1- Effect of Implementing Nursing Guideline among Patients ... and Surgical Nursing… · 1- Effect of Implementing Nursing Guideline among Patients with Lead Poisoning on Their Health

1st International Conference Nursing Practices & Era Challenges

Faculty of Nursing 30 January , 2017

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1- Effect of Implementing Nursing Guideline among Patients with Lead Poisoning on

Their Health Outcomes

Islam.I.Ragab1, Hanan G Mohamed

2 , Elamier H.M. Hussien

3 & Nadia.A. Mohamed

4

1. Lecturer, Medical Surgical Nursing Department, Faculty of Nursing South Valley University, Qena, Egypt.

2. Assistant Professor of Medical Surgical Nursing Department, Faculty of Nursing, Banha University, Egypt.

3. Lecturer, Zoology Department, Faculty of Science South Valley University, Qena, Egypt.

4. Assistant Professor of Obs and Gun Nursing Department, Faculty of Nursing South Valley University Qena,

Egypt.

Abstract

Aim: The study aimed to determine the effect of implementing nursing guidelines among patients' with lead

poisoning on their health outcomes. It was conducted in internal medicine department and outpatient clinic at Qena

university hospital. Convenience samples comprised of 60 adult patients from both sex and were confirmed with

lead poisoning. Two instruments were used in this study. Tool 1: Patients' knowledge regarding lead poisoning

and their complain questionnaire (tool 1- part I, II ) and attached to socio-demographic data. Tool 2: Nutritional

Profile among lead poisoning patients and clinical base data of laboratory investigations observational Checklist to

confirm the diagnosis with lead poisoning (tool 2 part I, II ). It was taken one time before implementing the nursing

guidelines, and three times, once every 5 days to monitor the difference rates in these parameters to evaluate the

effect of suggested nursing guidelines and therapeutic regimen (tool 3) on lead poisoning patient's outcomes ( tool1,

and tool 2). Result: The study findings revealed that mean ages was 44.93 + 11.77. In pretest, 78.33 % of them had

11-13 mcg/dL serum lead, after implementation of nursing guidelines decreased to16.67% of them , Also, there was

statistically significant difference (P = 0.001) in laboratory findings (P value 0.005). Concerning GIT 100% of

pretest they had abdominal pain, anorexia, and constipation by the 3rd week decreased to zero ((P value 0.005). As

regard neurological assessment short concentration, depression, and fatigue were statistically significant difference

(P = 0.005) respectively. Conclusions: There was statistically significant improvement after implementation of

nursing guidelines in their lab. investigations levels, systemic manifestations and their knowledge when compared

the posttest with pre assessment. Recommendations: additional successful clinical evidence is required with

validated laboratory findings to establish effective alternative medicines for treating lead poisoning.

Keywords: Implementing Nursing Guidelines, Lead Poisoning& Patient's Health Outcomes.

IntroductionLead poisoning is a type of metal poisoning and a

medical condition in humans caused by increased

levels of the heavy metal lead in the body (Abdel-

Maabou. et al., 2015). Lead interferes with a variety

of body processes and is toxic to many organs and

tissues , especially the nervous system, causing

potentially perpetual learning and behavior disorders

for young adults, also the bones, teeth, kidneys,

cardiovascular, immune, and reproductive systems. In

severe cases hearing loss, cataracts, tooth decay, and

reduced sperm count may occur, as well as abnormal

sperm also may causes termination or premature birth

in pregnant women. Seizures, coma, and death may

be occur (Goyer, 2014) and (Gracia, 2013). In acute

poisoning typical symptoms include abdominal pain,

confusion, headache, sluggishness, fatigue, irritability,

and developmental delay (Schep et al., 2014)loss of

appetite, vomiting ,anemia, weight loss, constipation,

and diarrhea. Absorption of great amounts of lead

over a brief time may cause shock (Wright et al.,

2011). Typical neurological signs are pain, muscle

weakness, paraesthesia, and rarely symptoms

associated with encephalitis. Young adult with chronic

poisoning may have hyperkinetic or aggressive

behavior disorders. Visual disturbance may present

with gradually progressing blurred vision as a caused

by toxic optic neuritis (Velez and O'Connell, 2014).

Lead poisoning is also dangerous for elderly adults,

the acute signs and symptoms include high blood

pressure, joint, and muscle ache, decrease in mental

functioning, numbness or tingling of the extremities.

In addition, memory loss, mood disturbed, astringency

and a metallic taste may be present. Chronic exposure

can lead to short-term memory loss, depression, loss

of coordination, stupor, slurred speech, lead hue of the

skin with pallor and/or rigidity is another feature. In

addition to a blue line along the gum with bluish black

edging on the teeth known as a burton line (Lanphear

et al., 2015)

Lead exposure is ubiquitous thus the whole population

is potentially exposed, especially people living in

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lower socioeconomic neighborhoods, in old, houses,

post-industrial areas or in close proximity to mining

and smelting areas or highways. Risk is increased

during pregnancy, at time spent in polluted

environments or children's risk behavior (hand-to-

mouth behavior) routes of exposure to lead include

contaminated of air, water, soil, food, household dust,

pottery, toys, traditional cosmetics as Kohl, and

consumer products. Occupational exposure is also a

source leads to lead poisoning as individuals who are

reached to lead from different sources such as gasoline

pump attendant, traffic policemen, solder, and

consumer products. Also, workers who sand, scrape or

blast lead-based paint, recyclers of metal are may

expose to lead poisoning as well as manufacturers of

bullets, ceramics, jewelry, and firemen. In addition,

construction workers, foundries and scrap metal

operations, lead smelters, bridge construction, and

those that work with stained glass, fishing sinkers,

computer electronics, and automotive repair

(Cleveland et al., 2011) and (Todd Jusko. et al.,

2014).

