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Nursing Care of Breast Cancer Patient, Receiving Radiotherapy

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À√◊Õ°“√ºà“μ—¥√à«¡°—∫‡§¡’∫”∫—¥ ·≈–/ À√◊Õ√—ß ’√—°…“

√à«¡°—∫°“√„ÀâŒÕ√å‚¡π‡ √‘¡°“√√—°…“ ®“°°“√»÷°…“

¢Õß«√“ߧ≥“ ®—π∑√ ÿ¢³ ≥  ∂“∫—π¡–‡√Áß·Ààß™“μ‘ æ∫

«à“Õ—μ√“°“√√Õ¥™’«‘μ∑’Ë 5 ªï (5 years survival) ¢Õß∑ÿ°

√–¬–Õ¬Ÿà∑’Ë √âÕ¬≈– 73.7 ‚¥¬Õ—μ√“°“√√Õ¥™’«‘μ∑’Ë Ÿß ¡’

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«‘π‘®©—¬ ·≈–°“√√—°…“∑’Ë¡’ª√– ‘∑∏‘¿“æ¡“°¢÷Èπ⁴ ·μà Õ¬à“߉√°Á¥’ Õ—μ√“°“√√Õ¥™’«‘μ∑’Ë Ÿß¢÷Èπ ∑”„À⺟âªÉ«¬∫“ß

√“¬¡’‚Õ°“ ‡º™‘≠°—∫¿“«–·∑√°´âÕπ®“°°“√√—°…“π“π

¢÷Èπ⁵ ‚¥¬‡©æ“–Õ¬à“߬‘Ëߺ≈¢â“߇§’¬ß®“°°“√ºà“μ—¥·≈–

Abstract

Breast cancer is the most common cancer in Thai women in recent years, and in 2012, its became the most common among all cancer in Thailand. Siriraj cancer registry reported the increasing of number of new patients on each year. Radiation therapy has established the role in breast cancer patients as curative treatment, loco-regional disease treatment, palliative radiation therapy and also loco-regional recurrence breast cancer. In Radiation therapy, nurse has taken the roles since prior, undergoing and after treatment, by helping and support the patient with treatment and side effect information. Also assessment, evaluation and together with the patient to manage radiation side effects, emotional support, provide contact and liaise with doctor and other healthcare providers. The aim of all actions is to let the patient pass through the whole treatment without ceasing, prevent and reduce the side effect that could be avoided, support social image and together with the quality of life.

Key words: breast cancer, radiotherapy, nursing care

°“√©“¬√—ß ’⁶ ∫∑∫“∑¢Õß√—ß ’√—°…“„π°“√√—°…“¡–‡√Áß

‡μâ“π¡ ¡’∑—È߇æ◊ËÕÀ«—ßÀ“¬¢“¥®“°‚√§ (curative treatment)

„π°√≥’∑’Ë‚√§Õ¬Ÿà‡©æ“–∑’Ë (locoregional disease) À√◊Õ≈¥

Õ“°“√·≈–§«“¡∑ÿ°¢å∑√¡“π®“°μ—«‚√§ (palliation) „π

°√≥’∑’Ë‚√§¡–‡√ÁßÕ¬Ÿà„π√–¬–·æ√à°√–®“¬ (metastatic dis- ease)⁷ „π∑’¡√—ß ’√—°…“ 欓∫“≈¡’∫∑∫“∑ ”§—≠„π

°“√‡μ√’¬¡μ—«ºŸâªÉ«¬‡æ◊ËÕ„Àâ¡’§«“¡√Ÿâ §«“¡‡¢â“„®

 “¡“√∂ªØ‘∫—μ‘μπ‰¥â∂Ÿ°μâÕß √—∫°“√√—°…“‰¥âμàÕ‡π◊ËÕß

§√∫∂â«π ‡π◊ËÕß®“°ºŸâªÉ«¬∫“ß√“¬¬—ߢ“¥§«“¡√Ÿâ °≈—«

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√ÿπ·√ߢÕß°“√‡°‘¥º≈¢â“߇§’¬ß¢≥–·≈–À≈—ß°“√√—°…“

¥â«¬√—ß ’ ‡π◊ËÕß®“°º≈¢â“߇§’¬ß¢Õß°“√√—°…“∫“ßÕ¬à“ß

‡™àπ ¿“«–·¢π∫«¡πÈ”‡À≈◊Õß (Arm Lymphedema) ‡ªìπ

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√—ß ’√—°…“

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∫∑∫“∑¢Õß√—ß ’√—°…“„π°“√√—°…“¡–‡√Á߇μâ“π¡ ¡’

∑—Èß à«π¢Õß°“√√—°…“‡æ◊ËÕ°“√À“¬¢“¥ (curative treatment)

‡™àπ °“√©“¬√—ß ’¿“¬À≈—ß°“√ºà“μ—¥‡μâ“π¡ÕÕ°∑—ÈßÀ¡¥

(Post-mastectomy radiation) °“√©“¬√—ß ’¿“¬À≈—ß°“√

ºà“μ—¥‡μâ“π¡ÕÕ°∫“ß à«π (Breast conservative therapy)

‡æ◊ËÕ°“√§«∫§ÿ¡‚√§„πºŸâªÉ«¬¡–‡√Áß√–¬–·æ√à°√–®“¬

‡©æ“–∑’Ë (Locally advanced breast cancer) ·≈–‡æ◊ËÕ°“√

ª√–§—∫§Õß·≈–∫√√‡∑“Õ“°“√ (Palliative radiation therapy and Loco-regional recurrence breast cancer) ‚¥¬§«√‰¥â

√—∫°“√©“¬√—ß ’¿“¬„π 4 -6  —ª¥“Àå ‰¡à‡°‘π 8  —ª¥“Àå

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®–®”≈Õß ·≈–«“ß·ºπ°“√√—°…“ (Simulation Technique) ªí®®ÿ∫—ππ’ȇ∑§π‘§∑’Ë„™â à«π„À≠à ®–‡ªìπ°“√«“ß·ºπ°“√

√—°…“·≈–°“√©“¬√—ß ’·∫∫ 3 ¡‘μ‘ (3D-CRT) ‚¥¬∑—Ë«‰ª μ”·ÀπàߢÕß°“√©“¬√—ß ’¡’¥—ßπ’È

1. °“√©“¬√—ß ’∫√‘‡«≥ºπ—ß∑√«ßÕ° (chest wall) À√◊Õ‡μâ“π¡∑—È߇μâ“ (intact breast)

„™â ”À√—∫ºŸâªÉ«¬¡–‡√Á߇μâ“π¡∑’Ë¡’§«“¡‡ ’ˬߠŸß (high risk) À≈—ß°“√ºà“μ—¥ mastectomy À√◊ÕºŸâªÉ«¬∑’Ë∑”

breast conserving surgery ‚¥¬°“√©“¬√—ß ’¥â«¬ medial

·≈– lateral tangential portals ‚¥¬§√Õ∫§≈ÿ¡ ∫√‘‡«≥

ºπ—ß∑√«ßÕ° À√◊Õ ‡μâ“π¡∑—È߇μâ“ ·≈–欓¬“¡„Àâ√—ß ’∂Ÿ°

‡π◊ÈÕªÕ¥·≈–À—«„®„ÀâπâÕ¬∑’Ë ÿ¥ ª√‘¡“≥√—ß ’∑’Ë„™â 45-50 Gy / 25-28 fractions / 5  —ª¥“Àå ∂Ⓡªìπ conserving surgery æ‘®“√≥“ boost ∑’Ë tumor bed ‡æ‘Ë¡Õ’° 10-20 Gy / 5-10 fractions

2. °“√©“¬√—ß ’∫√‘‡«≥μàÕ¡πÈ”‡À≈◊Õß supraclavicu- lar node field

‡ªìπ°“√©“¬√—ß ’‡æ◊ËÕ§«∫§ÿ¡‚√§∫√‘‡«≥μàÕ¡πÈ”

‡À≈◊Õß∑’ËÕ¬Ÿà‡Àπ◊Õ·≈–„μâμàÕ°√–¥Ÿ°‰Àª≈“√â“·≈–∫“ß  à«π¢ÕßμàÕ¡πÈ”‡À≈◊Õß∫√‘‡«≥√—°·√â ª√‘¡“≥√—ß ’∑’Ë„™â 45- 50 Gy / 25- 28 fractions / 5  —ª¥“Àå

