Vitamins
• Minerals: inorganic substances that are ingested & attach to enzymes/organic molecules
• Vitamins: organic compounds essential in small amount for bodily functions
o Attach to enzymes or coenzymes to help activate tissue building processes
• Enzymes: proteins secreted by cells and act as catalysts to induce chemical changes in other
substances
• Coenzyme: substance that enhances or is necessary for the action of enzymes
• Essential for daily ingestion- supplements, food/drinks (plant and animal sources)
• Deficiencies occur in acute or chronic illness (ex: in burns, AIDs) decreased intake; increased
output; anorexia; malabsorption conditions (ex. Gastric bypass; Crohn’s, etc.)
• Water soluble vitamins
o Dissolve in water and easily excreted in urine
o Not stored in the body in large amounts
▪ Need for daily ingestion
• Fat soluble vitamins
o Dissolve in fat and are stored in liver and fatty tissues
o Do not necessarily require daily ingestion
o Deficiencies occur with deprivation and inadequate storage, absorption
• “Megadosing” in cancer patients, athletes, health nuts
o American Dietetic Association defines megadosing as “doses of a nutrient that are 10 or
more times the recommended amount
o Claims made about vitamin C dosing decreasing cold and cancer risks
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o Known benefits: Pyridoxine (vitamin B6) with Isoniazid ; malabsorption syndromes
(everything); Cyanocobalamin (vitamin B12) for pernicious anemia
▪ Again, we need intrinsic factor secreted from parietal cells in stomach for absorption of
B12
• Mega dosing may help bypass intrinsic factor if there is a deficiency/ disease
▪ Mega dosing of Niacin (vitamin B3) to help lower triglycerides, LDLs
o Can be harmful!
▪ Hypervitaminosis- especially with the fat-soluble vitamins A, D, and K
• Less likely with water-soluble
o Although pyridoxine can lead to nerve damage
▪ can put more strain on GI tract
▪ may interfere with chemo/radiation
• because these therapies work to destroy cancer cells through oxidation
processes. Nutritional supplementation with antioxidants may impede such
treatment mechanisms
Fat-Soluble Vitamins
• absorbed by fat and easily stored in liver; not readily excreted in urine
• present in plant and animal foods
• primary stored in liver
• slow metabolism
• excreted in feces
• can reach toxic levels in body
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Vitamin A (Retinol)
Food Source Liver, fish, dairy products, egg yolks, dark green leafy veggies, yellow-orange veggies and fruits
Purpose Normal and night vision; normal cell growth; teeth and bone development; mucosal/epithelial
surface maintenance, cholesterol and steroid synthesis
Deficiency S/S Night blindness, xeropthalmia (dry eye), hyperkeratosis of skin and sclera, slowed infant growth,
generalized weakness, increased risk of infection
Replacement/ Supplementation
Aquasol A- PO: 50,000 units/day × 2 weeks, then 10,000–20,000 units daily for 2 months
Indications Pregnancy, Infant growth, known deficiency, Malabsorption condition, increased demand
Contraindication
s
Known allergy
Hypervitaminosis
Adverse Effects Headache, N/V, hyperpigmentation, abdominal pain, pruritis, hypercalcemia, malaise, lethargy
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Interactions absorption with laxatives, cholestyramine
toxic risk with Isotretinoin
• Carotenes in plants
o Over 600 types of compounds in plant-based foods
o Provitamin A carotenoids: carotene, cryptoxanthin
• Necessary for rhodopsin (retinal pigment)
o Beta carotene compounds is metabolized into retinAL, and then some is reduced to
retinOL, while the rest is oxidized to carboxylic acid and retinoic acid
▪ Retinoic acid is essential for normal cell growth, differentiation, and for the
development of the physical shapes of the body’s many part (morphogenesis)
• Isotretinoin is a Vitamin A related compound used for acne/psoriasis/ keratosis follicularis
• Toxic amounts
o May occur within few hours: irritability, drowsiness, vertigo, delirium, coma, vomiting, and/or
diarrhea may occur.
