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การพยาบาลผู้ป่วยโรคหลอดเลือดสมองร่วมกับโรคความดันโลหิตสูงและโรคเบาหวาน

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การพยาบาลผู้ป่วยโรคหลอดเลือดสมองร่วมกับโรคความดันโลหิตสูงและเบาหวาน ในโรงพยาบาลสมุทรปราการ จากผู้ป่วยจำนวน 2 ราย

การพยาบาลผู้ป่วยโรคหลอดเลือดสมองร่วมกับโรคความดันโลหิตสูงและเบาหวาน ในโรงพยาบาลสมุทรปราการ จากผู้ป่วยจำนวน 2 ราย

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  • 1. ..··l!.£.lnjAi1!1~ lJ'IUitjll&U:n.~t"~mw&l~I!TI .liS~tll1,t'I~~twW&lrt..!!H~~N/'HI!o"'I!!!'iSl!l!"W&ll1~[lffiI!LnUiM&~u• L09...........................................................··········Ll1l'lW~.~11~~UU _...':';:'f:'rK n.~!l&(!R~itl!~n~I1M.&'m!.w....n..,"'~rtFlIi~I<IUI<lI!• ....II&.s;;~~"".... ....................······~L~M.11'Mt:AW'SIAi1~ L6v~...."'"~~ .j"'l!~n~IlM.sl1ln~n.1Jl!..sll1q;tffiN/,II.l.IiI....!d!•.t.u.mM~=Ru,!!• L9v...................................·····················.i&pl1~ll.rml!.,L~, !!Ulf(!RUh,.~»Ml~!AII~n~IiIM.sl11. LAUSSLUnALH....U(4mt..M'~tlTlIiI~rtUt.J"'101rtB.SII.lln.....H..H~Uj• .."....Ii'"If,.".....,.....»...A ............................................Jlbii.lLUii.l~..lb tllL~ttLrtLIiI.....&l11.Mlr:tli.f~.!"~I1S!"aB!uownaudBlla,sq91)j;:tlTI 1100B!lPu940S36u!onpwd-18S3SJ'.SIf.~1.HL~(.jf"Tlrtml~!Tluil.~LM4• ~LV.............................................·..············..~tJ~.£IAM,}LlIlnM U,i!ISiS!~rt~I1.....&ll1. )I"'SlIiLf.ffi~!~~S1.1f.!/,1S.f:1"'!t!iUn~wrm"~~[l&w.!'M~tllI• 69"...............&Wt!tM~i1ML" F"'"..,'"Q &LU~~f~lArtlA~lInlJ'lul!jllsu: USMt~llHIAUSSIOISttll1.1..,slli~n1l!LnLIiIM&LU• If-I'".....I.... LVI'.............................................·······ii.lW~I1L'"W~!e .&lOIli1li'~LnLIiIM•.!.'I'.sHtmkSIi'N.1I. ",.II&_....,.. US.SllWSlIiLf.1l.SIf.&S""tMHS"li&lIJ,US'MW~RU"SLUtllI• Jf'"...II...II­ fIJ,H~!!.~nLI1M.&~""S!W.S~"'l:tu!:f~~ru.SIf.IA~nlArt• ee".......................................JI.M.1!:J.LM!C&[t slueJujUlJ€Qa41Er.>snOU9AleJIUMJO 4ldapUO!tJ9sUlaLU5u!u!wJe~apJ{)lS>J1ewpUl?1o!woJeuele<:}!pWd• SI:"................................................······························.~U.. .~lL"'~tb ~ ···········.~Ut;Hl .L",tub - 9,,,......................... !!UlfI1Ruitll~rtUiM.slf1. lJ'IUk&LUrt~L,(!>,~fvl~f:llln~"L~I9Lf'H~~I<&WI9~Lll• I[0,~aqwa3<l(l_~aqopo t~3qwn.'llS,aWDloA L