3. °“√©“¬√—ß ’∫√‘‡«≥ internal mammary node field

°“√©“¬√—ß ’∫√‘‡«≥ internal mammary node

®–æ‘®“√≥“©“¬√—ß ’∫√‘‡«≥π’È ‡¡◊ËÕæ∫¡’ clinical À√◊Õ patho- logical nodes positive À√◊Õ¢÷Èπ°—∫¥ÿ≈¬æ‘π‘®¢Õß√—ß ’·æ∑¬å ª√‘¡“≥√—ß ’∑’Ë„™â 45-50 Gy / 25-28 fractions / 5  —ª¥“Àå

§‘¥∑’˧«“¡≈÷° 3-4 cm. ®“°º‘«Àπ—ß

 ”À√—∫°“√°≈—∫‡ªìπ´È”∫√‘‡«≥√—°·√â (axillary recur- rence) æ∫‰¥âª√–¡“≥ √âÕ¬≈– 0.5-3 ‡∑à“π—Èπ ¥—ßπ—Èπ®÷ß

‰¡à¡’§«“¡®”‡ªìπμâÕß©“¬√—ß ’∫√‘‡«≥√—°·√â ¬°‡«âπ„π

√“¬∑’ˉ¡à “¡“√∂ºà“μ—¥μàÕ¡πÈ”‡À≈◊ÕßÕÕ°‰¥âÀ¡¥ „π

°√≥’∑’Ë¡’ clinical matted axillary nodes À√◊Õ∑“ß欓∏‘

«‘∑¬“√“¬ß“π«à“¡’ extracapsular invasion Õ“®æ‘®“√≥“

©“¬√—ß ’∑’Ë∫√‘‡«≥√—°·√â¥â«¬

º≈¢â“߇§’¬ß¢Õß°“√√—°…“¥â«¬√—ß ’  “¡“√∂·∫àß ÕÕ°‰¥â‡ªìπ 3 √–¬–¹⁷

1. Acute Radiation Complication §◊Õ μ—Èß·μà«—π·√°

∑’ˇ√‘Ë¡©“¬√—ß ’ ®π°√–∑—Ëß 3 ‡¥◊Õπ π—∫®“°«—π ÿ¥∑⓬¢Õß

°“√©“¬√—ß ’ ‚¥¬º≈¢â“߇§’¬ß∑’ˇ°‘¥¢÷Èπ„π√–¬–π’È¡—°®–

‡ªìπ·∫∫™—Ë«§√“«  “¡“√∂√—°…“„ÀâÀ“¬‰¥â

2. Sub-acute Radiation Complication §◊Õ „π™à«ß 3 - 6 ‡¥◊Õπ À≈—ß®“°«—π ÿ¥∑⓬¢Õß°“√©“¬√—ß ’ ‚¥¬º≈¢â“ß

‡§’¬ß∑’ˇ°‘¥¢÷Èπ„π√–¬–π’È‚¥¬ à«π„À≠à “¡“√∂∑’Ë®–√—°…“

„ÀâÀ“¬‰¥â

3. Chronic (Late) Radiation Complication §◊Õ À≈—ß 6 ‡¥◊Õπ ®“°«—π ÿ¥∑⓬¢Õß°“√©“¬√—ß ’ ‚¥¬º≈¢â“ß

‡§’¬ß∑’ˇ°‘¥¢÷Èπ„π√–¬–π’È‚¥¬ à«π„À≠à‰¡à “¡“√∂√—°…“

„ÀâÀ“¬‰¥â ¡—°®–‡ªìπ∂“«√

º≈¢â“߇§’¬ß¢Õß°“√√—°…“¥â«¬√—ß ’„πºŸâªÉ«¬¡–‡√Áß

‡μâ“π¡ ∑’Ë “¡“√∂æ∫‰¥â‚¥¬∑—Ë«‰ª (common radiation complication)‡™àπ °“√√–§“¬‡§◊Õߺ‘«Àπ—ß∫√‘‡«≥∑’ˉ¥â√—∫

√—ß ’ (skin reaction) Õ“°“√ÕàÕπ≈â“ (fatigue) ·≈–º≈¢â“ß

‡§’¬ß∑’Ë®”‡æ“–μàÕμ”·ÀπàߢÕß°“√©“¬√—ß ’ (specific or- gan complication) ‡™àπ À≈Õ¥Õ“À“√Õ—°‡ ∫ (esophagitis)

¿“«–ªÕ¥Õ—°‡ ∫®“°°“√©“¬√—ß ’ (radiation Pneumoni- tis) °“√‡°‘¥æ—ߺ◊¥∑’˺‘«Àπ—ß∫√‘‡«≥©“¬√—ß ’ (skin Fibrosis)

¿“«–·¢π∫«¡À≈—ß°“√√—°…“¡–‡√Á߇μâ“π¡ (arm lymphe- dema) ¿“«–°“√‡°‘¥æ—ߺ◊¥∑’˪ե®“°°“√©“¬√—ß ’ (radia- tion-induced pulmonary fibrosis) ·≈–¿“«–°“√‡°‘¥º≈

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·μà‡¡◊ËÕ‡°‘¥·≈â«°Á¡’Õ—πμ√“¬¡“°‡™àπ°—π¹⁸

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√—ß ’√—°…“

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 “¡“√∂ªØ‘∫—μ‘μπ‰¥â∂Ÿ°μâÕß  “¡“√∂√—∫°“√√—°…“‰¥âμàÕ

‡π◊ËÕß §√∫∂â«π  “¡“√∂ªÑÕß°—π·≈–®—¥°“√º≈¢â“߇§’¬ß

‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ ·≈–ª≈Õ¥¿—¬ ‡æ◊ËÕ„Àâ∫√√≈ÿ

«—μ∂ÿª√– ß§å¥—ß°≈à“« 欓∫“≈μâÕ߇ªìπºŸâ¡’§«“¡√Ÿâ„π

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º≈¢â“߇§’¬ß  “¡“√∂π”∑ƒ…Æ’∑“ß°“√欓∫“≈¡“‡æ◊ËÕ

„™âª√–‡¡‘πºŸâªÉ«¬„Àâ§√∫∑ÿ°¥â“π ·∫∫Õߧå√«¡ √«¡∑—Èß¡’

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°“√欓∫“≈ºŸâªÉ«¬°àÕπ‰¥â√—∫√—ß ’√—°…“

°“√‡μ√’¬¡§«“¡æ√âÕ¡°àÕπ°“√√—°…“®÷߇ªìπ

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∑—»π§μ‘∑’ˉ¡à∂Ÿ°μâÕߢÕߺŸâ§π„π —ߧ¡∫“ß à«π‡°’ˬ«°—∫

°“√©“¬√—ß ’ ºŸâªÉ«¬§«√‰¥â√—∫°“√ª√–‡¡‘π·≈–°“√¥Ÿ·≈

·∫∫Õߧå√«¡

1. °“√‡μ√’¬¡æ√âÕ¡∑“ߥâ“π√à“ß°“¬ ºŸâªÉ«¬§«√‰¥â

√—∫°“√ª√–‡¡‘π ¿“«– (performance status) °“√

ª√–‡¡‘π¿“«–‚¿™π“°“√ °“√À“§à“¥—™π’¡«≈°“¬ (body mass index) §”·π–π”¥â“π‚¿™π“°“√∑’ˇÀ¡“– ¡ ·≈–

°“√‡μ√’¬¡‡ ◊ÈÕºâ“∑’ˇÀ¡“– ¡„π¢≥–√—∫°“√©“¬√—ß ’ 2. °“√‡μ√’¬¡æ√âÕ¡∑“ߥâ“π®‘μ„® Õ“√¡≥å ºŸâªÉ«¬