o In infants, excessive amounts of vitamin A can cause an increase in cranial pressure,
resulting in symptoms such as bulging fontanelles, headache, papilledema (presence of
edematous fluid, often including blood, in the optic disc), exophthalmos (bulging eyeballs),
and visual disturbances
o D/C INTAKE
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Vitamin D
Food Source
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Purpose Calcium and phosphorus balance; helps absorption of Ca; bone calcification
Deficiency S/S
Replacement/ Supplementation
Ergocalciferol (D2)
Cholecalciferol (D3)
Indications Pregnancy, Infant growth, Known deficiency, Malabsorption condition, increased demand; Ricketts,
Tetany, osteoporosis; hypocalcemia
Contraindication
s
Hypercalcemia, renal dysfunction, renal stones, hyperphosphatemia
Adverse Effects HTN, fatigue, weakness, dysrhythmias (think of hypercalcemia), N/V, constipation
Interactions absorption with laxatives, cholestyramine
• Ergocalciferol (D2)- exogenous form from plant based
o Fish like salmon, herring; fortified milk, breads, cereals; animal livers, tuna fish, eggs, butter
o Normal serum level: 12-50 ng/mL
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o Ergocalciferol (Drisdol):
▪ indicated for use in patients with GI, liver, or biliary disease associated with
malabsorption of vitamin D analogues
▪ PO: 50,000–200,000 units/week
▪ Can be IV
• Cholecalciferol (D3)- endogenous form from 7-dehydrocholesterol that is produced in skin from
UV light
o Calcitriol
▪ vitamin D analogue used for the management of hypocalcemia in patients with chronic
renal failure who are undergoing hemodialysis
▪ also used in the treatment of hypoparathyroidism and pseudohypoparathyroidism,
vitamin D–dependent rickets, hypophosphatemia, and hypocalcemia in premature
infants
▪ PO and IV 0.25–2 mcg/day
o Calcifediol
▪ 25-hydroxylated form of cholecalciferol
▪ vitamin D analogue used primarily for the management of hypocalcemia in patients
with chronic renal failure who are undergoing hemodialysis
▪ also used for signs of hyperparathyroidism disease
▪ PO: 30–60 mcg once daily
• Vitamin D in coordination with parathyroid hormone and calcitonin regulates serum calcium levels
by increasing calcium absorption from the small intestine and extracting calcium from the bone
• Ergocalciferol and cholecalciferol are inactive and require transformation into active metabolites for
biologic activity.
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• Both vitamin D2 and vitamin D3 are bio transformed in the liver by the actions of parathyroid
hormone
• The resulting compound, calcifediol, is transported to the kidney, where it is converted to calcitriol,
which is thought to be the most physiologically active form of vitamin D
• Promotes intestinal absorption of Ca and Ph and helps deposit them in bone and teeth structures
Vitamin E
Food Source Fish, egg yolks, meats, vegetable oils, nuts, fruits, wheat germ, grains, fortified cereals
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Purpose Powerful antioxidant
Deficiency S/S Typically, only in premature infants: irritability, edema, thrombosis, hemolytic anemia
Replacement/ Supplementation
Aquasol E (d-alpha tocopherol) PO: 60–75 units/day
Indications ? protect polyunsaturated fatty acids (a component of cellular membranes); also been shown to
hinder the deterioration of vitamin A and C; unproved theory that vitamin E has beneficial effects for
patients with cancer, heart disease, premenstrual syndrome, and sexual dysfunction
Contraindication
s
Allergy
Adverse Effects Fatigue, headache, nausea, flatulence, elevated BUN, weakness
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Vitamin K
Food Source Cheese, spinach, broccoli, Brussels sprouts, kale, cabbage, turnip greens, soybean oils... LEAFY
GREENS
Purpose Blood coagulation (which occurs in liver) for clotting factors II, VII, IX, and X
