Lecture 13
Chapter 12
Vitamin and Mineral
Replacement
Vitamins
• Organic chemicals necessary for normal metabolic
functions, tissue growth & healing
• Body needs only a small amt. of vitamins daily easily
obtained through a well-balanced diet
• Vitamin supplements not necessary if a well-balanced
diet consumed • Vitamin deficiencies can cause cellular and organ
dysfunction - may result in slow recovery from illness
• Most people use vitamins for inappropriate reasons:
relieve tiredness, improve general overall health, or
prophylactic use
Vitamins
• Fat-Soluble Vitamins - A,D,E,K - they are metabolized
slowly, can be stored in fatty tissue, liver, & muscle - excreted in
the urine at a slow rate - Can build up in the body & become
toxic
- Vit. A - maintenance of epithelial tissues, skin, eyes, hair &
bone growth; s/s of dec. in A night blindness  dryness of
eyes and ulceration o the cornea  blindness
- Use - skin disorders (acne); excess doses  toxic - s/s loss of
hair & peeling; excess stored in the liver for up to 2 yrs.
- Sources: Beta carotene  carrots, spinach, tomatoes, &
pumpkin; Retinol (pre-formed A) only in foods of animal origin
 eggs, whole milk, butter & liver
Vitamins
Vit. D – assists in regulating calcium & phosphorus metabolism,
needed for Ca absorption from intestines -Excess vit. D results
in hypervitaminosis D and may cause hypercalcemia  elevated
CA+ level; early s/s D toxicity = anorexia, nausea, & vomiting
- Sources: milk, cereals & sunlight
-Vit. E - antioxidant properties protecting cellular components
from being oxidized & RBC’s from hemolysis - Lg. doses may
prolong prothrombin time
-Sources: fresh greens, veggies, seeds oils & wheat germ
--400-800 IU /day dec. the number of non-fatal heart attack. E
protects the heart & arteries  block free radicals; s/s toxicity =
fatigue, weakness, nausea, GI upset, HA,
Vitamins
- Vit. K - 4 forms – Vit. K 2 not commercially available stored primarily in the liver
- needed for synthesis of prothrombin & the clotting factors
VII, IX, & X
• Water-Soluble Vitamins – C & B complex - Not stored by
the body & readily excreted in the urine; not usually toxic
unless taken in extreme amts.
- Vit. C ( ascorbic acid) - aids in absorption of Fe & in the
conversion of folic acid
* Does not cure or prevent the common cold
* Excess doses of C  diarrhea & GI upset
Vitamins
* Absorbed thru GI tract, kidneys completely excrete
mostly unchanged.
*
Collagen syntheses requires vit.C for tissue repair
* Decrease effect of oral anticoagulants, smoking
decreases vit C level; megadoses of vit C taken with
ASA or sulfonamides  crystal formation in the urine.
* Found in citrus gruits & green veggies
Vitamins
-Vit. B complex - B1 (thiamine), B2 (riboflavin),
B3 (niacin), B6 (pyridoxine)
• Uses: improve nerve conduction d/t damage
from ETOH  (Thiamine); manage
dermatologic problems (dermatitis, cracked
sides of mouth)  (riboflavin); dec. chol.
(niacin); neuritis caused by INH tx for TB;
H2O soluble
• Large doses cause GI irritation & vasodilation,
resulting in a flushing sensation.
Vitamins
•Vitamin B12 - Essential for DNA synthesis ( like
folic acid), aids in conversion of folic acid to active
form
- needed in development of RBC’s & maintain
nervous system integrity
- B12 deficiency found in strict vegetarians (don’t
consume meat, fish, or dairy), crohn’s disease,
malabsorption syndromes  s/s numbness &
tingling in lower extremities, weakness, fatigue,
anorexia, loss of taste, diarrhea to note a few
Vitamins
•Folic Acid (folate) - absorbed from sm. intestine, active
form of folate circulated to all tissues; stored in liver &
tissues.