§«√‰¥â√—∫°“√ª√–‡¡‘𧫓¡«‘μ°°—ß«≈ ®“° ’Àπâ“ ∑à“∑“ß

§”查 ·≈–°“√°√–∑”ª√–‡¡‘𧫓¡√Ÿâ·≈–∑—»π§μ‘ ‡°’ˬ«

°—∫°“√√—°…“⁸ √«¡∑—Èß Õ∫∂“¡∂÷ߪí≠À“Õ◊ËπÊÕ∏‘∫“¬∂÷ß

°“√√—°…“ „Àâ¢âÕ¡Ÿ≈·≈–§”·π–𔇰’ˬ«°—∫°√–∫«π°“√

√—°…“μàÕ‡π◊ËÕß μ“¡·ºπ°“√√—°…“¢Õß·æ∑¬å º≈¥’¢Õß

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øíß·≈– √ÿªªî¥°“√ π∑π“ ´÷Ëß¡’√“¬ß“π°“√»÷°…“æ∫

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¡’º≈μàÕ§ÿ≥¿“æ™’«‘μ¢ÕߺŸâªÉ«¬²⁰

3. °“√‡μ√’¬¡æ√âÕ¡∑“ߥâ“π®‘μ —ß§¡  à߇ √‘¡„À⺟⠪ɫ¬·≈–§√Õ∫§√—«®—¥°“√∑“ß —ߧ¡Õ¬à“߇À¡“– ¡

∫∑∫“∑„π§√Õ∫§√—« ∑’Ë∑”ß“π §à“„™â®à“¬  ‘∑∏‘§à“√—°…“

欓∫“≈ √«¡∑—Èß∑’Ëæ—°Õ“»—¬√–À«à“ß°“√©“¬√—ß ’„π°√≥’

∫â“π‰°≈  à߇ √‘¡„π‡√◊ËÕß°“√ª√—∫μ—«√—∫§«“¡‡ª≈’ˬπ

·ª≈ßμà“ßÊ ∑’Ë®–‡°‘¥¢÷Èπ

4. °“√‡μ√’¬¡æ√âÕ¡∑“ߥâ“π®‘μ«‘≠≠“≥ ‡ªìπ°“√

¥Ÿ·≈¡‘μ‘∑’ˇ°’ˬ«¢âÕß —¡æ—π∏å°—∫»“ π“ §«“¡‡™◊ËÕ §«“¡À«—ß

§«“¡√—° §«“¡»√—∑∏“ ‡ªÑ“À¡“¬¢Õß™’«‘μ ·≈–°“√

· ¥ßÕÕ°æƒμ‘°√√¡§«“¡√Ÿâ ÷°∑’ËÕ¬Ÿà à«π≈÷°¢Õß∫ÿ§§≈ ∑’Ë

®– àߺ≈°√–∑∫μàÕ√à“ß°“¬ ·≈–®‘μ„® ´÷Ëß®–·μ°μà“ß°—π

„π·μà≈–∫ÿ§§≈ ‡™àπ°“√ à߇ √‘¡„À⺟âªÉ«¬π”§«“¡‡™◊ËÕ

∑“ß»“ π“¡“ª√—∫„™â°—∫μπ‡Õß °“√𔧫“¡√—°¢Õß

∫ÿ§§≈„π§√Õ∫§√—«¡“‡ªìπ·√ߺ≈—°¥—π„À⺟âªÉ«¬¡“√—∫

°“√√—°…“®π§√∫∂â«π

πÕ°®“°π’È ‡æ◊ËÕ„Àâ°“√√—°…“‡ªìπ‰ªÕ¬à“ß¡’

ª√– ‘∑∏‘¿“æ 欓∫“≈§«√‡μ√’¬¡º≈μ√«®∑“ߧ≈‘π‘° ‡™àπ º≈™‘Èπ‡π◊ÈÕ º≈ hormone receptors ‰¥â·°à estrogen recep- tor (ER), progesterone receptor (PR) ·≈– º≈ molecular receptors ‰¥â·°à human epidermal growth factor recep- tor 2 (HER2) º≈μ√«®∑“ß√—ß ’«‘∑¬“ ‰¥â·°à °“√‡Õ°´‡√¬å ªÕ¥ (CXR) °“√μ√«®§≈◊Ëπ·¡à‡À≈Á°‰øøÑ“ (MRI) À√◊Õ

‡Õ°´‡√¬å§Õ¡æ‘«‡μÕ√å (CT) À√◊Õ Õ—≈μ√“´“«π¥å™àÕß∑âÕß (ultrasound whole abdomen) ·≈–°“√∂à“¬¿“æ ·°π

°√–¥Ÿ° (bone scan) º≈μ√«®∑“ßÀâÕߪؑ∫—μ‘°“√ ‡™àπ CBC

‡π◊ËÕß®“° à«π„À≠ຟâªÉ«¬¡—°‰¥â√—∫‡§¡’∫”∫—¥°àÕπ¡“√—∫

√—ß ’√—°…“ ®÷ߧ«√ª√–‡¡‘π¿“«–´’¥ (anemia) À√◊Õ¿“«–

‡¡Á¥‡≈◊Õ¥¢“«μË” (neutropenia)

°“√欓∫“≈ºŸâªÉ«¬¢≥–‰¥â√—∫√—ß ’√—°…“

1. °“√¥Ÿ·≈º‘«Àπ—ß∑’ˉ¥â√—∫√—ß ’ ‡π◊ËÕß®“°°“√

‡ª≈’ˬπ·ª≈ߢÕߺ‘«Àπ—ß (skin reaction/ radiation derma- titis) ‡ªìπÕ“°“√∑’Ëæ∫‰¥â∑—Ë«‰ª„πμ”·Àπàß∑’ˉ¥â√—∫√—ß ’ æ∫‰¥â∂÷ß√âÕ¬≈– 95²¹ ‚¥¬º‘«Àπ—߇ªìπ°≈ÿࡇπ◊ÈÕ‡¬◊ËÕ∑’ˇ®√‘≠

‡μ‘∫‚μμ≈Õ¥‡«≈“ (rapid cellular mitosis) ®÷ß¡’§«“¡‰«

μàÕ√—ß ’ Ÿß ¡’°“√‡ª≈’ˬπ·ª≈ß∑“ß‚§√ß √â“ß·≈–Àπâ“∑’Ë º‘«Àπ—ß∫√‘‡«≥π’È®÷ß∫Õ∫∫“ß·≈–μâÕß°“√°“√¥Ÿ·≈‡ªìπ 摇»…²² ‚¥¬º‘«Àπ—ߢÕߺŸâªÉ«¬®–‡√‘Ë¡¡’Õ“°“√·¥ß (erythema) ‰¥âμ—Èß·μà 24 ™—Ë«‚¡ß·√°¢Õß°“√©“¬√—ß ’

·≈–®–‡√‘Ë¡‡ÀÁπ™—¥‡®π¢÷Èπ‡¡◊ËÕºŸâªÉ«¬‰¥â√—∫ª√‘¡“≥√—ß ’μ—Èß·μà 20-40 Gy μàÕ¡“ ’º‘«®–‡¢â¡¢÷Èπ (hyperpigmentation) æ√âÕ¡°—∫≈—°…≥–·Àâß∑’ˇ√’¬°«à“ dry desquamation ‡¡◊ËÕ

‰¥â√—∫ª√‘¡“≥√—ß ’μ—Èß·μà 45 Gy ¢÷Èπ‰ª ·≈–‡¡◊ËÕ‰¥â√—∫

ª√‘¡“≥√—ß ’¡“°°«à“ 60 Gy ¢÷Èπ‰ª º‘«Àπ—ߢÕߺŸâªÉ«¬®–

‡√‘Ë¡· ¥ß≈—°…≥–‡ªìπ·º≈·©–æ√âÕ¡°—∫¡’‡≈◊Õ¥ÕÕ° ∑’Ë

‡√’¬°«à“ moist desquamation ´÷Ëß·æ∑¬å¡—°®–„ÀâÀ¬ÿ¥æ—°

°“√©“¬√—ß ’ ®π°«à“·º≈®–¥’¢÷Èπ ‚¥¬§«“¡√ÿπ·√ß∑’ˇ°‘¥

¢÷Èπ¡’§«“¡ —¡æ—π∏å°—∫ªí®®—¬À≈“¬ª√–°“√ ‰¥â·°à ªí®®—¬

∑“ߥâ“π°“√√—°…“ ‡™àπ ª√‘¡“≥√—ß ’ μ”·Àπàß∑’Ë√—°…“

‚¥¬‡©æ“–∫√‘‡«≥√Õ¬æ—∫ √Õ¬·º≈ºà“μ—¥ °“√‰¥â√—∫√—ß ’

