increased intracranial pressure (iicp)20care%20nursing/%c… · • subdural hematoma • epidural...
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Increased Intracranial Pressure Increased Intracranial Pressure (IICP)(IICP)
"45����ก6��7����"�����"45����ก6��7����"�����
Increased Intracranial Pressure Increased Intracranial Pressure (IICP)(IICP)
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ICP : ICP : 5 5 -- 15 15 mm Hgmm Hg
Intracranial volume : brain Intracranial volume : brain 80 80 %%((11,,900 900 ml)ml) CSF CSF 10 10 % %
blood blood 10 10 %%
Normal relationship of the compartment
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Monro-Kellie
** �������������� ก�������ก ���ก���� ���������������� �!� #$����������� ����#�����%���&���� ��%������������������'�#�� ��( �)!�* #$����
��� '����)���ก ���ก���� &� �!� **
ก��กก���ก������ � ก����ก��������
Compensatory phase
– ก��ก�������� CSF
– ก����ก������� CSF
– ก�������ก�����ก�� ��� CSF
– ก����!����"���#��� ����
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!$����%����&�"'��������(� ก��!�� )��)�
• ��"��ก������"����!����"�����ก� %��
• "*�+� '����ก�� / ����ก� %��
• ก���� ��+�����-.�ก�� ��� CSF �������
“ Compliance I
ก�����"��� ก��"� � ��"'�ก����!����"�� ����������./
[������������ �!���+ก���� '����)���ก� ���ก���� * ����� �!���+ก���� ��%�,���������]
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����"0������� � ก����ก������������"0������� � ก����ก��������
• !����"�� #/����������������./
• !����"������� ��#��� ����������./
• !����"� CSF ������./
Conditions associated with increased ICP
Intracranial mass lesions• Subdural hematoma• Epidural hematoma• Brain tumor• Cerebral abscess• Intracerebral hemorrhage
Increased brain volume (cytotoxic edema)• Cerebral infarction• Global hypoxia-ischemia• Acute hyponatremia
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Conditions associated with increased ICP
Increased blood and brain volume (vasogenic edema)• Hepatic encephalopathy• Traumatic brain injury• Meningitis• Encephalitis• Hypertensive encephalopathy• Eclampsia• Subarachnoid hemorrhage• Dural sinus thrombosis
Increased CSF volume• Communicating hydrocephalus• Noncommunicating hydrocephalus• Choroid plexus papilloma
Cerebral edema
� Vasogenic edema - extracellular edema
( brain tumor & meningitis )
� Cytotoxic edema - intracellular space
diffuse brain swelling
( hypoxic & anoxic episode)
� Interstitial edema - periventricular tissue
( acute & chronic hydrocephalus )
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Herniation syndrome of the brain
�� Supratentorial herniationSupratentorial herniation- Cingulate herniation- Central or transtentorial herniation- Lateral transtentorial herniation( uncal herniation )
� Infratentorial herniation
Normal relationship of the compartment
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Uncal & transtentorial herniation
Central transtentorial herniation
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Herniation syndrome of the brain
Infratentorial herniation (Cerebellar tonsil)
Herniation syndrome of the brainTemporoparietal epidural hematoma
- Uncal herniation with lateral brainstem compression
- Compression & stretching of CN IIIunilateral dilatation of pupil
- Displacement of midbrain compression of piramidal tractcontralateral hemiparesisplantar extensor responses
(babinski’s sign) - Cerebellar tonsil
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Herniation syndromes
��R"�S�T��ก���ก�Tก���"��U 7V"���������WUX��Y�����X��� V�� IICP
Regional CBF CPP in areas CO2 ( hypercapnia)O2 ( hypoxemia ) Acidosis VasodilatationCBF CBV ICP Local Autoregulation "#$%
Regional CBF IICP &'ก)*+,-. Vasopressure ischemic Response MAP 01* CBF Edema 01* IICP
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Z!� Autoregulation ���
CBF / CPP ICPCPP No CBF Herniation Death
Clinical signs of increased ICP
Signs which are almost always present• Depressed level of consciousness
(lethargy, stupor, oma)• Hypertension, with or without bradycardia
