Micronutrients Flashcards
populations at risk for vitamin D deficiency
fat malabsorption, pancreatic insufficiency, decreased bile acid secretion, decreased intestinal surface area
the first part of the body to show micronutrient deficiencies
oral cavity
the first sign/symptom to detect a micronutrient deficiency
serum labs
B12 and Copper deficiency are identical, the distinguishing factor is
B12 is macrocytic and Copper is hypochromic
Non-B complex vitamins (water soluble)
B vitamins, ascorbic acid, choline
micronutrients absorbed primarily in the stomach
Intrinsic factor, alcohol, copper, molybednum
micronutrients primarily absorbed in the duodenum
iron, selenium, calcium, phosphorous, magnesium, copper, thiamine, riboflavin, niacin, folate, A,D,E,K
micronutrients primarily absorbed in the jejunum
pantothenate, vitamin B6, zinc, chromium, manganese, , thiamine, riboflavin, vitamin C, iron, magnesium, ADEK, calcium, phosphorous
micronutrients are primarily absorbed in the ileum
B12, bile salts/acids, magnesium, vitamin C, D and K
micronutrients absorbed in the large intestine
vitamin K and biotin
major micronutrients deficient in roux-en-y gastric bypass
iron, calcium, intrinsic factor, b12, copper, fluoride, vitamin D, bile salts and thiamine
most likely micronutrient deficiency with an ileal resection <100cm of terminal ileum left over
B12, sodium, bile salts/acids limiting fat absorption, limited fat soluble vitamins
micronutrient losses associated with loss of terminal ileum
B12, Bile salts, fat malabsorption, fat soluble vitamin malabsorption, decreased essential fatty acid absorption, gastric hypersecretion and SIBO B12 deficiency
if the colon is intact, bacteria can produce _____ ,____,____, and ___in the setting of a lost ileum
thiamine, riboflavin, pantothenic acid, vitamin K
is there any evidence to support vitamin A supplementation in wounds
No
deficiency of vitamin ___ can delay wound healing as scar tissue wouldn’t be able to form from collagen
vitamin C
role of vitamin E for wound healing
an antioxidant used in collagen synthesis
is vitamin E beneficial in wound healing
YES
this micronutrient is involved in cell replication and growth, a co-factor for collagen, protein synthesis and proliferation of epithelial cells
zinc
why is measuring plasma zinc not the best indicator of zinc status
low serum zinc is widely distributed in body proteins which are decreased during inflammation
populations at risk for zinc deficiency
poor oral intake, diarrhea, large wounds, vegan diet
high doses of zinc interferes with ____ absorption
copper
symptoms of zinc deficiency
mouth ulcers, white spots on fingernails
when is supplementing with a multivitamin indicated in patients with pressure injuries
when po intake is poor AND deficiency is suspected from symptoms or confirmed with labs
micronutrient deficiencies indicated by scaling around the nostrils
B12, B6, zinc, niacin
petechia (hemorrhagic spots) can indicate ____ deficiency
vitamin C or K deficiency
pellagrous dermatitis (hyperpigmentation of the skin in areas exposed to the sun) can indicate
niacin deficiency
populations at risk for EFAD
long term TPN without lipids, fat malabsorption, PN dependence with an egg allergy, extremely low fat diet from chyle leak, impaired pancreatic enzyme secretion , diseased small bowel
xerosis (abnormal skin dryness) could indicate
vitamin A deficiency or essential fatty acid deficiency
follicular hyperkeratosis (plaques around the hair follicle) can indicate
Vitamin A, C and essential fatty acid deficiency
dermatitis can indicate
zinc and EFA deficiency
dull rough hair that is easily plucked, discolored and mis distributed with poor texture or hair loss can indicate
zinc deficiency, EFA deficiency, biotin deficiency
bitot spots (greyish, raised granulations on the conjunctiva of the eye) can indicate
vitamin A deficiency
loss of night vision can indicate
vitamin A deficiency
thiamine deficiency can lead to _____acidosis
lactic
mechanism of thiamine deficiency leading to lactic acidosis
thiamine is depleted 2/2 impaired absorption and poor po intake. Thiamine is the co factor for carbohydrate metabolism in glycolysis and the krebs cycle. Low thiamine prevents pyruvate dehydrogenase from changing pyruvate into acetyl coA leading to a buildup of lactate (cori cycle) leading to severe lactic acidosis
