Environmental and occupational health and safety are two areas of focus in the Healthy People 2010 initiative, whose two goals are to increase the quality and years of healthy life and eliminate health disparities.¹ Approximately 70% of all premature deaths in the U.S. are directly linked to behavioral and environmental factors.¹ Our physical environment can be harmful, especially when individuals and communities are exposed to toxic substances, irritants, infectious agents, and physical hazards in homes, schools, and worksites.¹

Determining an individual’s risk and reducing exposure require routine exposure history screening with patient assessment and follow-up counseling when needed. Unfortunately, assessing exposure risk is not standard practice in primary care practice. Whether this represents providers’ lack of knowledge of the toxic effects of environmental and occupational exposures, or simply not enough time to conduct a comprehensive history in the clinical setting, it’s a missed opportunity to help patients.

Nurses can prevent and detect occupational and environmental illnesses and disease through assessment for exposures. This is accomplished through raising their level of suspicion for workplace injuries and illnesses and by learning how to take a detailed occupational history.

Obtaining a complete history affords the opportunity to investigate workplace or community exposures that might impact patients’ present and future health. This information enables nurses and other health professionals in hospital- and office-based settings to assess individual risk, to evaluate the need for prevention, to diagnose and treat occupational and environmental illnesses, and to develop an awareness of conditions in the community that may contribute to ill health.

The role of the nurse as investigator is an important means of detecting trends in exposure, illness, and injury. Nurses, at the front line of patient care, are positioned to retrieve this information from patients, who typically view nurses as trusted professionals and community members who can be relied on for accurate health care information. Through their interaction with patients, nurses can have a profound impact by identifying factors related to occupational or environmental exposures that may be overlooked by other health care professionals. In addition, the exposure history provides opportunities for patient teaching regarding the modification or implementation of administrative policies and procedures, engineering controls, work practices, and personal protection equipment.¹ Once exposures are identified, the nurse can begin to formulate a plan to reduce or eliminate exposure.

Our workforce

Approximately 140 million people work in the U.S. In 2006, a total of 4.1 million injuries and illnesses were reported in private industry.² There were 5,703 fatalities in 2006 to private sector wage and salary workers, government workers, and self-employed workers.² Temporary or permanent work-related disability from occupational injuries has led to $170 billion in lost wages, diminished productivity, and a variety of administrative and healthcare costs.¹ Our already diverse workforce continues to change. By the year 2010, women and minorities will comprise 47.9% and 30.8% of the workforce, respectively. The youth labor workforce is expected to grow more rapidly than the overall workforce. The largest component of the workforce, age 25 to 54 years old, is expected to decline from 71% to 66.6% by 2010. Workers aged 55 and older are projected to increase from 12.9% to 16.9% of the workforce by 2010.² On average, adults spend at least 25% of their time at work where they may be exposed to a variety of occupational safety and health hazards.

The community perspective

Many individuals, groups, and communities are at risk from environmental dangers. However, environmental health risks disproportionately affect those who are disadvantaged — minority groups and those with low incomes — in the communities where they live, work, and play.³ Communities with minority populations and high poverty rates are more likely to be located in close proximity to incinerators, hazardous waste sites, and industrial locations where they are apt to experience poor health and disease. In fact, these individuals often have the least control over mitigation of their exposures and are less likely to receive appropriate assessment and treatment of health problems that may arise from community or workplace exposures. For these individuals, worker advocacy, training and education programs, and medical surveillance may be inadequate to meet their needs or may not exist at all. Nurses can serve as key advocates and resources for this population by being cognizant of potential environmental hazards and their impacts on health.

Environmental health hazards

The USPHS recognizes the impact of hazards in the environment and the deleterious effects they can have on health.⁴ Toxins and hazardous substances are ubiquitous in the home, workplace, and community settings. Environmental exposures to substances, such as benzene, lead, pesticides, and ozone, are associated with cancer, asthma, reproductive disorders, and immune impairments. Exposure pathways to environmental hazards occur through air, water, soil, or food. Hazards are classified as chemical (such aerosols as dusts, mists, fumes, and vapors and gases), physical (noise, ionizing and nonionizing radiation, and hazardous motions or postures), biological (HIV, hepatitis, and TB), and psychosocial (stress and personal control of work). These hazards may be naturally occurring (e.g., radon) or may be manmade (e.g., environmental tobacco smoke).