Symptoms and signs which are sometimes present• Headache• Vomiting• Papilledema• Sixth cranial nerve palsies
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ก����'����� � ก����ก�����
1. Ventricular catheter
2. Subarachanoid screw
3. Epidural monitoring
4. Intraparenchymal
5. Subdural catheter
ICP monitoring
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ICP waveform
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Noninvasive ICP monitoring
Transcranial Doppler (TCD) ultrasonography
• measures the velocity of blood flow in thebasal cerebral arteries
• shows characteristic changes with increasing ICP
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Adjuncts to ICP monitoring
JUGULAR VENOUS OXYGEN SATURATION
(SJVO2) • assesses the adequacy of global cerebral
oxygen delivery
BRAIN TISSUE PO2 (PBTO2) MONITORING• measures regional oxygen tension
Provide continuous information regarding the adequacy of CPP and CBF
at the tissue level
Strategies & Interventions
for
Increased Intracranial Pressure
To maintainICP below 20 mmHg
and CPP above 70 mmHg
In routine intensive care unit (ICU) practice, the goal of ICP management is to maintain levels
below 20 mmHg.
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Protocol for ICP management in monitored patient
Surgical decompression
• Consider repeat CT scanning • Definitive surgical intervention • Ventricular drainage• If a ventricular catheter is in place, the
system should be opened to drainage and 5-10 ml of CSF removed
• Lumbar CSF drainage (5-20 ml/hr)• Decompressive hemicraniectomy
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ก��b�T�� ก��b�T�� ventricular drainageventricular drainage
SurgerySurgery
* Craniectomy * Craniotomy* V-P shunt / V-A shunt
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Sedation
Intravenous sedation to attain a motionless, quiet state
• A combination of a sedative-hypnoticand analgesic agent is usually most effective
• The preferred regimen is the combinationof an opioid, such as fentanyl (1-3 lg/kg/hr) orsufentanil (0.1-0.6 lg/kg/hr), to provide analgesiaand propofol (0.3-3 mg/kg/hr) for sedation
• Propofol may be the ideal sedative to usein patients with elevated ICP
CPP optimization
• Pressor infusion if CPP is less than70 mmHg
• Reduction of blood pressure if CPP is greater than 110 mmHg.
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CPP = MAP - ICP
Cardiac support & blood pressure controlCardiac support & blood pressure control
Hypotension Hypotension cerebral ischemiacerebral ischemiaSevere hypertension Severe hypertension cerebral edemacerebral edema
Elevated BP frElevated BP froom Cusm Cushhiningg’’ s response s response should not be treatedshould not be treated
Maintain BPs Maintain BPs 140 140 -- 150 150 mmHgmmHg
CPP = CPP = 70 70 mmHgmmHg
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Osmotherapy
• Mannitol 0.25-1.0 g/kg intravenously(repeat every 1-6 hours as needed)
HyperventilationHyperventilation
��! ��! Tidal volume Tidal volume 12 12 -- 15 15 ml/kgml/kg
��กk���T�� ��กk���T�� PaCOPaCO22 26 26 -- 30 30 mmHgmmHg
pH pH 77..3535--77..4545
End tidal COEnd tidal CO2 2 should be monitoredshould be monitored
PetCO2 30-35 mmHg
Hypocarbia Vasoconstriction Reduce CBFHypocarbia Vasoconstriction Reduce CBF
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High-dose pentobarbital therapy
• Load with 5-20 mg/kg, • Infuse 1-4 mg/kg/hr
• Pentobarbital typically requires a loading dose of 10-20 mg/kg, given in repeated
5 mg/kg boluses, until a state of flaccid coma with preserved pupillary reactivity is attained
Hypothermia
• Cool core body temperature to 32-33°C• Prolonged hypothermia can be dangerous
because of increased risk of infectious complications,
coagulopathy, and electrolyte derangements,• Rewarming should always be done slowly, over at least
a day, and passively, without active heating, to avoid rebound cerebral edema or a systemic inflammatory response syndrome
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� Elevate head of bed 15-30 degrees.