One of the greatest threat is lead paint that exists in

many homes, especially older ones; thus peoples in

older housing with chipping paint or lead dust from

moveable window frames with lead paint are at

greater risk (Toews et al ., 2011). Lead dust can

collect in windowsills, troughs, floors, carpets,

furniture, and ventilation filters. It can also get hands,

toys, and bottles. The presence of heavy metals in the

environment has grown because of its large

employment in many industrial and agricultural

activities. The term heavy metal refers to any metallic

chemical element that has a relatively high density and

is toxic or poisonous at low concentrations in plants,

animals and humans (Arieta, 2009). So, it can affect

all components of the environment and can move

through the ecosystem until it reaches equilibrium.

Lead accumulates in the environment, but in special

chemical environments, it will be transformed in such

a way as to increase its solubility (e.g., the formations

of lead sulfate in soils), its bioavailability or its

toxicity. The effects of lead at the ecosystem level are

usually seen as a form of stress (Birge et al., 2015).

Elevated lead in the body may be observed by

the presence of changes in blood cells visible with a

microscope and dense lines in the bones seen on X-

ray, but the main tool for diagnosis by measurement of

the serum lead level in which the results indicate how

much lead is circulating within the blood stream, not

the amount stored in the body. Treatment of lead

poisoning depends on two ways, first is prevention of

lead exposure which range from individual efforts to

national wide policies and frequent house cleaning and

hand washing may aids prevent from ingesting lead

(Rojas-Lopez, and Santos-Burgoa 2014). Second is medical/ or surgical intervention for

patients who have significantly high blood lead

volume or who have symptoms of poisoning by

chelation therapy as well as treatment of iron, calcium,

and zinc deficiencies, which are associated with

increased lead absorption, another part of treatment

for lead poisoning. When lead-containing materials

are present in the gastrointestinal tract (as evidenced

by abdominal X-rays), whole bowel irrigation,

cathartics, endoscopy, or even surgical removal may

be used to bullets and shrapnel present in or near

fluid-filled or synovial spaces. If lead encephalopathy

is present, anticonvulsants may be given to control

seizures, and treatments to control swelling of the

brain include corticosteroids and mannitol. Treatment

of organic lead poisoning involves, removing the lead

compound from the skin and preventing further

exposure (Norman et al., 2015).

Role of the nurse is depend on the extent of her

knowledge and experience about signs and symptoms

of lead poisoning. As well as early detection of it in

the outpatient clinics or at admission and faster

seeking for blood analysis that confirms the patient's

diagnosis for faster treatment (Guilarte, 2013). The

nurses should establish educational programs for the

patients and their families about the causes and effects

of lead poisoning, relationship between blood lead

range and in prospect medical or neuropsychological

disorders, importance of follow-up or serial blood lead

level assertiveness to observe effects of treatment,

identifying and termination possible sources of lead

exposure (Anderson et al,. 2013). Also, the patients

must be educated of lead avoidance, elimination of

exposure to lead. All workers should be informed

regarding the health risks of lead and sources that may

cause poisoning and clarify the jobs that have high

lead exposure rate. The most important role of the

nurse is to educate the patient a well, substantial diet

and how lead absorption is increased with a diet rich

in fats (Kosnett et al .,2015). Also, diets low in iron,

calcium, and vitamin C increase the likelihood of lead

absorption and result in lead poisoning and how

dietary fiber helps improve well peristalsis and

decreases the opportunity for lead absorption, thus, at

least 30 g of dietary fiber is suggested for adults each

day (CDC. 2010) &( Chisolm 2014).

Significant of the study

Lead exposure remains a concern for adults

specifically among special population subgroups at

increased risk for exposure. The number of patient

with unknown gastrointestinal, visual and neurological

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disturbances following up in internal medicine

department in Qena University Hospital in the last

year was 460 cases according to the (Hospital

Statistical Record, 2015). However, guidance for

clinicians as regard to screening and managing

patients who exposed to lead doesn't move along with

the scientific evidence, there are currently no national

recommendations by any medical or nursing

professional association that covers lead risk

assessment and management. So, this study was the

first study in this geographical area which will help

such group of patient to prevent or reduce risk of lead

poisoning.

Aim of the study: This study aimed to:

1. Determine the level of knowledge for patients

with lead poisoning.

2. Develop and implement of suggested nursing

guidelines.

3. Evaluate the effect of implementing nursing

guidelines for patient with lead

poisoning on their health outcomes.

Research Hypothesis:

1- Patients attending nursing guidelines regarding lead

poisoning will exhibit a total mean score of

knowledge more than before.

2- Lead poisoning patient's outcomes in posttest group

will exhibit improving more

than pretest group.

Operational Definition Health outcome: Related to inclusion criteria,

patients' complaint of gastrointestinal, visual,

neurological, and musculoskeletal will be minimize.

In addition, laboratory investigation including serum

lead, HB, Ca, hematocrit, coagulation time, uric Acid

and urine analysis will be within normal.

Subjects and method

Research Design: A Quasi experimental pre/posttest design was utilized

to fulfill the aim of the study.

Setting: The study was conducted at internal medicine

department and outpatient clinics at Qena University

Hospital.

Sampling and sample size: Consecutive patients (n=250), who admitted in

internal medicine department and outpatient at Qena

university hospital were recruited in March 2016.

