Lead Poisoning Nursing Care Planning and Management

Lead poisoning is preventable, and that is the whole point of your role. Lead accumulates in the body, usually from contaminated paint, soil, water, or products, and it hits young children hardest, driving cognitive, behavioral, and developmental damage. Recognize the signs, teach families where lead comes from, and push prevention.

What is Lead Poisoning?

Lead poisoning is a worldwide pediatric problem. Lead is a ubiquitous, versatile metal used since ancient times, with a long history of public exposure through food and drink. Lead poisoning (plumbism) was common in Roman times from lead water pipes and wine containers. In 1904, Australian physician J. Lockhart Gibson concluded that home lead paint poisoned children; despite his work and later US confirmation, lead was not banned from US household paints until 1978.

In 1991 the CDC defined blood lead levels (BLLs) of 10 µg/dL or higher as the "level of concern" for children aged 1-5 years. In May 2012 the CDC replaced "level of concern" with an upper reference value set at the 97.5th percentile of BLLs in US children aged 1-5 years across two consecutive National Health and Nutrition Examination Survey (NHANES) cycles.

Statistics and Incidences

Confirmed BLLs of 10 µg/dL or higher in US children younger than 72 months fell from 7.61% in 1997 to 0.56% in 2013. Even so, the CDC estimates at least 4 million US households contain children exposed to high lead levels, and about half a million US children aged 1-5 years have blood lead levels above 5 µg/dL, the reference level at which the CDC recommends public health action.

Children in minority or low-income families, or in older homes, are at particular risk. Lead remains a major problem in developing countries, and children with heavy exposure to automobile exhaust (where leaded gasoline is still sold), lead-based paint, or home manufacture of batteries, ceramics, or painted artifacts carry high lead burdens. From 1999-2002, non-Hispanic blacks and Mexican Americans had higher rates of elevated BLLs (1.4% and 1.5%) than non-Hispanic whites (0.5%). Lead poisoning chiefly affects children younger than age 6 years and adults in lead-risk occupations.

Causes

Lead toxicity comes from inorganic or organic lead. Most cases are inorganic lead, which enters by ingestion, inhalation, or transdermal absorption; ingestion is the most common route in children because of normal hand-to-mouth activity. Organic lead such as tetraethyl lead enters through the skin; tetraethyl lead, the main organic compound in leaded gasoline, is converted in the body to triethyl lead and inorganic lead.

Clinical Manifestations

The picture is vague, and that is the trap. Symptoms are rarely specific enough to point at lead. Watch for pallor (from associated anemia), lethargy or loss of consciousness after prolonged contact, bradycardia, hypertension (a sign of the increased intracranial pressure common with lead), and shortness of breath from respiratory depression.

Assessment and Diagnostic Findings

In the early 1990s, the CDC and the American Academy of Pediatrics (AAP) recommended universal lead screening in children at 1 and 2 years of age.

Whole blood lead level (BLL) is the criterion standard for confirming the diagnosis. A fingerstick capillary lead level is convenient for screening but properly collected capillary samples carry a 10% false-positive rate, so confirm any elevated result with a venous lead level. Erythrocyte protoporphyrin (EP) may be obtained in selected patients: lead disrupts heme synthesis, including the enzyme ferrochelatase, so EP accumulates and is easily detected because it fluoresces; EP is an adjunct in the presence of elevated lead levels of 55 mcg and higher. In Russia, hair sampling is the screening standard, but blood specimens are more sensitive than hair for detecting exposure. On abdominal radiography, radiopaque flakes clearly indicate pica. On long-bone radiography, radiodensity at the distal metaphyseal area (lead lines) marks true growth arrest; not pathognomonic but associated with chronic exposure.

Medical Management

Treatment means stopping further exposure, decontamination, chelation, and supportive care.

Decontamination applies to acute lead ingestion when lead paint chips show on plain abdominal radiographs; gastric lavage may be used, but secure the airway first in an obtunded child. Chelation is recommended for children with venous lead levels of 45 μg/dL or higher and includes oral succimer plus parenteral calcium disodium edetate (calcium EDTA) and British antilewisite (BAL, dimercaprol). Supportive therapy covers acute lead encephalopathy: protect the airway by endotracheal intubation if needed, treat seizures with benzodiazepines, maintain control with phenobarbital, and if seizures are hard to control, presume increased intracranial pressure and treat it (hyperventilation, mannitol, steroids).

Primary prevention is family education on lead sources, the role of pica, and the developmental hazards; nutritional assessment matters because lead absorption rises with poor diet, especially high fat intake or deficiency of calcium and iron. Secondary prevention is early detection through CDC screening criteria. Diet should be adequate in calories and replete with calcium, zinc, and iron; Normative Aging Study data suggest low vitamin D intake may increase lead accumulation in bone, while low vitamin C and iron intake may raise blood lead in middle-aged to elderly subjects.

Pharmacologic Management

Chelating agents bind lead and promote excretion, and patients on chelation need close monitoring for the agents' toxicities. Dimercaprol, first developed as an antidote for lewisite toxicity, is water soluble and rapidly crosses the blood-brain barrier; it forms a nonpolar compound with lead excreted in bile and urine and is the drug of choice in acute lead encephalopathy, where the first dose is given and the second dose is given combined with calcium EDTA after a 4-hour interval.

Nursing Management

Nursing Assessment

Take a history for lead in household furniture or fixtures, lead-containing materials, and contaminated food or beverages. On exam, look for hyperactivity or lethargy, irritability, pallor, and signs of shock.

Nursing Diagnoses

Major diagnoses are delayed growth and development related to lead's effect on the brain, disorganized infant behavior related to irritability and lethargy, and ineffective breathing pattern related to shortness of breath.

Nursing Care Planning and Goals

The child reaches a normal blood lead level, communicates and interacts with the parents, and returns to a normal breathing pattern.

Nursing Interventions

Reduce exposure: a child with symptomatic lead poisoning (with or without encephalopathy) is treated only at a pediatric center with an ICU and managed by a multidisciplinary team that may include critical care, toxicology, neurology, and neurosurgery, with close monitoring of neurological status and fluid balance. Give edetate calcium disodium (EDTA) intravenously as ordered, since intramuscular administration is painful. Monitor for side effects: all chelating drugs can be toxic, so follow frequent urinalysis, blood cell counts, and renal function tests. Educate the family on prevention and nutrition. Remove lead-containing materials: discard old painted toys of unknown paint content, avoid canned goods from foreign countries, and cover walls with paneling or Masonite.

Evaluation

Goals are met when the child has a normal blood lead level, communicates and interacts with the parents, and breathing returns to normal.

Documentation Guidelines

Document individual findings including contributing factors, interactions, the nature of social exchanges, and specifics of behavior; characteristics of vomitus; cultural and religious beliefs and expectations; the plan of care and teaching plan; responses to interventions, teaching, and actions; and attainment or progress toward the desired outcome.