  • 2. '.,..1t?rtmruwMtfl1r" 6.7 25 'tltlU;14 i11."t· 1""" 2554 nn'U11' ill't1jLM, • ~ 4 ",'l1J,~tlUlm'1i'1lm~ lY1n;!un, nlt11.jLfin, . _ , ... It Ii>! nijIlJ11'n~~1UU~U l$sment of CO'11a and , A Practical Scale, 64, ,re. In: Chestnut RM, • ai, authors, Early evere Traumatic Brain ang M, Ratanalert S: !diction in acute sub­ IJ!'Oi 40:22-25, 1993, 'fl1IfH@J1",4lJ~~:rt!~ ::II'lYl lNt'I!J'11J1ftl'lYiti ~, f!'1ftUmmlft11 .'~lJ~;IntZiU"NU ....1I11.1I'i;.UYlfL~1I111' m'i'Vl!l11J1~r.i'U'l!lb'iflVl~il~Uiiill11fi~il~i'l~n1Jb'ifl fl'l1JJI>i''I..Ib~-MI11fi-3~ v ~~:tb'il%1J"WJ1'1..1 I n'iiliillm::l1 tjUUl1 ~l'0·d'-l~L 't'ltl.1.J.~ .,.:10-. '" • ,. ",,,,,_,1,.. _'","'" _ ; Nursing Care for Stroke with rlypertension and Diabetes melitus I A Case Study Objective: The purpose 0: teis study was to develop guidelrne for providirg healthcare, physical rehabilitation and promoting family participation Abstract' The resull of clineal study was rrorr 2 patients with stroke, hypertension and diabetes "I1ellill,s, The first patient was suffered fro'll hemorrhagic slroke, while the second one was an ischemic stroke. The most important modifiable risk factors of both patients were hypertensron (hgh brood pressure), diabetes meliitus, The other modifiable ~ac:ors of the first one were alcohol drink:ng and Cigarette smoking, the second ons witn high choiesterol and obesity For the clinical diagnosis, botll of them were hospitallzed vitI) improper self-care, :nabllity ':0 move li:nb on right side of the bOdy and mability to un(:1erstand formulates speech. O!her compLcations were respiratory infections and breathing discomfort caused by secretion. Ottlsr factors were Emotional disturbances and clinical depression such as a sense of grief fo~ their physical and mental :osses ana a sense of hopelessness that disrupts an ind/ldua!'s ability to function. Family member and caregiver '.vere 8:S0 concerned 'hat tney were not able 10 prOVide proper healthc9re to pa'ients, The f:nal factor was a