A convenience sample comprised of 60 adult patients

from both sex and were confirmed with lead

poisoning. They were selected according power

analysis (using the program epi-info to estimate the

sample size) using the following parameters:

1. Population size 250

2. Expected frequency 24%

3. Maximum error 10% 4. Confidence coefficient 95%.

They were willing to participate in the study and

assigned to pre/ post study and receiving nursing

guidelines. So, the patients (n=190) with other

diagnosis rather than lead poisoning were excluded.

The analyses were finally based on 60 patients. An

overview of sample recruitment for the present study

is presented in the following figure below

Overview of sample recruitment for the present

study:

The Subjects inclusion criteria was:

Conscious patients.

Age from 20- 60years.

Serum lead more than 7 mg/dL.

Serum HB. Less than 12 g/dL.

Serum ca. less than 8.5mg/dL.

Hematocrit less than 36%.

Coagulation time less than 9 minutes.

Uric Acid less than 7mg/dL.

Urine analysis; random Urine protoporphyrin

more than 300 mg, and

Complaining of gastrointestinal and visual

disturbance, neurological changes,and

musculoskeletal disabilities.

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Tools of data collection:

Tool 1 : Patients' knowledge regarding lead

poisoning and their complaint questionnaire. It

includes two parts:

Part I: Patients' knowledge assessment regarding

lead poisoning: This tool was developed by the

researcher. It aimed to identify the patient's related

information about lead poisoning (definition,

occupational source, nutritional source, cosmetic

use, environmental source, source of drinking and

houses, signs and symptoms, complications, medical

treatment, mode of prevention as regard diet, ideal

blood lead level, in addition to sources and methods

of lead exposure). It attached to socio-demographic

characteristics (age, gender, residence, education

level, occupation, and length of stay

Scoring System:

A four point Likert scale of responses was used,

such as poor Understand=0, pass =1, good

Understand=2, and very good Understand=3. Above

60 is satisfactory and unsatisfactory is less than 50.

The total score of the knowledge was 99, designed

as the following :

-Definition of lead 3

-Percentage of lead in the blood 3

-Route of lead entrance in the body 15

-Sources of lead toxicity 15

-Effects of lead on the different body system 18

-Physical Symptoms of lead toxicity 18

-Psychological symptoms of lead toxicity 3

-Methods of prevention of lead toxicity 15

-Purpose of treatment of lead toxicity 3

-Methods of treatment from lead toxicity 6

Part II: Patients' Complaint Assessment, it

comprises all Patients 'problems of the affected body

systems, gastrointestinal system includes: abdominal

pain, loss of appetite, vomiting, constipation

/diarrhea , metallic test in the mouth, and rigidity of

the gums (burton line). Musculoskeletal assessment:

it includes (joint pain, muscle weakness/pain,

paraesthesia, tingling of extremities), visual

assessment includes: blurred vision, cataracts,

visual acuity, as well as neurological assessment it

includes: short concentration, depression, loss

coordination, confusion, fatigue, irritability, slurred

speech, coma, and seizures.

Tool 2: Nutritional Profile among lead poisoning

patients and clinical base data observational

Checklist: This tool was adopted (Rabinowitz. Et

al., 2015): to collect necessary data for patients with

lead poisoning and it was consisted of:

Part I: Nutritional profile Assessment: it includes

A-Numbers of meals, duration of meals, contents of

meals, and water drinking sourced. It attached to

socio-demographic characteristics

B-Body weight (kg), Height (meters), (to determine

the dose of iron and ferrotron tablet which depend

on wt. and ht. (DeSilva., 2012)

C- Body mass index (BMI) kg/m2

(BMI = weight (in

kg) / height square (in meter)

Part II- Clinical base data: It includes the

following:

1-laboratory investigations assessment to

confirm the diagnosis with lead poisoning and to

evaluate the effect of suggested nursing guidelines

and prescribed treatment with supplement of

nutrition for patient with lead poisoning on patient's

health outcomes. It included: (serum hemoglobin,

serum lead, serum calcium, serum hematocrit,

coagulation time) and pretest for subsequent

evaluation and once every 5 days after 5th

, 10th

, and

15th

days posttest to monitor the rate of these

parameters.

2- Blood pressure and Heart rate

3- Electro- encephalography

Tool 3: Nursing guidelines and Therapeutic

Regimen It included the following:

Part I: Suggested Nursing guidelines:

It developed by (Gracia., 2013) and comprised the

following:

Definition of lead, percentage of lead in the blood,

route of lead entrance in the body, sources of lead

toxicity, effects of lead on the different body system

physical and psychological symptoms of lead

toxicity, symptoms of lead toxicity methods of

prevention as well as the prescribed treatment from

lead toxicity.

Part II: Therapeutic Treatments and Diet

Regimen

It was approved by the doctor to force the lead out

of the body by circulating it in the blood.

It included:

1. 50 mg/ml of iron (low molecular iron) added

to 500ml dextran 5% given IV. It was

prescribed according to weight and height

once a day for two days then followed by,

ferrotron tablets.

2. Ferrotron capsule once a day (it is iron

combined with amino acid in order to

facilitate its absorption without causing

constipation) for ten days.

3. Prescribed diet contain (Norman. et al.,

2015)

- High protein about (70 g/day),

- Iron (18 mg/day),

- Carbohydrates (225-325 g/day),

- Fats (24g/day),

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- Calcium (1.200mg/day) in addition to vitamin

D (600IU/day),

- Vitamin C (120mg/day) and zinc (12mg/day).

This was given with meal at lunch time till

serum lead level decreased to normal level or

accepted decreased level that approved to

discharge ( less than or equal 5 mcg/dL)

Method

Administrative approval:

- An official was forwarded from the dean of the

faculty of Nursing, requesting a permission to

conduct the study.