- essential for body growth
- needed for DNA syntheses, lack  disruption cell
division
- deficiency during 1st trimester of preg. = affects level.
of CNS in fetus  neural tubal deficets (spina bifida or
anencephaly)
- s/s deficiency  anorexia, nausea, stomatitis, diarrhea,
anemia, leukopenia,
-Sources: Added to grains, pasta, rice, grits, flours.
Minerals
•Iron (ferrous sulfate, gluconate, or funarate)
vital for Hemoglobin regeneration, 1 cause of anemia is iron
deficiency.
- Sources: liver, lean meats, egg yolks, dried beans, green
veggies & fruit
• Copper – needed for formation of RBC”S & connective
tissue, also imp. in the production of NE & dopamine
• Zinc – may alleviate common cold
• Chromium – may help to normalize blood glucose by
inc the effects of insulin on cells
• Selenium – antioxidant works with vit. E , may dec. risk
of lung, prostate, & colorectal CA
Vitamins
• Hyperalimentation - Total Parenteral Nutrition (TPN)
- Administered through a central line (delivers nutrient
into the superior vena cava  empties into the R atrium
of the heart)
- Used to ‘feed’ clients when unable to tolerate PO
nutrition or GI system needs a ‘rest’
- Most important ingredients = dextrose (10%), amino
acids
- May also include electrolytes, vitamins and minerals
depending on clients lab values. Ordered daily per the
MD
Chapter 45
Endocrine System
Endocrine Pharmacology
Endocrine System
* Hormones = chemical substances synthesized from
amino acids & cholesterol that act on body tissues &
organs and affect cell activity.
2 categories:
•Proteins or small peptides
•Steroids – hormones from the adrenal glands &
gonads are steroids all others are PRO.
Endocrine System
* Endocrine glands include:
pituitary or (hypophysis), thyroid,
parathyroid, adrenal, gonads, and
pancreas
*
Hypothalamus & Pituitary are
closely related both anatomically
and functionally, together they help
regulate all bodily processes by
using at least 15 hormones; both
lobes of pituitary are under control
of the hypothalamus, the
hypothalamus communicates w/ ant.
pit by release-reg factors  portal
blood vessels; comm w/post. pit. is
neuronal
Endocrine System
• Pituitary Gland - Located at base of brain, 2 lobes
- Anterior (adenohypophysis) - master gland - secretes hormones
that stimulate the release of other hormones
- Posterior (neurohypophysis) - secretes antidiuretic hormone
(ADH, vasopressin) & oxytocin
* Anterior Pituitary Gland secretes 6 various hormones targeting
glands & tissues – controlled by hypothalamus
1) growth hormone (GH) - stimulates growth of tissue/bone
2) thyroid-stimulating hormone (TSH) - acts on thyroid gland to
promote synthesis and release of thyroid hormones.
3) adrenocorticotropic hormone (ACTH) - stimulates adrenal
cortex to release adrenocortical hormones
Endocrine System
4) follicle-stimulating hormone acts on ovary to promote follicular
growth & development; In testes, FSH promotes spermatogenesis.