cost of medical treatment and managmg caregiver untll te,,,y CQuid be discharged from hospital, A rehabilitation or mu!Udiscipfnary team can implement this study as to help the patients, such as preventing cO'l1phcaUon or infectior, redUCing physica' handicap, mobility and experses, Moral supporting and working on abHity are crucia: for patients to relearr: ano adapt the hemipiegic limb during functional act;vlt'es to create lasting permanent changes. Educating family members and soc:al imeraction playa supporfng role to preventing stroke relapse and deteriorate as we!!. Key word: Patients with Stroke, "ypertension and Diabetes Mellitus, N~.vs:ng Care SunlJn Sangr:.J~gsee, B N.S. Department of nursmg Sar:1utprakan nospita: Samutprakan prtMnCe 10280 . , J l'it'fl'll'l11fll'Hll't'fltl I;25 ". 6 7 2 5 5 4[ Reg 0 MedJ2011: 513-518
  • 3. 'T!~1l1My/lmtu.nnV'1l8! (i7 Reg67MedJ fj;f 25 1J:J:r~' 4 (i),f. HI 25S4 Va!. 25 NO.4514 'U~lll1lti'il nnil~mn mmtmn~ ~th!Jtr~j,I~~ill ,~t.~)J'fl~~~1J1tJt;M~l" ~Ut~1ill ~~,,~~t~1'lLIJ1l'11U lul'li:~~. , jj,r~~th::::~-.1ff ~~'tI?lm'fl'''1tJ!fi~1~1)'Yltn ~U;1l"ilT)-ltUIV!~ll@ll,ftiJ!§l!<~tN ~-lm'"l fl'1i111 bt~~'fl'inl,.t~~~~1:t]~n11;.r(il h~l'~~iIllliflI'Wl)J~~ 11f»m1lJ,;!Ulo'l;;~'i tbft ~1~~LJ1'l11U L~'Ell'Iii;Uln11,'".aliul!J tilu "Ull'11~bm~iIl"~~tm"l',., "" '" 'Ii , "" ..I j.< " ..;J , " " "'!Iv ...- ... nJ. ''. 'V lv, I . . nl'j'''fYUfJ~Jl'I'Y'i~l,;,)t1 ~~~ ::;lY;'f'llt~{j ~i'1nJ ~ViV'l'l'f.lUfl1')~%"f')'W~ lJ ~'l.ml~~ 1J.~1mjrYlbl1J1fH£iJ':;tJ ~am ~M n~,nLmUlJLV!JUqulUt;~'j.!~fl V ,lit>iIllIJtl~h,jOjl;l'lf'~1IJ.;!Utaii,"~" ,,;~t!~ ,U1l'111.{'JUll! 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  • 4. 515 1'ift'1'i1'lf:mfuwnt1~1uR 6.7 Reg6,7MedJ n;1'{jmlJ1ii~t1'mt~'fm'«'ilIflb.~'8~i1~'€>lh~f~L'~J~fiI';1l;i'..!b~fIl~~b~~t~·rHU'1V!';lT.J : f1nU~f1l'!'l 25 fluvii 4 M,fI - JUI. 2554 Vol- 25 No,4 " > :hRnr!'~lU lul'l!'~l n~l~b~~"~'!I"m1l~'" l11~11.1m~'!lLiI'l'JJfl1l'l ::::1101UJTW11tJdju,n'i1 U~lJ!l~ (Hemorrhagic 1~111''II~!ll11tbr,1Ilh~ ..;... '~"f '" 1n11"').j~n ~,t!u"'~!J ~mn1m!J11J1~1'1'/1J'l,. jj'~~11~~ULL:N UC)J~l Ilii~m1~~ '~fll1.1t~lJ:J" 2.ifrJmmdh!';~IlI't"l '" '''1 rl 3~ln"'!l~!l~ l.m1~fi~ 1.h!J I'l~iliJ!ymJi11.1 lnillJLi!1~i[~rlJJ'lJi!l!h~ mbYl!lil!l~nlJm1In", ,ft~r,1::;1~ll'llJJ't,x~th!J v, , "" '"~t!r.)tJ~.f1r.i'1VlI.