- A written approval was obtained from the

director of internal medicine department to

carry out the study and from responsible

physician for accepting and writing the

treatment and diet regimen for patients with

lead poisoning in Qina University Hospital.

- A structure questionnaire and systemic

observational assessment sheet were designed

by the researcher based on the review of

current related literature to assess the patient’s

knowledge.

Ethical consideration:

An informed consent for participation in the study

was taken from each participant

after full explanation of the aim of the study. They

were informed that their participation in this study

was voluntarily. The participants were given the

opportunity to refuse participation and they could

withdraw at any stage of the data collection without

giving any reason. The studied sample also assured

that any information collected would be confidential

and used for the research purpose only.

Validity and reliability:

The tool 1 was tested for content validity by 7

experts of academic medical and nursing staff at

Qena University. Modifications were done

accordingly, and then the tools were developed in its

final format and tested for reliability using internal

consistency for the tools was measured using &

Cronbach test which were reliable 0.75, respectively.

A pilot study It was done on (6) patients who was involved in the

sample to test the tool clarity, and applicability

(tool 1) and to estimate the time needed to fill the

sheet. Modifications were done as required by

the researchers.

Data collection:

Each interview took a time of about one hour

utilizing tool 1. The data were collected in 7 months,

from March till September 2016. The data collection

was done through the following phases:

Assessment phase: (Pretest) Once the researcher interviewed with patients

individually, got their written consent to participate

in the study. An interview questionnaire was

applied which is concerned by patients' socio-

demographic (tool 1part I) and they asked about

knowledge utilizing (tool 1part I). Then, the

subjects of patient's complaint were assessed (Tool

1-part II) which concerned by assessment the effect

of high lead level on different body systems.

Finally, nutritional profile assessment was taken

which includes a numbers of meals, duration of

meals, contents of meals, and water drinking sourced

as well as measure the body weight and height to

determine the dose of iron and ferrotron tablet which

depend on wt. and ht. utilizing tool 2(part I) For

confirming the patients' diagnosis with high level of

serum lead, the researcher took blood sample for

serum. Patients who matched high level serum lead

(7- up to 10 microgram/deciliter) were included in

the study and who weren't match with study criteria,

excluded. Hemoglobin, serum calcium, serum

hematocrit, coagulation time, and uric acid were also

investigated utilizing tool 2 part II as well as body

mass index (BMI) were calculated (tool 2 part I).

Subsequently, it was taken one time before

implementing the nursing guidelines as a baseline

assessment.

Implementation phase:

- The guideline developed by the researcher

thorough review of literature.

- All participants of patients got the suggested

guidelines which conducted through two

sessions for each patient and the duration of

each session was around 20 to 30 minutes.

- At the beginning of the first session, patients

were oriented regarding the guidelines

contents, its purpose and the impaction on their

health condition. Each session ends by

summary to its contents and a feedback from

the patients was elicited to ensure that all

information was understood and maximized

educational benefits. At the end of the first

session, patients were informed about the time

of the next one using simple Arabic language.

- Once after confirming the diagnosis all patients

got prescribed three meals rich in protein,

carbohydrates, vitamins C, Calcium, zinc, iron

and low in fats and advising increases drinking

of water up to 3-4 litter/day, in addition to

ordered medical treatment as dietary

supplement contains iron with multivitamins

and essential trace elements needed to force the

high circulated lead to get out of the body with

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feces or urine gradually, 50mg/ml of iron (low

molecular iron ) added to 500ml dextran 5%

given IV. First small test dose as given 10 ml

IV push first to determine if the patient is

allergic to this form of iron solution. It was

prescribed according to weight and height once

a day for two days then followed by ferrotron

capsule once a day (it is iron combined with

amino acid in order to facilitate its absorption

without causing constipation) for ten days. At

the same time ordered of diet contain high

protein about (70 g/day), iron (18 mg/day),

carbohydrates (225-325 g/day), fats (24g/day),

calcium (1.200mg/day) in addition to zinc

(12mg/day) and vitamin D (600IU/day),

vitamin C (120mg/day). This was given with

meal at lunch time till serum lead level

decreased to normal level or accepted

decreased level that approved to discharge

(less than or equal 5 mcg/dL)

Evaluation phase: (posttest)

After implementation of designed nursing

guidelines, evaluation of the patient's outcomes was

done by using tool1 part I, II and tool 2 part II,

three times (after 5 days, 10 days and 15 days) to

evaluate the effect of suggested nursing guidelines

on lead poisoning patient's health outcomes.

Statistical Analysis:

The data obtained were reviewed prepared for

computer entry, coded, analyzed and tabulated.

Descriptive statistics as (number and percentage,

mean scores and stander deviation) was done using

computer program SPSS version (18). Chi-square,

P-value and T-value used to compare differences in

the distribution of frequencies between the pre/post

study subjects.

