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sc khe ngh nghip trong chin lc chm sc sc kho ngi lao ng Mc tiu: sau bi hc ny, hc vin c kh nng 1.

M t c mc tiu, ni dung hot ng ca mn hc SKNN 2. Trnh by c cc nguyn tc trong cng tc CSSK ngi lao ng . 3. Nu c cc mc tiu cn t c trong cng tc CSSK ngi lao ng. 4. Trnh by c cc bc trong lp k hoch CSSK ngi lao ng

Ni dung 1. Khi nim c bn v lch s ca sc kho ngh nghip 1.1. nh ngha v sc kho ngh nghip C nhiu nh ngha v sc kho ngh nghip ( SKNN). Mt nh ngha n gin l sc kho khi lao ng (health at work), tng t vn sc kho pht sinh t lao ng (Health problems arising from work). Mt nh ngha khc l sc kho ca cng ng lao ng (the health of the working population). Chng ta hy xem xt phng trnh sau Lao ng (Work ) Sc kho ( Health)

Lao ng c th nh hng n sc khe. Xut pht im ca sc khe ngh nghip lin quan ti kha cnh ny. V d bi c th gy tn thng phi ca cng nhn, do nh hng ti sc khe ca h. Mt khc, sc khe c th nh hng ti lao ng. R rng rng mt cng nhn m au hoc b ri lon khng c th lao ng c v.v. SKNN ph hp vi quan im hin i l lin quan ti c hai v ca phng trnh, mi quan h gia lao ng v sc khe, l hai mt ca vn . 1.2. V tr ca SKNN trong khoa hc y hc v trong Y hc d phng Sc kho ngh nghip l mt trong nhng b mn thuc khoa hc Y hc d phng v Y t cng cng. Vi s phi hp ca nhiu mn khoa hc khc nh vt l, ho hc, k thut cng ngh, v sinh, sinh l, sinh ho, c cht, dch t hc, sc kho mi trng, cc b mn lm sng SKNN c mc ch cui cng l hn ch c cc yu t nguy c bo v sc kho ngi lao ng. SKNN c nhim v phc v lao ng sn xut, chm sc sc kho ngi lao ng cng nghip cng nh nng nghip, tiu th cng nghip

Mi trng nhim Chn on

Bnh

Nhn

bit

nh

gi

vn

iu tr v cha khi Bin Mi trng tt Ngi kho Hnh 1. Tng tc gia con ngi v mi trng 2. Mc tiu, ni dung hot ng trong sc kho ngh nghip 2.1. Mc tiu: t mc tiu tng qut ca y hc Sc khe l tnh trng thoi mi v th cht , tm thn v x hi ch khng phi l tnh trng khng mc bnh, tt nguyn (OMS 1946). Sc khe ngh nghip c mc tiu chung l : Tng cng v duy tr mc tt nht v th cht, tm l, x hi ca mi ngi lao ng, phng nga c mi tc hi n sc khe do nguyn nhn iu kin mi trng lao ng xu c cc yu t tc hi; Tuyn chn v m bo cho mi ngi lao ng c lm nhng ngh thch hp vi kh nng tm sinh l ca h (WHO v ILO - Ngh quyt hi ngh lin tch thng 1/1950 v thng 4/1963). Hin chng ca WHO, bn tuyn ngn Alma Ata v CSSKB, chin lc php kim sot, d phng

Sc khe cho mi ngi ca WHO v cng c ca ILO v v sinh an ton lao ng cng vi nhng vn khc qui nh quyn c bn i vi sc khe c th t c cao nht cho mi cng nhn. t c mc tiu ny phi m bo cc dch v y t lao ng n vi mi cng nhn trn th gii bt k tui, gii, dn tc, ngh nghip, dy lm cng, qui m hoc v tr lm vic (Bc kinh 10/1994). 2.2. i tng v ni dung ca sc khe ngh nghip: 2.2.1. i tng: - Nghin cu mt cch c h thng nh hng ca tng yu t tc hi trong qu trnh lao ng, hon cnh, iu kin mi trng lao ng i vi sc kho v s p ng thch nghi ca c th. - Tm ra nhng bin php, gii php v mt k thut cng ngh, v sinh hc, ecgnmi ci thin iu kin lm vic, hp l ho sn xut tng cng sc kho, nng cao kh nng lm vic, tng nng sut lao ng, phng pht sinh tai nn lao ng (TNL), bnh ngh nghip (BNN). - Nghin cu son tho, c th ho cc vn bn di lut v iu l, tiu chun v sinh lao ng, khm tuyn, khm nh k, gim nh BNN cho mi ngi lao ng v cc qui trnh thanh tra VSL, khm cha bnh, phng bnh ti cc c s sn xut, cng lm trng, x nghip ...

2.2.2. Ni dung ca sc kho ngh nghip bao gm. -V sinh lao ng (Occupational hygiene). Vai tr ca cc nh v sinh l nhn bit, nh gi v kim sot cc yu t v cc stress ca mi trng lao ng c nh hng ti s thoi mi, tin nghi v sc kho ngi lao ng. - An ton lao ng (Occupational safety). Vai tr ca cc k s an ton l tm ra cc yu t nguy c gy ra chn thng v xut cc gii php v an ton lao ng, phng chng TNL. - c cht ho hc (Toxicology) l khoa hc nghin cu mi lin quan gia c th v cht c, xc nh gii hn nng tip xc ti a cho php v d phng cc nhim c ngh nghip - Tm l lao ng (Psychology of work) nghin cu c im yu t tm l trong qu trnh lao ng, phng chng cng thng v tng cng kh nng lao ng, sc khe cho cng nhn. - Sinh l lao ng (Physiology of work) nghin cu cc bin i v s thch ng ca c th trong cc loi hnh lao ng khc nhau tm ra gii hn sinh l ca ngi trong qu trnh lao ng v xut cc gii php phng chng mt mi, tng cng sc kho v kh nng lao ng. - Ecgnmi (Ergonomics) l khoa hc lin ngnh nghin cu v cc phng tin, phng php sn xut, mi trng lao ng v sinh hot ph hp vi cc c im hnh thi, sinh

l, tm l ca con ngi h lm vic nng sut cao, an ton v thoi mi. - Bnh ngh nghip (Occupational diseases) nghin cu nhm pht trin sm nhng trng hp ri lon sc kho, ng thi xy dng tiu chun on, iu tr, gim nh bnh ngh nghip. 3. Cng tc chm sc sc kho (CSSK) ngi lao ng . 3.1. CSSK ngi lao ng Cng tc CSSK ngi lao ng c thc hin m bo cc nguyn tc : - Cng bng y c ngha l ngi lao ng b sc to sn phm cho x hi v vy h phi c chm sc p ng vi nhu cu ca h. - Cng ng tham gia theo quan im x hi ho s nghip chm sc v bo v sc kho nhn dn. - Qun trit d phng tch cc c mi trng an ton v sinh, t c hi v khng nguy him n sc kho ngi lao ng - K thut thch hp, kt hp y hc hin i vi y hc c truyn - T lc cnh sinh c ngha l mi ngi t nguyn nng cao sc kho ca mnh bng cc bin php d phng, tng cng tp luyn, cng

ng nghip tm ra cc gii php ci thin iu kin lao ng, nng cao sc khe. 3.2. Mc tiu cn t c trong cng tc CSSK ngi lao ng - Gim ti thiu tnh trng nhim mi trng v cc gnh nng th lc, thn kinh tm l trong cc c s sn xut. Khng xy ra cc v nhim c ngh nghip hoc TNL cho cng nhn. - Tnh trng nhim mi trng ti cc c s sn xut t nhn, c nhn v tp th cn c kim sot bi h thng y t lao ng cc tnh, a phng. - m bo mi ngi lao ng khi m au, TNL, bnh ngh nghip phi c chy cha bng cc hnh thc. ng thi quyn li ca h c thc hin theo ng php lnh BHL v lut lao ng. c th pht hin nhng trng hp bnh tt cc c s phi tin hnh khm nh k u n. - Cng c h thng Y t lao ng cc tnh, qun huyn v cc Trung tm y t ngnh, cc c s. m bo cc hot ng gio dc thc v sinh, an ton lao ng cho cng nhn, ng vin h tham

gia vo phong tro ci thin iu kin lao ng, nng cao sc kho ni lm vic . - B xung v hon chnh cc vn bn php qui v y t lao ng.

3.3. nh hng cng tc Y t lao ng giai on 20062010 Theo Chin lc pht trin YHDP, trong c cp ti cng tc YHL 3.3.1. Mc tiu chung : - Tng cng cng tc qun l v gim st mi trng lao ng, c bit i vi ngnh ngh nng nhc, c hi v nguy him c nguy c cao gy BNN - Thc hin v trin khai cng tc CSSK cho NL trong cc ngnh ngh, lao ng c th nh lao ng n, lao ng nng nghip, lao ng trong cc doanh nghip va v nh. - y mnh cng tc khm pht hin, gim nh v tng bc gim t l mc cc bnh ngh nghip. 3.3.2. Mc tiu c th - Hon thin, b sung cc vn bn php quy v y t lao ng, bnh ngh nghip. Xy dng k hoch v an ton VSL v chng trnh phng chng BNN trong ngnh y t giai on 2006- 2010.