� Normal saline (0.9%) at 80-100 cc/hr (avoid hypotonic fluids)
� Intubate and hyperventilate (target pCO2 26-30 mmHg)
� Mannitol 20% 1-1.5 g/kg via rapid intravenous
infusion
� Foley catheter
� CT scan and urgent neurosurgical consultation
Emergency measures for ICP reduction
Respiratory supportRespiratory support
Positive airway pressurePositive airway pressure(Mechanical Ventilator)(Mechanical Ventilator)
Positive end expiratory pressurePositive end expiratory pressure(PEEP) < ICP(PEEP) < ICP
Intensive care
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��T���ก���S��7qX�������T�7�� �b��T���ก���S��7qX�������T�7�� �b
Ventilation monitoringVentilation monitoring
ก��r���q!�XXกqXกs�tb�ก"XT �S���!�ก�Tก��r���q!�XXกqXกs�tb�ก"XT �S���!�ก�Tก��V�ก�"��U 7กs�tquv7ก��V�ก�"��U 7กs�tquv7
��T�� ��T�� PaCOPaCO22 b������������7�ก��ก��b������������7�ก��ก���"��U 7V"�qX �"��U 7V"�qX alveolar ventilation alveolar ventilation
Noninvasive ventilatory monitoringNoninvasive ventilatory monitoring
�"w7ก����T �"w7ก����T PCOPCO2 2 �7���� �bqX� !"#� �7���� �bqX� !"#� X ����X�7WUX X ����X�7WUX ((End tidal COEnd tidal CO22))
PetCOPetCO22 ������US�ก��� ������US�ก��� PaCOPaCO22 "�����"����� 11--5 5 ����.."�X�"�X�
(( 3030--35 35 ����.."�X�"�X�) )
Capnography Capnography
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Maintain patent airway & Maintain patent airway & adequate ventilation adequate ventilation
T T����� ��WUXbS��"w7����7�v7 T T����� ��WUXbS��"w7����7�v7 ((use protocoluse protocol))"�����7��กk��ก���� �b"�����7��กk��ก���� �b��!��! OO22 100 100 % % ก�X7ก��T T����� ก�X7ก��T T����� 11//2 2 -- 1 1 7���7���T V�T V�ก����!ก����!���WUX��� �� �b���WUX��� �� �b
Prevent hypercapnia & hypoxemiaPrevent hypercapnia & hypoxemia
Evidence :Evidence : Assessment Assessment (breath sound)(breath sound)
Patient Preparation Patient Preparation (positioning, information)(positioning, information)
HyperoxygenationHyperoxygenation
((100100% FiO% FiO22 11min,min, PaOPaO2 2 100100% SaO% SaO2 2 > > 9595%%))
Hyperventilation Hyperventilation (tidal volume(tidal volume 1212--15 15 ml/kg)ml/kg)
Normal saline instillation Normal saline instillation ((r��������ก��� r��������ก��� support)support)
Maintenance of asepsis Maintenance of asepsis (CDC guidelines)(CDC guidelines)
ก��T T������7��X��XT���Xก��T T������7��X��XT���X"#IJ*KLMNK-ON hypercapnea & hypoxia secondary brain damage
กO)PQP"#IJ* sharp increase ICP cerebral ischemia
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ก��T T������7��X��XT���Xก��T T������7��X��XT���X
Catheter selection Catheter selection ((11//22--22//3 3 of EET)of EET)
Depth of insertion Depth of insertion ( ( "J.RS "J.RS carina)carina)
Negative pressure Negative pressure ( < ( < 150 150 mmHg)mmHg)
Duration of procedureDuration of procedure (<(<15 15 sec)sec)
Number of passesNumber of passes ((2 2 passes)passes)
Post Post -- suctioningsuctioning ((1010--min rest period)min rest period)
(Day et al., (Day et al., 20012001: JBI, : JBI, 20052005; Price et al, ; Price et al, 20032003))
ก��T T������7��X��XT���Xก��T T������7��X��XT���Xก����!ก����! neuromuscular blockage drugs neuromuscular blockage drugs �Tก��rX�Tก��rX
((���� ���� blood pressure blood pressure �T��T�)) �!Xก���7��b� ���U��!Xก���7��b� ���U�
ก����! ก����! PEEP PEEP �7� !"#� �7� !"#� IICP IICP ���q!X��R"r��rT! ���q!X��R"r��rT!