Results

Table (1): distribution of the study group according Socio-demographic data

Pre/Post group (n=60) Items

% No

23.33

35

30

11.67

14

21

18

7

Age:

20-29

30-39

40-49

50-59

44.93+11.77 Mean + SD

50.00

50.00

30

30

Gender:

Male

Female

100 60 Marital status:

30

20

20

20

18

12

12

12

pratiy:

Not pregnant:

Pregnant:

Types of Para:

Multipara(more the two baby)

Previous Abortion:

71.67

21.66

6.67

43

13

4

Occupation :

Worker

Employee:

Not worked:

41.67

58.33

25

35

Level of education:

Basic education

University education

66.67

33.33

40

20

Residence:

Rural

urban

61.67

38.33

37

23

length of hospital stay:

5-9 days

10-15 days

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Pre/Post group (n=60) Items

% No

166.03+19.16

107.10+34.72 Mean + SD of Height (cm):

Mean + SD of Weight (kg):

43.33

20

36.67

26

12

22

Pulse:

Normal pulse:

Tachycardia (↑100):

Bradycardia: (↓60):

58.33

33.33

25

35

20

15

blood pressure:

Prehypertension:

Stage I hypertension:

Stage II hypertension:

Table (2): Frequency distribution of the study group according lead sources (n=60)

Lead source

Pretest group

No %

Occupational source:

- Gasoline station

- Ceramic factories

- Auto repair

- Paints and dyes works

19

8

13

20

31.67

13.33

21.67

33.33

Nutritional source:

- Storage candid food or water

- Eating or drinking in glued ceramic pots

60

60

100

100

Cosmetics use (kohl): 40 66.67

Environmental dust exposure:

- Chelating of dust

Always:

- Amount of dust

Big amount:

60

60

100

100

Drinking source:

- Tab faltered water

- Tab not faltered water

- Mineral water

20

35

5

33.33

58.33

8.33

Houses:

- Leaving in old with chelated paint houses

- Leaving in new paint houses

16

44

26.67

73.33

Table (3A): Frequency distribution of knowledge score level obtained during pre/posttest question of implementing

nursing guidelines (n=60)

Scores allotted Very good good Pass Poor

% No % No % No. % No.

Total knowledge

Pre- test

Post test

0

52.33

0

32

0

38.33

0

23

10

1.67

6

1

90

6.67

54

4

P- value (X2 value) 0.000 *(49.2)

* statistical significant difference

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Table (3B): Mean Scores, Standard deviation and Significant Differences of knowledge between pre/posttest of 1st

,2nd

and 3rd

assessment after implementing nursing guidelines. (n=60)

Variables

Total score

pretest posttest p- value Mean + SD Mean + SD

- Definition of lead poisoning 3 0.0541 + 0.13 2.31 + 1.17 0.005 **

- Percentage of lead in the blood 3 0.0541 + 0.13 2.31 + 1.17 0.005 **

- Route of lead entrance in the body

15 3.17 + 1.01 8.67 + 2.71 0.005 **

- Sources of lead 15 3.17 + 1.01 8.67 + 2.71 0.005 **

- Effects of lead on the different body system

18 3.98 + 1.21 9.92 + 2.91 0.005 **

- Physical symptoms of lead toxicity

18 3.98 + 1.21 9.92 + 2.91 0.005 **

- Psychological symptoms of lead toxicity

4 0.65 + 0.14 2.63 + 1.18 0.005 **

- Methods of prevention 15 3.17 + 1.01 8.67 + 2.71 0.005 **

- Purpose of treatment 3 0.0541 + 0.13 2.31 +1.17 0.005 **

- Methods of treatments 6 1.33 + 0.14 4.63 + 2.03 0.005 **

Total mean score 99 4.919 + 2.036 44.815 + 14.06 0.005 **

*Significant (P< 0.05) ** highly significant p= 0.001

Table (4): Frequency distribution and significant difference of Laboratory Investigation between pretes and

postest phase after implementing nursing guidelines . (n=60)

Variable

Study sample

Z

P.V Pretest Posttest

1st Assessment

2nd

Assessment

3rd

Assessment

n % n % n % n % Serum uric acid{ NF:2.5-7mg/dL NM:4.0-8.5 mg/dL} - 5-8 mg/dL (normal) - 9-12 mg/dL (Mild high) -> 12 mg/dL (Moderate high)

5 15 40

8.33 25

66.67

6 17 37

10 28.33 61.67

23 29 8

38.33 48.33 13.33

38 20 2

63.33 33.33 3.33

2.132 1.94 1.00

0.001**

0.005

*

0.005*

Serum Ca (N:8.5-10.5) mg/dL - 9-10.5 mg/dL (normal) - 6--8.5 mg/dL (mild low) - 4 -5.5 mg/dL (moderate low)

0

15 45

0 25 75

1

19 40

1,67

31.67 66.67

9

21 30

15 35 50

20 21 19

33.33

21 31.67

2.52 3.10 1.99

0.001

**

0.001**

0.005

*

Serum lead (N: 5-10 mcg/dL) - 5-10 mcg/dL

- 11-13 mcg/dL

13 47

21.67 78.33

20 40

33.33 66.67

30 30

50 50

50 10

83.33 16.67

12.55

0.006

**

Hemoglobin (Hb)( NF: 12-15g/dL NM: 13-17g/dL) - Normal ( 13-13.9) - Mild low (10-10.9)g/dL - Moderate low ( 8.9-9)g/dL - Severe low ( < 8)g/dL

0 5

16 39

0

8.33 26.67

65

8

20 10 22

13.33 33.33 16.67 36.67

25 30 5 0

41.67

50 8.33

0

51 9 0 0

85 15 0 0

21.5

0.001**

Serum Iron: N:60-170 mcg/dL - > 55- 65 normal - > 45- 55 (low) - 35- 45 (very low)

0

21 39

0 35 65

20 20 20

33.33 33.33 3.33

45 15 0

75 25 0

51 9 0

85 15 0

3.38 3.53 3.31

0.005**

** **

Hematocrite (Hct): (NF: 36%-47% NM: 40%-52%) - Normal -30%--35% very low -35%-- < 40% Low