- Qun l mi trng lao ng v BNN ti cc tnh/ thnh ph cng nghip trng im. - Tng cng hot ng phng chng cc BNN bi phi- silic, bnh ic ngh nghip, bnh nhim khun ngh nghip trong nhn vin y t, lao ng nng nghip v lng ngh. - Tng cng thng tin, tuyn truyn v nng cao nhn thc v SKNN cho NL 3.3.3. Cc ch tiu - 100% NL c CSSK, khm sc kho nh k nhm pht hin cc BNN v bnh lin quan n ngh nghip. - Gim 10% s mi mc BNN hin c so vi giai on 2001- 2005. Pht hin v d phng cc bnh mi pht sinh. - Tng 20% s c s lao ng c gim st mi trng lao ng hng nm. - Gim 10% cc v TNL 3.3.4. Cc gii php chnh - u t : u t v c s vt cht v trang thit b cho y t lao ng cc tuyn. - Tng cng cng tc qun l: Hon thin h thng php lut v bo v sc kho cho NL - Kin ton t chc v cng c mng li y t lao ng v phng chng tai nn thng tch cc tuyn

- Nng cao nng lc hot ng v y t lao ng cho cc tuyn - X hi ho cng tc CSSK cho NL 4. Qun l sc kho & Bnh ngh nghip 4.1. Cng tc lp h s sc kho theo di v qun l v sinh an ton ti cc c s sn xut, vic lp h s y t x nghip l cng vic cn thit. Trong h s cn khai thc y cc thng tin c bn v : - Tnh hnh chung - iu tra VSL ca x nghip - Phn v sinh chung ca x nghip 4.2. Khm tuyn Khm sc kho khi tuyn dng l yu cu bt buc cho mi doanh nghip. y l c s cc doanh nghip tuyn chn c nhng ngi c sc kho thch hp cho tng ngh v cng vic. Hin nay chng ta c tiu chun khm tuyn cho cc ngnh ngh ni chung v mt s ngnh ngh c bit ni ring. 4.3. Khm sc kho nh k Khm sc kho nh k nhm pht hin sm nhng trng hp ri lon sc kho v sng lc sc kho ngi lao ng v pht hin nhng trng hp mc bnh ngh nghip. Nhng ngi lao ng c sc kho loi IV, loi V v cc bnh mn tnh c theo di, iu tr, iu dng phc hi chc nng v sp xp cng vic ph hp. Nhng trng hp nghi

mc bnh ngh nghip c a ra gim nh, nu xc nh chnh xc c iu tr, iu dng phc hi chc nng v hng ch n b theo quy nh ca nh nc. 5. Lp k hoch v chm sc sc kho cho ngi lao ng Hng nm ti cc doanh nghip phi xy dng bn k hoch hot ng v cng tc an ton v sinh lao ng, phng chng bnh ngh nghip bo v sc kho cho ngi lao ng. 5.1. Cc yu cu khi lp k hoch Bn k hoach phi p ng nhu cu CSSK ngi lao ng Cc gii php phi c s gp v ng thun ca NL cng nh lnh o v cc ban ngnh c s v phi ch trng ti hiu qu khi s dng cc ngun lc. Bn k hoch cn bao gm cc hot ng trong lnh vc v sinh lao ng, ci thin iu kin lao ng, khm pht hin v iu tr bnh trong ch ti phn xng c nguy c cao, nhng ni c nhiu NL b nh hng. K hoch phi da trn quy nh hnh chnh v quy ch chuyn mn v m bo tnh kh thi v bn vng 5.2. Cc bc lp k hoch 5.2.1. Cc cu hi t ra cho ngi lp k hoch :

Thc trng cng tc an ton v sinh lao ng v y t c s hin nay ra sao? C nhng vn g tn ti? Trong s nhng vn tn ti, nhng vn no l vn u tin cn gii quyt? Nhng mc tiu g cn t ra khi lp k hoch? S chn nhng gii php no? thc hin cc gii php phi c cc hot ng g? thc hin cc hot ng cn thi gian bao lu, thi gian bt u v kt thc? Cn c ngun lc bao nhiu v u? 5.2.2. Cc bc lp k hoch Tng ng vi cu hi t ra trn, c 5 bc lp k hoch : Bc1: Phn tch nh gi tnh hnh Qua thu thp nhng thng tin lin quan cng tc n cng tc an ton v sinh lao ng v sc khe ngi lao ng ca cc c s sn xut theo cc ch s sau: - Cc ch s hnh chnh c bn: Tn doanh nghip, b phn sn xut kinh doanh, tnh hnh nhn lc, sn xut, c im dy truyn cng ngh... - Cc ch s v Cng tc v sinh ATL nh nhim mi trng lao ng ( c kt qu c th), nguy c tai nn lao ng, chy n... - Cc ch s v tnh hnh sc kho, bnh tt chung v bnh ngh nghip ca ngi lao ng. - Cc ch s v t chc v hot ng ca Y t c s.

Bc 2 . Xc nh cc vn tn ti v xc nh u tin - Lit k cc vn tn ti : + Vn v mi trng lao ng + Vn v an ton lao ng + Vn v t chc lao ng + Vn v sc kho ngi lao ng + Vn v ngun lc y t - Xc nh u tin: Sau khi c nhng thng tin cn thit thu thp bc trn, chng ta tin hnh phn tch, xem xt v xc nh nhng vn u tin ti c s sn xut. Cc tiu ch xem xt vn u tin, l : + Mc ph bin ca vn + Mc trm trng ca vn + nh hng n nhiu ngi + Kh nng thc thi, khng qu tn km v tin ca, vt t + Tnh hiu qu + Mi ngi u quan tm ti vn v sn sng tham gia gii quyt Bc 3: Xy dng cc mc tiu Mc tiu c xy dng trn c s cc vn u tin cn gii quyt. Mc tiu cn phi vit c th, r rng c kh nng thc thi.

Bc 4. Xc nh cc gii php thc hin v nhu cu ngun lc Cn lu khi chn cc gii php v xc nh ngun lc : - Tu iu kin thc t ca tng c s, gii php mang tnh kinh t v kh thi. Bn cnh gii php chnh c vai tr then cht v mt k thut, cn c nhng gii php h tr. Xc nh nhng ngun lc c th huy ng, d kin nhng thun li v tr ngi. Mt bn k hoch khng nu r ngun lc cn thit th k hoch s khng th thc thi c. - Vic tnh ton ngun lc cng chi tit cng tt, cn c khon ngn sch d phng v c d tr qu thi gian cn thit. Cc bin php can thip trong k hoch bo h lao ng v chm sc sc kho bao gm: + Cc bin php v k thut cng ngh, an ton thit b + Cc bin php v k thut v sinh lao ng + Trang b bo h lao ng + Chm sc sc khe ngi lao ng, phng chng bnh ngh nghip v tai nn lao ng + Tuyn truyn, gio dc, hun luyn v ATVSL, bo v sc khe, v.v... Trong qu trnh thc hin nu c kh khn v ngun lc hoc c nhng vn pht sinh c th iu chnh mc tiu v iu chnh k hoch.

Bc 5. Lp bng k hoch chm sc sc khe ngi lao ng Mt bng k hoch bao gm cc phn sau:

Tn bn k hoch; Tn cng vic/hot ng; D kin thi gian thc hin; Phn cng trch nhim: ngi thc hin, ngi gim st; D ton kinh ph: Chi ph nhn cng, chi ph vt t, chi ph qun l; Kt qu phi t c; Ph duyt bn k hoch.

Tn ca bn k hoch:................................................

TT Hot ng (1 ) (2)

Thi gian (3)

Ngi thc hin (4)

Ngi gim st (5)

Kinh Kt ph (6) phi

qu

t c (7)

Ngi Ph trch n v

lp

hoch

Ni dung mu h s y t x nghip 1. Phn chung: - Loi x nghip, s phn xng, s lng CBCNV - a im x nghip so vi khu vc dn c, hng gi - T chc y t v tnh hnh sc khe 2. Phn iu tra VSL ca x nghip: - c im ca x nghip: m t dy chuyn sn xut, c im nguyn liu v thnh phm - Tnh hnh chiu sng (cc b, chung), loi hnh chiu sng (t nhin, nhn to) - Tnh hnh thng gi, ht bi, ht hi c (ti ch, chung)

- M t cc yu t THNN bao gm vi kh hu, bi, hi kh c, ting n, rung chuyn, phng x, yu t sinh hc,... - Vn an ton my mc + Vn hnh my mc c an ton khng ? + C s dng nhng thit b a vo v ra nguyn vt liu an ton ? + C che chn nhng b phn nguy him ca my khng ? + C bo dng my mc thng xuyn khng ? - Cc trang thit b bo h lao ng cp pht + Cc loi trang b BHL c pht + C s dng BHL khng ? 3. Phn v sinh chung: - Cung cp nc - Gii quyt cht thi cng nghip: cht thi rn, nc thi - C s phc li - C s y t 4. Kt lun v kin ngh

Cu hi lng gi 1.M t SKNN 2.Trnh by cc nguyn tc trong cng tc CSSK ngi lao ng . mc tiu, ni dung hot ng ca mn hc

3.Nu cc mc tiu cn t c trong cng tc CSSK ngi lao ng. 4.Trnh by cc bc trong lp k hoch CSSK ngi lao ng

Cc yu t nh hng ti sc kho ngi lao ng v bin php d phng Mc tiu bi ging: Sau bi hc ny, hc vin c kh nng: 1. Trnh by c cc yu t chung nh hng ti sc kho ngi lao ng 2. Trnh by c cc yu t nh hng lin quan n iu kin lao ng 3. xut c cc bin php phng chng cc yu t nh hng ti sc kho ngi lao ng 4. Trnh by c cc ni dung trong chng trnh nng cao sc kho ni lm vic Ni dung 1. Khi nim v sc khe Sc kho l quyn li c bn nht ca con ngui v rt quan trng i vi s pht trin kinh t v x hi. Sc kho phi c nhn nhn nh mt ti sn ca con ngi v x hi cng ging nh bt k ca ci vt cht no. Theo T chc Y t th gii Sc kho l tnh trng hon ton thoi mi v th cht, tinh thn v x hi, khng n thun l khng c bnh, khng c tt. Sc kho c ngha ton din v gm nhiu mt khc nhau nh sc kho th cht, tinh thn, tm thn, tnh dc, x hi v sc kho mi trng.
Mi trng X hi

Th cht

Tm thn

Cm xc

X hi

Tinh thn

Tnh dc

Hnh 1. Cc mt ca sc kho. Ngun: T chc Y t th gii (1996). Hng dn xy dng ni lm vic c nng cao sc kho. 2. Cc yu t nh hng n sc kho ngi lao ng C nhiu yu t c nh hng trc tip hoc gin tip n sc kho v s thoi mi ca ngi lao ng v chng tc ng tng h vi nhau. Cc yu t ni lm vic nh mi trng lao ng v cc iu kin v sinh, cc yu t t chc v vn ho ni lm vic, nhim v ca tng c nhn v cc hot ng cng vic, tt c u c nh hng n sc kho cng nhn. Cc yu t v li sng v iu kin sng ca cng nhn cng nh vn ha cu trc cng ng c nh hng n sc kho ca h. Hnh di y ch ra mi quan h tng tc gia sc kho v cc yu t quyt nh sc kho ti ni sng v ni lm vic.