Deficiency S/S deficiency results in coagulation disorders caused by hypoprothrombinemia
Rare as intestinal flora can synthesize vitamin K
Replacement/ Supplementation
Phytonadione (Vitamin K1) PO: 1.25–10 mg single dose
IM/IV: 1–10 mg single dose
Indications Malabsorption and inadequate bile amounts; newborns receive prophylactically a vitamin K shot;
Warfarin reversal
Contraindication
s
Allergy; caution if clotting disorders
Adverse Effects Headache, brain damage (in large doses), nausea, rash, hemolytic anemia; potential for anaphylaxis
• 3 types of vitamin K
o phytonadione (vitamin K1), menaquinone (vitamin K2), and menadione (vitamin K3)
o K2 is synthesized by the intestinal flora, which provides an endogenous supply
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• Essential for effective blood clotting because it facilitates the hepatic biosynthesis of factors II, VII, IX, and X
• ****If vitamin K for warfarin reversal, the patient becomes unresponsive to warfarin for approximately 1 week
after vitamin K administration****
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Water-Soluble Vitamins
• Act primarily as coenzymes or oxidation-reduction agents in important metabolic
pathways. Unlike fat-soluble vitamins, water-soluble vitamins are not stored in the
body in appreciable amounts
• The vitamin B complex is a group of 10 vitamins that are often found together in food,
although they are chemically dissimilar and have different metabolic functions
• Vitamin C (ascorbic acid), the other principal water-soluble vitamin, is concentrated in
citrus fruits
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Vitamin B1 (Thiamine)
Food Source Yeast, liver, enriched whole-grain products, beans
Purpose Carbohydrate metabolism, works with ATP and Kreb’s cycle; maintains PNS, GI tract, cardiovascular
system
Deficiency S/S Results in Wernicke’s encephalopathy; Beriberi (brain lesions, polyneuropathy, etc.)
Often occurs from ETOH
Replacement/ Supplementation
Thiamine- 100 mg/day until normal dietary intake is established
Indications subacute necrotizing encephalomyelopathy, maple syrup urine disease, and lactic acidosis
associated with pyruvate carboxylase enzyme deficiency and hyper-beta-alaninemia; Wernicke’s,
Beriberi, pellagra (niacin deficiency), neuritis (nerve inflammation) in pregnancy; poor appetite, UC,
diarrhea
Contraindication
s
Allergy
Adverse Effects Restlessness, pulmonary edema, weakness, cyanosis, nausea
• Thiamine: precursor for the formation of thiamine pyrophosphate that eventually becomes ATP
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Vitamin B2 (Riboflavin)
Food Source Green, leafy vegetables; Eggs, dairy products; Nuts, legumes; Meats, liver; Yeast, enriched whole-
grain products
Purpose 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
Deficiency S/S cutaneous, oral, and corneal changes that include cheilosis
often caused by ETOH, liver dx, malignancy, Probenecid
Replacement/ Supplementation
Riboflavin- PO: 5–30 mg/day
Indications microcytic anemia; acne; migraine headache; congenital methemoglobinemia (presence in the blood
of an abnormal, nonfunctional hemoglobin pigment); muscle cramps; and Grierson-Gopalan
syndrome
Contraindication
s
Allergy
Adverse Effects Restlessness, pulmonary edema, weakness, cyanosis, nausea; yellow-orange urine
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Vitamin B3 (Niacin)
Food Source Liver, turkey, tuna, peanuts, beans, yeast, enriched whole-grain breads and cereals, wheat germ
Purpose Nicotinamide (metabolic product of Niacin) is useful form for metabolic reactions with carbs, proteins,
purine, lipid metabolism, tissue respiration; glycogenosis
Niacin has role in antilipemic drugs
Deficiency S/S Pellagra (s/s include various psychotic disorders; neurasthenic syndrome; crusting, erythema, and