symptoms of Wernicke’s Encephalopathy
confusion, poor muscle coordination, abnormal eye movements (aterexis)
vitamins that affect the oral cavity
b vitamins
bilateral fissures (angular stomatitis) indicate which deficiency
riboflavin, niacin, pyroxidine, iron
cheilosis (cracked, dry swollen lips) can indicate which deficiency
B2, B6, Niacin, iron
bloody gums can signify which deficiency
vitamin C
glossitis can signify which deficiency
riboflavin , B6, niacin, B12, folate, iron
swollen, beefy red tongue can indicate which deficiency
niacin
poor blanching (capillary refill) can indicate which deficiency
iron
koilonychia (Spoon shaped nails with raised edges) can indicate what deficiency
iron, protein (could be genetic)
reverse ridging of the nails/white banding can indicate
hypercalcemia
splinter hemorrhage could indicate which deficiency
vitamin A, vitamin C
flaky nails could indicate which deficiency
magnesium, selenium
products that act as free radical scavengers and co factors are
antioxidants
vitamins A, C, E, selenium and zinc are
antioxidants
critically ill patients may need more of this/these to reduce free radical damage, but have shown no increased benefit for mortality, LOS or ventilator time
antioxidants; provide the RDA of each
what is the recommendation of providing antioxidants on the ICU for critically ill patients
provide the RDA of each
vitamin needs in burns patients with <20% TBSA
provide daily multivitamin supplementation
MVI recommendations for burn patients with >/= 20% TBSA
increase MVI
Zinc recommendations for burn patients with > 20% TBSA
20,000 mg
Vitamin C recommendations for burn patients with >20% TBSA
500 mg
When should selenium and copper be provided to burn patients with >20% TBSA
BID IF deficient
plasma zinc levels are ____ indicators of nutrient deficincies
poor
what is the best indicator for B12 deficiency
MMA levels
night blindness indicates ____ deficinecy
vitamin A
bitot spots and hyperkeratosis indicates ___ deficiency
vitamin A
toxicity of vitamin A results in inhibited ____ growth and ___ disease
bone; kidney
populations at risk for vitamin A deficiency
fat malabsorption, pregnancy, malnutrition
what are the 2 forms of vitamin D
Ergocalciferol (D2) and Cholecalciferol (D3)
where is most of vitamin D absorbed
distal small intestine
vitamin D active form
1,25 dihydroxyvitamin D
which organs play a role in vitamin D
skin kidneys, liver
this form of vitamin d helps absorb calcium in the gut
calcitriol
symptoms of vitamin d deficiency
osteomalacia, tetany, hypocalcemia
patients on long term PN are at risk for vitamin D deficiency true or false
true
______ serum calcium signals the release of parathyroid hormone
low
Parathyroid Hormone increases calcium by
renal retention to make calcitriol, stimulates osteoclasts to break down bone, calcitriol stimulates the gut to increase calcium absorption
vitamin D deficiency is indicated in serum assays as
= 20 ng/mL
treatment for vitamin D deficiency
50,000 IU every week for 9 weeks, and 1,000 IIU a day thereafter
what is alphatocopherol
vitamin E
where is vitamin E primarily absorbed
jejunum
main function of vitamin E
antioxidant; traps free radicals
populations at risk for vitamin E deficiency
fat malabsorption, chron’s , ileal /small bowel resection, long term TPN
age spots, vision loss and anemia indicate ____ deficiency
vitamin E
which vitamins are contraindicated with coumadin use
vitamins E and K
the 2 forms of vitamin K
Phyllaquinolone and Menaquinonone
where is vitamin K synthesized
intestines, gut microflora
primary absorption site of vitamin K
jejunum
main functions of vitamin K
blood clotting, PT time, INR, clots the blood
there are high amounts of _____ in ILE fat emulsions which can affect a person’s INR
vitamin K
ILE injections in TPN contain up to _____ micrograms of vitamin K
1,000 mcg
If someone’s blood is thinning too much and their INR is elevated while on TPN with lipids what can be done
discontinue or decrease lipid infusion or take out the multivitamin as will high levels of vitamin K
primary site of vitamin C absorption
ileum/jejunum
this vitamin plays a role as an antioxidant, collagen synthesis, carnitine synthesis, increases iron absorption