Cc iu kin v mi trng lao ng Vn ho v t chc ni lm vic Cc nhm lm vic

Ni mi ngi

Lm vic

Cc thi quen v phong cch lm vic Cc li sng

Mng li nhm /gia nh

Sng
Vn ho v cu trc cng ng Cc iu kin sng (mi trng cng ng)

Ngun: T chc Y t th gii (1996). Hng dn xy dng ni lm vic c nng cao sc kho. Trong qu trnh lao ng con ngi phi tip xc nhiu vi cc yu t nguy c : yu t vt l, ha hc, sinh hc, iu kin lm vic khng hp l v ecgnmi v mt s loi hnh lao ng nng nhc v th lc, cng thng v thn kinh tm l ph hp vi v s cc loi vn x hi v tm l c xc nh l cc yu t nguy c hoc cc iu kin lm vic c hi xut hin thng xuyn, phi hp v tc ng qua li vi nhau. Cc yu t ny l cc nguy c gy tn thng ngh nghip, bnh ngh nghip, cng thng ngh nghip. 2.1. Cc yu t chung nh hng ti sc kho ngi lao ng

2.1.1. c trng c nhn Cc yu t tui, gii, yu t di truyn, tnh nhy cm ca tng c th c nh hng n sc kho. 2.1.2. Yu t vn ho x hi, kinh t v phong tc tp qun Cc yu t vn ho x hi bao gm trnh vn ho ca NL, phong tc tp qun, an ninh x hi v gia nh... cng nh thu nhp kinh t nh hng n sc kho. 2.1.3. nh hng ca li sng khng lnh mnh ti sc kho Ht thuc l l mt trong cc yu t nguy c ca nhiu bnh nh bnh tim mch, bnh phi, ung th.... c bit i vi NL khi phi tip xc vi cc yu t c hi mi trng lao ng, tc hi s tng ln nhiu khi km theo thi quen ht thuc. Ngoi ra li sng bung th nh mi dm, nghin chch l nhng yu t nguy c ly truyn HIV/AIDS v nhng bnh ly qua ng tnh dc. 2.1.4. Cc yu t mi trng sng tc ng n sc kho - nhim mi trng khng kh xung quanh - nhim ngun nc - nhim mi trng t 2.1.5. Cc yu t dinh dng tc ng n sc kho Ch n cng nh thi quen dinh dng nh hng n sc kho v s pht sinh, pht trin bnh. iu ny cng quan trng i vi NL, bi v cc ngh, cng vic khc nhau i hi nhu cu dinh dng khc nhau. 2.1.6. Cc yu t thuc v chm sc sc kho - Mng li t chc y t - Kh nng tip cn vi cc dch v y t 2.2. Cc yu t lin quan n iu kin lao ng 2.2.1. Yu t lin quan n mi trng lm vic : - Yu t vt l: Vi kh hu xu, bc x mt tri (tia cc tm), ting n, rung, bc x....

- Yu t ho hc v yu t l ho: bi hu c, bi sinh hc, ho cht bo v thc vt... - Yu t sinh hc: vi trng, siu vi trng, k sinh trng, nm mc, cn trng. 2.2.2. Yu t lin quan n tm sinh l lao ng Ecgnmi, li sng, tc phong lm vic... Phn nhiu nhng tc hi ny lin quan n t chc lao ng, thit k v tr lao ng nh: - Lao ng th lc nng nhc - T th lao ng g b - Cc Stress ( tm l, x hi...) - Cng thng thn kinh gic quan, nhp iu lm vic - Tnh n iu ca cng vic - Thi gian lao ng - ngh ngi khng hp l. 3. Tc hi ngh nghip v bnh ngh nghip 3.1. Tc hi ngh nghip Trong mi ngnh ngh, ngi lao ng phi tip xc vi cc yu t nguy c c trong qu trnh lao ng ( hay cn gi l yu t tc hi ngh nghip THNN). Cc yu t THNN lun thay i ph thuc vo qu trnh sn xut. Cc yu t ny c nh hng xu ti sc khe ngi tip xc, c th gy nn bnh ngh nghip (BNN) hay bnh c tnh cht ngh nghip. Theo nh ngha, "bnh ngh nghip l bnh pht sinh do iu kin lao ng c hi ca ngh nghip tc ng i vi ngi lao ng". Tu theo iu kin lao ng c th ca tng ngh m gy nn cc bnh ngh nghip khc nhau nh bnh bi phi silic do tip xc vi bi silic, bnh bi phi- bng do tip xc vi bi bng, bnh nhim c ch v c v hu c do tip xc vi chHin nay nc ta mi c 24 bnh trong danh mc bnh ngh nghip c bo him. Trong thi gian ti s tip tc b sung thm mt s bnh na. THNN khng hn s mi mi gn cht vi ngh nghip m khng th phng trnh c. Tri li, con ngi c kh nng

thay i n, hn ch n, thm ch loi tr hn ra khi iu kin lm vic. mi ngnh ngh c th c nhiu yu t THNN. Cc yu t ny s tc ng phi hp vi nhau. Theo kt qu nghin cu ca L Trung v CS ( ti nghin cu khoa hc Cp B 2002) cho thy: Cc yu t THNN gp trong ngnh sn xut vt liu xy dng l bi, nng, n. Trong ngnh dt l bi, ting n, nng m, ch lao ng ca kp, t th lao ng khng thun li. Trong ngnh giy ngi lao ng phi tip xc vi ting n cao v mt s hi kh c c bit l Clo v H2S. Theo s liu bo co ca Cc YTDP trong Hi ngh trin khai cng tc y t lao ng giai on 2006- 2010 (Bc Ninh thng 2/2006) cho thy giai on 2001- 2005 mc d c nhiu ci thin so vi trc y nhng trong nhiu ngnh ngh, cc yu t THNN vn cn mc ng ch : t l s mu o vt TCCP cao nht l ting n (30,8%), rung chuyn ( 27,9%), bi (22,3%), nh sng (21,4%), vi kh hu (17,3%), phng x, in t trng (11,9%), hi kh c (9,9%) Mi trng nhim nh hng ti sc khe ngi tip xc. T l NL c pht hin BNN l 28.782/ 236.187 ngi khm ( 12,2%) v t l c gim nh/ Tng s pht hin l 26,4%. Trong s cc BNN c gim nh th cao nht l nhm cc bnh bi phi v ph qun (78,1%), nhm bnh do yu t vt l (14,3%), bnh nhim c ngh nghip ( 4,4%), da ngh nghip (2,5%) V vy vic gim st v khng ch cc yu t THNN l cn thit v cp bch nhm bo v sc khe ngi lao ng. Phn loi 3.1.1. Tc hi ngh nghip lin quan n qu trnh sn xut

Yu t vt l - iu kin kh tng xu: nhit , m qu cao hoc qu thp s kt hp ca cc iu kin kh tng xu nh nhit , m, tc gi, bc x nhit - Bc x in t: sng v tuyn in (in t trng cao tn), tia hng ngoi, tia t ngoi - Bc x ion ho: tia X, tia bc x khc - Ting n, rung chuyn - p lc cao, thp Yu t ho hc v l ho - Cc cht c trong sn xut - Bi trong sn xut Yu t sinh hc - S cm nhim v s xm nhp ca vi sinh vt v k sinh trng, nm mc - S tip xc vi ngi bnh hoc sc vt mc bnh, hoc b sc vt mc bnh cn, t 3.1.2. Tc hi ngh nghip lin quan ti t chc lao ng - Thi gian lm vic qu lu, thng ca, lm thm gi - Cng lao ng qu nng, ngh ngi khng hp l - S bt hp l trong vic sp xp sc lao ng - Lm vic t th g b qu lu - S cng thng qu mc ca mt c quan hoc ca mt h thng no

3.1.3. Tc hi ngh nghip lin quan n iu kin v sinh ni lm vic - Din tch phn xng cht hp, my mc thit b t qu gn nhau - Thiu thit b thng gi thong kh hoc c nhng khng hon ton, hiu lc km - Thiu thit b bao che v cch nhit chng nng, chng bi, chng hi kh c, hoc c nhng khng hon ho. - Chiu sng cha tt: nh sng khng hoc chiu sng khng hp l - Vic thc hin cc qui tc v v sinh cng nghip v an ton lao ng cn cha trit - Thiu trang thit b bo h lao ng 3.1.4. Tc hi ngh nghip lin quan n tm sinh l hc - Do qu ti v th lc c tnh, c ng - Do qu ti v thn kinh tm l c chia ra + Tnh n iu ca cng vic do phi lp li nhiu ln cc phn vic. Mc n iu ph thuc thi gian lp li cng mt cng vic. Mc t v trung bnh khi chu k thng xuyn c lp i lp li t 1/2 n 1 pht. Mc cao khi chu k di 0,5 pht. + Cng thng thn kinh v cc gic quan. Da trn vic quan st qu trnh thc hin cng vic : Mc khng ng k khi phi vn hnh my tin, khoan, ca. Mc cng

thng trung bnh khi lm trn gin gio khng che chn, li tu, li xe, sa cha thit b in. Mc cao khi cng vic i hi chnh xc cao nh khi vn hnh cc my o, tip xc vi cc cht d n, d chy hoc lm vic trn cao. + Nhp iu lm vic cao biu th bng s ng tc trong 1 pht. Mc va phi khi c 20 ng tc tay, chn hoc 10 ng tc mnh. Mc trung bnh khi c 20- 40 ng tc tay, chn hoc 11- 20 ng tc mnh. 3.2. Bnh ngh nghip (BNN) 3.2.1. nh ngha - Khuynh hng th nht: BNN l mt bnh gy nn do lao ng hoc do nhng iu kin lao ng v mc trong thi gian lao ng. Theo nh ngha ny BNN c hiu rt rng bao gm BNN, bnh c tnh cht ngh nghip v bnh lin quan n ngh nghip. - Khuynh hng th hai: BNN l mt bnh c trng ca mt ngh do yu t tc hi trong ngh tc ng thng xuyn, t t vo c th ngi lao ng m gy nn bnh ( Thng t lin B 08. TCCB 1976) Hin nay theo nh ngha c quy nh trong B lut lao ng ca nc ta : BNN l bnh pht sinh do iu kin lao ng c hi ca ngh nghip tc ng i vi ngi lao ng 3.2.2. Phn loi 3.2.2.1. Phn loi theo nh ngha - BNN hay BNN thc s bao gm: + BNN c hng ch bo him : 25 bnh + BNN cha c hng bo him - Bnh c tnh cht ngh nghip 3.2.2.2.Phn loi theo nguyn nhn