√—°…“√à«¡°—∫‡§¡’∫”∫—¥ ´÷Ëß¡’º≈μàÕ√–∫∫¿Ÿ¡‘§ÿâ¡°—π ·≈–

ªí®®—¬¥â“πºŸâªÉ«¬ ‡™àπ ‚√§√à«¡ ‚√§‡∫“À«“π ‚√§‰μ ºŸâ  ŸßÕ“¬ÿ √«¡∂÷ß°“√¥Ÿ·≈μπ‡Õß ·≈–¿“«–‚¿™π“°“√²¹

°“√欓∫“≈·≈–°“√¥Ÿ·≈º‘«Àπ—ß∫√‘‡«≥∑’ˉ¥â√—∫°“√

©“¬√—ß ’^21-23

1.1 ºŸâªÉ«¬ “¡“√∂Õ“∫πÈ” ‚¥¬„™â ∫Ÿà‡¥Á°ÕàÕπÊ À≈’°‡≈’ˬ߰“√øÕ°¢—¥∂Ÿ À≈—ßÕ“∫πÈ”„™âºâ“πÿà¡Ê ´—∫‡∫“Ê

·∑π°“√‡™Á¥μ—«μ“¡ª°μ‘

1.2 ¥Ÿ·≈º‘«Àπ—ß„Àâ –Õ“¥ ·Àâß ·≈–‰¡àÕ—∫™◊Èπ À≈’°‡≈’ˬ߰“√‡ ’¬¥ ’º‘«Àπ—ß §«√ «¡„ à‡ ◊ÈÕºâ“À≈«¡Ê

‡π◊ÈÕºâ“ÕàÕππÿà¡ ‰¡à„ à¬°∑√ß¡’‚§√ßÀ√◊Õ¬°∑√ß√—¥·πàπ

‰¡à «¡ √âÕ¬§Õ

1.3 À≈’°‡≈’ˬ߰“√„™â°√–‡ªÜ“πÈ”√âÕπÀ√◊ÕπÈ”‡¬Áπ

√–«—߉¡à„À⺑«Àπ—ß∂Ÿ°·¥¥®—¥Ê ‚¥¬μ√ß §«√°“ß√à¡ À√◊Õ

 «¡„ à‡ ◊ÈÕª°ªî¥∫√‘‡«≥∑’ˉ¥â√—∫°“√©“¬√—ß ’°àÕπÕÕ°

πÕ°∫â“π

1.4 Àâ“¡„™â¡’¥‚°π¢π „π∫√‘‡«≥∑’ˉ¥â√—∫°“√

©“¬√—ß ’ §«√„™â°√√‰°√À√◊Õ‡§√◊ËÕß‚°π·∫∫Õ‘‡≈°‚∑π‘§

1.5 ºŸâªÉ«¬§«√‰¥â√—∫ª√–‡¡‘πº‘«Àπ—ß∫√‘‡«≥∑’ˉ¥â

√—∫°“√©“¬√—ß ’Õ¬à“ßπâÕ¬ —ª¥“Àå≈–§√—Èß ‡æ◊ËÕ„Àâ°“√¥Ÿ·≈

√—°…“μ“¡√–¥—∫§«“¡√ÿπ·√ß

1.6 ºŸâªÉ«¬§«√¥◊Ë¡πÈ” –Õ“¥ Õ¬à“ßπâÕ¬ 8-10 ·°â«

(200- 250 ´´/ ·°â«) ‡æ◊Ëՙ૬‡æ‘Ë¡§«“¡™ÿà¡™◊Èπ„À⺑«Àπ—ß 1.7 À“°¡’·º≈Õ—°‡ ∫ À√◊Õμ‘¥‡™◊ÈÕ ∑”§«“¡

 –Õ“¥·º≈¥â«¬ 0.9% NSS ·≈– “¡“√∂„™â Betadine

∑“∫√‘‡«≥∑’Ë©“¬√—ß ’‰¥â À≈’°‡≈’ˬ߰“√μ‘¥æ“ ‡μÕ√å ∫π º‘«Àπ—ß∑’ˉ¥â√—∫√—ß ’√—°…“ √à«¡°—∫°“√√—∫ª√–∑“πÕ“À“√

‚ª√μ’π Ÿß ‡æ◊ËÕ à߇ √‘¡°“√À“¬¢Õß·º≈

À≈—° ”§—≠¢Õß°“√¥Ÿ·≈º‘«Àπ—ß∑’ˉ¥â√—∫√—ß ’Õ¬Ÿà∑’Ë

°“√À≈’°‡≈’ˬ߰“√√–§“¬‡§◊Õß °“√¢—¥∂Ÿ ·≈–°“√‡æ‘Ë¡

§«“¡™ÿà¡™◊Èπ„À⺑«Àπ—ß ªí®®ÿ∫—π¡’·π«∑“ߪؑ∫—μ‘ (practice guideline) „πμà“ߪ√–‡∑» ¬Õ¡√—∫„Àâ∑“‚≈™—Ëπ∫“ßμ—«

√–À«à“ß°“√©“¬√—ß ’‡æ‘Ë¡§«“¡™ÿà¡™◊Èπ„À⺑«Àπ—ß ≈¥

Õ“°“√§—π®“°º‘«·Àâ߉¥â²³ Õ¬à“߉√°Á¥’μâÕߪ√÷°…“·æ∑¬å

‡æ◊ËÕæ‘®“√≥“§«“¡‡À¡“– ¡„πºŸâªÉ«¬·μà≈–√“¬

2. °“√¥Ÿ·≈·≈– à߇ √‘¡¿“«–‚¿™π“°“√ ‡π◊ËÕß

®“°¢≥–√—∫°“√√—°…“ √à“ß°“¬ºŸâªÉ«¬¡’§«“¡μâÕß°“√

æ≈—ßß“π„π√–¥—∫ Ÿß √à«¡°—∫ºŸâªÉ«¬Õ“®‡°‘¥Õ“°“√

À≈Õ¥Õ“À“√Õ—°‡ ∫ (Esophagitis) ´÷Ëß¡’°≈‰° °“√‡°‘¥

‡™àπ‡¥’¬«°—∫¿“«–‡¬◊ËÕ∫ÿ∑“߇¥‘πÕ“À“√Õ—°‡ ∫¢≥–‰¥â√—∫

√—ß ’ (radiation mucositis) ‚¥¬Õ“°“√· ¥ß§◊Õ ª«¥

· ∫¬Õ¥Õ° °≈◊π‡®Á∫ ∑”„Àâ√—∫ª√–∑“πÕ“À“√‰¥âπâÕ¬≈ß

·π–π”„À⺟âªÉ«¬√—∫ª√–∑“πÕ“À“√ÕàÕπ∑’Ë¡’‚ª√μ’π ·≈–

æ≈—ßß“π Ÿß ‡™àπ π¡ ‰Õ»°√’¡ πÈ”º÷Èß Õ“À“√∑’ˉ¡à¡’√ ®—¥

‡æ◊ËÕ≈¥°“√√–§“¬‡§◊Õß ·π–π”„π‡√◊ËÕß°“√·∫àßÕ“À“√

‡ªìπ¡◊ÈÕ‡≈Á°Ê ‡™àπ 4- 6 ¡◊ÈÕμàÕ«—π ‰¡àπÕπ¿“¬À≈—ß¡◊ÈÕÕ“À“√

„Àâπ—ËßÀ√◊Õ¬◊πÀ≈—ß√—∫ª√–∑“πÕ“À“√Õ¬à“ßπâÕ¬ 30 π“∑’

