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Occupational Health Guide for Primary Care
- 1. Occupational Health in Primary Care Maureen Ryan PhD, RN, FNP-BC
- 2. Occupational Health Occupational health deals with all areas of health and safety in the workplace, with a special focus on prevention of hazards. Workers’ health has several determinants, including personal risk as well as risk factors of the workplace leading to cancers, accidents, musculoskeletal diseases, respiratory diseases, hearing loss, circulatory disorders, stress related disorders and communicable diseases and others. World Health Organization (2007). Workers’ health: global plan of action
- 3. Occupational Health Founded on a variety of scientific principles including public health, medicine, nursing, epidemiology, toxicology, industrial hygiene, safety and social and behavior science Healthy People 2020 calls for increased access to healthcare services (think on site clinic) and an increase in comprehensive worksite health promotion programs, including educational programs on substance abuse and stress.
- 4. American Association of Occupational Health Nurses Promote a safe and healthy workforce and workplace Identify health problems and hazards in the workplace; develop health and safety programs focused on reducing risk and hazard Assure that health and safety programs are in compliance with federal, state and local regulations
- 5. American Association of Occupational Health Nurses Assess and monitor the health states and interventional outcomes for employees Serve as a resource for employees and the employer for selection of appropriate and cost- effective health care resources Monitor heath care outcomes to establish effectiveness
- 6. Occupational Health Advanced Practice Nurses may also develop strategies to maximize employee health (exercise session prior to starting work) that will maximize employee productivity and reduce costs for the company. The APA may also educate management on the impact of worker’s health issues on the profitability of the company. Plays an important role in development of polices and procedures which may impact workers health.
- 7. Occupational Health Advanced Practice Nurses in occupational health enhance the health of workers through preventative medicine, clinical care including acute injuries, disability management, research and education. The role of the Advanced Practice Nurse in Occupational health may also include health promotion/disease prevention.
- 8. Occupational Health A variety of services may be offered such as drug testing, pre-employment physical exams, Department of Transportation certification exams, injury management, disability assessments, worksite wellness programs, safety training, and annual physical exams (including yearly PFT’s and blood testing for environmental exposures). Advanced Practice Nurses may also work as program managers or disability managers within the organization.
- 9. What is a work related injury or illness? United States Department of Labor- Occupational Safety and Health Administration 1904.5(a) Basic requirement. You must consider an injury or illness to be work- related if an event or exposure in the work environment either caused or contributed to the resulting condition or significantly aggravated a pre-existing injury or illness. Work relatedness is presumed for injuries and illnesses resulting from events or exposures occurring in the work environment, unless an exception in 1904.5(b) specifically applies. Exceptions: voluntary participation in a health program, eating, preparing food, common cold or flu, being a member of the general public vs. employee
- 10. When do workers compensation benefits begin? In Michigan, all work related medical care is covered. Salary benefits do not start until the worker has missed 7 days of work. If a worker is out of work for between 8-14 days, payment starts on day 8 and continues to day 14. If a worker is out of work for more than 14 days, payment is retroactive to day 1. Payment is generally 80% of after tax wages prior to the injury (there is a formula).
- 11. Common Work Related Injuries Carpal Tunnel Syndrome Foreign Body to Eye Corneal Abrasion Epicondylitis
- 12. Carpal Tunnel Syndrome Compression of Medial Nerve as it travels through the carpal tunnel Pain and paresthesia in the median nerve distribution- palmar aspect of the thumb, index and middle fingers and radial half of ring finger.
- 13. Carpal Tunnel Syndrome Most common entrapment neuropathy of the upper extremity, affecting 3% of the general adult population. Three times more common in woman than men, increases with age Risk factors: family history, diabetes, obesity, hypothyroidism, pregnancy and rheumatoid arthritis Patients often wake up and shake the hand and wrist to relieve pain (Flick sign, 93% sensitive, 96% specific for CTS) Pain may be localized to the wrist, hand forearm or shoulder Paresthesia predominates early in the course of the disease, weakness of thumb abduction and opposition can occur later on with motor involvement.
- 14. Work related Carpal Tunnel Syndrome High degree of repetition and force Gripping with hand, such as stapling or use of hand machinery Repetitive hand motions Awkward hand positions Mechanical stress on the palm Use of vibration Link between CTS and keyboarding is uncertain Common Occupations: Hairdressers Cashiers Knitters Bakers People who milk cows Butcher Mechanic Painter
- 15. Assess work history Current job, time at job, tasks, products made, potential exposure to toxins Do symptoms change between work and home? Have you had similar symptoms in the past? Do you have symptoms like this on vacation? Any recent changes to tasks or work at home? Previous work or work injuries Part time work? Time spent at each task at work? How stressful is your job? Do you enjoy your job? Hobbies at home? Home activities and projects? Other medical health problems or medications? (Generally not shared with the employer)
- 16. Occupational Carpal Tunnel Syndrome Physical exam: note skin and muscle development of the hand and wrist Range of motion and strength of individual finger joints and wrist Tinel’s Sign- taps the median nerve, and tingling into the fingers of the median distribution is a positive sign Phalen’s Sign- patient puts the back of the hand together for one minute to assess tingling
- 17. Occupational Carpal Tunnel Syndrome Wear splint to reduce pressure on carpal tunnel Take NSAID’s to reduce swelling Avoid prolonged bending at wrist Avoid bending neck forward or slouching Use of warmth and cold to reduce pain Exercises to increase strength of fingers Modification of work activities- variety of activities vs. one
- 18. Occupational Carpal Tunnel Syndrome Electromyography- electrodes are placed on the forearm and electrical current is passes though the patient. Measurements are taken how fast and how well the median nerve transmits messages to the muscles. If positive, then refer to Specialist for evaluation and surgery
- 19. Eye Injuries in Occupational Health Highest risk for injuries in laborers, fabricators, equipment operators, repair workers, and production and precision workers One half of all injuries occur in manufacturing, service and construction industries Eighty-one percent of injuries occur in men, with most workers 25-44 years of age. Ninety percent of eye injuries could be prevented with the proper use of eye equipment However, a worker may have on safety googles and still have a work related injury such as a piece of metal going into the eye Workers must be extremely careful with use of lasers.