- Do yu t ho hc nh nhim c ch, benzen, ho cht tr su - Do yu t vt l nh bnh rung chuyn ngh nghip, bnh phng x.. - Do yu t ho l nh cc bnh bi phi - Do vi sinh vt nh bnh vim gan, leptospiro 3.2.3. c im Nguyn nhn gy BNN do rt nhiu yu t c hi trong qu trnh sn xut khc nhau nn BNN c nhiu hnh thi, th bnh. C th nu 1 s c im ca BNN: - BNN phn ln thuc h ni khoa - BNN c th thuc cc chuyn khoa khc nh bnh da ngh nghip, ic ngh nghip - V mt lm sng BNN thuc nhiu chuyn khoa khc nhau. a s BNN l bnh mn tnh, xut hin vi du hiu khng c trng, tin trin chm, ngm ngm - BNN c th l bnh truyn nhim hoc bnh x hi - Mt yu t c hi c th gy BNN hoc c TNL Mn tnh: BNN Cp tnh: TNL 3.2.4. Chn on BNN Mun chn on mt trng hp mc BNN phi da vo 3 yu t: - Yu t tip xc - Triu chng lm sng - Cn lm sng 3.2.5. iu tr a s BNN iu tr ch lm dng qu trnh tin trin ca bnh, cn nhng tn thng khng hi phuc c. V nguyn tc iu tr: - Tch bnh nhn ra khi mi trng lao ng tm thi hoc vnh vin

- Thi cht c ra khi c th - Chng hin tng x ho phi trong cc bnh bi phi - a vo c th nhng cht c tc dng i khng - iu tr triu chng - Nng cao th trng - iu tr d phng 3.2.6. BNN c hng bo him Nm 1976: 1. Bnh bi phi Silic 2. Bnh bi phi atbet 3. Bnh ic ngh nghip 4. Bnh nhim c ch v c, ch hu c 5. Bnh nhim c thu ngn 6. Bnh nhim x (bc x ion ho) ngh nghip 7. Bnh nhim c benzen 8. Bnh nhim c mangan Nm 1991 9. Lot da, lot vch ngn mi, vim da, chm tip xc (Bnh da ngh nghip do crom) 10. Bnh xm da ngh nghip 11. Bnh rung chuyn ngh nghip 12. Bnh bi phi bng 13. Bnh lao ngh nghip 14. Bnh vim gan do virut ngh nghip 15. Bnh do Leptospira ngh nghip 16. Bnh nhim c TNT Nm 1997: 17. Bnh nghip 18. Bnh 19. Bnh 20. Bnh 21. Bnh Nm 2006 nhim c Asen v cc hp cht Asen ngh nhim c Nicotin ngh nghip nhim c ho cht tr su ngh nghip gim p ngh nghip vim ph qun mn tnh ngh nghip

22. 23. 24. 25.

Bnh hen ph qun ngh nghip Bnh nhim c monoxit cacbon ngh nghip Bnh nt du ngh nghip Bnh vim, lot da, mng ngh nghip

3.3. Qun l cc yu t THNN phng chng BNN 3.3.1. Nguyn tc qun l: C th c nhiu yu t THNN cng tn ti mt ni lm vic. phng chng cc yu t c hi cho sc khe NL, hn ch nh hng ca nhng yu t ny n mc thp nht, khi tin hnh cc bin php qun l v ci thin iu kin lm vic cn lu my vn : Cc bin php phng chng yu t nguy c cn phi t ra sm, tt nht l ngay t khi mi thit k xy dng x nghip. V d chn a im, b tr mt bng, thit k h thng thit b v sinh,... Phi c s kt hp cht ch gia Ban gim c, cn b y t v cn b on th nh cng on , c bit l cn b ph trch an ton lao ng trong vic xut gii php ci thin iu kin lao ng. Vai tr cng nhn cng tham gia bn bc xut v thc hin cc ci thin v iu kin lao ng. Tin hnh cng tc tuyn truyn, gio dc sc khe trong cng nhn, cn b, ch doanh nghip lm mi ngi hiu r v thc hin cc bin php d phng, xy dng thc t nguyn chp hnh nhng qui nh v an ton v sinh lao ng, ci thin iu kin lao ng, nng cao sc khe. Cng tc lp k hoch, t chc thc hin, n c, gim st, kim tra thanh tra v sinh - ATL phi c theo di thng xuyn, phi c tin hnh tht tt. Nm chc cc nguy c v c cc bin php kim sot ph hp l mt trong nhng yu t quyt nh m bo s pht trin bn vng ca cc doanh nghip.

3.3.2. Cc bc cn tin hnh trong vic khng ch THNN - Xc nh cc yu t nguy c c trong mi trng lao ng Quan st v tm hiu dy chuyn cng ngh Lit k cc nguyn vt liu, ho cht s dng v cc yu t pht sinh trong qu trnh sn xut T c th s b c on cc THNN c mt ni lm vic. T la chn cc k thut o lng thch hp xc nh phm vi v mc ca cc THNN. - Xc nh mc nguy him ca cc THNN o c cc yu t nguy c v da vo tiu chun ti a cho php i vi tng THNN suy on xem cc yu t nguy c ny nh hng nh th no vi ngi lao ng. nh gi s ngi cng nh mc , thi gian tip xc ca ngi lao ng vi tng yu t THNN. Mc d c nhiu THNN cng tn ti trong mt mi trng sn xut nhng tnh cht nguy him v kh nng loi tr c khc nhau. Trong iu kin hn ch v nhn lc, vt lc v k thut th vic la chn u tin trong vic loi tr THNN l cn thit. Mt s tiu chun sau y c th c cn nhc khi la chn u tin: + Tnh cp bch: nhiu THNN do tnh cht nguy him v mc nh hng ca n nn phi tin hnh loi b (nh mt s cht c nguy him, cht phng x,...). +Kh nng thc thi: iu ny tu thuc vo nhiu yu t nh gi thnh, tnh n gin ca phng php, iu kin nhn lc, trang thit b,...Cc yu t ny s c cn nhc khi la chn THNN s c loi tr trc tin. +Tnh hiu qu phi c lu khi la chn k thut, phng php cng nh loi THNN s c loi b. - Kim tra, xem xt cc thit b k thut d phng hin c y l bc cn lm trc khi trin khai cc bin php d phng mi. N cho php nh gi hiu qu, cht lng ca cc thit b ny, t c k hoch b sung hoc sa cha.

-Thit k, thc thi v duy tr cc bin php d phng thch hp: Sau khi la chn c yu t THNN cn can thip trc, kt hp vi cc k thut d phng hin c, mt phng n v loi tr cc yu t ny c xut. Mt trong cc nguyn tc c bn ca vic d phng cc THNN l nn p dng nhiu bin php i vi mt THNN bi v mi mt bin php s tc ng ln cc khu khc nhau trong qu trnh xm nhp, chuyn ho v o thi ca cht c v mi bin php c nhng u, nhc im ring. 3.3.3. Cc bin php d phng THNN - i vi ngun pht sinh ra cc THNN C th p dng 2 nguyn tc: Can thip i vi ngun pht sinh ra THNN loi b hoc lm gim bt s hnh thnh v gii phng cc THNN Trong trng hp THNN pht sinh, cn hn ch s khuych tn, lan rng ca THNN vo mi trng sn xut bng cch p dng cc bin php can thip bao vy ngun pht sinh cht c hoc can thip trung gian gia ngun v ngi lao ng. thc hin 2 nguyn tc ny, c th p dng cc bin php sau: Thay th nguyn, nhin liu c c tnh cao bng cc nguyn, nhin liu khng c hoc c c tnh thp hn. Tt hn l thay i qu trnh sn xut hoc trang thit b c nh hng khng tt ti ngi lao ng bng cc iu kin thch hp hn, t c hn. y l bin php trit nhng ch c th p dng trong mt s trng hp v thng th gi thnh cao. V d : Thay th benzen bng toluene, si thu tinh thay th si amiant, mi nhn to thay cho mi t nhin

Bo dng my mc, trang thit b thng xuyn. iu ny s m bo ko di tui th ca my va hn ch pht sinh cc THNN. Phng php lm t : Bng cch s dng nc lm m nguyn vt liu, phun nc ti cc ngun pht sinh bi trong qu trnh thao tc s lm gim hm lng bi trong mi trng. Ngoi ra , vi cc mi trng nng, phun nc hoc dng mn nc ngn gia ngun nng v ngi cng nhn s lm gim nhit mi trng. C gii ho, t ng ho qui trnh sn xut nhm: -Gim cc THNN lin quan ti qu trnh sn xut nh bi, hi kh c -Gim s ngi tip xc vi cc THNN Bin php ny khng nhng c hiu qu trong phng chng cc THNN m cn lm tng nng xut lao ng v cht lng sn phm. Tuy nhin u t ban u thng tn km. - Can thip vo s lan truyn THNN t ngun ti ngi lao ng Trong trng hp ny, cc THNN lin quan ti qu trnh sn xut vn tn ti, nhng chng c th hn ch c nh p dng cc bin php can thip. C th p dng cc bin php sau: Cch ly: tc l to ra mt ro chn gia ngun THNN v ngi lao ng. Tu theo tng loi THNN m c cc ro chn thch hp. Khi ro chn ny c t gia ngun v mi trng hn ch khuych tn THNN th gi l cch ly ngun. Nu ro chn t gia mi trng nhim v ngi cng nhn th gi l cch ly cng nhn. Ngoi ra cn hnh thc cch ly bng thi gian nh sau khi n mn, ph , mt lc cho bi lng xung ri cng nhn mi vo lm vic. Thng thong gi: ch l hnh thc lm gim nng , nh hng ca cc THNN trong mi trng. C th: - Ht cc b: Khng kh xung quanh ngun c c ht v a ra ngoi mi trng sn xut nh h