‡æ◊ËÕ≈¥°“√√–§“¬‡§◊ÕßÀ≈Õ¥Õ“À“√

3.  à߇ √‘¡°“√πÕπÀ≈—∫„π‡«≈“°≈“ߧ◊π °“√æ—°

ºàÕπ °“√∫√‘À“√¢âÕμàÕ ·≈–‰À≈à ·≈–ÕÕ°°”≈—ß°“¬∑’Ë

‡À¡“– ¡°—∫ ¿“æ√à“ß°“¬·≈–Õ“¬ÿ ‡™àπ°“√‡¥‘π °“√

‡≈àπ‚¬§– ‡æ◊Ëՙ૬≈¥Õ“°“√ÕàÕπ≈â“

4. ª√–‡¡‘𧫓¡«‘μ°°—ß«≈®“°°“√√—°…“ ®“°

 ’Àπâ“ ∑à“∑“ß §”查 ·≈–°“√°√–∑”  à߇ √‘¡°‘®°√√¡∑’Ë ºŸâªÉ«¬ “¡“√∂∑”‡æ◊ËÕ √â“ߧ«“¡ ÿ¢≈¥§«“¡«‘μ°°—ß«≈

°“√„™â°≈ÿà¡ π—∫ πÿπ (group support) À√◊Õ Õ“™’« Õπ“¡—¬

°“√欓∫“≈ºŸâªÉ«¬¿“¬À≈—߉¥â√—∫√—ß ’√—°…“§√∫

°“√欓∫“≈ºŸâªÉ«¬¿“¬À≈—ß√—∫√—ß ’√—°…“§√∫ ·∫à߉¥â

‡ªìπ 2 √–¬–§◊Õ°“√欓∫“≈¿“¬À≈—ß√—∫√—ß ’√—°…“§√∫ 4- 6  —ª¥“Àå·√° °“√欓∫“≈π’È®–„Àâ°àÕπ°“√√—°…“ ‘Èπ ÿ¥

‡æ◊ËÕ„À⺟âªÉ«¬·≈–≠“μ‘∑”§«“¡‡¢â“„® ´—°∂“¡ ‡°’ˬ«°—∫

º≈¢â“߇§’¬ß∑’ˇ°‘¥¢÷Èπ·≈–¬—ߧߡ’Õ¬Ÿà ‡æ◊ËÕ„Àâ “¡“√∂

π”°≈—∫‰ª¥Ÿ·≈μπ‡Õß∑’Ë∫â“π‰¥â ·≈–°“√欓∫“≈‡æ◊ËÕ ªÑÕß°—π·≈–®—¥°“√º≈¢â“߇§’¬ß√–¬–¬“« §◊Õ°“√

欓∫“≈¿“¬À≈—ߺŸâªÉ«¬√—∫°“√μ√«®μ‘¥μ“¡º≈°“√

√—°…“§√—Èß·√°

°“√欓∫“≈¿“¬À≈—ß√—∫√—ß ’√—°…“§√∫ 4-6  —ª¥“Àå·√°

1. °“√¥Ÿ·≈º‘«Àπ—ß ‡™àπ‡¥’¬«°—∫¢≥–√—∫√—ß ’μàÕ‰ª Õ’°ª√–¡“≥ 4- 6  —ª¥“Àå À≈’°‡≈’ˬ߰“√øÕ°¢—¥∂Ÿ  “¡“√∂„™â‚≈™—Ëπ≈Ÿ∫‰≈⺑«Àπ—ß∫√‘‡«≥∑’ˉ¥â√—∫√—ß ’‡æ◊ËÕ‡æ‘Ë¡

§«“¡™ÿà¡™◊Èπ ·≈–‡æ‘Ë¡ª√– ‘∑∏‘¿“æ°“√øóôπøŸ ¿“æ º‘«Àπ—ß²¹

2. ¥Ÿ·≈„À≥â√—∫°“√√—°…“ ·≈–°“√欓∫“≈º≈¢â“ß

‡§’¬ß∑’ˇ°‘¥¢÷Èπ¢≥–√—∫°“√©“¬√—ß ’ (acute radiation com- plication) μàÕ‡π◊ËÕß ‡™àπ °“√∑”·º≈ °“√√—∫ª√–∑“π Õ“À“√ÕàÕ𠂪√μ’π Ÿß  ”À√—∫ºŸâªÉ«¬∑’Ë¡’¿“«–À≈Õ¥

Õ“À“√Õ—°‡ ∫

3.  à߇ √‘¡°“√øóôπøŸ ¿“æ√à“ß°“¬ºŸâªÉ«¬¿“¬À≈—ß

√—ß ’√—°…“ ¥â«¬°“√ à߇ √‘¡Õ“À“√∑’ˇÀ¡“– ¡ ‡™àπ

Õ“À“√‚ª√μ’π Ÿß ”À√—∫ºŸâªÉ«¬¡’¿“«–∑ÿæ‚¿™π“°“√

Õ“À“√∑’Ë¡’ —¥ à«π§√∫ 5 À¡Ÿà·≈–À≈“°À≈“¬ ”À√—∫

ºŸâªÉ«¬∑—Ë«‰ª Õ“À“√‡©æ“–‚√§ ”À√—∫ºŸâªÉ«¬∑’Ë¡’¿“«– ÿ¢

¿“æÕ◊ËπÊ ‡™àπ ‚√§‡∫“À«“π ‚√§§«“¡¥—π‚≈À‘μ Ÿß À√◊Õ

‚√§‰μ  à߇ √‘¡°“√¥◊Ë¡πÈ” –Õ“¥ Õ¬à“ßπâÕ¬ 8-10 ·°â«/«—π (200- 250 ´´/ ·°â«)  à߇ √‘¡°“√πÕπÀ≈—∫ °“√æ—°ºàÕπ

·≈–°“√ÕÕ°°”≈—ß°“¬∑’ˇÀ¡“– ¡

4. ·π–π”°“√μ√«®μ“¡π—¥∑ÿ°§√—Èß ‡æ◊ËÕμ‘¥μ“¡

º≈°“√√—°…“ ¿“«–·∑√°´âÕπ ·≈–°“√°≈—∫‡ªìπ´È”¢Õß‚√§

√«¡∑—ÈßÕ“°“√º‘¥ª°μ‘∑’˧«√¡“æ∫·æ∑¬å°àÕπ°“√π—¥À¡“¬

‡™àπ º‘«Àπ—ßÕ—°‡ ∫∫√‘‡«≥∑’Ë©“¬√—ß ’ À“¬„®ÀÕ∫‡Àπ◊ËÕ¬

¡’‰¢â Ÿß À√◊Õæ∫«à“¡’‡π◊ÈÕßÕ°„À¡à

5.  à߇ √‘¡°“√øóôπøŸ®‘μ„®ºŸâªÉ«¬¿“¬À≈—ß√—ß ’√—°…“

°“√ à߇ √‘¡§«“¡§‘¥‡™‘ß∫«° ‡ √‘¡ √â“ߧ«“¡æ√âÕ¡„π

°“√°≈—∫ Ÿà —ߧ¡

ª°μ‘°“√μ√«®μ‘¥μ“¡º≈°“√√—°…“®–ª√–°Õ∫‰ª

¥â«¬ °“√´—°ª√–«—μ‘ μ√«®√à“ß°“¬ °“√μ√«®·¡¡‚¡·°√¡

·≈–°“√μ√«®¿“¬„π  ”À√—∫ºŸâªÉ«¬∑’ˉ¥â√—∫¬“ŒÕ√å‚¡π

‡ √‘¡°“√√—°…“

°“√欓∫“≈‡æ◊ËÕªÑÕß°—π·≈–®—¥°“√º≈¢â“ß

‡§’¬ß√–¬–¬“«

º≈¢â“߇§’¬ß√–¬–¬“«¢Õß√—ß ’√—°…“μàÕ°“√√—°…“

¡–‡√Á߇μâ“π¡∑’Ë “¡“√∂æ∫‰¥â §◊Õ ‡ª≈’ˬπ·ª≈ߺ‘«Àπ—ß

∫√‘‡«≥∑’Ë©“¬√—ß ’ ≈—°…≥–º‘«®–À¬“∫¢÷Èπ™—Èπ„μ⺑«Àπ—ß Àπ“μ—« (skin fibrosis)  à«π„À≠à‰¡à√ÿπ·√ß ¿“«–·¢π

∫«¡À≈—ß°“√√—°…“¡–‡√Á߇μâ“π¡ (arm lymphedema)

¿“«–ªÕ¥Õ—°‡ ∫ À√◊Õ‡ªìπº—ßæ◊¥®“°°“√©“¬√—ß ’ (Radia- tion pneumonitis À√◊Õ Radiation induced pulmonary fi- brosis (RIPF)) ´÷Ë߇°‘¥‰¥âπâÕ¬ ·μà‡¡◊ËÕ‡°‘¥®–¡’§«“¡√ÿπ·√ß