~~:; ~ ~ Ll.fl ~~~fl~L'JtltU':~ ~t'l Lt'f'h'l l1ih.1Nl'lmlJ1mJr.::~, ~1.h!:l.11 ~lJlJ1!11~Ji1!J 41.;u2552 dJlJlI"mlil I~ 255', ,tbi,t!~IJ~ 2 2553 cl1lJlmlJilu"I{~ 1~~~ bHIJ1Wr1U 111'1 "I~b1AIJI"~lbfll'''~ ~ 1;;1W~~iPlfjf11iJ~thtJb'll,j 1~~~1~m~~il1It~l,/i ''''~liil'l~11JJV1 nl11',,< 1'lJi~1!J ('!llJ ncnnlil171'l , n1nii(iln11iii@n~'1l't1.l ... 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UD~II1~'11l'ltJ1lJ1itJilunln.hn1~mlJnl~ 1'" "" ,., , '" J ~ l'lt llJ~j).jl 'lI ,nllll~I.lI1n'1nIJ11:W~·~lJ~ nl1' 1~t).jt< n11~IR1,:"iJrJ'" fl11111bl~';1':;m:'l~mlJ1il lVlu,UlJ ~";hui'~fll~ ~J1J1~ '1l1j').jru ii~~).jt~~Jil.;t~1':1:Jn~ b~ff~'L.'h ~ n"lnJ£liMn'1 T'V'ltl11Jl flt] Ul..J~ ~1MJ~1'W iJ01 T ... I ' " .... """ " J1J J1Jlil1).jlJ ~:IJJlJ~"n 17fiU'11J'J~ "~~m1IJUYln'llfll;J ~ 01~ fn",lfiU11J1~11'l'Iru/1~"~~1~~'1l ,il'1l~ 5. ~t:Jt~ ~'J'Mn ~iiJ!Y'''nlj',! 1b1'l~t1,~h t1?'~l~'W~2J~ilJi"I:Jf!'LJ jIiJ~p-J h~1)litr}..I1,n ~{'.,!.fIirmll''!l btfl ~ulu.Mu "'tlm~Mn'l¥l "'Rni!'1ll;i>:l~i.ill~tllub~"UClll~l'lijntJnn11 l'l!J~1~, ,"IIlnlj',~!J~~fi1~'iI~q,:1!Jl1l'11,j,,~J1J '~'1lJ1Ji).j'1l~ ' ? I " ~1 U'elJu 2551 !J 2552 "il~l 2553, ;J91IJ1lJ 148 11U 124 1I1l~135 ntJ 1I11).j~,Ji11J ~~~U1!Jh~1.1i!lIll'~"J'l~3J~~ ~,~ • ' 0 "' 1 '~I ~ 0 'V1~"lI1njrY'l'l"Jn~, L'W b:f4'Y1tll1J'1fl',,,'1'W v:ry ~1J5'~'lV1nlJ~9U ulU,/i~U111'11'1ll~i>l.;t~ii ,j~ ~~~,,~ IIJC!'1,;JJJCri'lI"b " ,.., "" "~",I' ~"~ " 2551 " 2552 ,'~"U 2553 JJ~u~~'1M11:W~'~~~1,j~ !~ ";,,,11.1 ;.197nu 1,25511U lbj1~1,1381'1~ 'i,,~ q1!1tJcmmllJ "'lJ1lJ 6A57 nu 6,61911tm,,~ 6,343 nU~lJJ~ci>l1J m1~mn1:1f1>1~'1lIllI1i~Vl1).j!l~~1l.1fr1Jl~~ ~ ~ • <, ~ Y , . ~ ~ ." fYll:JJIJIU,~7l~fj~~L~fl::: t:lPl bl11W"J1U I.Ufl1~'U ~ k"'''1Iil'dftni'l ~r'~l ~'flat5fw~ur::::nI1~~ilIH~"ll'fl~r:rl1'Jui-.'l~'!J-J11!j~.J... "l;I 'U'iI .. ~ 1 tI" '1 (' .... ,d ... 