Copyright  2002 Delmar Learning, a division of Thomson Learning, Inc., ALL RIGHTS RESERVED
Josh Claassen
Background scenario
Josh, a 17-year old boy, is brought to the clinic by his mother. He is complaining of
nausea and fatigue and has not felt well for more than a week. His 14-year old sister is
in the waiting room.
Interview
Josh’s Mother:
"I thought he might have a mild case of the flu, but it has not gone away and I am
worried."
Josh:
"I have been trying to study a lot and I think it’s getting to me. I need a vacation."
Josh’s Sister, Buzzy:
"Mom, Josh didn’t tell you, but he bought this big bottle of vitamin A off the web. He said
it wouldn’t hurt him and it would help his Acne because it was just like Accutane only
less expensive."
Examination
Vital signs:
Temperature: 98.7° F
Pulse: 100
Respiration: 18
Blood pressure: 115/78
Observation:
Respirations are regular.
Skin is very dry.
Lips are chapped.
Client’s face is flushed.
Client has moderate acne infection on his forehead, cheeks, and shoulders.
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Blood work:
Elevated blood cholesterol:
240 mg/dL
(normal: <180 mg/dL)
Triglyceride levels:
200 mg/dL
(normal: 40 to 160 ,g/dL).
Additional information as time passes
Josh’s mother runs home and brings in his shoebox full of supplements. You determine
that Josh has been taking a total of 25,000 IU of vitamin A per day for the past four
months to relieve some of the symptoms of severe acne. You research the signs and
symptoms of vitamin A toxicity. She also mentions that he had previously taken
Accutane for his acne problems. You research Accutane. The physician diagnoses Josh
as having an excessive accumulation of vitamin A (hypervitaminosis A).
Background
Vitamin A is needed for healthy skin, eyes, and mucous membranes. It is used by the
body in bone and tooth development, embryonic growth, and proper cell functioning.
Vitamin A bolsters the body’s immune system. The recommended daily allowance
(RDA) of vitamin A is approximately 3000 international units (IU) a day for men and 700
µ, or 2300 IU, for women. The upper safe limit is 10,000 IU a day for adults.
Vitamin A is found in animal products, whole milk, fish and fish oil, and fortified food
products such as cereals. Low-fat and fat-free milk is often fortified with vitamin A. The
vitamin is often included in multivitamin compounds.
Vitamin A, which is fat soluble, is hazardous in excess, since the body cannot easily
eliminate it, resulting in excessive accumulation in the liver. Taking a vitamin A
supplement increases the risk of vitamin A toxicity. Signs of vitamin A toxicity include
nausea; vomiting; vision dificulties; headaches; dry, scaly skin; bone pain; and fatigue.
Treatment
Treatment for vitamin A toxicity includes assessing the client to determine the sources
or factors contributing to the overdose and discontinuing ingesting the vitamin until
symptoms subside. Client education on proper vitamin dosages, counseling on the
effects of overuse of vitamins, and follow-up care to ensure that the symptoms of
toxicity have abated are important. Community health nurses need to assess for friends
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or family who might also be using excessive vitamin A following a similar belief system
or diet regimen.
Accutane
Accutane (isotretinoin) is a form of vitamin A and is prescribed for severe acne when
other medications have not been successful. Vitamin A supplements are not to be taken
in addition to the medication, as the combination creates an excess vitamin A intake.
Accutane has common side effects, including chapped lips, dry skin, itching, and
dryness of the nose. Less common side effects include rash, gastrointestinal distress,
headache, depression, and urinary symptoms. Accutane can cause birth defects,
miscarriage, or premature birth and should not be taken by women who are pregnant.
Accutane may increase the lipid levels in the blood, and these should be monitored
while the client is taking the drug.
Additional information
Ingestion of too much vitamin A secondary to knowledge deficit
Nursing diagnoses:
00126
00037
00093
00118
00120
Deficient knowledge (vitamin A toxicity)
Risk for poisoning
Fatigue
Disturbed body image
Situational self esteem
Quiz
1. Josh Classen presents with excessive accumulation of vitamin A (hypervitaminosis
A). what is the appropriate nursing diagnosis for this case?
a. Mononucleosis
b. Deficient knowledge (vitamin A toxicity)
c. Hypervitaminosis
d. Liver disease
2. Vitamins are not made in our bodies, so they must come from our diet. Supplements
enable us to get the vitamins and minerals that we may be missing from food. The
quantity of nutrient that is needed regularly is expresed as RDA. What do the letters
RDA stand for?
a. Recommended dietary allowance.
b. Researched daily acquirement.
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c. Recombinant dietary allowance.
d. Recommended daily allowance.
3. Acne is a common problem among adolescents. Severe acne is often treated with
this drug when other approaches have failed:
a. Antibiotics
b. Hydrochlorothiazide
c. Accutane
d. Boric acid
4. Vitamin A is hazardous when taken in excess. Which statement explains why taking
vitamin A supplements could lead to vitamin A toxicity?
a. It is fat soluble and builds up in the system.
b. It is water soluble and builds up in the system.
c. It is not stored by the body.
d. It reacts with red blood cells to form toxic byproducts
5. A 16-year old female has been diagnosed with hypervitaminosis A. Hypervitaminosis
A is defined as:
a. A condition caused by combining Accutane and vitamin A
b. A condition caused by an overdose of vitamin C
c. A condition caused by excessive vitamin A intake
d. A condition usually caused by water-soluble vitamins
6. Taking a vitamin A supplement increases the risk of vitamin A toxicity, which may
lead to a variety of symptoms. An overdose of vitamin A over time can result in:
a. Restlessness
b. Nausea
c. Fever
d. Dehydration
7. Accutane (isotretinoin) is a form of vitamin A and is often the last medication
prescribed for severe acne when other medications have failed. Which of the following
is not an adverse reaction likely to be caused by the acne treatment?
a. Skin itching and dryness of the nose
b. Increased blood cholesterol, lipid, and tgriglyceride levels
c. Muscle aches
d. Oily skin
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8. Vitamin A supplements are not to be taken when isotretinoin is prescribed to prevent
excessive intake of the vitamin. What other precaution should be taken when using
isotretinoin?
a. Isotretinoin can only be applied once a day to prevent skin sensitivity.
b. Isotretinoin use must be monitored with periodic examinations.
c. Isotretinoin should not be used by asthmatic clients.
d. Isotretinoin should not be prescribed to clients under 16 years of age.
9. Vitamin A bolsters the body’s immune system and is essential for cell functioning,
growth, and development. Yet excessive ingestion of vitamin A can be very harmful and
can:
a. Cause muscle damage
b. Result in excessive accumulation in the liver
c. Cause/contribute to skin cancer
d. Lead to eczema
10. The client diagnosed with vitamin A toxicity is educated on proper vitamin dosages
and counseled on the effects of overuse of vitamins. Treatment for high doses of
vitamin A will include:
a. Tapering the dose of the vitamin downward over 30-60 days
b. Discontinuing ingesting the vitamin until symptoms subside
c. Increasing fluid intake to help flush out the vitamin
d. Epinephrine
Copyright  2002 Delmar Learning, a division of Thomson Learning, Inc., ALL RIGHTS RESERVED
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