¿“«–°“√‡°‘¥æ—ߺ◊¥¢Õߺ‘«Àπ—ß (skin fibro- sis)

^17,24

‡ªìπ¿“«–∑’Ëæ∫‰¥â„πºŸâªÉ«¬∑’ˉ¥â√—∫ª√‘¡“≥√—ß ’ Ÿß ‚¥¬

°“√‡°‘¥æ—ߺ◊¥ (skin fibrosis) ¡’¢—ÈπμÕπ¢Õß°“√‡°‘¥¥—ßπ’È §◊Õ

‡¡◊ËÕº‘«‡°‘¥°“√Õ—°‡ ∫‡√◊ÈÕ√—ß ®–‡√‘Ë¡°≈“¬‡ªìπ myofibroblasts ·≈–°≈“¬‡ªìπæ—ߺ◊¥ (fibrosis) „π∑’Ë ÿ¥

° √ – ∫ « π ° “ √ π ’ È Õ “ ® „ ™ â ‡ « ≈ “ „ π ° “ √ ‡ ° ‘ ¥ π “ π ‡ ª ì π ª ï

≈—°…≥–º‘«Àπ—ß®–μ÷ß·¢Áß ¡’‚Õ°“ ‡ªìπ‡π◊ÈÕ쓬 (radion-

√Ÿª∑’Ë 1 °“√‡ª√’¬∫‡∑’¬∫¿“«–·¢π∫«¡¢Õß·¢π 2 ¢â“ß „πºŸâªÉ«¬·μà≈–√“¬

ecrosis)  ”À√—∫¿“«–π’È °“√ªÑÕß°—π∂◊Õ«à“‡ªìπ°“√√—°…“

∑’Ë¥’∑’Ë ÿ¥

°“√欓∫“≈¿“«–°“√‡°‘¥æ—ߺ◊¥¢Õߺ‘«Àπ—ß 1. Õ∏‘∫“¬∂÷ß°≈‰°°“√‡°‘¥æ—ߺ◊¥ §«“¡®”‡ªìπ·≈–

§«“¡ ”§—≠„π°“√𫥇æ◊ËÕªÑÕß°—π°“√‡°‘¥

2.  Õπ· ¥ß °“√π«¥ ¥—ßπ’ȧ◊Õ „™â§√’¡À√◊Õ‚≈™—Ëπ

∑“º‘« ∑“∫√‘‡«≥∑’Ë©“¬√—ß ’„Àâ∑—Ë«∑—Èß∑√«ßÕ° ·≈–À—«‰À≈à

„™âπ‘È«∑—Èß 4 π«¥ ‡ªìπ≈—°…≥–§√÷Ëß«ß°≈¡ °¥πÈ”Àπ—°≈ß æÕª√–¡“≥ ‚¥¬‡√‘Ë¡À≈—ß®“°©“¬√—ß ’§√∫·≈⫪√–¡“≥

4 - 6  —ª¥“Àå Õ¬à“ßπâÕ¬§√—Èß≈– 15 - 20 π“∑’

3. „π°√≥’∑’˺ŸâªÉ«¬¡’·º≈ ¡’°“√Õ—°‡ ∫ ∫«¡·¥ß À√◊Õ¡’‰¢â ߥ°“√π«¥®π°«à“Õ“°“√‡À≈à“π—Èπ®–À“¬

4. ªí®®ÿ∫—π°“√∑” Hyperbaric oxygen ¬—߉¡à¡’

¢âÕ¡Ÿ≈‡™‘ߪ√–®—°…å«à“ “¡“√∂≈¥À√◊Õ∑”„À⺑«Àπ—ß°≈—∫

¡“¡’ ¿“懥‘¡ ·μà “¡“√∂≈¥Õ“°“√∫«¡ ·¥ß ·≈–ª«¥

‰¥â²⁵

¿“«–·¢π∫«¡À≈—ß°“√√—°…“¡–‡√Á߇μâ“π¡

(arm lymphedema)

¿“«–·¢π∫«¡À≈—ß°“√√—°…“¡–‡√Á߇μâ“π¡ §◊Õ ¿“«–

∑’Ë¡’πÈ”‡À≈◊Õߧ—ËßÕ¬Ÿà„π‡π◊ÈÕ‡¬◊ËÕ„μ⺑«Àπ—ß ‡π◊ËÕß®“°¡’°“√

Õÿ¥μ—πÀ√◊Õ∑”≈“¬¢Õß∑àÕπÈ”‡À≈◊Õß®π∑”„ÀâπÈ”‡À≈◊Õß

‰À≈‡«’¬π°≈—∫‰¥â‰¡à¥’ ‡ªìπ¿“«–·∑√°´âÕπ¿“¬À≈—ß°“√

√—°…“∑’Ëæ∫‰¥â„π¡–‡√Á߇μâ“π¡‚¥¬‡©æ“–ºŸâªÉ«¬∑’ˉ¥â√—∫

°“√ºà“μ—¥‡≈“–μàÕ¡πÈ”‡À≈◊Õß√à«¡°—∫°“√©“¬√—ß ’⁶ À“°

‡°‘¥¿“«–π’È·≈⫉¡à “¡“√∂√—°…“„ÀâÀ“¬¢“¥‰¥â ‡ªìπ

¿“«–‡√◊ÈÕ√—ß∑’ËμâÕß√—°…“‰ªμ≈Õ¥™’«‘μ °“√ªÑÕß°—π®÷߇ªìπ  ‘Ëß∑’Ë¥’∑’Ë ÿ¥²⁶ °“√√—°…“ à«π„À≠à‡ªìπ·§à‡æ’¬ß°“√·°â‰¢

™—Ë«§√“« ‡™àπ °“√∑”°“¬¿“æ∫”∫—¥ °“√π«¥ (massage)

°“√𫥉≈àπÈ”‡À≈◊Õß (Manual Lymphatic Drainage (MLD))

°“√„™â·√ß°¥ (compression) ´÷ËßÕ“®‡ªìπ ª≈Õ°·¢π (pres- sure garment) À√◊Õ ºâ“¬◊¥æ—π (elastic bandage) ·≈–

 ÿ¥∑⓬§◊Õ°“√ºà“μ—¥ ´÷Ëß°Á¡’‚Õ°“ °≈—∫¡“‡ªìπ´È”‰¥âÕ’°²⁷

√Ÿª∑’Ë 2 ºŸâªÉ«¬·μà≈–√“¬∑’Ë„ àª≈Õ°·¢π

√“¬ß“πÕÿ∫—μ‘°“√≥å°“√‡°‘¥Õ¬Ÿà∑’Ë√âÕ¬≈– 21 (14.9 -29.8)

·≈–„π°“√»÷°…“‡¥’¬«°—ππ’Èæ∫«à“√–¬–‡«≈“∑’ˇ°‘¥Õ¬Ÿà„π

™à«ß 12 ∂÷ßπâÕ¬°«à“ 24 ‡¥◊Õπ ·μà°Á¡’°“√»÷°…“æ∫«à“¡’

‚Õ°“ ‡°‘¥‰¥â∂÷ß 30 ªï¹¹

°“√μ√«®¿“«–·¢π∫«¡  “¡“√∂μ√«®‰¥â¥—ßπ’È 1. °“√«—¥‡ âπ√Õ∫«ß·¢π ·≈–°“√«—¥ª√‘¡“μ√

¢Õ߇À≈«∑’Ë – ¡Õ¬Ÿà (Limb circumference and volume)

‡ªìπ«‘∏’∑’Ë„™â«‘π‘®©—¬·≈–μ‘¥μ“¡Õ“°“√°—π‡ªìπ à«π¡“°

°“√«—¥‡ âπ√Õ∫«ß¢Õß·¢π ®–«—¥‡ª√’¬∫‡∑’¬∫°—∫¥â“π μ√ߢⓡ „πμ”·Àπàß∑’Ëμ√ß°—π (circumferential measure- ments at standard distances)  à«π°“√«—¥ª√‘¡“μ√