thng qut ht. N s l l tng nu hi kh c, bi ht ra c x l hoc thu hi li. Phng php ny c hiu qu cao nhng cng ch p dng trong mt s trng hp v gi thnh thng cao. - Thng thong ton th: thng l dng qut ht hoc thi gi vi mc ch lm gim, pha long nng ca hi, bi c. Tuy nhin cch ny c th lm khuych tn THNN ra mi trng xung quanh. - Cc bin php khc lin quan n mi trng sn xut v bo v ngi lao ng + T chc v b tr sn xut hp l y l qu trnh b tr cc dy chuyn sn xut, quy trnh cng ngh cng nh s dng nhn lc hp l trong sn xut. Bng vic t chc lao ng hp l ta c th hn ch c s ngi tip xc vi cc THNN, gim bt cc yu t c hi trong mi trng sn xut. Di y l mt s nguyn tc c bn trong vic t chc lao ng hp l: Cch ly cc dy chuyn sn xut pht sinh yu t c hi hn ch tip xc Cc thit b, my mc phi c ch to hoc thay i cho ph hp vi kch thc ngi Vit Nam (ecgnmi thit k v sa cha) B tr cng vic cho ph hp vi c im sinh l cng nh kh nng ca ngi lao ng. Hn ch cc cng vic n iu, t chc thi gian lao ng v ngh ngi hp l. Tuyn truyn ng vin ngi lao ng hng say vi cng vic, yu ngnh yu ngh. iu ny khng ch lm tng nng xut lao ng m cn to ra tm l lao ng tt cho ngi cng nhn, gim bt stress ngh nghip. T chc tt vic chm lo i sng cho ngi lao ng h yn tm sn xut. +T chc chiu sng hp l

Chiu sng khng v khng hp l ti ni sn xut s lm gim nng xut lao ng, mt chng mt mi gy hi cho mt v d gy tai nn lao ng. Ch phi chiu sng hp l. Vi cc ngnh ngh m sn phm cn chi tit, chnh xc th cn ch ti nh sng ti v tr sn xut quan trng hn nh sng chung ca ton phn xng. Ngoi ra, cn ch vic chn loi chp n, chn gc chiu sng thch hp, chn mu sc thch hp, khng chi mt. Tn dng ngun chiu sng t nhin qua h thng ca s, ca ra vo, ca trn mi nh.. + V sinh phn xng, my mc y l cng vic quan trng nhm lm tng tui th cho thit b, my mc, duy tr kh nng tng phn nh sng ca mi trng v gim s tch lu THNN trong mi trng nh bi, cht ci vi ni sn xut c s dng qut thi gi th vic ny cng cn thit v gi c th lm khuych tn tr li mi trng cc bi, cht c l lng xung trc y. + B tr h thng bin bo v vng gii hn iu ny l cn thit phn bit vng c THNN v vng an ton, gip cho vic hn ch ti a s ngi tip xc vi cc THNN + Cc bin php phng h c nhn Bin php phng h c nhn nhm bo v cho ngi lao ng khi tip xc vi cc yu t THNN. Ty theo loi THNN m c trang b phng h thch hp nh knh bo v mt, mt n, khu trang cho ng h hp, qun o, ng, gng cho da, nt tai gim n, m nn bo v u. Thng thng mt loi trang b phng h ch bo v c mt s THNN nht nh. Ngoi ra, hiu qu ca trang b bo h tu thuc nhiu yu t nh cht lng ca trang b, vic cng nhn c t gic s dng v s dng ng hay khng. + Bin php y t, bao gm: Khm tuyn cng nhn trc khi vo lm vic. Tu theo tng ngnh ngh a ra tiu chun khm ph hp nhm

tuyn chn nhng ngi c sc kho vo lm trong nhng ngh nht nh. Mt s vn cn cn nhc nh th lc, tui, gii tnh, cc bnh l mn tnh. Tuyn truyn gio dc sc khe cho cng nhn v tc hi v cc bin php phng chng cc THNN, cch s cu, cp cu khi cn thit. a ra cc hnh thc thch hp gip cng nhn tn trng qui tc an ton, v sinh trong lao ng nh ni qui, bin php khen thng, k lut,... Thc hin thng xuyn gim st mi trng. Vic gim st thng xuyn s c ch li: Pht hin kp thi nhng THNN mi Theo di s bin ng ca cc yu t THNN cng nh mc nhim mi trng c cc gii php kp thi nh gi hiu qu ca cc bin php can thip vi ngun THNN v mi trng. Khm sc kho nh k thng xuyn cho cng nhn nhm pht hin cc biu hin sm ca nhim c ngh nghip trc khi c triu chng lm sng. T ta c bin php d phng, iu tr thch hp. Do khm sc kho nh k phi kt hp c khm lm sng v cn lm sng. Bin php Bin php Theo di v qun l bnh nhn mc bnh ngh phng h nghip k thut v Nhng cng nhn sinhc gim nh mc bnh ngh nghip phi c hng ch theo nh quy nh. ng thi phng y t phi c k hoch theo di v qun l nhng i tng ny ngn nga s tin trin ca bnh v phc hi sc kho.
H cht c t ngun pht sinh ti c th Qu trnh nh hng hp Ngun ngi lao ng v v Tiu tr tc ng ca cc bin php can pht sinh othi thip c minh ho ho hnh 1

THNN

Da, nim mc

Bin php k thut cng

Bin php y t

iu tr

ngh

Hnh 1. ng hp thu cht c v bin php d phng 4. Trin khai chng trnh nng cao sc kho ni lm vic Trong mi trng lm vic, nng cao sc kho m rng khi nim v cc yu t nh hng ti sc kho ngi lao ng. N xem xt ti c cc yu t v t chc, x hi, chnh tr, kinh t, chnh sch v cc quy nh trong mi trng lm vic v cng ng xung quanh. Ngay u nm 1987 sau Hi ngh Ottawa v nng cao sc kho, U ban cc Chuyn gia ca WHO hp ti Geneva nhn mnh tm quan trng ca vic nng cao sc kho cho ngi lao ng. U ban nh ngha nng cao sc kho ti ni lm

vic l qu trnh cho php con ngi kim sot v ci thin sc kho ca mnh . Phm vi ca n t vic chm sc iu tr bnh tt n ngn nga bnh bao gm vic phng nga cc nguy c n thc y t c sc khe ti u. V vy, cng tc nng cao sc kho khng ch thuc phm vi trch nhim ca lnh vc y t m cn l vic phi xy dng li sng lnh mnh c c hnh phc. Hin chng Ottawa v Nng cao sc khe (21/11/1986) tuyn b: Nng cao sc kho to ra iu kin sng v lm vic an ton, thoi mi. 4.1 Ti sao cn phi nng cao sc kho ti ni lm vic. - Ngi lao ng c sc kho v mi trng lm vic lnh mnh l mt trong nhng vn qu gi nht ca mi quc gia. Mt lc lng lao ng kho mnh l mt ngun nhn lc quan trng v l nn tng i vi phc li kinh t x hi ca t nc. Mt lc lng lao ng khng c sc kho c th gy tn tht v kinh t do ngh vic, cc tai nn, chi ph trc tip hoc gin tip cho y t. - Tt c cc thnh vin ni lm vic c trch nhim chung bo v ngi lao ng v cng ng trnh khi cc yu t nguy him ni lm vic v cc yu t ngh nghip c hi i vi sc kho. - Ni lm vic l khu vc l tng tin hnh cc bin php nng cao sc kho cho mt qun th dn c ln v khp kn. a s ngi lao ng dnh gn 1/3 cuc i

ni lm vic. Nhng thng tin phng bnh, gio dc sc khe gip nng cao cc thi quen m bo sc kho c th c truyn t mt cch c hiu qu ti ni lm vic. Cc ni lm vic c c s h tng v mi t chc phi hp v pht trin cc chng trnh nng cao sc kho. - Mt khc, sc kho ca cng nhn cng b nh hng bi cc yu t khng lin quan n ngh nghip v vy vic nng cao kin thc v k nng qun l sc kho c li cho c cng nhn, gia nh h v k c ni lm vic. 4.2. Khi nim nng cao sc kho ni lm vic Mt ni lm vic c nng cao sc kho l to ra mt mi trng h tr c gi tr duy tr v nng cao sc kho cho tt c mi ngi. Mi trng ny cho php ngi s dng lao ng v ngi lao ng ci thin v nng cao sc kho ca bn thn h nhm gip cho h c ngh lc, lc quan v hi lng hn trong lao ng. Hn na, lc lng lao ng lc quan, khe mnh s to ra nhiu ca ci vt cht hn. Ni lm vic lnh mnh hay l mt ni lm vic c nng cao sc kho l nhm : - To mi trng lm vic an ton, c h tr v sc kho.