Occupational and environmental factors may adversely impact health status in a variety of situations. Consider the following —

• A teenager skating at an indoor ice skating rink who complains of headache, fatigue, and dizziness due to carbon monoxide poisoning from a faulty ice-resurfacing machine
• A 30-year-old unconscious man who presents in the emergency department after suddenly developing headache, dizziness, vomiting, and diarrhea at home after mixing pesticides to spray his trees
• A deli worker in a supermarket who complains of chronic sinusitis, tearing eyes, and hand dermatitis due to latex allergy from repeated use of latex gloves
• A garment worker who complains of numbness in some of her fingers as a result of more than a thousand repetitive movements of her hands and wrists during the course of a workday

While occupational health nurses may routinely assess for such factors, a growing consensus is that a heightened awareness of occupational and environmental risk factors is needed in all areas of clinical nursing practice.⁵

The CDC’s National Institute for Occupational Safety and Health performed a study to monitor injury trends and aid with prevention activities.⁶ The researchers found that in 2004 an estimated 3.4 million nonfatal ED-treated injuries and illnesses occurred among workers of all ages, with a rate of 2.5 cases per 100 full-time workers aged greater than or equal to 15 years. Workers aged less than 25 years had the highest injury and illness rates.⁶ More than three fourths of all nonfatal workplace injuries and illnesses were attributed to contact with objects or equipment, bodily exertion, and falls.⁶ They also noted that between 1996 and 2004 no significant reduction occurred in the overall number of ED-treated occupational injuries and illnesses. The researchers recommended that interventions should continue to target workers at highest risk and reduce exposure to those workplace hazards with the greatest potential for causing severe injury or death. They also suggested that future studies should emphasize prevention-effectiveness and dissemination of successful interventions to reduce work-related injuries and illnesses.⁶

Occupational and environmental health history

Key questions need to be incorporated into a routine health history to gain vital information. The use of a mnemonic in clinical assessment can serve as a tool to conduct a focused environmental exposure history, such as I PREPARE (see illustrations).⁷

Consider asking patients the following set of questions. It takes only a few minutes and may be tailored to patients’ specific complaints.

1. What are your current, past, and longest-held jobs? An assessment of a patient’s job history needs to include past and longest-held jobs because many exposures are associated with long latency periods before an adverse pathophysiologic effect can be detected. For some occupational illnesses, the latency period from time of exposure to development of symptoms is highly variable and sometimes very long. A classic example of an exposure with a long latency period is asbestos. It takes an average of 20 years before the signs of asbestosis may be detected, and up to 35 years for mesothelioma — cancer of the pleural or peritoneal linings — to become evident.⁸ Taking a thorough job history, therefore, is crucial to making the link between exposure and health outcomes.

2. Have you ever been exposed to any radiation, chemical liquids, dusts, mist, or fumes? People are commonly exposed to such agents as radon, solvents, pesticides, lead, asbestos, and tobacco smoke. Exposure to these substances may occur as a result of industrial or natural processes (e.g., radon decay), water and soil contamination, or indoor air pollution. The most frequent human health outcomes of concern are cancer, genetic or chromosomal effects, reproductive and developmental toxicity, acute and chronic toxicity, and neurotoxicity. Specific agents associated with these outcomes include benzene, ionizing radiation, anesthetic gas, cyanide, and mercury.

Nurses should determine whether patients wear appropriate personal protective equipment, such as a respirator, gloves, and goggles, when working around potentially hazardous agents. Employers are required to provide workers with the personal protective equipment necessary to safely complete job tasks. They must also provide workers with appropriate medical evaluations and training mandated by the Occupational Safety and Health Administration (OSHA). Employers who fail to provide these measures place workers at risk for occupational injuries and illnesses.

3. Do you believe there is any relationship between your current symptoms and your activities at work or home? Determining the temporal relationship between symptoms and exposures may indicate an occupational or environmental etiology. The answers to the following questions may even establish a cause and effect relationship. Ask patients —

• Do your symptoms subside after you’ve been home from work for a few hours?
• Do you feel better during weekends or your days off?
• Do you notice improvement while on vacation?
• Have other individuals at work, home, or in the community experienced similar symptoms?

