

that may lead to anemia.• Assess client for signs and symptoms of iron

deficiency anemia such as fatigue, malaise, pallor, shortness of breath, tachycardia, and cardiac dysrhytmias.

• Assess client’s RBC count, hemoglobin, hematocrit, iron level, and reticulocyte count before start of and throughout therapy.

Iron Nursing Diagnoses• Nutrition, less than/more than body requirements,

imbalanced inadequate intake of food sources of iron

• Knowledge, deficient of food sources of iron• Decision-making, readiness for enhanced related

to food choices and vitamin/mineral supplementation

Iron Planning• Client will name six foods high in iron content• Client will consume foods rich in iron• Client with iron deficiency anemia or with low

hemoglobin will take replacement as recommended by health care provider, resulting in laboratory results within desired range

• Nursing interventions• Encourage client to eat a nutritious diet to obtain

sufficient iron.• Store drug in light-resistant container• Administer IM injections of iron by Z-track method

Iron Client Teaching• Instruct client to take the tablet or capsule

between meals with at least 8 ounces of juice or water to promote absorption. If gastric irritation occurs, instruct the client to take with food.

• Advise client to swallow the tablet or capsule whole.

• Instruct the client to maintain upright position for 30 minutes after taking oral iron preparation to prevent esophageal corrosion from reflux.

• Do not administer the iron tablet within 1 hour of ingesting antacid, milk, ice cream, or other milk products such as pudding.

Iron Client Teaching Continued• Inform client that certain herbal drugs can

decrease absorption of iron and other minerals.• Advise client to increase fluids, activity, and

dietary bulk to avoid or relieve constipation.• Instruct adults not to leave iron tablets within

reach of children.• Encourage client to take on the prescribed

amount.• Be alert that iron content varies among iron salts;

therefore do not substitute one for another.• Advise client that drug treatment for anemia is

generally less than 6 months.

Iron Diet• Counsel client to include iron-rich foods in diet:

liver, lean meats, egg yolk, dried beans, green vegetables, and fruit.

Iron Side Effects• Advise client taking the liquid iron preparation to

use a straw to prevent discoloration of tooth enamel.

• Alert client that the drugs turns stools a harmless black or dark green.

• Instruct client about signs and symptoms of toxicity, including nausea, vomiting, diarrhea, pallor, hematemesis, shock, and coma, and report occurrences to health care provider.

References• Kee, J. L., Hayes, E. R., McCuistion, L. E., & et al,

L. E. (2012). Pharmacology: a nursing process approach. (7th ed.). St. Louise, MO: Elsevier.

Quiz• 1. ---------- is an antidote for Warfarin( Coumadin) overdose? •  • A. Vitamin B • B. Vitamin E• C. Vitamin K• D. Zinc•  • 2. Vitamin E shouldn't be taken with ------------•  • A. Zinc• B. Iron • C. Chromium • D. None of the above  

  

• 3. Which type of herbal preparation uses petroleum jelly? • Tea• Syrup• Salve• Exctract•  • 4. Which Herb is known as “herbal Prozac?”

• Echinacea• Ginko• Aloe Vera• St. John’s Wort•  

• Name 3 foods rich in Iron???•  •  What do you instruct a client to do if he has gastric

irritation when taking the tablet/capsule?•