Nutritional Support Products, Vitamins, and Mineral Supplements

Vitamins

• Required for normal body metabolism growth and development

• Components of enzyme systems that release energy from ingested carbohydrates, proteins, and fats

• Required for formation of RBCs, nerve cells, hormones, genetic material, bone and other tissues

Fat-Soluble Vitamins

• Vitamins A, D, E and K are stored in the body when taken in excess

• Absorbed from the intestines with dietary fat. Absorption requires the presence f bile salts and pancreatic lipase

Water-Soluble Vitamins

• b complex and Vit. C

• Are not stored in the body

• Rapidly eliminated

Who Needs Supplemental Vitamins?

• Pregnant

• Smokers

• ETOH

• Older adults

• Immunocompromised

• Malabsorption syndromes

Vitamin A

• Retinol

  • liver, milk, butter, cheese, cream, egg yolk, fortified milk, margarine, ready-to-eat cereals

• Beta-carotene

• Sources - spinach, collard greens, kale, mango, broccoli, carrots, peaches, pumpkin, red peppers, sweet potatoes, winter squash, watermelon, apricots, and cantaloupe

• Headaches; diarrhea; nausea; loss of appetite; dry, itching skin; elevated blood calcium, hair loss, liver damage

• not take a supplementary vitamin product that contains more than recommended amounts of vitamin A

  • Males 900 mcg; females 700 mcg

• Excessive doses of vitamin A during pregnancy may cause birth defects

Vitamin E

• Vegetable oils, margarine, salad dressing, other foods made with vegetable oil, nuts, seeds, wheat germ, dark green vegetables, whole grains, and fortified cereals

• not take a supplementary vitamin product that contains more than the recommended amounts of vitamin E

  • Adult <1000 mg

• Overdose

  • Risk of bleeding; decrease platelet aggregation; fatigue, headache, blurred vision

Vitamin K

• Spinach, Brussel sprouts, broccoli, cabbage, cauliflower, Swiss chard, lettuce, collard greens, carrots, green beans, asparagus, & eggs

• Avoid excessive doses of vitamin K

• Take only as directed by a health care provider

• Keep intake of vitamin K-containing foods constant.

• if taking warfarin, report any use of vitamin K to your provider.

Vitamin B1

Thiamine (Vitamin B1) - whole grain and enriched breads and cereals, liver, nuts, wheat germ, pork, and dried peas and beans

Vitamin B3

• Niacin- all protein foods and whole grain and enriched breads and cereals

• Facial flushing – 325 mg ASA po 30-60 minutes prior

• Take oral niacin preparations, except for timed-release forms, with or after meals or at bedtime to decrease stomach irritation.

• After taking a dose of oral niacin, sit or lie down for approximately 30 minutes. Niacin causes blood vessels to dilate and may cause facial flushing, dizziness, and falls. Facial flushing can be decreased by taking aspirin 325 mg orally, 30 to 60 minutes before a dose of niacin (if aspirin is not contraindicated). Itching, tingling, and headache may occur. These effects usually subside with continued use of niacin.

Vitamin B6

Pyridoxine - meats, fish, poultry, fruits, green leafy vegetables, whole grains, and dried peas and bean

Vitamin B12 (cyanocobalamin), Folic Acid

• B 12 - meat, fish, poultry, shellfish, milk, dairy products, eggs, and some fortified foods

• Folic acid - liver, okra, spinach, asparagus, dried peas and beans, seeds, and orange juice; breads, cereals, and other grains are fortified

• Pernicious anemia - vitamin B12 injections for life; any chronic vitamin B12 deficiency requires lifelong treatment

• you are pregnant or breast-feeding, requirements may be greater; you usually may need additional vitamin supplements.

• Keep follow-up appointments and obtain necessary lab tests

Vitamin C

• Citrus fruits and juices, red and green peppers, broccoli, cauliflower, Brussel sprouts, cantaloupe, kiwi fruit, mustard greens, strawberries, and tomatoes

• Vitamin C improves the absorption of iron

• Acidifies the urine, may alter the excretion of some drugs

Minerals and Electrolytes

• Essential constituents of bone, teeth, cell membranes, connective tissues and many essential enzymes

• Maintain fluid, electrolyte and acid-base balance

• Maintain osmotic pressure, nerve and muscle function; assist in diffusion

• Influence growth process

Patient Teaching for Minerals

• a well-balanced diet contains all the minerals needed for health in most people. Exceptions are iron and calcium, which are often needed as a dietary supplement in women and children. Note - herbal preparations of chamomile, feverfew, and St. John’s wort may inhibit iron absorption. The safest action is to take mineral supplements only on a health care provider’s advice, in the amounts and for length of time prescribed. All minerals are toxic when taken in excess.

• Minerals are often contained in multivitamin preparations, with percentages of the recommended dietary allowances supplied. These amounts differ in various preparations and should be included in estimations of daily intake

• Keep all mineral or electrolyte substances out of reach of children to prevent accidental overdose. Acute iron intoxication is a common problem among young children and can be fatal.