ascorbic acid
delayed wound healing, petechia, bleeding gums, corkscrew hair, and decreased immune function are symptoms of which deficiency
vitamin C
toxicity of vitamin C can lead to
renal stones
vitamin C recommendations for stage 1 to 2 pressure wounds
100-200 mg/day
vitamin C recommendations in known vitamin C deficiency
100mg 3x/day
primary site of thiamine absorption
jejunum
what is the most common cause of B1 deficiency
alcoholism
energy production, synthesis of NADPH, CHO metabolism, and role in KREBS cycle are the roles of what micronutrients
thiamine
Beri Beri is a manifestation of which vitamin deficiency
thiamine
populations at risk for thiamine deficiency
gastric bypass, alcoholism, hyperemesis gravidarum, LTPN, malnutrition, lasix
thiamine deficiency causing psychosis and memory disturbances and fatal lactic acidosis
Wernicke Korsakoff
nystagmus of the eyes, lower extremity weakness, cardiac failure, sodium/water retention, increased lactic acid are symptoms of what deficiency
thiamine deficiency
How much thiamine is recommended for asymptomatic B1 deficiency in PN
5-20 to 300 mg daily (replete magnesium/lasix)
thiamine recommendations for wernicke’s encephaloopathy
100-200 mg IV or IM 3x/day for 3-5 days
maintenance thiamine supplementation for wernicke’s encephalopathy
100 mg oral B1 3x/day for 1-2 weeks
this micronutrient makes up flavinmononucleotide and flavin dinucleotide
riboflavin (B2)
absorption of riboflavin occurs primarily in
small intestine enhanced by bile salts
this micronutrient plays a role in the electron transport chain, antioxidant against lipid peroxidation
Riboflavin (B2)
Sebhorric dermatitis, cheilosis, angular stomatitis and glossitis are symptoms of what deficiency
riboflavin
forms of Niacin (B3)
Nicotinic acid, nicotinamide
B3 (niacin) can be synthesized from
tryptophan
this micronutrient nakes up NAD,NADP, is a hydrogen donor in metabolism and activates folate
niacin (B3)
pellagra dermatitis is a symptom of ____deficiency
niacin (B3)
this micronutrient plays a role in metabolism or nutrients, central nervous system development, immune function and conversion of homocysteine to cysteine
pyroxidine (b6)
this micronutrient makes up GTAC of DNA
pyroxidine (b6)
what is the active form of vitamin B12
methylcobalamine
absorption of vitamin B12 depends on
intrinsic factor
populations at risk for B12 deficiency
use of PPIs, ileal/cecal valve removal, H. Pylori, vegans
cognitive decline, dementia, osteoporosis and GI symptoms are manifestations of which deficiency
B12
typical dose of vitamin B12
100-1000 mg
deficiency of vitamin B12 leads to ____ anemia
megaloblastic anemia (pernicious anemia)
B12/megaloblastic anemia can be masked by ______ deficiency
folate
Vitamin B12 converts homocysteine to
methionine
Vitamin B12 makes up the enzyme methylcobalamin which is a cofactor for methionine synthase which converts homocysteine to methionine. B12 also makes up the enzyme 5-adenosylcobalamin to become tetrahydrofolate. B12 deficiency will trap the conversion of folate. B12 and Folate will both be low
Methyl Folate Trap
Megaloblastic anemia (pernicious anemia) results in either ____ or ___ deficiency
B12 or Folate
Formal name of folic acid/folate
Folate/Tetrahydrofolate
primary absorption of folic acid occurs in the
jejunum
folate absorption depends on this micronutrient
zinc
folic acid absorption is inhibited by _____ and ____
zinc deficiency and impaired bile flow
This micronutrient plays a role in amino acid and nucleic acid metabolism, synthesis of purines/pyrimidines (DNA) and helps convert homocysteine to methionine
folic acid
populations at risk for folate deficiency
pregnancy, Gastric bypass
folate deficiency results in _____ anemia
megaloblastic anemia
cheilosis, dementia, weight loss, and megaloblastic anemia are symptoms of ____ deficiency
folate
medications that interfere with folate
phenytoin, birth control, rifampin
biotin is primarily absorbed in the
jejunum
biotin can be synthesized by
gut flora
skin pallor, dermatitis, glossitis, cheilosis, lethargy and alopecia are all sx of ____ deficiency
biotin
Pantothenic acid (B5) is a major component of
Con enzyme A
This nutrient plays a role in fatty acid metabolism, ketogenic amino acid, bile salt/steroid/hormone synthesis, beta oxidation and the kreb’s cycle