((PEEP PEEP IICP , PEEP IICP , PEEP ��U ��U < ICP < ICP "�XTY� "�XTY� ))
(Day et al., (Day et al., 20012001: JBI, : JBI, 20052005; Price et al, ; Price et al, 20032003))
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Positioning & Turning� Neutral head alignment at all times
� Avoid knee & hip flexion
� 300 head elevation - every 100 of head elevation, the ICP thought to drop by 1 mmHg (Wong, 2000)
� Turn patient & ensure neutral head alignment at all times
� Passive limb exercises no significant rise in ICP
� A set of activities after ET suctioning significant rise in ICP
Temperature controlTemperature control
�� Hypothermia blanket Hypothermia blanket
����T���� ����T���� shivering shivering IICPIICP
�� Antipyretic drugs : Antipyretic drugs : Paracetamol is effective Paracetamol is effective
As a general standard, acetaminophen and cooling blankets should be given to all patients
with sustained fevers in excess of 38.30C
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Seizure controlSeizure control
MMaintenance for euvolemiaaintenance for euvolemia��T���"�����7 ��T���"�����7 serum osmolarity , electrolyte serum osmolarity , electrolyte V��V�� glucoseglucose
0.9% (normal) saline or lactated Ringer's solution,(Isotonic)
Phenytoin (Dilantin) Phenytoin (Dilantin)
Fluids managementFluids management
L O C (Glasgow coma score)L O C (Glasgow coma score)Pupillary size & reactionPupillary size & reactionEye movementEye movementMotor functionMotor functionReflexesReflexesVital signsVital signs
Neurological assessmentNeurological assessment
Identifying the patient at Identifying the patient at riskrisk
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Glasgow Coma ScaleGlasgow Coma Scale
ก������� ก����� ก������������
����� 4����������"#ก 3���������%&'(�� 2��*��� 1
,�-��'��-����� 5/0'/� 4�����-�(1��2�3 3/* �/"# ��*�(1��2� 2��*�(�* �/"# 1
����������(ก�4 6(ก(6� �����%&'(�� 5�7 89�9���" 489� �:4�(ก�4 389���#"#�:4�(ก�4 2��*������������# 1
��7�uกbS�7�7"4�������7�uกbS�7�7"4�����
���bT ����Z��bS�����qX"4��������bT ����Z��bS�����qX"4�����
����T�����!X� ก����T�����!X� ก
r����7XRbb���r����7XRbb���
Management of Urinary elimination & bowel function
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��V�7ก�bก���ก��� ����r����!��ก�7� !"#� ��V�7ก�bก���ก��� ����r����!��ก�7� !"#�
��T�������7�� ��T�������7�� LabLab
"~Xก�7X�ก����ก "~Xก�7X�ก����ก
��T���ก����! ���T���ก����! �
T V��RqX7��� T V��RqX7���
"~Xก�7Y���V��กt!X7 "~Xก�7Y���V��กt!X7 -- Pressure sore, DVT, RI, UTIPressure sore, DVT, RI, UTI
General nursing managementGeneral nursing management
Drug therapyDrug therapy
��T���X�ก��q!���� qX ���UrT!�����T���X�ก��q!���� qX ���UrT!���
Osmotic diureticOsmotic diuretic
CorticosteroidsCorticosteroidsAnticonvulsantsAnticonvulsantsAntacidAntacidStool softenersStool softenersHistamine blockersHistamine blockersAntipyretics Antipyretics
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Managing factors known to IICPManaging factors known to IICP
VasalVasalvava�� s maneus maneuvvererBowel managementBowel managementIsometric muscle contractionIsometric muscle contractionControl Control sshiveringhiveringEmotional upset & noxious stimEmotional upset & noxious stimuuliliClustering of nursing activitiClustering of nursing activitieess
Managing factors known to IICPManaging factors known to IICP
Control environmental stimuli Control environmental stimuli
: : excessive noise, unnecessary lighting, painful stimuli, excessive noise, unnecessary lighting, painful stimuli,
unfamiliar voiceunfamiliar voice
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"45����ก��� ������U����X �7� !"#� ��U��IICP
# ��ก���T�qX cerebral tissue perfusion �7WUXb�ก ����T�7�7ก����ก���k�� , ��X��� ��WXb�ก��XT��WXT�7��X�T�ก��
q!X� ��7���7R7 : • GCS 1P1N T.OP pupil U+TVW. I$'XYกY)Y%O+ZS0#N1P1N
K[OI#OIO)\].กO)"K1RMS.&J[TSN0T.TO.-S%1N J)RS"K1RMS.&J[0^^"ก)_NNSJ)RS"ก)_N"J%$%P SBP #QNTVW. Pulse pressure ก[-ONTVW. $̀ab) -̀O1N0+Z0)N JO%]b"'c.0^^ cheyne-stokes '[Pd$)e* SO"b$%. L̀ก"ก)_N ก)*+,ก
• ICP >15 mmHg• CPP <70 mmHg
ก��� ����
� #LN"ก+01* L̂.fVก neuro signs & vital signs
� ]J-กO)a%O^O1"aRMS1P01*'hSNกL. IICP
� )LกeO)*PL^TSN MAP ]J-S%QZ].)*PL^ 100 mmHg
� )LกeO)*PL^S,iJjQIYกO%]J-S%QZ].)*PL^'ก+Y
� PQ01]J-&P-)L^%O barbiturates, sedatives +OI0k.กO))LกeO
� J1$ก"1$M%N#YMNก)*+,-.f$M&IZaVN')*#NKl
� 'hSNกL. Rebleeding ( ruptured aneurysm )
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q�T"������Y���7ก���S����T�7�� �b��!���
q!X� ��7���7R7
� LOC 1P1N K[OI#OIO)\].กO)&S1P1N "#IJ*"J.$%[
� JO%]b")_[+RW. &P-%Y."#$%NK)RPK)OP ก)*#L^ก)*#ZO%
� mnN"#$%NJO%]b&P-%Y."#$%N"#IJ*
� "#$%NกO)foONO.TSN"K)RMSN`Z[%JO%]bkYP'ก+Y
ก��� ����
� ')*"IY.fON"PY.JO%]b� bLPfZO.S. "'1$M%.fZO.S.� PQ01K[OI`RW.].fON"PY.JO%]b� PQP"#IJ*S%ZONI$')*#YfpYjOa� PQ01")RMSNกO)]J-.WoO� Percussion & vibration \-O&IZI$T-SJ-OI� ]J-%O1*1O%"#IJ*
33
V��V�7ก���� �br����"������Y��ก��V�ก�"��U 7กs�t�T�
q!X� ��7���7R7� JO%]b].1Lกei*+-SNSSก0)NIOก SL+)OกO)JO%]b K[OI1VกkYP'ก+Y JO%]b&IZ#IMoO"#IS
� LOC 1P1N
� Spontaneous tidal volume < 7 ml/kg
� PaO2 < 80 mmHg PaCO2 > 45 mmHg
ก��� ����� ')*"IY.1Lกei*กO)JO%]b
� PQ01fON"PY.JO%]b]J-U1ZN I$กO))*^O%SOกOdP$
� PQ01]J-kQ-'v[%&P-)L^SSกwY"b.01*"K)RMSN`Z[%JO%]b
� PQ01]J-กO)JO%]bI$')*#YfpYjOa
� ]J-กO)a%O^O1"aRMS1P01*'hSNกL.jO[* IICP
� +YP+OI')*"IY. Spo2 01* ABG "'c.)*%*y
34
���U ��XY���r����TR�qX7vS�V�� electrolytes( 7vS�q�T �t�T� ��7��WXT� )
q!X� ��7���7R7� 'n##O[*SSกIOก ( > 200 ml/hr )
� Specific gravity < 1.005
� SZS."a1$% 'Oก0J-N kY[J.LN0J-N
� CVP < 5 mmHg
� Na > 145 mmEq/L
� Serum osmolarity > 300 mOsm/kg
ก��� ����
� #LN"ก+SOกO) / SOกO)0#PN� PQ01]J-&P-)L^.WoOS%ZONaS"a$%N� L̂.fVก I/O� ก)i$I$ DI 0af%lSOb]J- Minirin %Ob*SSก{fpY|jO%]. 15-30 .Of$ 'n##O[*b*SSก.-S%1N +-SN)*ILP)*[LNกO)]J- IV fluid "a)O*SOb"กYP.WoO"กY. I$jO[*.WoO"'c.aYe (water intoxication) &P- +-SN')*"IY.)*PL^K[OI)Q-#Vก+L[ kQ-'v[%b*I$SOกO)wVI1N
� +)[b[LP)*PL^ electrolytes f,ก[L.
35
���U ��XY���r����TR�qX7vS�V�� electrolytes( 7vS��ก�7 �t�T� ��7��WXT�US� )
q!X� ��7���7R7� I > O
� LOC 1P1N SO"b$%.
� CVP > 12 mmHg
� Na <135 mEq/L
� Serum osmolarity < 280 mOsm/Kg
ก��� ����
� #LN"ก+SOกO) / SOกO)0#PN
� L̂.fVก I/O
� PQ01]J-&P-)L^.WoO < 1,000 ml/d
� \-O Na ]."1RSP+MoO 0af%lb*]J- 3% NaCl
� PQ01]J-&P-)L^%OTL^'n##O[*+OI0k.กO))LกeO
� +)[b[LP)*PL^ electrolytes f,ก[L.
36
���U ��Xก���ก�TY���V��กt!X7 : กO)+YP"`RWS ( RI, UTI, wound infection, invasive procedures) 0k1กPfL^, DVTq!X� ��7���7R7� .S.].fZO"P$%[.O.y &IZI$กO)"K1RMS.&J[ J)RSI$กO)"K1RMS.&J[.-S% I$SO"b$%. #oO1Lก
� JO%]bJS^"J.RMS% +-SN]`-0)NIOกTVW. 1Lกei*"#IJ*T-. #$T,Z."J1RSN I$ก1YM. I$&T-
� 0k1^[I 0PN I$ discharge I$ก1YM.� 1Lกei* CSF T,Z. I$&T-� Braden score >16� TOP.WoO
��X��������������กก���V���6��ก�������5�������� Tr���������
q!X� ��7���7R7� กO)^OP"b_^"กYPTVW.ก)*fL.JL.� TOPK[OI)Q-01*T-SIQ1"ก$M%[กL^กO)'XY L̂+Y+L[ กO))LกeO กO)a%Oก)ilU)K
� กO)boOกLP"[1O"T-O"%$M%I� #\O.กO)il]. ICU ")ZN)$^ S,'ก)il 01*"K)RMSNIRSI$IOก .ZOก1L[
� กO)#RMS#O)bOกf$IkQ-)LกeO01*PQ01
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