- Duy tr sc kho cho lc lng lao ng v nng cao sc kho tr thnh mt phn lng ghp ca cng tc qun l doanh nghip. - y mnh s tham gia ca ngi lao ng v ngi s dng lao ng - Li cun s tham gia ca cc thnh vin trong gia nh ca cng nhn. to c nhng ni lm vic c nng cao sc kho, cn c cc bin php an ton v v sinh lao ng v mt lot cc bin php khc tc ng n cc mi trng th cht, x hi v vn ho. Nm 1995 U ban hn hp ILO/WHO v sc kho ngh nghip xc nh trng tm chnh ca y t lao ng l: Duy tr v nng cao sc kho cho ngi lao ngv kh nng lao ng. Ci thin cng vic v mi trng lm vic. Thc hin t chc lao ng v vn ho trong lao ng. Cc kha cnh ny cng c phn nh trong Chin lc ton cu ca WHO v sc kho ngh nghip cho mi ngi do Hi ng Y t Th gii ban hnh nm 1996. 3.3. Li ch ca chng trnh nng cao sc kho ti ni lm vic Hnh thnh lc lng lao ng kho mnh. Lc lng lao ng kho mnh ng vai tr sng cn i vi s pht trin kinh t v x hi

Mi ngi ni lm vic nhn thc c cc yu t khng lin quan n cng vic c nh hng n sc kho cng nhn v kch thch mi tc ng qua li gia cc gia nh v cng ng. Nng cao nhn cch o c ca cng nhn Thc y cc mi quan h cng nghip Thc y thng tin tuyn truyn Ci thin vn ho ni lm vic Tng nng sut lao ng 4.4. Cc bc trin khai mt chng trnh nng cao sc kho ni lm vic Bt u chng

1. Thnh lp Ban ch o

2. nh gi v phn tch nhu cu

9. B sung v cp nht

3. Xc nh mc tiu v u

8. nh gi qui trnh v kt qa

4. Xc nh cc ch tiu v bin php

7. H thng gim st v bo co 6. Thc hin cc k hoch

5. Xy dng k hoch chi tit

S cc bc trin khai chng trnh NCSK ni lm vic 4.5. Cc gii php nng cao sc khe ni lm vic 4.5.1. Hng dn xy dng chng trnh nng cao sc khe ni lm vic ca WHO : Lng ghp NCSK ngi lao ng trong cc chnh sch v qun l sn xut, kinh doanh. m bo c s tham gia ca mi ngi trong cng ng trong vic xut v thc hin cc gii php. Ci thin mi trng lm vic tr nn an ton, h tr v lnh mnh hn cho ngi lao ng. Khuyn khch li sng v tc phong lm vic lnh mnh m bo cc dch v y t lao ng, bo him x hi cho ngi lao ng. Tng cng cho cc hot ng no em li nh hng tch cc n cng ng v mi trng xung quanh. 4.5.2. Cc bin php ci thin iu kin lao ng ti cc doanh nghip : Phng php WISE ( Work Improvement in Small Enterprises)

- Nguyn tc c bn ca phng php WISE: C 6 nguyn tc c bn Da trn tnh hnh thc t ca a phng Tp trung vo cc thnh tu ca a phng Gn iu kin lao ng vi cc mc tiu qun l khc p dng hc i i vi hnh Khuyn khch trao i kinh nghim: tho lun theo nhm nh Tng cng s tham gia ca mi ngi, cng ng - Cc bc trin khai : Thm thc a v s dng bng kim tm ra nhng im tt v cha tt Xc nh nhng im cn ci thin theo th t u tin Tho lun nhm vi s tham gia ca cn b lin ngnh, cn b chnh quyn a phng, ngi lao ng v cc gii php ci thin ph hp Cc a phng lp k hoch thc hin cc ci thin nh k gim st vic thc hin cc ci thin - Ni dung ci thin: Bo qun v vn chuyn nguyn vt liu Thit k v tr lm vic An ton my mc, ha cht Mi trng lao ng Cng trnh phc li v T chc lao ng

Cu hi lng gi 1.Trnh by cc yu t chung nh hng ti sc kho ngi lao ng 2.Trnh by cc yu t nh hng lin quan n iu kin lao ng 3. xut cc bin php phng chng cc yu t nh hng ti sc kho ngi lao ng 4.Trnh by cc ni dung trong chng trnh nng cao sc kho ni lm vic

Gim st mi trng v tnh trng sc khe cng nhn Mc tiu: Sau khi hc xong hc vin c kh nng : 1- Xy dng c qui trnh gim st mi trng lao ng 2- Xc nh v nh gi c cc ch s trong theo di sc kho cng nhn Ni dung Qua vic gim st y t trong lao ng (medical supervision) chng ta hiu c vic nh gi c mi trng lao ng ln tnh trng sc kho cng nhn tip xc vi yu t c hi. Vic nh gi c ngha l nh gi mc nhim c c xc nh qua vic o cht lng cng nh s lng nhng yu t c hi mi trng lao ng cng nh phn ng ca c th i vi yu t ny. Vic gim nh ny to ra 1 h thng nh gi mi trng lao ng cng nh tnh trng sc kho. T gim st c tt c cc yu t c hi cho sc khe v pht hin sm ri lon tnh trng sc khe. tip xc vi mt s cht c .

1. Gim st mi trng Mun bo v sc kho ngi cng nhn phi to ra mt mi trng xung quanh tt . Trong cng nghip, mi trng l thay i, ph thuc vo qu trnh sn xut. Vic gim st mi trng bao gm vic o c tt c cc yu t gp trong lao ng. Vic o c nhng yu t mi trng bn ngoi thuc v chuyn khoa ring m cc nc khc nhau mang tn khc nhau v sinh cng nghip (M), c cht cng nghip (Rumani), v sinh lao ng (Nga), ... gim nh mi trng, mi ngnh s khi tho ra mt k hoch v pha xc nh nhng yu t mi trng gp trong lao ng. l yu t ho hc, vt l, sinh vt, tm l v khoa hc lao ng. 1.1 Nghin cu liu/p ng v liu/hu qu: Vic o c nhm mc ch xc nh liu ( dose) ca yu t c hi hp thu mi trng lao ng. Vi mc ch ny vic o c khng phi ch l mt phng php phn tch n gin cc cht c ho hc tn ti ni lm vic hoc l cng ca yu t vt l m n cn phi da trn c trng sinh hc ca con ngi. Vic o c trong y hc lao ng theo di khng nhng xc nh liu xm nhp vo c th m cn xc nh mi quan h liu/ hu qu ( dose/effect) v liu - p ng (dose/ response).

+ Liu/hu qu l mi lin quan gia liu tip xc v tnh trm trng ca tc ng. Liu cng cao nh hng cng trm trng. Mi lin quan, liu / hu qu c th xy dng cho c nhn hay (tng nhm). Khng phi cc phn ng ca c th l nh nhau i vi cng yu t mi trng, v vy mi lin quan liu / hu qu i vi mt c th c bit s khc vi mi lin quan liu / hu qu ca nhm trung bnh Mi lin quan liu / hu qu cung cp thng tin c gi tr i vi vic lp k hoch nghin cu dch t hc 1 s nh hng c th d o c hn nhng nh hng khc hoc nhng nh hng c ngha c bit i vi sc kho cng ng. Mi lin quan liu/ hu qu gip cho ngi nghin cu la chn cc nh hng thch hp cho nghin cu. Trong qu trnh xy dng cc tiu chun an ton, mi lin quan liu / hu qu cng cho cc thng tin c ch cho vic nh gi nh hng can thip v cc nh hng c th s dng cho cc mc tiu phn loi. Nu cc tiu chun an ton c xy dng mc m cc nh hng t cp tnh phi c can thip, th cc nh hng cp tnh hn cng c phng nga. + Liu / p ng l mi lin quan gia liu tip xc vi t l % ca nhm tip xc mc mt hu qu c trng, v d nng bi trong khng kh v t l % cng nhn mc bnh bi phi.

Cc mi lin quan liu / hu qu v liu / p ng c bit quan trng trong DTH mi trng lao ng v n l nn tng xy dng cc tiu chun an ton v sinh lao ng. Mi lin quan liu / hu qu c th dng quyt nh cc nh hng no c th phng chng c. Nu mt quyt nh c lin quan n mc p ng v c th chp nhn c th mi lin quan liu / p ng s cho ta v mc liu ti a c th p ng c . T chc Y t th gii xut bn tp v Hng dn cht lng khng kh (WHO 1987) v Gii hn ti a cho php cc cht tip xc trong lao ng (WHO 1989) s dng cc nghin cu ny. 1.2 Gim st mi trng lao ng: Gim st mi trng lao ng l mt trong hai ni dung ca gim st y t. Qua vic gim st chng ta nh gi c nguy c tip xc ca ngi cng nhn. i tng ca php o ny rng bi v bn cnh nh gi mc nhim c chng ta cn thu c nhng s liu khc c ch nh: + Kim tra hiu qu ca bin php k thut phng h + Nhng thng bo mi c ch nghin cu bnh cn. iu ny cho php chng ta nh gi li nng ti a cho php i vi mt s cht c hi. + C th phn bit nhng yu t c hi mi.

+ C th xc nh nhng yu t c li cho sc kho. Cn lu l c nhng ch s mi trng chnh xc, khi o c mi trng bt buc phi tun theo mt qui trnh k thut bao gm k thut phn tch v ly mu. Trong ti liu "Hng dn cht lng khng kh" ca WHO nm 1987 v "Gii hn ti a cho php cc cht tip xc trong lao ng" ca WHO nm 1989 nhn mnh ti cht lng s liu o c mi trng, chng hn mt s khi nim nh: - Kh nng lp li: s khc nhau gia cc php o c tin hnh mt thi gian no , vi cng mt thit b o do cng mt ngi thc hin khi xc nh cng mt loi cht. - Tnh chnh xc: mc sai lch ca mt lot cc php o c th hin nh l h s bin thin. - chnh xc: s khc nhau gia gi tr o c v gi tr thc - Gii hn nhn bit: nng nh nht c th xc nh c. thu c kt qu chnh xc, khi o c mi trng bt buc phi tun theo mt qui trnh k thut bao gm k thut phn tch v ly mu. - K thut phn tch: Nhng phng tin v qu trnh k thut rt nhiu v ngy cng hon thin. Nhiu nc i ti tiu chun ho k thut phn tch v mt s yu t mi trng.