5) luteinizing hormone (LH) – promotes ovulation in women, in men
acts on the testes to promote androgen production
6) prolactin – stimulates milk production
*** Growth hormone (GH) - Somatrem (Protropin) &
somatropin (Humatrope) - If GH deficiency diagnosed and
dwarfism can result - these drugs may be used. Very expensive
therapy
* Posterior Pituitary Gland – secretes 2 hormones 1) antidiuretic
hormone (ADH, vasopressin) & 2) oxytocin (ch. 47)
- ADH promotes H2O rebsorption from the renal tubules to maintain
H2O balance – Dec. ADH lg. amts. H2O excreted called diabetes
insipidus (DI)  fluid vol. dec & electrolyte imbalance
Endocrine System
• Thyroid Gland - Located anterior to the trachea, has 2 lobes
(butterfly like), secretes 2 hormones: Thyroxine (T4), &
triiodothyronine (T3) – thyroid hormones have 3 actions:
• 1) stimulation of energy use inc. basal metabolism rate;
• 2) stimulation of the heartleads to inc rate & force of contraction
 inc cardiac output;
• 3) promotion of growth and development(brain & skeletal muscle).Can be either a thyroid deficiency (hypothyroidism), or an
overabundance (Hyperthyroidism)
* Hypothyroidism – a dec. in thyroid hormone secretion;
-primary cause is thyroid gland disorder or secondary cause is lack
of TSH secretion = slow metabolic rate - s/s (lethargic, weak, edema,
slow pulse, constipation, wt. gain, emotional changes)
- Drugs containing T4 & T3 are used to treat this
Endocrine System
• Levothyroxine sodium (Levothroid, Synthroid) - drug of
choice for replacement therapy, Used to treat simple goiter &
chronic lymphocytic thyroiditis
- Action – inc. T3 & T 4, inc. metabolic rate, inc. cardiac output,
PRO synthesis, glycogen usage, O2 consumption, & body
growth
- SE - N & V, diarrhea, cramps, nervousness
- DI - Many – increase effects of oral anticoagulants, with
adrenergic agents (decongestant or vasopressor) cardiac & CNS
effects increase.
• Liothyronine (Cytomel) – a synthetic T3 not for maintenance
but for initial tx. of Myxedema, because of it’s rapid onset of
action
Endocrine System
* Hyperthyroidism - inc. circulating T3 & T4 from
overactive thyroid gland - s/s rapid metabolic rate (Inc. HR,
palpitations, nervousness) - symptoms mild to severe
(Thyroid storm can cause death from vascular collapse).
--Graves disease or thyrotoxicosis most common due to Inc.
function of thyroid
-Rx = surgical removal of part of gland, radioactive iodine
therapy or antithyroid drugs
- s/s – rapid pulse, palpitations, excessive perspiration, heat
intolerance, nervousness, irritability, bulging eyes, and
weight loss
Endocrine
•Purpose of Pharm tx: reduction of thyroid hormones T3 & T4
by inhibiting thyroid secretion
•Propylthiouracid (PTU), & methylthiouracil (Tapazole) are
affective thiomide antithyroid drugs
- Use – hyperthyroidism (thyrotoxic crisis) and in prep for
subtotal thyroidectomy
- Action - Blocks synthesis of T3 & T4 - does not destroy, but
prevents oxidation of iodide
Usually takes a period of a few days to 3 wks before symptoms
improve
*Ask MD about using iodized salt & eating shellfish - contain
iodine and may alter the effectiveness of drug
Endocrine System
• Adrenal Glands - located at the top of each kidney &
composed of 2 sections: adrenal medulla (inner section) &
adrenal corex (surrounds the adrenal medulla)
- adrenal medulla releases epi. & norepi. & is linked to the
sympathetic nervous system
- adrenal cortex  2 major types of hormones called
(corticosteroids) 1) glucocorticoids & 2) mineralocorticoids
- main glucocorticoid = cortisol
- main mineralocorticoid = aldosterone
Endocrine System
• Corticosteroids promote Na retention & K excretion. A
Na ion is reabsorbed from the renal tubules in exchange for
a K ion; K ion then excreted.
- Influences electrolytes, carbohydrates, protein & fat
metabolism - deficiency  serious illness or death
- in corticosteroid secretion = Addison’s disease
- in cotricosteroid secretion = Cushing’s Syndrome
Endocrine System
• Glucocorticoids - influenced by ACTH, released from the
ant. pituitary gland. Affect carbohydrate, protein, & fat
metabolism
- can cause Na absorption from the kidney = H2O retention,
K loss & inc. BP
- Cortisol - main glucocorticoid = antiinflammatory,
antiallergic & antistress effects
- Indications for therapy = trauma, surgery, infections,
emotional upsets, anxiety
- Most of the wide variety of glucocorticoid drugs called
cortisone drugs - synthetic
Endocrine System
- Cortisone drugs can be given orally, parenteral (IM, IV),
topical (creams, ointments), aerosol (inhaler)
- Uses - inflammatory conditions (MS, rheumatoid arthritis,
MG, ulcerative colitis), shock, head trauma, asthma,
contact dermatitis, anaphylaxis, debilitating conditions
(malignancies), organ transplant recipients
- Many glucocorticoids - some more potent than others
- SE - TONS!! - fluid retention, muscle weakness, CV
problems, hard on GI system , headache, inc. ICP, masks
signs of infection, susceptibility to infection
Endocrine System
• Dexamethasone (Decadron) - PO, IV, IM
Action - Not clearly defined. Decreases inflammation,
suppresses immune response, stimulates bone marrow
Use - Cerebral edema, inflammatory conditions, allergic
rxns, neoplasias
SE - Can effect all systems
* Do not D/C drug abruptly - rebound inflammation poss.