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  • 5. : '11"''ln'ltJn1'1UWftUUfl1 6.7 11;; 25 tI!lLY. <1 ;lJ I'L . :.f! 2554516 bbllZh~ bU1~11.l ClUl!JiIJihJ1~<Wi rn1M11~fn~11J1 ri~.l •V"" ..., "'~ Jt v <V n11Jn11b~ UU1!Jbll rI .l~!J 9Z~ ~!J 1"1n11.l~ 1!J!J'11J11U iJ:r:::i'i:t.!L1H Ul~fJf>l;i1 :r'JJtjfnl"J:l~tN~tJl1Jlfl~.Jvm1:w ~~r1I'lL1~~1t'hU!l [h4'm1i!J~1E~INIJ1~tn119>Umi::, ., , 4. ,..... ~ '" ~ ~ , ~1~~tl"~"J'l.l "~Z11~~1J~11 23 ~.lA1~1~:f1N~1~UIJ b~ ~~ B'ood Cholesterol 182 rng/dl b,~~~~ Blood Triglycerides 178 mgldl innri1U"Z'1l1rnmMl~"mfu ~ ? ' ? '" >.1 ,.J}i 1 '1111:;Nnil.llJ1lNYm1U1IH1iil.l1iU~U1!J.l'il.!tll'l1i.l ~t!'1tJiitnnlnllm~tyl ~Vlt~iV1 t~"ll't.itjj1~1-:J"ll'11'tl'iltUl'l..j n~1Mrl~:h~rn!J~mfu bb'll.l'll'.'ih"'ll11~t.l~N lP.lb'il~11l 11'1 Motor Power ih'l'll11 grade 4 i1~~1!J grade 5 v..!!/ .... .,. il'lnM~", Glasgow Coma Scale E4 V5 M6, pupil3 mm React:on To lig'lt both Eye ~111J".llai1111 196;63 • il,,/iblJlllnh'ill'l ~1'l"1 92 ~1'~/.l1Yi IlM11n1l"ln!Jh 24 .flf~/.llVi ,mnwiJ 37 !l"~1b'l!!H;!J1 Pi1~~1mo]jl<li.i, . ~~;j~~Il~l"1l1Ill~~~ 96% ~~rn~~j"l~~~1l1~~111~'l9 W,'i~tJ ~ nl :i'(OJd';l~ ~'fm";'il:nJtlil~tl fl ~ f.J f1 n'):r~ ~Vl'"'1til n"1l L'i'6 l'ifllJfi~l~tJf~"fl"(CT scan Bran) "lI Basa: ganglia Hemo~rhage size 1,5 x 2 ems Occioul Id~action ~L'"lt:ih1r~;..i1b~~:;i'i11il9>[tl"ll·}.m'r'{W'1J1~3 ~fl d J''''; .J 1. n1~1J'lI1l1'll'1l~I.l~'U~l'IlJ~~1'l1llIm'!fl"91n I'IlJTl~1Mulii1'l.m!<~Tltln'ilb~1l:;J'W!J.JYl'1l 2 ~u1m~mvi'ilm1iil"'m1~11!JI~;lJllM~1 "" ......s ...: oJ l'il!JJJ1ii'i.l lll'1l0~CnlJlnmnV.l:lI'JWtlU 3 01:V1!Jh11li:hb:iI'lfr11i.i11l~"1nYm LWitrVlt!",''1 jn-qIYlrtui:1 ,~:wv:;,V~tYll.t,fi:1:j.W~~~l.fI .'1 ~ "' 1 ~4. ~~ 'lEIJIl1'l~n"'IJ.l111l"~ .l1~~"'IJ;j (;,y­ perglycemia) 5. mj'~Mvi1'l~fl~1nmyd:l;jbilt'l~1nWlll:l.i'l1~• 6. ll1JiJbl~.in11ii1.;(hE~9911~LtJ~U.llbll~'l ,;. _.Ii, _, 7. It'itFl~'ilnl1~HYll'n''d ~'Wr~':J1J'Yl'l~bLf!UjJ~;:;ql'J:: 8. 1iiTl,,111n'r11''hn,;.-j'.~tJ1~''1';;.l ,d1'l~'''n , "';.>4 _ .J U'll!.!-~1'll11fl'1l'!L'N "1nn'mllJWUcfi~l1cYm~IJ"H 9. 1'l'l1IJl~nil"lru~11.lif1'£HIlVlI'l~ lti£N~1n 'li1utviitlMlll'1l'l1IlV; 1O. ~U'l!Ji1i'l~11<~Mnn"1IlL~!J1n1Jm1!.Jb~lJ lh!J'llI:l~lll.llt'" "" v " "I 11 .CYl L'l°Jll'l ~ 11;. ~ ll~ ~ ~ ~1" W'!l1J ,t.;n1' 1JBtTM~ltd!ln~uhJtl~~trl'! ~Ul!J"E~ 2 Lil.lh~~~!lI'l'~~VlIIJ~~1i'l~~1~ '~!l~ (lsche'Tlic stroke) u~4'!Jl~!J~~!lrr1Hn",l~~~ i1f1ru~fl L:Jllhi'1m1IJi1I.l:~;;biI ~~ ll,d~fll!J1'.l11'! ~111!l ~L1;;~J'f·111~n~1<~d.iMtlL~fl~"lJI~tjl 3 t~"€l~ i1,,~tI:~tJ~ ~'1l~i1~m~m111~b3J.!1.i,i1~",~~ ~i'l Blood CtlOlestero 196 mg/d' h~~~j Blood Triglycerrdes 164'Tlgld: iiw niiim~IJt'llm1iIIlD n.;rTl~ ClU1!J1;J~~u ~1IJn"!'u"I ~ ' I l " ; 1l1~'l111'tnV1' i1J111:ii1.!1l!1~~1 ~ n1~1:l!llllh,r~n1!J ~1n1~lb"~Tl~01n~~~ 1l~nfm'iul!J~~nlii'1 wiIlllli~i.- , 'Il 'Il '« ,I -"I '1 <4 .. •-"1 <d "'" , u1r,Ut'l ,£lJ1n b111!l!lV'illi IIJlJm1~,'!lm CY"'llj!ln11 fL1l1~'l'.lfl'V11.lfdj!lAn11i1~n ~'I.l'iJ1-!h~'iJ·~11i~!.! "N Grade:l liiilllllll''l UJil!l11l1rlmnf~ ill'lil'l l);iJ !l1011U11J Glasgow Coma Sca:e E=4 V=5 M=4, pupil 3 mm Reaction To Light both ~~1IJi'i''!l"i11'l 1851 105 jj"~I!Jmlh~1'l 'il1i~j' 64 ~f~!!.!1Yi !I11111n1nn!J19 28 ~f~1Il1Yi mll~J1il 36.2 !l~~1l~jjl~!l1'1 ~1m1lJlo]jlJ, . {.l'll!l"'f]'1ln;h~.!blii1'l~ 94 % ~l'lm1bi1119i'1~.l1~Yb v1'."lJJniii ~~nl1~1~'uj'jn~mC:J'f]1ll1illlnfiltrat:on At left lowe, lobe l"IJ'!l~nb~~~ Crepitation At left lower lobe tJ~nli~j'';l'''ilfln"1ll1tJ¥lrllJ~'JL;f:fjf~~~~ (CT scan Brai;)) Y'tlJ Right Frontal Basal ganglionic infraction no Hemorrhage ~U1tliJil(jJV 11la~-iifl~U"'llU'll~n11 'YUJI'U'":fj 4 fi'El 1. 1!.Ji'l~1"1'1Jt~n::,j,'".IIl,wmw'iild'H"1ni1 I'nllJ~",1lniii'll!i<n11lv~ ,1tl".,~t'lUl;IJ!i~ , , 2. tJ~~ ~1~~lil!1~'l'l nn11,WIJ~·~1!.J;1l1.l Vlft'El'" ~~'f] ~:(i~'fFl "'.'1'" II) tv' ... .., d 3. ~1J1UlJml~mU ''l~IJ'~~1b'il!JU1i~1l lll!i~ ~ ..'11r1lJm1l1ru!lUlv.!!m 4. 111~~1!J"~1aJi11l1~~1'l1iJ11Wcri!i~'llnm" • L~'W~lt l~I:Jn'Q v;n'klJbti~·..,:; l'~~£j'JU,i'j:;1:iJ~UNL'Cl ".' ~ ~.Ii 1 - ,5. ~u')tl~tll,):::lPl@lt'ti 'W1::;1J'UVll~L"'kO.nLl Lr.; ~'1'W~1-1 dlfl~"nnnl~'lin i,o".oj <v ~ 4 6. ~m!J!.JJ'11~1~tlllI.l1111~1l1.llii~Vl~~ (Hy­ perglycemia) I I " " , ..l d ... 7. ~U~U~'!lln1mJII'J.lu'LIl~l'!!)~~1mn~ m~~UJ?lIJ~"~'!l~ Eiectrolyle Reg8.7MedJ Va'. 25 No 4 8. il~muiil ~ .. 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  • 6. • • .,m1M~n1fU"1Jtftl1lf 6.7 Reg 6.7 MedJ ~ 25 fJliii114 ~.fj. ~ ii.A. 2554 fl '; 1~fJ11] i'l ~Ihtlhr/.tf.tHOl ~ftTI ~ea,'il-lt')unl.fI1f' P1'l1:J(ih,jli'l.:.::iVl'~~~n::bM!.1J 1~I)'I 'U : fl'j'{u~n1:r:n Vol 25 No.