- Ly mu: C th lm bng nhiu phng php khc nhau. i vi cht ho hc vic ly mu cn phi lu nhng yu t sau: - Tnh cht tc nhn gy c - Chn mu - a im ly mu - Tn s v thi gian ly mu - Thi k ly mu. Th d: - Trong trng hp tc dng cp ca cht ho hc (NH3 - Cl2 ,H2S ...) ch s mi trng s thu c qua vic xc nh nng cao nht ca cht (nng nh). - i vi cht c tc dng mn, tch lu ch s tip xc da trn nng trung bnh theo thi gian. Gi tr trung bnh ny c tnh ton trong 7-8 gi lm vic trong ngy hoc 40 gi trong tun. - Mt s tc nhn c th c t hai tc ng tr ln, chng hn nh benzen c th l tc nhn gy m nng cao v l tc nhn gy ung th nng thp,... nn xc nh c nng nh v nng trung bnh trong ngy. Kt qu ca nhng php o ny biu th ch s cha ng bn ngoi, thc ra n biu th s lng cht c m c th tip xc trong n v thi gian 40 gi/tun. Nhng nhng gi tr ny khng biu th mt cch chnh xc mc tip xc vi cht c do mt s nhc im sau:

K thut ly mu: Khng ly c hon ton. S dao ng nng cht nhim trong mi trng theo cc thi im khc nhau ca qu trnh sn xut trong ngy, trong tun v thng ca nm. - Trong qu trnh sn xut ngi cng nhn lun di

chuyn v tr, nu t mu v tr c nh khng phn nh y mc tip xc. - Cc phng tin bo h lao ng c s dng mc rt khc nhau, cc lai cng rt khc nhau V vy khng phn nh s hp thu t mi trng vo c th mt cch chun xc nu ch s dng ch s nhim mi trng. - Mc gng sc th lc, iu kin vi kh hu nng l nhng yu t tng cng h hp v vy tng cng s hp thu, iu ny khng c tnh n. - Cng nhn c th to nn nhng tnh hung nhim gi to nu khng c iu tra k lng s a n nhng lm ln quan trng. - Nhiu phng thc tip xc nh qua ng tiu ho v nht l qua da khng c tnh n. Vi nhng nhc im ny cho thy nhng ch s mi trng ny khng y chnh xc v n khng cho chng ta nhng thng bo v liu xm nhp vo c th. Vi mc ch ny chng ta s dng nhng ch s cha ng bn trong qua vic xc nh cht c hoc chuyn ho ca n trong mu, nc tiu, khng kh th, tc mng...

2. Gim st tnh trng sc kho Vic gim st nhm mc ch nh gi tnh trng sc kho ca c nhn hoc tp th trong phm vi mi trng lao ng ca h. Vic nh gi bao gm kim tra v phng nga ri lon tnh trng sc kho. Vic gim st nhm mc ch: - Pht hin sm ri lon tnh trng sc kho. - Pht hin ra nhng ngi th hin tnh nhy cm i vi mt tip xc no . - Phn bit nhng ngi b tn thng mt tip xc no . V d: thiu mu vi cht c trn h thng to mu (benzen, ch) - nh gi hiu qu ca bin php phng chng cht c trong khu vc sn xut. - nh gi xu hng tnh trng sc kho ca nhm cng nhn. 2.1- Pht hin sm ri lon tnh trng sc kho. Nhm chuyn gia WHO v gim st mi trng v sc kho (1995) nh ngha vic pht hin sm nh sau: Vic pht hin ra nhng ri lon v c ch ni mi v c ch b tr trong khi nhng thay i ho sinh, hnh thi hc v chc nng ang cn hi phc c.

Khm ph ri lon sc kho bao gm xc nh khi nim sc kho v khi tho ra tiu chun ri lon tnh trng sc kho. 2.1.1- Kho mnh l khng phi ch l khng c bnh m l trong tnh trng hon ton thoi mi v th cht, tm thn v x hi. Sc kho c gi gn v pht trin qua tng tc gia c tnh di truyn ca c th (genotype) v mi trng ton b bn ngoi. Mi trng lao ng thit lp mt phn ca mi trng chung. - Sc kho c th b ri lon do s c mt ca yu t c hi. Yu t ny c th tc dng trc tip hoc gin tip. - Sc khe c th b ri lon do s vng mt hoc thiu ht ca yu t bn trong nh thiu s hot ng c, hot ng tr c, hot ng chc nng cc c quan, p ng c nhn. Hiu bit v vai tr ca nhng yu t ny i vi sc kho l gin on v kh xc nh. Tt nhin khi nh gi sc kho cn phi n tt c cc loi yu t. 2.1.2- Tiu chun ri lon sc kho Chuyn gia OMS a ra nhng loi tiu chun sau pht hin ri lon tnh trng sc kho. - Thay i mt s ch s sinh ho hoc hnh thi hc c th o c qua phn tch phng th nghim. Th d ALA niu trong nhim c ch. Cholinesteraza trong

nhim c HCTS ln hu c, thay i nhim sc th trong tip xc vi phng x ion ho v.v... - Thay i v tnh trng sinh l v chc nng h thng sinh l. VD: Thay i chc nng h hp trong tip xc vi bi, thay i in tm trong tip xc vi cht ho hc, thay i chc nng hot ng h thng thn kinh trong tip xc dung mi hu c. - Thay i trng thi ca c th c nh gi qua tin s bnh v bng cu hi. V d : chong vng, kch thch nim mc khi tip xc vi dung mi . - Thay i ton b do tc dng trn nhiu h thng sinh l. Nhng thay i ny khng c hiu v sinh ra do yu t khng lin quan n lao ng. V d nh: dinh dng, bnh ly truyn. Tt nhin chng c th quan trng trong vic nh gi sc kho minh ha cc tc dng cng vic lin quan vi sc kho v c th ch c gi tr lm r mt tc dng. Trong nhng tiu chun trn, nhng thay i v ch s sinh ho hoc hnh thi hc nh l nhng ch s bo trc tnh trng cp bch v bnh. Theo di nhng thay i sinh ho thuc v gim st sinh hc. 2.1.3- Gim st sinh hc l mt trong hai ni dung ca gim st y t. N phn nh s tc ng tng hp ca cc cht nhim qua nhiu phng thc xm nhp khc nhau vi nhng mc gy hi khc nhau. Cc xt nghim ny c khi rt n gin, t tn km v gii thch kt qu d hn. D

sao, s p ng ca cc c th rt khc nhau vi cng mt liu lng hp thu. khc phc nhc im ny i vi nghim php tip xc ngi ta thng tin hnh trn mt tp th ngi ri tnh tr s trung bnh. Cc ch s theo di sinh hc gm c 3 loi tng ng vi qu trnh xm nhp, qu trnh gy tn thng sinh ho v qu trnh biu hin bnh l trn lm sng . + Ch s v s hp thu cht c (ch s tip xc ) . Bao gm cc xt nghim xc nh cht c hoc cht chuyn ho ca n trong mu v cc ng o thi: nc tiu, hi th, tc, mng ca ngi tip xc. Cc xt nghim loi ny phn nh mt phn liu hp thu t mi trng nhng cng ni ln kh nng o thi, tch lu v chuyn ho cht ca c th. Chng c th hoc khng phn nh mt cch chnh xc tc hi ca cht c hp thu trong c th. Cc gi tr o c c c ngha tin on nguy c ca s tip xc . i vi mt s cht c nh benzen, thu ngn ... vic xc nh cc khu chuyn ho b ri lon mt cch c hiu cha t c, ngha ca ch s ny tr nn rt quan trng trong d phng. + Cc ch s v s ri lon chuyn ho sinh ho . Cc xt nghim loi ny c vai tr c bit quan trong vic pht hin cc tn thng sinh ho giai on nhim c dc l (pharmacological intoxication). Ngi ta nhn thy rng mc nhim mi trng trm trng dn ti mt s thm nhim nng n, nhng mc thm nhim c th

khng phn nh mc tc hi trn c th (v cn tu thuc vo cc c ch chng c ca c th). V vy cc xt nghim loi ny c tc dng pht hin bnh giai on sm cn c kh nng hi phc c. Mt iu khng may l rt t yu t tm c xt nghim c hiu nh ALA niu trong nhim c ch v hot tnh men ChoE trong nhim cc cht khng cholinesterase . + Ch s v s ri lon chc nng : Hu qu ca qu trnh nhim c dc l mc nng hn, cc tn thng biu hin bng cc triu chng lm sng. Mt s cht c c th gy tn thng khng hi phc khi c biu hin lm sng. Nh vy trong khm nh k, nu pht hin c nhng bnh nhn c du hiu lm sng th cn hiu rng bn cnh cn c nhng ngi khc b bnh giai on sm hn. Ch s u biu th cho s tch cha bn trong, hai ch s sau biu th cho s p ng . Hin nay c 2 xu hng chn cc loi xt nghim; mt xu hng l theo di hin tng tip xc qua kt qu nghin cu mi lin quan gia liu hp thu v s p ng m qui nh gii hn ti a cho liu hp thu m bo khng xy ra s p ng bnh l. Tuy vy khng phi lc no cng xc nh c mi tng quan gia hp thu v p ng. V vy mt khuynh hng th hai l ch ch cc xt nghim v hu qu .

Trn c s cc xt nghim sinh hc ngi ta quy nh tiu chun cho php v mt sinh hc: gi tr ngng gii hn sinh hc ( Biological threshold limit value ) . Gi tr ngng gii hn sinh hc cho php i vi ch s tip xc v ch s p ng sinh hc ng gp trong vic bo v sc kho ca nhm i tng tip xc ngh nghip. Trn c s ca nhng s liu ny i vi mt s cht ho hc c th khi tho k hoch phng bnh i vi c nhn hay nhm ngi. Hi tho CEC - WHO - EPA (Berlin 1979) chun b mt bng lit k nhng cht gy nhim mi trng chnh m y t quan tm n cng nh cc m ca c th con ngi, cc b phn, cc dch cn c quan tm thu thp cho cng vic gim st sinh hc. Hi tho kt lun rng cc cht gy nhim quan trng nht m chng trnh gim st sinh hc cn c trin khai nh gi s tip xc ca dn chng. l : asen Cadmi : mu , nc tiu , tc : mu , nc tiu , phn , thn , gan

v i khi nhau thai . Ch : mu , nc tiu , phn , thn ,

gan , xng v i khi nhau thai . Thu ngn v c : mu , nc tiu , thn , no . Thu ngn metyl : mu , no , tc . TSS clor hu c : mu , sa , m m ng vt . penta clophenol : nc tiu .

benzen

: mu , hi th .

Cacbon monoxit : mu , hi th .