desquamation of the skin; scaly dermatitis; inflammation of the oral, vaginal, and urethral mucosa,
including glossitis (inflamed tongue); and diarrhea or bloody diarrhea)
Replacement/ Supplementation
Niacin- PO: ER: 500–2000 mg/day
nicotinic acid- PO: Up to 500 mg/day
Indications Prevention of pellagra, deficiency, hyperlipidemia, PVD
Contraindication
s
Allergy, liver disease, severe hypotension, PUD, arterial hemorrhage
Adverse Effects flushing, pruritus, and GI distress; decreased glucose tolerance; N/V; headache, dysrhythmias
• Body can produce small amount of Niacin from tryptophan amino acid
Vitamin B6 (Pyridoxine)
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Food Source Organ meats, meats, poultry, fish, eggs, peanuts, whole grain products, vegetables, nuts, wheat
germ, bananas, fortified cereals
Purpose metabolic functions, such as protein, carbohydrate, and lipid use in the body; Essential for GABA
synthesis; important part in the conversion of the amino acid tryptophan to niacin (vitamin B3) and
the neurotransmitter serotonin; synthesis of Heme
Deficiency S/S sideroblastic anemia, neurologic disturbances, seborrheic dermatitis, cheilosis, and xanthurenic
aciduria (formation of xanthine crystals or “stones” in urine)
Convulsions; hypochromic microcytic anemia; glossitis; peripheral neuropathy
May occur in ETOH, cirrhosis, hyperthyroid, HF, TB with use of specific meds
Replacement/ Supplementation
Pyridoxine- PO/IV: 2.5–10 mg/day; PO/IV: 50–300 mg/day
Indications Deficient intake; replacement with use of certain meds like Isoniazid, hydralazine; seizures; morning
sickness (HMMMM....)
Contraindication
s
Allergy
Adverse Effects Neurotoxicity (goes away with med d/c); flushing, lethargy, headache, paresthesia’s
Interactions Reduces Levodopa activity
• Vitamin B6 (pyridoxine) is composed of three compounds: pyridoxine, pyridoxal, and
pyridoxamine
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o Pyridoxine, pyridoxal, and pyridoxamine are all converted in erythrocytes to the active
coenzyme forms of vitamin B6: pyridoxal phosphate and pyridoxamine phosphate
Vitamin B 12 (Cyanocobalamin)
Food Source Liver, kidney, shellfish, poultry, fish, eggs, milk, blue cheese, fortified cereals
Purpose required coenzyme for many metabolic pathways, including fat and carbohydrate metabolism and
protein synthesis. It is also required for growth, cell replication, hematopoiesis, and nucleoprotein
and myelin synthesis
Deficiency S/S GI lesions, neuro changes that may result in degenerative CNS lesions, megaloblastic anemia
Often caused by malabsorption, ETOH, chronic hemorrhage, chronic use of H2 blockers or PPIs
Replacement/ Supplementation
Cyanocobalamin- PO, IM/SUBQ:1000 mcg/month.
Nascobal- Intranasal gel: 500 mcg/week
Indications Deficiency; poor intake; gastric bypass, malabsorption; great for vegetarians; pernicious anemia
Contraindication
s
Allergy; sensitivity to cobalt element; hereditary optic nerve atrophy
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Adverse Effects Thrombosis, diarrhea, hypokalemia, pruritis, flushing, pulmonary edema
Interactions anticonvulsants, aminoglycoside antibiotics, or long-acting potassium preparations decreases the
oral absorption of vitamin B12
• The cells that have the greatest requirement for vitamin B12 are those that divide rapidly, such
as epithelial cells, bone marrow, and myeloid cells
• Cyanocobalamin is involved in maintaining sulfhydryl groups in the reduced form.
o deficiency can lead to neurologic damage that begins with an inability to produce myelin
and is followed by gradual degeneration of the axon and nerve head
• Best route for megaloblastic anemias is IM
• water-soluble B-complex vitamin required for maintenance of body fat and carbohydrate
metabolism and protein synthesis
• needed for growth, cell replication, blood cell production, and the integrity of normal nerve
function.