- 20. Eye injuries in Occupational Health Take an in-depth history Record near and far vision (with and without corrective lenses) Inspect: Eyelids, conjunctiva, pupils, red reflex exam, cornea (noting any opaque areas), note any metallic bodies. Evert eyelids Fundoscopic exam Slit lamp: search cornea and conjunctiva. Make note of anterior chamber. Equipment needed for eye exams: Eye chart Fluorescein Dye Tetracaine PH paper Slit lamp Short acting mydriatic agent such as Mydriacyl) Corneal Drill with burrs 18 gauge needle
- 21. Eye Injuries in Occupational Health Corneal abrasions: Eye may be very sensitive, patient may have tearing and difficulty opening the eye Instilling tetracaine can be therapeutic and diagnostic- pain is relieved, problem is from the cornea Note where the abrasion is -this is a large abrasion over the visual axis- use the face of a clock as a reference.
- 22. Eye Injuries in Occupational Health Corneal Abrasion at the 6o’clock to 9 O’clock position Corneal ulceration (may be visible with naked eye)
- 23. Eye Injuries: Occupational Health Skating Rink Pattern Dendritic Body- Herpes
- 24. Corneal Abrasion: Occupational Health Patching for comfort is ineffective for corneal abrasions Some providers will non-infected corneal abrasions with topical antibiotics, although evidence is limited Erythromycin and Bacitracin are preferred. Addition of Acular may be beneficial for symptom relief, however may delay healing Liquid tears may provide some relief Foreign body sensation until cornea is healed Mydriatic medications are no longer recommended for routine corneal abrasions Offer oral pain medication Recheck in 1-2 days Refer if not resolved in 3 days
- 25. Foreign Body in Eye: Occupational injury Complete eye exam including visual acuity (check for blood in anterior chamber) Instill topical anesthesia Use 18 gauge needle to remove metallic foreign body Rust ring: remove using an 18 gauge needle or Ophthalmic Burr
- 26. Chemical Burns: Occupational Health Alkalis (pH greater than 10) are more dangerous than acids (pH less than 4) Litmus paper is used to establish alkalinity or acidity Immediately start irrigation- Morgan lens (physiologic saline) irrigate for 1 hour May stop when pH paper is near neutral (6-8 pH)
- 28. Protection of Eyes: Occupational The Occupational Safety and Health Administration mandates employers provide workers with adequate eye protection such as googles with side shields Welding causes 1,200 injuries per year secondary to corneal burns. Welder’s helmet and safety googles are essential Outdoor workers need sun protection to prevent macular degeneration Eye glasses are not a substitute for safety glasses Workers exposed to fruits and vegetables may be exposed to allergens that will cause conjunctivitis If employee comes in after an exposure to a chemical, they are mandated to provide a Material Safety Data Sheet which will give the chemical components of the substance.
- 29. Epicondylitis: Occupational Health Occurs at the lateral or medial surface of the elbow Lateral epicondylitis is referred to as “Tennis Elbow” with medial referred to as “Golfers Elbow” Risks for medial: forceful work such as wrist bending/twisting, and forearm twisting bending such as assembly work Sharp pain over the epicondyle
- 30. Epicondylitis: Occupational Health Recent studies show that tennis elbow is often due to damage to a specific forearm muscle. The extensor carpi radialis brevis (ECRB) muscle helps stabilize the wrist when the elbow is straight. This occurs during a tennis groundstroke, for example. When the ECRB is weakened from overuse, microscopic tears form in the tendon where it attaches to the lateral epicondyle. This leads to inflammation and pain.
- 31. Physical Exam: Tennis Elbow Palpation: Maximal tenderness is elicited 1-2 cm distal to the origin of the ECRB at the lateral epicondyle. Pain is increased with resisted wrist extension, with the wrist radially deviated and pronated and the elbow extended Pain may also increase when the patient attempts to lift the back of a chair with the elbow extended and the wrist maximally pronated. Resisted extension of the middle finger is also painful secondary to stress placed on the ECRB tendon, as it is preferentially stressed in this position when it must contract synergistically to anchor the third metacarpal, such that extension can take place at the digits. [9] Increased pain is noted with resisted supination, gripping hand shaking. Always examine ROM of the shoulder, elbow, and wrist on the affected side.
- 33. Treatment of epicondylitis Interventions: Reduction of stress by changing job duties NSAID’s Elbow Strap Physical therapy Injections Surgery