Tuy nhin nhm gim st sinh hc cng c nhng hn ch. u tin l bt tin cho i tng nghin cu nn h c th t chi tham gia. Mt khc gim st sinh hc ch c p dng trong trng hp cc hp cht c c th hp th. N khng th p dng trong trng hp mt s cht gy nhim mi trng c tm quan trng ln th hin tc dng ngay lc hp th ( v d SO2 , NO2 , ozon v mt s cht oxi ho ) hoc trng hp ting n hay tia phng x c ion . 2. 1. 4 Nhm chuyn gia OMS khi tho mt s

ngh nhm pht hin sm ri lon sc kho trong tip xc vi vi cht ho hc, yu t vt l v bi cng nghip . a) Pht hin sm ri lon tnh trng sc kho do ch v c. Trc khi xut hin bt k mt triu chng ch quan cng nhn tip xc vi Pb, qua xt nghim c th thy r s thay i sm thun nghch xut hin trong c th. Nhng thay i ny do Pb tc ng trn s to thnh Hb v l c liu trong tip xc vi Pb . Trong trng hp tip xc mn - xc nh ALA , Coproporphyrin l ch s v hu qu do tip xc vi ch ca c th. Nu nh o thm nhng ch s tip xc PbS , PbU chng ta thu c nhng thng bo v mi quan h gia tip xc v nhng ch s tc dng sinh hc . Mi quan h ny c trnh by bng di :

Mc

tip PbB (g/ 100ml)

PbU (g / l

ALAD (% ) 0 <70 60-90 >90

PPE (g/ 100ml) < 50 <60

ALAU

CPU

xc vi Pb

(g / l ) (g/l ) <5 <10 < 150 <150 100200 >200

Khng xc Tip nh Tip va Tip nng

tip 10 - 20 < 50 xc 15-40 xc 17- 70 xc >70 <120 100200 >150

50-200 5-20 >100 >10

Trn c s nhng s liu ny, hi ngh v Pb ( Amsterdam 1968) a ra mc chp thun tip xc vi Pb v c l PbB = 70- g/100ml, PbU = 130 g/l , ALAU = 10mg/l, CPU =300 g/l. Mc ny ph hp vi nng ch trong KK 150 g/m3 ( 40h/tun ). Trn c s ny ngi ta ngh ni dung gim nh cng nhn tip xc vi Pb ( WHO 1975 Geneva ) nh sau: * loi tr s c mt ca tip xc ngh nghip vi mt nhm cng nhn ch cn nh gi mt thng s : 1) o s lng CPU nu nh khng c mt c nhn no vt qu mc 3 hay l mc trung bnh ca nhm xp x mc 2 c ngha l khng c s hp th ch (Pb) r rng. 2) o ALAU : nu nh khng c mt c nhn no vt qua mc 5mg/l khng c s hp th Pb

3) Nghim php tng bi tit ch = EDTA : c kh nng gy ri lon sc kho nu nh lng bi tit Pb > 0,8 - 1 mg / 24h (k thut phi c thc hin phng TN chuyn khoa) * Nu nh tn ti vn ch. Khi cn phi p dng 1 qui trnh bao gm vic kim tra y hc nh k mt khong thi gian nht nh. Trong cn phi nh gi tnh trng ch quan sc kho ca cng nhn v xc nh ch s sinh hc tip xc /tc dng, thng lm ALAU, PbB, Hb. N s cho chng ta thy s tht cng tip xc v s loi ra nhng i tng tip xc nng. Tn s kim tra ph thuc vo mc tip xc . + Nhng c nhn c tip xc nng hoc tr li khng c biu hin nhim c s c nghin cu 1 cch cn thn : nh gi nhng thng s khch quan v ch quan, s c mt bnh khc v nhng thng s khc cng c th phi o ph thuc vo nhu cu c nhn: chc nng thn kinh ngoi vi. + Nu nh mt cng nhn th hin du hiu v triu

chng nhim c cn phi kim tra ton b. + Nng Pb, ALA, Coproporphyrin trong nc tiu b nh hng ca th tch nc tiu, tt nht nn xc nh creatinin v kt qu s biu th bng s gam ALA, Pb/gram creatinin b) Pht hin sm ri lon tnh trng sc kho do thuc tr su (TTS) + TTS clor hu c: c tch tr trong cht bo cc m : h thng thn kinh, gan, m m.

- Ch s tip xc : xc nh nng TTS trong m m. i vi vic gim nh cng nhn tip xc th phng php ny khng th chp nhn. Mt phng php thc hnh n gin trong vic theo di tip xc l o nh k TTS Clor hu c trong mu. Ngi ta a ra mc tip xc vi DDT v aldrin.

TTS D DT

Mc 1

Mc 2

Mc 3 > 0.2 2 g/ml

0.2 g/ml 0.2 - 0.5 g/ml

ALdrin/ dieldrin0.1 g/ml 0.1- 0.2 g/ml

Mc 1 : gi tr di n khng gy tc dng xu. Mc 2: gi tr cn thit phi kim tra nhc li mt khong thi gian nht nh. Ch gii hn trn. nh gi tnh trng sc kho ni chung. Mc 3: gi tr i hi c hot ng iu tr bao gm tch tm thi ngun tip xc . - Ch s tc dng khng bit c phn ng sinh hc c bit. Tuy nhin c th nh gi chc nng gan qua mt s enzym nh SGOT/SGPT, LDH1/LDH5 . + TTS phosphor hu c : tc dng c ca n gn lin vi s c ch men cholinesteaza v s tch lu mt lng ng k Acetylcholin xinap thn kinh c. - Ch s tip xc: nh lng trong nc tiu cht chuyn ho paranitrophenol (PNP) trong tip xc vi parathion,

metylparathion , Clorthion , malathion. S bi tit cao nht xut hin khong 6h sau tip xc cui cng, lng c ngha c th pht hin trong nc tiu thi gian 10 ngy sau tip xc cui cng. Khng th a ra mc cho php trong nc tiu v c nhn xt cho thy bi tit PNP gim trong nhim c cp, nhng mt khc mt lng ln PNP bi tit trong trng hp khng c triu chng lm sng. iu ny c th gii thch qua s khc nhau v thi gian trong s tin trin ca cholinesteaza v PNP. Mt phng php mi i vi ch s tip xc cho hu ht TTS phosphor hu c l vic xc nh cht chuyn ho dimetyl v dietylphorphat. - Ch s tc dng TTS phosphor hu c c ch c hai men ChE hng cu (tht) cng nh ChE huyt thanh (gi). Ngc vi ChE gi trong huyt thanh, ChE tht trong hng cu phn nh mt cch cht ch tnh trng c ch ChE trong m thn kinh. Nh vy s c ch ChoE gi c coi nh l mt ch s nhy cm cho s hp th, th s c ch ChoE tht c coi l mt hin tng c bit ca s tr li Do gi tr ca men thng bin ng theo c nhn nn cn thit xc nh gi tr ca n trc khi tip xc. Xc nh ny l iu kin ch yu nh gi mc gim ChE. Trn nguyn l ny ngi ta xc nh nhng gi tr nhim c sau do gim hot tnh men:

- Gim 30% so vi trc khi tip xc cn phi xc nh lp li mt thi gian thch hp v nh gi iu kin lao ng ni chung. - Gim 50 % cn phi ngng ngay tip xc v nh gi iu kin lao ng OMS trong mt lot bo co k thut (1967) a ra nhng phng php xc nh choE. Nhng test sinh ho chng t s ng trong vic pht hin sm ri loi sc kho do yu t ngh nghip. la chn nhng test, nhm nghin cu WHO Genena 1975 a ra nhng tiu chun sau: - Test cn tn t thi gian, trang thit b, nguyn vt liu v ngi. - Test khng gy c hi vi sc kho khng gy ra mt bt li no vi i tng kim tra. - Nhng gi tr ca test cn phi ph hp vi tip xc ngh nghip trong phm vi liu cao hoc xung quanh gii hn cho php c ngha l n phc v giai on sm, thun nghch trc khi c nh hng n tnh trng sc kho. 2.2. Pht hin ngi nhy cm vi tip xc c bit tnh bin ng ca c nhn . Khng phi vi cng mt iu kin tip xc nh nhau p ng cc cc th nh nhau. Tn ti bin ng ln gia cc c th v mt p ng sinh hc i vi tc dng ca yu t

ho hc. Trong trng hp ny chng ta s dng phng php nghin cu dch t hc c cht. Dch t hc c cht nghin cu mi quan h hin tng tip xc v p ng sinh hc. Vi cht ho hc, n yu t ni sinh v ngoi sinh. + Yu t ni sinh : To ra s khc nhau v cc kiu p ng ca c th i s tc dng ca yu t bn ngoi, l: - Tui : ngi c tui p ng sinh hc gim i vi cht ho hc, vt l. - Ging : Trong nghin cu trn ngi t nguyn ph n trng thnh tr li bng s tng PPE mc ch mu thp hn nam gii trng thnh v ng cong liu / hu qu thp hn. - Kiu gen to ra s khc nhau ng hc c cht. S khc nhau nh hng ti thi gian hp th, phn b, chuyn ho v bi tit cht ho hc ra khi c th . Hin nay c bit mt s thay i c hiu v gen lm tng tnh nhy cm vi mt s cht c. Thiu ht G6 P Dehydrogenase tng nhy cm vi mt s cht c trinitrotoluen.... + Yu t ngoi sinh : thc phm bnh ang mc hoc bnh mc t trc, iu kin kinh t x hi. Cn phn bit gia tng tnh mn cm v tng tnh nhy cm.

Mt s ngi tng nhy cm p ng mnh m hn mt liu nh so vi ngi khc. ngi tng mn cm s tr li xut hin (vi iu kin ) vi cht tip xc trc y. Trong trng hp ny xut hin d ng. Pht hin tng tnh mn cm vi tc dng ca yu t khc nhau Trong tip xc vi cht gy d ng a ra test da vi antigen ch yu c mt ni lao ng. Trong trng hp tip xc vi ting n cn o thch lc . o thch lc s c nhc li mt tun, mt thng v sau 90 ngy t khi tip xc vi ting n. Nhng ngi c biu hin mt ngng trn 30 dB v khng hi phc coi nh mn cm vi ting n v cn phi ngng tip xc. 2.3. Thay i tnh trng sinh l v chc nng ca h thng sinh l. S dng test chc nng phi. c s dng nhiu, n gin, d thc hin v c ch li trong vic pht hin sm ri lon h hp l vic o kh nng thng kh (nh o dung tch sng, th tch th ra ti a giy,...).

Cu hi lng gi 1- Xy dng c qui trnh gim st mi trng lao ng 2- Xc nh v nh gi c cc ch s trong theo di sc kho cng nhn tip xc vi mt s cht c .

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