Teach - take w/ food or milk, S&S of early adrenal
insufficiency (fatigue, weakness, joint pain), warn about
long term therapy cushing symptoms (moon face)
Endocrine System
• Prednisone (Deltasone, Orasone) - PO
Action - Suppression of inflammation & adrenal function
Use – Dec. severe inflammation, immunosuppression, dermatologic
disorders
SE – N, V, diarrhea, inc. appetite, sweating, depression, mood
changes, HA, flushing
Teaching - do not d/c abruptly - Best to start medication at lowest
effective dose
CI – psychosis, fungal infection, Caution w/ diabetes
• Hydrocortisone (Cortef) - PO, IV, IM, enema
Action - Decreases inflammation
Use - Inflammation, adrenal insufficiency, ulcerative colitis
Endocrine System
• Glucocorticoid Inhibitors - Ketoconazole (Nizoral) - an
antifungal drug, aminoglutethimide (Cytadren) - an
antineoplastic hormone antagonist
- inhibit glucocorticoid synthesis
- Nizoral - Rx Cushing’s syndrome & adjunct to surgery or
radiation
- high doses can cause fatal vent. dysrhythmias
- Cytadren – temporary RX of selected clients w/ Cushing’s
syndrome, esp. clients w/ adrenal adenoma, carcinoma,
adrenal hyperplasia
Endocrine System
• Mineralocorticoids - secrete aldosterone
- maintains fluid balance by promoting reabsorption of Na
from the renal tubules
- Na attracts H2O = H2O retention
- hypovolemia ( in circulating fluid)  more aldosterone
secreted to Na and H2O retention  restore fluid balance
- W/ Na reabsorption = K lost hypokalemia
- severe in aldosterone  hypotension & vascular
collapse - Addison’s disease
Endocrine System
• Fludrocortisone (Florinef) - an oral mineralocorticoid
given w/ a glucocorticoid
Action - Increases Na+ reabsorption & K+ secretion
Use - Addison’s disease (adrenocortical insufficiency)
SE - hypertension, Na+ & H2O retention
Alert - monitor clients BP & electrolytes ( esp. K+)
* Can cause a neg. nitrogen balance - a high-protein diet
indicated
Chapter 43
Disorders of the Eye
Eye Disorders
• Diagnostic Aids – Used to locate leisions or foreign objects & to
provide anesthesia. Fluorescein sodium – a dye turns scratches green
& circle foreign objects in green.
• Topical Anesthetics - used for exams & removal foreign objects proparacaine HCL (Ophthaine, Ophthetic), tetracaine HCL
(Pontocaine) - anesthesia in 1min. lasts about 15 min. blink reflex
temporarily lost - patch the eye
• Antiinfectives - frequently used for eye infections
- Conjunctivitis (inflammation of the membrane covering the eyeball
& lining the eyelid) -SE local skin/eye irritation, allergy to med.
• Lubricants - Used for ‘dryness of the eyes’ - artificial tears,
contact lens wearers, CNS disorders that result in unconsciousness
or dec. blinking - most are OTC
Eye Disorders
Glaucoma – characterized by
visual field loss 2nd ary to optic
nerve damage, due to increase
intraocular pressure, caused by
an increase in production of
aqueous humor this circulates
around the iris and then in the
anterior chamber, it exits to the
trabecular mesh work and the
canal of Schlemm. If outflow
is impeded, back pressure will
develop and the IOP will rise.