0 35 25

0 58.33 41.67

13 13 34

21.67 21.67 56.67

30 9

21

50 15 35

60 0 0

100 0 0

3.99 3.89 3.53

0.0005

** ** **

Coagulation time: (N: 2-9 minutes) - 5-9 minutes - 10-14 minutes

12 48

20 80

30 30

50 50

49 11

81.66 18.33

60 0

100 0

10.18

0.001

**

*Significant (P< 0.05) ** highly significant p= 0.001 Post 1: Done after 5 days

post 2: Done after 10 days post 3: Done after 15 days

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Table (5): Frequency distribution and significant difference of systemic assessment( patient's complaint)

between pre/postest phase after implementing the nursing guidelines . (n=60)

Variables

Pretest

group

Posttest

Z P.V 1

st

assessment

2nd

Assessment 3

rdAssessment

n % n % n % n %

Gastrointestinal:

- Abdominal pain

- Anorexia

- Nausea

- Vomiting

- constipation

- Astringency

- Burton line

60

60

60

56

60

50

53

100

100

100

93.33

100

83.33

88.33

41

39

20

34

30

32

53

68.33

65

33.33

56.67

50

53.33

88.33

0

0

0

0

5

0

53

0

0

0

0

8.33

0

88.33

0

0

0

0

0

0

53

0

0

0

0

0

0

88.33

3.99

3.15

2.57

2.78

1.99

3.71

2.78

0.005 **

0.005**

0.005**

0.005**

0.005**

0.005**

1.00 ns

Musculoskeletal:

- Joint pain

- Muscle weakness

- Paraesthesia

60

55

60

100

91.67

100

49

47

50

81.67

78.33

83.33

26

21

40

43.33

35

66.67

9

3

11

15

5

18.33

12.7

0.005**

Visual:

-Blurred vision

48

80

29

48.33

17

28.33

8

13.33

15.1

0.0005**

Neurological

- Short concentration

- Depression

- Fatigue

46

60

60

76.67

100

100

40

50

60

66.67

83.33

100

20

40

41

33.33

66.67

68.33

15

25

10

25

41.67

16.67

11.76

0.005**

* : Significant (P< 0.05). ** highly significant p= 0.001 ns: No significant (P>0.05)

Post 1: Done after 5 days post 2: Done after 10 days post 3: Done after 15

Table (6): Mean scores of knowledge and signifecant changes with lab. investigations obtained during pretes

and posttest of implementing nursing guidelines (n=60)

blood investigations

Knowledge

P-V Pre test posttest

M+SD M+SD

Serum uric acid 0.85+0.75 2.00+0.00 <0.001***

Serum Ca 0.06+0.44 1.97+0.16 <0.001***

Serum lead 0.28+0.53 1.92+0.99 <0.001***

Hemoglobin 0.99+0.94 1.42+0.50 <0.001***

Serum Iron 2.20+4.41 7.78+1.25 <0.001***

Hematocrite 1.20+0.60 1.66+0.53 <0.001***

Coagulation time 3.33+1.55 15.40+7.51 <0.001***

Random Urine protoporphyrin 2.20+4.41 2.00+0.00 <0.001***

Total 11.23+9.30 33.34+18.94 0.001

*Significant (P< 0.05) ** highly significant p= 0.001

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Table (7) Mean scores of knowledge and signifecant changes with patients' complaint obtained during pretes

and posttest of implementing nursing guidelines (n=60)

Patient complaint

Knowledge P-V

Pre test posttest

M+SD M+SD

Gastrointestinal: 0.05+0.43 1.92+0.99 <0.001**

Musculoskeletal: 0.22+0.50 1.42+0.50 <0.0001***

Visual: 0.94+0.93 7.78+1.25 <0.01*

Neurological: 3.23+1.45 2.00+0.00 <0.01*

total 10.25+9.33 29.44+16.94 0.001

*Significant (P< 0.05) ** highly significant p= 0.001

Table 8: Mean scores ,standard deviation and significant differences of the studied subjects for Lab.

Investigation, Patients' complaint and BMI with knowledge scores obtained pre/posttests phase of implementing

nursing guidelines (n= 60).

Variables

Total Knowledge

F-ratio

P. V Pretest Posttest

Mean + SD Mean + SD

Lab. Investigations 126.13+1.34 200.86 +2.02 4.52 ** -

BMI 3.52 +0.33 3.54 + 3.34 - 1.001 ns

Patient's complaint 10.25+9.33 29.44+16.94 - 0.001*

not significant F< 3.32 for unequal numbers

Significant F > 3.33 for unequal numbers * : Significant (P< 0.05).

Table 1: Shows distribution of the studied sample

according to the patient’s characteristics. It revealed

that their mean ages ranged between 44.93 + 11.77

respectively. They were equally 30 male and female,

respectively, while all subjects were married. More

than half of females were pregnant, multipara and

have pervious abortion (20%) respectively. Three

quarter of subjects were worker, but more than half

were university educated and more than one third

were live in rural area. However 43.33% of subject

had normal pulse and more than half had

prehypertensive. Also more than one third of all

subjects were had stage I hypertension but they had

normal EEG.

Table (2): Shows distribution of the studied sample

according lead sources. It revealed that the study

subject's nutritional source as using storage candid

food or water and eating or drinking in ceramic glued

pots were equally 100%. But, cosmetics source were

more than one third of the study subjects. Also, the

entire study subjects were exposure to big amounts of

environmental dust and always chelating it. Also, more

than half were use tab. not faltered water and about 3/4

of the study subject leaving in new painted houses.

Table 3a: Illustrated knowledge level obtained during

pre/posttest of implementing nursing guidelines. It

showed that there was significance statistical difference

between pre and posttest as regard knowledge level of the

studied sample (X2 = 49.2, p= 0.000).