·1 517 .~~~'11U'i~m.j1,;n1;' ~ ~ ~~~,~'~~~~'il~'IlU!Il~'I'" ;8l~mliiflfl1j',n'"hA~ ~UIl~tj'~,U1V111J ~),btJ 1m 3 t~'ill.! lj~{m~m ~ ~~ Blood Clolesterol l'ycerides 164 mg/dl ~l.htJhil'11u~~nlj'fu ~~1~nl1t'!lnfi111~nl ~ ~l.htf~n,r~ ~o;l.1fo; Wl1')::-;6~tn r~1~U't!n11 l~n U~U1l1i1~'llr;,'fi'f)U ln1:ri'nln~~ l.1;n", l.1i:l lie E=4 V=5 M=4, pupil ::ye ~~ilJ~.JT~~Vl 185/ f~1W1~ !l~l1mnn~19 11~~1'll!J~ ";lmllJ,o!ilJ ~~G11fi1119~~u1vHh Ifl~Y<U Infiltration At left lalion At left lower lobe fiI~fl~ (CT scan Brain) 19lior.ic Infraction no bU~~{if.l1iJ""t1Y1'I-.'l nl d It ' ... .... ... ru l~ Lfjt!.:JW'f) L"..J't"l"'1 nlJ !~l'l11.1~;;1'l~ 'Innl';'l~dJfl'J l:tl ~'W1'kI 1-' ... .... ~ 1~1"1-!i'l1''ilUUV<~·'! ,"!l~ :~1I11lm'l1,rl~191n'l1~ imui'lz1!Ji1"Nlfl ~bl':ul:m~I~1.ImtJl'1 ~ d JlJlmi'lll.!ti'l'~~ll~ (Hy, ~t1"utll~lrt!l~~'I nLn'" 8, i'1~fl1~i1hfl1l1t;f'Ji'l'11~1t11m~~J,'~" li;ju~'i~'1:tl191n{ll~ul~r,Jr1n~J,~~~'Clllol1~ 9, UUUi,~,;rl1fUii1~~~~C1~,U~Ll."U~~ 1C, l~tI..:lMfln'inn ~ lttJ'H;~Y,1J~eil.;J"1n ~~}nl "ii1mM~fllf1'4 Lf>,~1JJ~~~ ,J • .... 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  • 7. 518 ~'nlJ'Ihm'A~~r:itht tJiT]Eh~n r,oIi~~n'1lum"tN;11~~ ~~. . . ~'ilh~l'imml1 "11:'~'il1iill~:;'li1'111Ji'llm1n1l1~iJum~: 3, m1~~7il.lU'lYlc<m1I:JL,~~1l~!Jt7'''~~~ "" "''''''I "" <V d 'i' '-"I ~~WJ(ijgilJft-l b~ ~t 'iH~'W'1'Vl1~~V'ltI'1n't.u.ml'il"1l'E}d.J ~t1-l~1U«J:I'iJ fl~l~ LIl1J7~1JlJ ll~zi11ll7&i ~"1lJ ~ Lh~ iill~ ~ ~~ 1< ~ ~. . 4, nC~~~1li1~<liJLll'i1~L!.111Z.L~~U'ltb~l >l"'1l"'L;!l~II~J'!l< Lr; IIIif~II'l t tiffu n ,t~ U"!l t 111~i1Ylilml'i 1, n!l<!l1~m71lJ m~1j'JI1'1l1tF~1i'l~f 'lYll'Jlllm,l'iYlti ~1~ ~f1'lnlJ~nn,nih 'nnil~n1'J1 e'h}W~ti'li'l!'~'~6J 'OJ Yl1<!l1!j11'11!1Vlf' iljJY<Mf<i1 2, nt"Yll'i. 'iYll'll«1'l ""~1fr~11IlIfM~jJ~Q!l'n1h 2550 2. 1'J~11 'nvJ'IJ~1Jlf U"Zi'Jr~<. n1",u~u~~nlin1u., ,... "" ""'~.~ 1'tllJ"'lU. nl~LYl"~: ".L!l.Il"~~, 2546. 3. "1m~u5i.m~m!n1rnmm"U"ZLhuuU~UIj'iJm" 'n1"J1~!jnVl1-t'nf'l~ilr ;;lJ,f~f~Y 31!~l,,1'I~: lIlJ" ,)n~"hnlll, 2552. - ..4. 1~Vl~'1 ~~lJJ1 L'~~!lru l1NU~lJ1n. nl~"~lm,,~u~!J . , ~, ~ n~I'lLLlJ1JlH ril'·J~j. ;;lJY<~i'~Vi 3. nt~jYl"'J>l11J",~, 2551, Reg 6. 7Med J Vol. 25