• Supervise children about using fluoride supplements (e.g., remind them to spit out oral rinses and gels rather than swallow them).

• Keep appointments with health care providers for periodic blood tests and other follow-up procedures when mineral or electrolyte supplements are prescribed (e.g., potassium chloride).

Iron

• Beef liver, red meats, fish, poultry, clams, tofu, oysters, lentils, dried peas and beans, fortified cereals, bread, and dried fruit

• Take with vitamin C to increase iron absorption, increase fluid intake to prevent stomach upset

• do not take iron with coffee or other caffeine-containing beverages because caffeine decreases absorption. Take iron and caffeine preparations at least 2 hours apart

• Avoid dairy, milk products because they decrease absorption

• do not crush or chew slow-release tablets or capsules

• Dilute liquid preparations with water, drink through a straw, and rinse the mouth afterward to avoid staining the teeth

• Expect that stools will be dark green or black. Report constipation or change in color or consistency of stool to the health care provider

Iron, Copper, Zinc, Mercury, Lead Chelate Agents

• Deferoxamine is used to remove excess iron from the body; major indication is acute iron intoxication

• Penicillamine chelates copper, zinc, mercury, and lead to form soluble complexes that are excreted in the urine

• Succimer chelates lead to form water-soluble complexes that are excreted in the urine

Potassium

• Mix oral solutions or effervescent tablets with at least 120 mL of water or juice to improve the taste, dilute the drug, and decrease gastric irritation

• do not crush or chew slow-release preparations

• Take after meals initially to decrease gastric irritation. If no nausea, vomiting, or other problems occur, the drug can be tried before meals because it is better absorbed from an empty stomach

• do not use salt substitutes except on the recommendation of a health care provider. Salt substitutes contain potassium chloride and may result in excessive intake

• Teach patent - Do not stop taking the medication without notifying the health care provider who prescribed it, especially if you are also taking diuretics or digoxin.

• Signs and symptoms of hypokalemia (< 3.5): palpitations, premature ventricular contractions on ECG, confusion, dizziness, muscle weakness, abdominal distension, frequent voiding of large amounts of urine

• Signs and symptoms of hyperkalemia (> 5): muscle weakness, palpitations, tall peaked T-waves on ECG, ventricular arrhythmias, slow pulse, fatigue, shortness of breath

Tube Feedings

• Verify placement of feeding tube prior to initiating

• Patient in sitting position (risk of aspiration)

• Administer solution at room temperature, if cold – stimulate cramping

• not administer more than 500 mL per feeding (including 60 to 90 mL of water for flushing the tube)

• Administer slowly, over approximately 30 to 60 minutes, rapid stimulates N & V

• Follow institutional protocols in the care of patients with feeding tubes

• Use best practices assessing correct tube placement, maintaining patency of tubes, positioning of patients, prevention of aspiration, gravity or pump administration of feeding products, and administration of free water and flushes

Continuous Tube Feeding

• Change containers and tubing daily.

• Intermittent feedings, rinse all equipment after each use (at least every 8 hours), and change at least every 24 hours

• Most people receiving 1500 to 2000 mL of tube feeding daily need approximately 1000 mL or more of free water daily

• Water can be mixed with the tube feeding formula, given after the tube feeding, or given between bolus feeding

• be sure to include the amount of water used for flushing the tube in the total daily intake

Administering Medications via Tube

• Give liquid preparations when available

• When liquid preparations are not available, it may be necessary to crush some tablets and empty some capsules and mix them with 15 to 30 mL of water

• Not all tablets/capsules can be crushed – not enteric coated, extended release, etc.

• do not mix medications with the tube feeding formula. If the absorption of a drug is affected by the tube feeding formula (e.g., phenytoin), discontinue the tube feeding for the recommended interval prior to drug administration; then, resume feeding at the recommended interval after drug administration

• do not mix medications. Give each one separately

• Flush the tube with water before and after each medication to get the medication through the tube and maintain patency

Nursing Interventions

• Promote well-balanced diet – 5 servings of fruits and vegetables

• Oral multivitamin may benefit most people

• Provide relief for symptoms that interfere with nutrition – pain, N, V & D

• Provide palatable supplements at appropriate times for patients needing increased protein-calorie intake

• Promote exercise and activity

• Minimize sedative-type drugs

• Weigh and calculate BMI

• Monitor I&O, UO, v/s, glucose, electrolytes, CBC

• Follow all protocols and best practices related to administration of medications and tube feedings.

Assessing Patient Nutritional Status

• Assess usual eating patterns, weight, BMI, appetite, ability to chew & swallow, diseases, medications

• Assess laboratory reports when available:

  • CBC for decreased red blood cells, hemoglobin, and hematocrit.

  • Serum electrolyte reports for abnormal values: sodium, potassium, and chloride; carbon dioxide content, a measure of bicarbonate

• Monitor weight, fluid intake, urine output, vital signs, blood glucose, serum electrolytes, and complete blood count for patients receiving parenteral nutrition. Obtain these values daily, weekly, or as ordered