Table 3b: Show Mean Scores, Standard deviation

and Significant Differences of knowledge between

pre/posttest after implementing nursing guidelines. It

revealed that the implementing of the nursing

guidelines significantly affected on the subjects'

knowledge in posttest phase and the highest mean

score in the following area: definition of lead

poisoning, Percentage of lead in the blood

Psychological symptoms of lead toxicity and

methods of treatment ( P.V = 0.005 **) respectively.

Table (4): representative the significant difference of

Laboratory Investigation between pretest and posttest

phase after implementing nursing guidelines (n=60).

It showed there was highly statistically significant

improvement between pretest and posttest subjects

regarding coagulation time, hematocrit, and in

random urine protoporphyrin. In which significant

change was seen after implementing nursing

guidelines in serum iron and hemoglobin as well as

serum lead (P value 0.006) also, there was

statistically little significant changes (P value 0.17)

between pretest and posttest subjects in Ca (P value

0.005). Finally, as a result of implementing nursing

guidelines, the results show that no significant

differences were found for body mass index between

pretest and posttest three assessment phases (P value

1.001).

Based on the Table 5, Illustrated Significant

Difference Of Systemic Assessment (Patient's

Complain) Between Pre/Posttest Phase After

Implementing The Nursing Guidelines Of The

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Studies Sample (No=60). There was significant

difference between the pretest and by the end of the

assessment of posttest regarding to all gastrointestinal

assessment parameters. Concerning to

musculoskeletal system, joint pain, muscle weakness,

and paraesthesia changed with significant difference

on 3rd

assessment (P.V=0.005**). Regarding to

neurological system, short concentration, depression,

and fatigue had a significant difference between pre

and posttest of the assessment, but still a least of

studied sample suffered from previous mentioned

problems. (P.V=0.005**)

Table 6: shows the relation between the knowledge

mean scores with blood investigations obtained

during pretest and posttest of implementing nursing

guidelines (n=60). It revealed that there is highly

statistical significant difference between the mean

knowledge scores and the lab. investigation as regards

pre and posttest phases after implementing nursing

guideline mainly in coagulation time , serum iron, uric

acid and serum lead ( P = 0.001).

Table 7: Illustrated mean scores of knowledge and

significant changes with patients' complain obtained

during pre and posttest of implementing nursing

guidelines. It revealed that there was highly significant

difference improved between the mean score of

knowledge and the mean of patients' complain as regards

pre and posttest of gastrointestinal (p =<0.0001) and

musculoskeletal (p (<0.0001) , while there was little

significant difference improved as related to visual and

neurological assessment respectively, of the studied

sample. p ( <0.01)

Table 8 :Illustrates Mean scores, standard deviation

and significant differences of the studied subjects for

Lab. investigation, patients' complaint and BMI with

knowledge scores obtained pre/posttests phase of

implementing nursing guidelines (n= 60). It revealed

that a significant difference was seen between total

gain knowledge and lab. results and among studied

sample in posttest phase of assessment after

implementing nursing guidelines F-ratio = 4.52 **

(F > 3.33) . Concerning the patients' complain, also,

there was significant changes the patient's complaint

with total knowledge gained by patients (P.V =

0.001). In relation to body mass index,

implementation of nursing guidelines hadn't effect on

it and no significant change between pre and posttest

assessment (P.V = 1.001).

Discussion Lead poisoning is a medical condition that occurs when

people are exposed to lead components through

breathing, swallowing, and rarely, through the skin

(Rabinowitz. 2015). Lead is a colorless, tasteless, and

odorless metal that may be found in dirt, dust, toys,

dishes, and furniture. Lead as a consequence of its

capacity contradicting with biochemical event present in

cells throughout the body, inorganic lead exerts a broad

spectrum of multisystem adverse effects. These health

impacts range from subtle, subclinical changes in function

to symptoms of life-threatening intoxication (Schwartz.

2007). In this study, researcher provided health-based

recommendations of the treatment of adults' lead reached

tried to primary and secondary prevention of lead-

associated health problems. Regarding to

sociodemographic data and clinical characteristics, our

results show that one fifth of studied subjects were

multipara and had perfused abortion. These results are

consistence with Borja-Aburto et al. 2009 who reported

that adverse effects on reproductive outcome constitute a

certain risk of lead exposure to women in reproductive

age.

Based on this study, more than half of the study subjects

were pre-hypertensive, one third was in stage I

hypertension, illustrated a link between lead exposure and

subsequent development of hypertension. These results

are consistence with (Harlan. et al., 2007) who

mentioned that, chronic and acute lead poisoning may

lead to evident clinical symptoms of cardiac and vascular

damage with potentially lethal consequences. Regarding

to pulse, our results showed that more than one third were

normal and approximately one third had bradycardia.

This is in accordance with (Andrzejak. et al., 2014).

In the studied subjects, occupationally who exposed to

lead, their heart rate (HR) was lower than in healthy men,

but (Tymchenko., and Evstafyeva., 2013) confirmed

that during their study period which there were

significantly increased, representing decrease in heart rate

Regarding to EEG, the majority of the studied sample

was normal, and the minority had encephalitis, this is in

accordance with (Kumar. et al., 2009) which stated that,

an adult may have increased resistance to the

development of lead encephalopathy due to the capacity

of the mature adult brain to separated lead away from its

mitochondrial site of action within cerebral and cerebellar

neurons.

( Firestone., 2004) and (Needleman., 2004) say that, in

adults, occupational exposure is the cause of lead

poisoning and people can be exposed when working in

facilities that produce a variety of lead-containing

products. Regarding to sources of lead poisoning, the

results showed that according to occupational source

less than half were belonging paints and dyes works.