• available as OTC preparations and by prescription.
o Most of the over-the-counter cyanocobalamin-containing products are oral multivitamin
preparations, whereas many of the cyanocobalamin-only products contain large doses for
parenteral injection and are available by prescription only
o Other available dosage forms are an intranasal gel and a sublingual tablet
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Vitamin C (ascorbic acid)
Food Source Broccoli, green peppers, spinach, Brussels sprouts, citrus fruits, tomatoes, potatoes, strawberries,
cabbage, liver
Purpose required for several important metabolic activities, including collagen synthesis and the maintenance
of connective tissue; tissue repair; maintenance of bone, teeth, and capillaries; and folic acid
metabolism; erythropoiesis; enhances absorption of iron; required for synthesis of lipids, proteins,
steroids; aids in cellular respiration; can help prevent infections
Deficiency S/S Scurvy (weakness, edema, gingivitis and bleeding gums, loss of teeth, anemia, subcutaneous
hemorrhage, bone lesions, delayed healing of soft tissues and bones, and hardening of leg muscles)
Replacement/ Supplementation
Ascorbic Acid- PO/IV/IM/SUBQ: 100–250 mg 1 or 2 times daily
Indications Deficiency; pregnancy, lactation, hyperthyroidism, fever, stress, infection, trauma, burns, smoking,
and the use of certain drugs (e.g., estrogens, oral contraceptives, barbiturates, tetracyclines, and
salicylates)
Contraindication
s
Allergy
Adverse Effects None really unless excessive dose consumed; headache, N/V; increased urine acidity (as this is an
acid)
Interactions PCN G, erythromycin
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• Vitamin C is reversibly oxidized to dehydroascorbic acid and acts in oxidation-reduction
reactions
• Undocumented if vitamin C can help treat common cold
• Ascorbic acid is a water-soluble vitamin required for the prevention and treatment of scurvy.
• required for erythropoiesis and the synthesis of lipids, protein, and steroids
• available both in over-the-counter preparations, such as multivitamin products, and by
prescription
• Ascorbic acid is available in many oral dosage forms and an injectable form
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Minerals
• Essential inorganic compound
• Building block for many body structures and thus are necessary for a variety of physiologic
functions
• needed for intracellular and extracellular body fluid electrolytes
• necessary for muscle contraction and nerve transmission, and are required components of
essential enzymes
• Iron is essential to produce hemoglobin, which is required for the transport of oxygen throughout
the body
Calcium
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Food Source Dairy products, fortified cereals and calcium-fortified orange juice, sardines, salmon
Purpose involved in the proper development and maintenance of teeth and skeletal bones; important catalyst
and cofactor in many of the coagulation pathways in the blood; essential for the normal maintenance
and function of the nervous, muscular, and skeletal systems, and for cell membrane and capillary
permeability; Transmission of nerve impulses, Contraction of cardiac, smooth, and skeletal muscles,
Renal function, respiration, and blood coagulation
Deficiency S/S Hypocalcemia
Due to low intake, low vitamin D, high Phos, hypoparathyroid, rickets, osteoporosis
Replacement/ Supplementation
(see calcium table below- table 53.12)
Indications Adult osteomalacia, Hypoparathyroidism, Infantile rickets or tetany, Muscle cramps, Osteoporosis,
Renal insufficiency, Pregnancy and lactation, Renal failure(caution), Steatorrhea, Vitamin D
deficiency
Contraindication
s
Allergy
Adverse Effects Hypercalcemia- think of those s/s; rebound HTN, renal stones, metabolic alkalosis, hypokalemia,
N/V
Interactions Tetracycline ABX may cause Chelation; Digoxin may cause arrhythmias
• Most abundant mineral element in the body
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• Accounts for 2% of body weight
• Highest concentration in bones and teeth
• Efficient absorption requires adequate amounts of vitamin D
• Calcium is available in both oral and parenteral forms.
• Consult manufacturer instructions for recommended dosages.
• The pharmacokinetics of calcium is highly variable and depends on individual patient
physiology and the characteristics of the specific drug product used.
• Medication errors and confusion are common with calcium products, because the amount
of the salt is not the same as the amount of elemental calcium.
• For example, calcium carbonate 1250 mg is equal to 500 mg of elemental calcium.
Depending on the institution, the drug may be profiled as 1250 mg, but the tablet is
labeled as 500 mg.
• Additional confusion occurs with the injectable forms, calcium chloride and calcium
gluconate.