¢Õ߇À≈«„™â«‘∏’ water displacement method ‡ªìπ°“√«—¥

ª√‘¡“μ√πÈ”∑’Ë∑âπÕÕ° ‡¡◊ËÕ«“ß·¢π≈ßÕà“ß«—¥´÷ËßÕÕ°·∫∫

„Àâ¡’∑’Ë√Õß√—∫·≈– “¡“√∂∫Õ°ª√‘¡“μ√πÈ”∑’Ë∑âπÕÕ°¡“‰¥â

‚¥¬°“√«—¥®–«—¥·¢π∑—Èß 2 ¢â“߇ª√’¬∫‡∑’¬∫°—π

2. °“√μ√«®‚¥¬„™â‡§√◊ËÕß¡◊Õ摇»…∑“ß√—ß ’ ¡’°“√

√–∫ÿ«à“°“√ ·°πμàÕ¡πÈ”‡À≈◊Õß (Lymphoscintigraphy)

‡ªìπ°“√μ√«®∑’Ë„Àâº≈·πàπÕπ∑’Ë ÿ¥⁵ πÕ°®“°π—Èπ  “¡“√∂

μ√«®‚¥¬°“√μ√«®§≈◊Ëπ·¡à‡À≈Á°‰øøÑ“ À√◊Õ‡Õ°´‡√¬å

§Õ¡æ‘«‡μÕ√å

°“√欓∫“≈¿“«–·¢π∫«¡À≈—ß°“√√—°…“

¡–‡√Á߇μâ“π¡

1. ª√–‡¡‘𧫓¡√Ÿâ §«“¡‡¢â“„®¢ÕߺŸâªÉ«¬‡°’ˬ«°—∫

¿“«–·¢π∫«¡À≈—ß°“√√—°…“¡–‡√Á߇μâ“π¡·≈–°“√

®—¥°“√Õ“°“√

2. „À⧔·π–π” „π°“√®—¥°“√‡°’ˬ«°—∫¿“«–·¢π

∫«¡À≈—ß°“√√—°…“¡–‡√Á߇μâ“π¡ ‡™àπ °“√®—¥°“√‚¥¬ „™â ª≈Õ°·¢π À√◊Õ ºâ“¬◊¥æ—π √«¡∑—Èß°“√ Õπ· ¥ß°“√π«¥

·≈–°“√𫥉≈àπÈ”‡À≈◊Õß

2.1 °“√„™â·√ß°¥‚¥¬ª≈Õ°·¢π ‚¥¬∑—Ë«‰ª

·æ∑¬å®– —Ëßμ—¥ª≈Õ°·¢π‡æ◊ËÕ„Àâ‡À¡“–·°àºŸâªÉ«¬·μà≈–

√“¬∑¥·∑π°“√„™âºâ“¬◊¥æ—π ¡’°“√»÷°…“æ∫«à“°“√„™âºâ“

æ—π À√◊Õª≈Õ°·¢πμàÕ‡π◊ËÕß 6 ™—Ë«‚¡ß®–‡°‘¥ª√–‚¬™πå

 Ÿß ÿ¥²⁸

2.2 °“√𫥉≈àπÈ”‡À≈◊Õß π‘È« ¡◊Õ ·≈– ·¢π

‡ªìπ°“√π«¥∑’Ë®–μâÕ߉≈àπÈ”‡À≈◊Õß®“°π‘È« ¢÷Èπ¡“‡√◊ËÕ¬

·≈–¥—π„À⇢ⓠŸàμàÕ¡πÈ”‡À≈◊Õß ‚¥¬ª°μ‘°“√𫥉≈àπÈ”

‡À≈◊Õß §«√∑”‚¥¬π—°°“¬¿“æ∫”∫—¥ À√◊ÕºŸâ∑’ˉ¥â√—∫°“√

Õ∫√¡ „π°√≥’∑’˺ŸâªÉ«¬·≈–≠“μ‘ ‰¡à “¡“√∂‰ª√—∫∫√‘°“√

∑’Ë‚√ß欓∫“≈„°≈â∫â“π μâÕ߉¥â√—∫§”·π–π”·≈–°“√

 Õπ· ¥ß‚¥¬π—°°“¬¿“æ∫”∫—¥ ‡æ◊ËÕ„Àâ “¡“√∂∑”‡Õß

∑’Ë∫â“π‰¥â ®“°°“√∑∫∑«π°“√»÷°…“²⁷ æ∫«à“¬—ß¡’º≈°“√

»÷°…“∑’Ë¢—¥·¬âß°—π«à“ °“√𫥉≈àπÈ”‡À≈◊Õß®–‰¥â ª√–‚¬™πå∑’Ë·∑â®√‘ßÀ√◊Õ‰¡à ·μàÕ¬à“߉√°Á¥’ ¬—߉¡à¡’°“√

·π–π”„Àâ‡≈‘°∑”

3. ·π–π”°“√¥Ÿ·≈μπ‡Õß ”À√—∫ºŸâªÉ«¬∑’ˉ¥â√—∫°“√

©“¬√—ß ’∫√‘‡«≥∑√«ßÕ° ‡æ◊ËÕ‡æ‘Ë¡ª√– ‘∑∏‘¿“æ¢Õß°“√

‰À≈‡«’¬π ¢Õ߇≈◊Õ¥·≈–πÈ”‡À≈◊Õߥ—ßπ’È

3.1  à߇ √‘¡°“√ÕÕ°°”≈—ß°“¬·¢π À—«‰À≈à

‡·≈– à«πÕ◊ËπÊ ¢Õß√à“ß°“¬ „πÕ¥’μºŸâªÉ«¬ºà“μ—¥‡μâ“π¡

√à«¡°—∫°“√©“¬√—ß ’ ‚¥¬‡©æ“–Õ¬à“߬‘Ëß °“√ºà“μ—¥‡≈“–

μàÕ¡πÈ”‡À≈◊Õß ®–‰¥â√—∫§”·π–π”„Àâ®”°—¥°“√„™â·¢π

¢â“ß∑’Ë∑”ºà“μ—¥ ª√–°Õ∫ºŸâªÉ«¬ à«π„À≠à°≈—«∑’Ë®–„™â·¢π²⁷

·≈–°≈—«¿“«–·¢π∫«¡®÷ßÀ≈’°‡≈’ˬ߰“√ÕÕ°°”≈—ß°“¬∑’Ë μâÕß„™â·¢π ·≈–À—«‰À≈à „π™à«ß‡«≈“‰¡à°’˪π’È¡’°“√

»÷°…“·∫∫°“√∑¥≈Õß·∫∫ ÿà¡·≈–¡’°≈ÿࡧ«∫§ÿ¡ (ran- domized controlled trial) „πºŸâªÉ«¬¡–‡√Á߇μâ“π¡∑’Ë¡’

¿“«–·¢π∫«¡ 141 √“¬ ‚¥¬„ÀâÕÕ°°”≈—ß°“¬  —ª¥“Àå

≈– 2 §√—Èß §√—Èß≈– 90 π“∑’ ‚¥¬¡’°“√ÕÕ°°”≈—ß°“¬

À≈“¬Ê∑à“ √«¡∑—Èß¡’°“√¬°¥—¡‡∫≈ (dumbbells) À√◊Õ

‡§√◊ËÕß¡◊Õ∑’ËμâÕß„™â·√ßμâ“π²⁹ ´÷Ëߺ≈°“√»÷°…“²⁷ ‰¥â √ÿª«à“

°“√ÕÕ°°”≈—ß°“¬ ∑’ËμâÕß„™â·√ߢÕß·¢π§àÕπ¢â“ß¡“°π’È

‰¡à‰¥â‡æ‘Ë¡§«“¡‡ ’ˬߢÕß°“√‡°‘¥¿“«–·¢π∫«¡„πºŸâªÉ«¬

¡–‡√Á߇μâ“π¡À≈—ß°“√√—°…“¥â«¬°“√ºà“μ—¥·≈–/À√◊Õ©“¬

√—ß ’ πÕ°®“°π’È„π°“√»÷°…“π’È ‰¥â√“¬ß“π«à“ “¡“√∂≈¥

°“√§—ËߢÕßπÈ”‡À≈◊Õß„πºŸâªÉ«¬∑’Ë∑”°“√ÕÕ°°”≈—ß°“¬‰¥â

Õ’°¥â«¬

3.2  à߇ √‘¡°“√π«¥º‘«Àπ—ß∫√‘‡«≥∑’Ë©“¬√—ß ’