2 types: 1) Primary Open
Angle Glaucoma
2) Acult Angle Closure
Eye Disorders
• Pharm tx reduces IOP by 1) facilitating aqueous humor
outflow or 2) reducing aqueous humor production
• Miotics - used in open-angle glaucoma to lower the
intraocular pressure & increasing aqueous outflow 
decrease retinal damage & loss of vision.
- Direct-acting cholinergics & cholinesterase inhibitors = 2
types of miotics
- cause a contraction of the ciliary muscle & widening of
trabecular meshwork
- Systemic absorption poss. but not common
Eye Disorders
*Pilocarpine (Isopto Carpine, Pilocar)
- Action - produces miosis (contracts pupil) which widens
angle, allows outflow of aqueous humor & dec. intraocular
pressure; Onset = 10-30 min; duration 4-8 hrs
- SE - headache, eye pain, decreased vision. Systemic
absorption: N & V, frequent urination, inc. salivation
--Ocusert is a disk with time release pilocarpine, replaced q 7 d.
-CI = retinal detachment, adhesions, infection(eye), Many illness
caution: asthma, HTN, CVD, UT obstruction, GI obstruction
Eye Disorders
• Beta Adrenergic Blocking Agents – Timolol
maleate (timoptic), Carteolo (cartrol), betaxolo
(betoptic)
- 1st line drugs for glaucoma; these cause less disturbance of
vision the pilocarpine. Basic pharm discussed previously
- Action – dec IOP in glaucoma by dec production of aqueous
humor  increase outflow
- Used in initial tx & maintenance – eye drops
- SE = locally stinging, conjunctivitis blurred vision, dry
eyes; can be absorbed systemically  effect on heart & lung
These effects are the greatest concern. Can produce AV block,
bronchospasm . CI in heart failure.
Eye Disorders
•Carbonic Anhydrase Inhibitors - interfere w/
production of carbonic acid  dec. aqueous humor
formation & dec. IOP
- used for long term Rx of open-angle glaucoma
- used only when other agents not effective
- drugs developed as diuretics
* Acetazolamide (Diamox) - PO
SE - lethargy, anorexia, drowsiness, polyuria, hypokalemia
- clients frequently d/c from side effects
- do not use w/ clients allergic to sulfonamides
- can cause photosensitivity
Eye Disorders
• Osmotics - generally used pre-op and post-op to dec.
vitreous humor volume  dec. IOP
- Use - in the emergency Rx of acute closed-angle
glaucoma d/t ability to rapidly reduce IOP
* Mannitol (Osmitrol) - IV
- SE - headache, nausea, N & V, diarrhea, electrolyte dist.
- also used to dec. ICP in head trauma
• Anticholinergic Mydriatics & Cycloplegics - Mydriatics = dilate the pupils
Eye Disorders
- cycloplegics - paralyze the muscles of accommodation
- both are used in diagnostic procedures & ophthalmic
surgery
- relax the ciliary & dilator muscles of the iris by blocking
acetylcholine
* Atropine sulfate (Atropisol) - cycloplegic
SE - tachycardia, photophobia, dryness of the mouth
s/s toxicity = dry mouth, blurred vision, photophobia,
constipation tachycardia, confusion hallucinations
• Beta-Adrenergic Blockers - used to dec. elevated IOP in
chronic open-angle glaucoma. Dec. aqueous production
and inc. outflow
Eye Disorders
* Other Ophthalmic Products:
- Antifungal - Natamycin (Natacyn) - (Sol’n)
- Antiviral - Vidarabine (Vira-A) - (Oint) inhibits
viral replication
- Corticosteroids - Dexamethasone (Maxitrol) (Oint.) dec. inflammatory/redness - corneal
abrasions
- Antibiotics - Tobramycin (Tobrex) - (Oint. or
Sol’n) inhibits or kills organisms causing infection
- eye infections, corneal abrasions