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

VitaminsVit. 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 heartleads 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

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

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

- 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

•Carbonic Anhydrase Inhibitors - interfere w/ production of carbonic acid dec. aqueous humor formation & dec. IOP

- used for long term Rx of open-angle glaucoma

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