‡™àπ‡¥’¬«°—∫°“√ªÑÕß°—π·≈–∫√√‡∑“°“√‡°‘¥ æ—ߺ◊¥¢Õß º‘«Àπ—߇π◊ËÕß®“°°“√𫥇æ‘Ë¡ª√– ‘∑∏‘¿“æ°“√‰À≈

‡«’¬π¢Õ߇≈◊Õ¥·≈–πÈ”‡À≈◊Õß³⁰

4. ·π–π”ºŸâªÉ«¬®—¥∑” ¡ÿ¥∫—π∑÷° ·≈–«—¥¢π“¥¢Õß

·¢π‡æ◊ËÕμ‘¥μ“¡¿“«–¢Õß‚√§ ¡’À≈—°∞“π‡™‘ßª√–®—°…å

«à“°“√ μ‘¥μ“¡Õ“°“√¢Õß‚√§√à«¡°—∫°“√„À⧔·π–π”

·≈–°“√ÕÕ°°”≈—ß°“¬®–™à«¬„Àâ°“√欓°√≥å¢Õß‚√§¥’

¢÷Èπ²⁷

5. ·π–π”ºŸâªÉ«¬§«∫§ÿ¡Õ“À“√ ·≈–πÈ”Àπ—° ∂÷ß

·¡â«à“º≈®“°°“√»÷°…“¬—ߧߡ’§«“¡¢—¥·¬âß°—π«à“°“√¡’

πÈ”Àπ—°‡°‘π¡“μ√∞“π‡ªìπªí®®—¬‡ ’ˬßμàÕ°“√‡°‘¥·≈– àß

‡ √‘¡¿“«–·¢π∫«¡À√◊Õ‰¡à ®“°°“√»÷°…“¢Õß°«—π ·≈–

§≥– (Kwan, et al., 2013)³¹ √–∫ÿ«à“°“√¡’¥—™π’¡«≈°“¬

(Body Mass Index (BMI)) ¡“°°«à“ À√◊Õ‡∑à“°—∫ 26 ‡ªìπ Àπ÷Ëß„πªí®®—¬‡ ’Ë¬ß „π¢≥–∑’Ë Œ“‡¬ ·≈–§≥– (Hayes et al., 2012)³² √–∫ÿ«à“§«“¡Õâ«π‰¡à„™àªí®®—¬‡ ’Ë¬ß ·μà

‡π◊ËÕß®“°§«“¡Õâ«π‡ªìπÀπ÷Ëß„πªí®®—¬‡ ’ˬߢÕß°“√‡°‘¥

¡–‡√Á߇μâ“π¡^33,34 ·≈–‚√§Õ◊ËπÊμ“¡¡“ ºŸâªÉ«¬®÷ߧ«√

§«∫§ÿ¡Õ“À“√ ·≈–πÈ”Àπ—°

¿“«–°“√‡°‘¥æ—ߺ◊¥∑’˪ե®“°°“√©“¬√—ß ’ (Radiation-induced Pulmonary Fibrosis (RIPF))

°“√‡°‘¥æ—ߺ◊¥∑’˪ե  à«π„À≠à‡ªìπº≈ ◊∫‡π◊ËÕß®“°

°“√‡°‘¥ªÕ¥Õ—°‡ ∫®“°°“√©“¬√—ß ’ (acute radiation pneu- monitis) ´÷Ë߇ªìπº≈¢â“߇§’¬ßª√–‡¿∑‡©’¬∫æ≈—π ‚¥¬

 à«π„À≠à‡¡◊ËÕ‰¥â√—∫°“√«‘π‘®©—¬®“°°“√‡Õ°´‡√¬åªÕ¥

·≈–‰¥â√—∫¬“ ‡μ’¬√Õ¬¥å Õ“°“√·≈–Õ“°“√· ¥ß¡—°À“¬

‰ª ·μà∂â“°“√Õ—°‡ ∫‡√◊ÈÕ√—ß®–𔉪 Ÿà°“√‡°‘¥æ—ߺ◊¥¢Õß

‡π◊ÈÕªÕ¥μ“¡¡“^17,35 ´÷Ëß à«π„À≠ຟâªÉ«¬Õ“®®–‰¡à¡’

Õ“°“√„¥Ê‡≈¬ ·μà¡’¿“æ‡Õ°´‡√¬åº‘¥ª°μ‘ „π∫√‘‡«≥

‡¥’¬«°—∫¢Õ∫‡¢μ°“√©“¬√—ß ’

°“√欓∫“≈

1. ª√–‡¡‘π°“√√—∫√Ÿâ·≈–§«“¡‡¢â“„®¢ÕߺŸâªÉ«¬μàÕ

¿“«–·∑√°´âÕπ∑’ˇ°‘¥¢÷Èπ

2. ‡ªî¥‚Õ°“ „À⺟âªÉ«¬´—°∂“¡ „π à«π∑’ˇ°’ˬ«°—∫

° “ √ √ — ° … “ ª √ –   “ π ß “ π „ À â ‰ ¥ â æ ∫ · æ ∑ ¬ å ‡ ® â “ ¢ Õ ß ‰ ¢ â

‡π◊ËÕß®“°¿“«–æ—ߺ◊¥∑’˪ե®“°°“√©“¬√—ß ’ ‰¡à¡’‚Õ°“ 

À“¬¢“¥³⁵ ·μà‚¥¬ª°μ‘ºŸâªÉ«¬Õ“®®–‰¡à¡’Õ“°“√∑“ß

§≈‘π‘°‡°‘¥¢÷Èπ‡≈¬μ≈Õ¥√–¬–‡«≈“¢Õß‚√§

3. ·π–π”Õ“°“√∑’˧«√¡“æ∫·æ∑¬å ‡™àπ ¡’‰¢â Ÿß

‰Õ¡“° ÀÕ∫‡Àπ◊ËÕ¬

4. °“√Ωñ°°“√À“¬„® (breathing exercise) √à«¡°—∫

°“√ÕÕ°°”≈—ß°“¬ ∂◊Õ«à“‡ªìπÀπ÷Ëß„π¡“μ√∞“π°“√√—°…“

·≈–°“√®—¥°“√Õ“°“√∑’ˉ¡à„™â¬“³⁶∑’Ë√—∫√Õß‚¥¬ Pulmonary fibrosis organization ´÷Ë߇ªìπÕߧå°√∑’Ë¥Ÿ·≈ „À⧫“¡√Ÿâ·≈–

¢âÕ¡Ÿ≈·°àºŸâªÉ«¬∑’Ë¡’æ—ߺ◊¥∑’˪ե ‰¡à«à“®“° “‡Àμÿ„¥°Áμ“¡

´÷Ëß°“√Ωñ°°“√À“¬„®  “¡“√∂∑”‰¥â‚¥¬ π—ËßÀ≈—ßμ√ß ºàÕπ§≈“¬°≈â“¡‡π◊ÈÕ§Õ ·≈– ‰À≈à À“¬„®™â“Ê ºà“π∑“ß

®¡Ÿ° ‰¡à§«√À“¬„®≈÷° ‰¡à§«√„ÀâªÕ¥¢¬“¬¡“°„π™à«ß

·√°Ê À√◊Õ™à«ß∑’Ë¡’Õ“°“√‡Àπ◊ËÕ¬ π—∫ 1 ·≈– 2 À“¬„®

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√—°…“„π°“√√—°…“‚√§¡–‡√Áß. §≥–·æ∑¬»“ μ√å »‘√‘√“™

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»√’™—¬ §√ÿ π∏‘Ï, ™¡æ√  ’μ–∏π’. ·π«∑“ß√—ß ’√—°…“„πºŸâªÉ«¬

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®”π«πºŸâªÉ«¬¡–‡√Á߇μâ“π¡∑’ˉ¥â√—∫°“√√—°…“¥â«¬√—ß ’‡æ‘Ë¡

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e17.

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©“¬√—ß ’. ΩÉ“¬°“√欓∫“≈ ‚√ß欓∫“≈»‘√‘√“™.

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