Panthothenic acid (co-enzyme A)
This micronutrient converts phospholipids into lecithin (phosphotidylcholine)
choline
this micronutrient plays roles in the formation of lecithin, acetyl choline synthesis and production of lipoproteins
choline
Populations at risk for choline deficiency
long term PN, pregnancy, hypermetabolic state
hepatotoxicity especially on TPN without supplementation can be a result of _____ deficiency
choline
choline deficiency is typical in ______ syndrome and _____
short bowel and long term TPN
_____ is a component of intralipid 20% solutions’ as an emulsifyer (lecithin)
choline
which form of iron is best absorbed in the gut
Ferrous Form Fe2+
_____ enhances heme/non heme iron absorption
ascorbic acid
Iron is primarily absorbed in
the duodeum/jejunum
____ reduces iron in the Ferric Form (3+_) to the Ferrous Form (Fe2+)
ascorbic acid
populations at risk for iron deficiency
child bearing age, excess blood loss, older adults, antacid/PPI/H2 receptor antagonist use, gastric bypass, chron’s disease, pernicious anemia, celiac disease
what type of anemia is microcytic, hypochromic with decreased MCV
Iron Deficiency Anemia
Koilynchia, glossitis, poor capillary refill and fatigue are symptoms of ______ deficiency
iron
Why isn’t iron routinely added to PN
it can cause microbial growth
if iron MUST be added to PN which form is preferred
Fe dextran
Iron dextran cannot be added to a TNA becuase
it will destabilize the solution
this form of iron cannot be added to a TNA TPN mixture
Fe Dextran
Zinc absorption relies on ____ release from the stomach
HCL
Zinc absorption is inhibited by these medications
acid reducers
zinc is bound to _____ which is abundant in the body, so serum levels are not the most accurate
albumin
this mineral is part of the makeup of metalloenzymes, plays a role in wound healing, insulin synthesis, immune function and glucose control
zinc
Excess zinc can cause _____ deficiency
copper
Increased zinc can cause copper deficiency because
they fight for the same receptor
Rash, scaly dermatitis, poor wound healing, alopecia, altered taste/smell, decreased immune function and Iron deficiency anemia are all results of ____ deficiency
zinc
populations at risk for Zinc deficiency
older adults, ETOH use, wound drainage , GI losses from DIARRHEA, DIARRHEA, liver disease HIGH OUTPUT FISTULA
without food sources how quickly will iron deficiency occur
6 months
is iron in standard trace elements
no
without thiamine, pyruvate will convert to
lactic acid
wound healing, cell differentiation, epithelial cell development and collagen synthesis are functions of
vitamin A
vitamin toxicity for vitamin A can occur over ____ IU a day
25,000 IU/day
aluminum appears in TPN becaus
of aluminum contamination during manufacturing
how can you reduce aluminum toxicity
reduce or eliminate aluminum containing antacids, sucralafate
deferoxamine
a medication to treat almunium toxicity
patients receiving long term PN are most likely to have increased requirements above the RDA of
selenium
a deficiency in this vitamin can lead to lactic acidosis and death
thiamine (B1)
vitamin D and parathyroid hormone regulate calcium metabolism in the
intestines
bone
kidneys
a patient with vitamin A deficiency is likely to manifest the following symptom
dermatitis
supplemental zinc may impair the absorption of this nutrient
copper
the following lab value is likely to be low in acute pancreatitis
Calcium
the adjusted calcium for a patient with a serum albumin of 2.4 and serum calcium of 7.2 is
8.5
Iron is best absorbed in the
duodenum
the usual parenteral dose of selenium is
50-100 mcg
cheilosis (cracked corners of the mouth) indicates deficiency of
riboflavin, niacin, Fe, pyridoxine
Action of Proton Pump Inhibitors and effect on B12 absorption
Protein is bound to vitamin B12. Absorption requires optimal gastric acid to cleave B12 from the protein in food and bind to intrinsic factor. Free B12 will bind to R protein then Intrinsic factor in the small intestine for absorption. PPI’s decrease HCL which will interfere with absorption
serum creatinine is mostly influenced by the amount of a person’s
muscle mass; the lower the muscle mass the lower the creatinine