By asking these questions, nurses can learn a great deal about where and when the symptoms occur and who is affected. For instance, if a patient identifies symptoms that occur while at work and subside after he or she returns home, then the workplace would be the suspected source. A stronger case can be made to support work-relatedness if other employees at the workplace are similarly affected.

4. Can you describe your typical workday? Workers’ job titles alone do not offer enough information about the type of work they perform and the potential for exposure. A description of a typical workday can better characterize the job. Nurses should obtain information about specific tasks (e.g., lifting, bending, sitting, climbing, grinding, spraying) and materials or agents used (e.g., solvents, particles, metals, pesticides). It is equally important to ascertain changes in work routines or processes. For example, the use of a new product, an increase in workload, or a change in schedule may trigger symptoms in workers who were previously asymptomatic.

5. What are your hobbies? One area that should not be overlooked when eliciting an exposure history is patients’ leisure pastimes and practices. For example, activities, such as building models (glues and solvents), working on motor vehicles (asbestos and carbon monoxide), and making stained glass (lead solder), can be hazardous. Additionally, ingredients in some folk or nontraditional healing medications and cosmetics may put patients at risk. For example, some cosmetics produced outside of the U.S. have been known to contain lead or mercury.

Taking a closer look

When a preliminary assessment indicates a potential exposure at home, nurses should make further inquiries; for example, knowledge of the geographical location of the home may provide useful information.⁹ Consider whether the home or apartment is located near a major highway, gasoline station, factory, or hazardous waste site. And be vigilant for passive exposure, which occurs when household members bring hazards home to their families from residues left on skin or clothing from work.

Nurses commonly encounter complaints related to insulation (e.g., asbestos, fiberglass, urea formaldehyde foam), the home heating and cooling systems, and cooking equipment. If carbon monoxide exposure is suspected, ask about the source and condition of heating, cooling, and cooking methods. Malfunctioning furnaces, fireplaces, or stoves can produce excessive levels of this substance.

Serious adverse effects also have been associated with several household products, including methylene chloride (used for paint stripping and thinning); tetrachloroethylene (used to dry clean clothing); and paradichlorobenzene, a substance in air fresheners, toilet bowl deodorizers, and moth crystals.¹⁰ Problems associated with these agents include angina (methylene chloride); erythema and blistering of the skin; increased risk of liver cancer (tetrachloroethylene); and headache, dizziness, nausea, and eye and skin irritation (paradichlorobenzene).^8,11 Unfortunately, many people do not read the labels on products, so they are not familiar with the associated risks.

Obtaining information about how patients use, store, and dispose of products is vital to a comprehensive patient assessment. Nurses need to identify hazardous products and how they are applied. For example, with lawn care products and pesticides, do the homeowners use certified personnel or do they apply the substances themselves?

Pediatric exposure

Children, infants through adolescence, are in a dynamic state of growth with cells multiplying and organ systems developing at a rapid rate, which makes them more vulnerable to the toxic effects of environmental hazards that can lead to permanent and irreversible damage.¹² All children are affected by these hazards and factors, such as the child’s developmental stage and socioeconomic status, significantly influence the degree of risk.¹²

Infants and toddlers are likely to spend a considerable amount of time on the floor, carpet, or grass where they may be exposed to formaldehyde or pesticide residues; they are also susceptible to breathing particles of such substances as mercury and radon that settle out or accumulate at lower levels, respectively. Poverty can compound the adverse effects of toxicant exposure because it is often associated with inadequate housing, poor nutrition, and limited access to health care.^12,13

Children have a higher metabolic rate than adults and may consume greater amounts of food and fluid — some of which might be contaminated — and encounter proportionally greater exposure. Pediatric exposures can result from children’s hand-to-mouth behaviors of eating indiscriminately or of putting their mouths on objects that may be contaminated (e.g., wooden playground equipment treated with arsenic and/or creosote) or soiled by lead-tainted dirt. According to the American Academy of Pediatrics, 25% of U.S. children remain at risk of lead poisoning.¹⁴