Some lead compounds are colorful and used widely in

paints, and lead paint is a major route of lead exposure.

Also the results demonstrated that one third of the study

sample working in gasoline station, this result is

consistent by the findings of other studies with Salvato, et

al., 2003) and (Henretig., 2006) and Nuwayhid, etal

(2001). Two scenarios could have been operating in the

study workers which may have result in elevated blood

lead. Firstly, benzene workers neglect to use face mask

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during work and use the protective cloths and wash their

body after work (Nuwayhid. et al., 2001).

This clearly indicates that they are more likely to be

exposed to lead due to occupational incidences than the

general population. Due to lack of awareness about their

exposure, workers usually eat, smoke or drink while at

work and such workplace practices may aggravate their

exposure (Markowitz., 2000). Also, the results found

more than half of the study samples were use cosmetics

specially kohl this results are consistent with the results of

(Mahmood. et al .,2009) and (Clark. et al .,2009) which blood lead levels was significantly higher in the

participant to whom kohl was applied and greater than 20

micrograms/dl in three of them. Also, according to this

study, all the study subject was exposed to big amounts to

dust which revealed to that the lead poisoning can be

found in all parts of subjects' environment such as the air,

soil, water, and even inside their homes.

As regarding laboratory values, the present study showed,

there was highly statistically significant improvement

between pretest and posttest subjects regarding

coagulation time hematocrit, and in random urine

protoporphyrin. In which significant change was seen

after implementing nursing guidelines in serum iron and

hemoglobin as well as serum lead by using medical

treatment (Iron injection at first 72 hours according to

height, weight, and hemoglobin level followed by using

iron tablets in addition, to diets reach in calcium, Vitamin

C, and Zinc. The result is to some extent similar to

(Sebahat, et al.,2007) which indicated that, iron

deficiency not only causes hypochromic microcytic

anemia, but also increases the absorption of other

elements such as lead (Pb) and cadmium (Cd). The

finding of this study also supported by (Jain, et al., 2015)

which concluded that Lead level ≥ 10 μg/dl was

significantly associated with anemia, decreased iron

absorption and hematological parameters affection. High

blood lead levels were associated with low serum iron

and forrotron.

However, the current study is similar to the estimation

obtained for adult in Egypt (Mostafa, et al., 2009)

explained that for reducing lead absorption the key

nutrients appear to be vitamin C, calcium, iron and, to a

lesser degree, zinc and phosphorus. Dietary deficiencies

in any of these can increase lead absorption, through

supplementation of individuals with already high levels of

these nutrients in their diet that may have much impact on

lead absorption. Further, since these minerals compete

with, or alter lead absorption during digestion, taking

concentrated supplements at one point of time, unless

deficient in that particular nutrient may affect continuing

lead absorption, once the supplements have been

processed through particular stage of digestion. (Alasia,

et al., 2010) showed that the results of their study in the

same line with our study as the mean values of serum

urea, creatinine and uric acid were significantly high in

patient with high blood lead level.

Regarding patient’s knowledge, the findings of the

present study showed that there was highly significant

difference improved between the mean score of

knowledge among patients with lead poisoning and the

mean of their complaint as regards pre and posttsest of

gastrointestinal and musculoskeletal, while there was little

significant difference improved as related to visual and

neurological problems of the studied sample regarding to

short concentration, and depression. (Al-Saleh. 2015)

Confirmed in his similar study that educational programs

that used with university girls diagnosed with mild to

moderate lead poisoning has excellent effect in treating

the gastrointestinal, muscular complies as well as

neurologically.

Also, the present study showed that high significant

improvement was seen between total gain knowledge and

lab. results among studied sample in posttest phase of

assessment after implementing nursing guidelines in

coagulation time, serum iron, uric acid, serum lead and

random urine protoporphyrin and hemoglobin.

According to (Mark, 2016) Learning may effect on

behavior of individual that have a responsible to

contribute to primary prevention and early intervention

efforts to eliminate the occurrence of lead poisoning and

address its effects on children and adults. While much

work to prevent and to intervene early with lead

poisoning has already been achieved through public

health, housing, and medical officials, the role to

identifying and providing appropriate educational

services to who may have been exposed to lead has been

less clear.

Advice-giving approaches aimed at stimulating dietary

behavior change are typically based on variations of the

Knowledge- Attitude - Behavior model. This model is

based on the assumption that exposing an individual to

new information leads to a gain in knowledge, prompting

changes in attitude, which, in turn, will result in improved

dietary behavior. But it needs long days for returning the

nutritional parameter to normal, it was consistent with this

study which showed that BMI was insignificant

comparing between pretest and posttest, with total score

of knowledge, total laboratory investigation. (Paglia. et al

., 2013) and (Rabinowitz.2015)

Conclusion The present study concluded that there was statistically

significant improvement in patients' attending nursing

guidelines regarding lead poisoning with total mean score

of knowledge more than before/ post followed their

therapeutic regimen with iron, Forrotron and nutrition.

Moreover, after implementation of nursing guidelines and

gained their knowledge improved their lab. investigations

levels, and systemic manifestations when compared the

posttest with pre assessment phase

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Recommendations Results of this study calls for the following

recommendations:

1. Establish Diet Therapy Booklet including rich fibers

diet, diet rich in iron calcium and vitamin C, and low

fat in diet.

2. Periodically, or annually schedule Health education

guidelines for all workers in all industries.

3. Lead avoidance or termination of exposure to lead.

4. An importance of follow-up or serial blood lead level

determinations to monitor effects of lead, identifying

and eliminating possible sources of lead poisoning

exposure.

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