• Calcium chloride provides about three times as much elemental calcium as calcium
gluconate, but they are both ordered as 1 g or 1 ampule. Calcium chloride can cause
severe problems if it infiltrates from the intravenous line.
• For that reason, it is recommended that it be diluted or given through a central
line if it is given by intravenous push.
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• Adding to the confusion is calcium acetate (PhosLo), which is used not for
calcium replacement but to bind phosphate in renal patients
Magnesium
Food Source Meats, seafood, milk, cheese, yogurt, green leafy vegetables, bran cereal, nuts
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Purpose Essential for enzyme systems associated with energy metabolism Required for Nerve physiology,
Muscle contraction
Deficiency S/S Hypomagnesemia
May be due to: Malabsorption, Alcoholism, Long-term intravenous feedings, Diuretics and PPIs,
Metabolic disorders (hyperthyroidism, diabetic ketoacidosis)
Replacement/ Supplementation
Magnesium sulfate
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
Contraindication
s
Allergy; renal failure, heart block, Addison disease, hepatitis
Adverse Effects Hypermagnesemia; Tendon reflex loss; Difficult bowel movements; CNS depression; Respiratory
distress; Heart block; Hypothermia
Interactions CNS depressants
• Required in higher amounts for those with diets high in protein-rich foods, calcium, and
phosphorus
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• Magnesium is a mineral that has a variety of dosage forms and uses
• essential part of many enzyme systems.
• Magnesium sulfate is the most common form of magnesium used as a mineral replacement. It is
available in both oral and injectable forms.
Phosphorus
Food Source Milk, yogurt, cheese, peas, meat, fish, eggs
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Purpose Required for ATP; cellular energy transfer; development and maintenance of the skeletal system and
teeth
Deficiency S/S May be due to malabsorption, extensive diarrhea or vomiting, hyperthyroidism, hepatic disease, and
long-term use of aluminum or calcium antacids
Replacement/ Supplementation
Indications Deficiency
Contraindication
s
Allergy; hyperphosphatemia, hypocalcemia; renal impairment
Adverse Effects N/V; confusion, weakness; respiratory distress
Interactions Antacids reduce absorption
• Zinc
o Trace element
o Essential in metabolic reactions of proteins and carbohydrates
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o Important for normal tissue growth and repair, especially wound repair
o Found in:
o Red meats, liver, oysters, milk products, eggs, beans, nuts, whole grains, fortified cereals,
certain seafoods
Nursing Implications
• Follow specific guidelines for administration, especially if parenteral
• Provide nutritional counseling about necessary foods to include in the diet
• Monitor for therapeutic responses
• Monitor for adverse effects
Key points (from pharm book)
• OTC use of vitamins and minerals may lead to serious problems and adverse effects and
requires careful consideration before self-medication. A prescriber may be consulted before use
if there are any questions or concerns.
• Incorporate the nutritional status of the patient into the nursing care plan to provide
comprehensive care during vitamin or mineral therapy.
• Provide information about dietary needs and the body’s need for vitamins and minerals as part
of the patient’s health promotion.
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• Focus patient education related to vitamin and mineral replacement on dietary sources of the
specific nutrient, drug, and food interactions and adverse effects. Instruct the patient on when it
is necessary to contact the prescriber.
• Vitamins and minerals can be dangerous to the patient if given without concern or caution for the
patient’s overall condition and underlying disease processes.
• Never assume that because the drug is a vitamin or a mineral it does not have adverse reactions
or toxicity.
Nutritional Supplements
• Nutrients: dietary products that undergo chemical changes when ingested (and metabolized)
that cause tissue to be enhanced and energy to be liberated
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o Required for cell growth and division; enzyme activity; synthesis of carbs, fats, proteins
o Secrete hormones, wound healing, immune, gut integrity, ETC.
• Nutritional support may be required
• Malnutrition: The body’s nutritional needs are not met by nutrient intake.
• Enteral nutrition: administration of food or nutrients through the gastrointestinal (GI) tract
• Parenteral nutrition: administration of nutrients directly into the circulation by means of an
intravenous (IV) solution