Physical examination

The physical examination of patients with occupational and environmentally related diseases may help to determine the etiology of their illness. Unfortunately, the physical symptoms caused by most environmental agents do not point to the specific causative agent. As a result, other tests must be used to arrive at a diagnosis.¹⁵

In patients with suspected occupational lung disease, such as occupational asthma, a pulmonary function test and chest X-ray may be necessary.¹⁵ Occupational asthma occurs with exposure to chemicals. Occupational asthma causes reversible, obstructive pulmonary dysfunction. Computed tomography (CT) and high-resolution computed tomography (HRCT) have been shown to provide earlier detection of silicosis and asbestosis.¹⁵

As with any other illness, laboratory testing may be necessary to arrive at a definitive diagnosis. Examples of laboratory tests that can be used to diagnose specific environmentally induced illnesses include urinalysis to detect arsenic and cadmium, bacterial cultures to diagnose tuberculosis and anthrax, and fungal studies to diagnose coccidioidomycosis and histoplasmosis.¹⁵

Diagnosis

One of the reasons why occupational and environmental illnesses are underdiagnosed is that they can resemble other chronic diseases. Examples of this include: 1) lung cancer caused by asbestos or radon, but can be attributed to cigarette smoking; 2) abdominal pain caused by lead poisoning, but can be misdiagnosed as appendicitis; 3) hearing loss caused by noise, but can be attributed to advanced age; and 4) occupational asthma can be misdiagnosed as intrinsic asthma.¹⁵ In general, an occupational or environmental etiology should be considered if the illness does not respond to standard treatment, is improved while on vacation, or if the origin is unknown.¹⁵

Treatment and management

Once an occupational or environmental illness has been identified, the next step is to prevent further exposure to anyone working or living within that area connected with the illness. It is at this point that the healthcare provider becomes the patient’s advocate. This may involve contacting officials in government or industry who can deal with the hazardous exposure. The treatment plan depends on the type of occupational or environmental illness.¹⁵

Where to go for information

Healthcare professionals need quick, accurate information about chemicals and hazardous substances. Local and state health departments should be used as primary resources because of their knowledge about community concerns. Employer, manufacturer, or government agencies, such as the Environmental Protection Agency (EPA), the National Institute for Occupational Safety and Health (NIOSH), and OSHA can provide more specific information. For example, OSHA, under the Right-to-Know Law, requires manufacturers to create a Material Safety Data Sheet (MSDS) for each chemical that they produce. In addition, employers who use the chemical are required to retain a copy of the MSDS on file in the workplace.¹⁶ MSDSs contain the chemical and trade names, as well as physical, safety, and health hazard data, emergency procedures, reactivity data, special protection information, and precautions for proper use. Caution should be used when reviewing MSDSs because they are sometimes incomplete, inaccurate, or difficult to interpret.¹⁷ Some MSDSs may report only limited information on human health effects and may not provide supplemental information on the combined or synergistic effects of multiple chemical exposures.

Regional poison control centers also can provide information even when the chemical generic name is unknown because they are equipped with Poisindex, a database designed to identify and provide ingredient information about more than 750,000 commercial, pharmaceutical, and biological substances. Poisindex also contains treatment information for exposures to the listed substances along with a treatment protocol for unknown toxins. Many emergency departments also have access to this database.

If a patient is experiencing symptoms that appear to be related to an occupational or environmental exposure, healthcare professionals can contact an occupational health nurse (OHN) for more information. Focusing on the promotion, protection, and restoration of workers’ health, OHNs are the largest group of healthcare professionals at the workplace. More than 10,000 nurses belong to the American Association of Occupational Health Nurses (AAOHN). OHNs often work with occupational health physicians who monitor any adverse effects of the workplace environment on the health of both individuals and populations. At times, patients may be referred to an industrial hygienist, who is involved with the recognition, evaluation, and control of work-related factors or stresses that may cause illness or impaired health or well-being.

Conducting an exposure history gives nurses a starting point for promoting nurse-patient communication and a professional relationship, addressing prevention issues, and heightening awareness of occupational and environmental illnesses. With information gathered from the exposure history, nurses can counsel patients about strategies to prevent further exposure to hazards, communicate the nature and extent of health risks arising from exposures, and probe into the exposure or hazards as possible agents for current or future health problems.

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