viagra over the counter thailand cheap metformin shortage 2011 herbal tea suppliers in india buy shampoo online new zealand overnight pharmacy buy bupron sr online sinemet buy online ireland generic compazine can i buy vermox at walgreens t4 levothyroxine sodium tablets clonidine reviews hot flashes generic uk paypal atacand what is clonidine side effects where to buy endep canadian pharmacy #1 online drugstore optumrx customer service phone number buying apcalis sx trental discounts codes can you buy diflucan pharmacy generic ordering lipothin on line get cefadroxil toronto purchase ciprofloxacin hcl ephedraxin coupon code purchasing ginseng online canine doxycycline side effects probalan express canada where can i order terramycin donde puedo comprar la pastilla cytotec en mexico university of florida acai berry study arthrotec 50 200 mg mcg side effects buy cipro without a script most reliable place to buy colchicine online where is actonel made where can i get zerit pills buy cialis 60 mg cheap nolvadex buy online clomid ovulation pain long best place order viagra online forum buy generic dilantin online side effects of propecia acne is synthroid generic or brand levothyroxine dosage too low generic capoten overnite shipping we are festival upminster tickets provera no prescription compare prices buy tretinoin 0,025 online from usa cialis for daily use cheap drugstore .com azithromycin 1 g orally single dose chlamydia rginal levitra voltaren online bestellen changing from lexapro to celexa viagra online canada purchase furosemide billig kaufen can singulair cause weight gain children can you buy ventolin over the counter in america inhalers buy lopid 50 overnight buy cheap pariet ex benicar vs diovan dosage generic septilin no prescription costa allegra for sale lincocin para que se usa is there a shortage of amaryl ordering proscar uk is it illegal to order generic femcare cymbalta medicine information where to buy propecia in mexico how to use benzac gel norvasc side effects swelling ankles how to use lasix para que se usa el nootropil generic cialis garantito canadian pharmacy midamor where to buy eurax lotion generic equivalent for benicar how long does it take for trileptal to work for bipolar vytorin peak sales strattera free shipping nizagara brand order what does motrin do to your stomach motilium on line a good web page to buy tamoxifen with no script accutane prix en pharmacie en france how to buy shuddha guggulu buy cholestoplex online gonorrhea meningitis treatment buy celadrin boots ponstel medicine generic ventolin inhaler mobic next day delivery assert cloridrato de sertralina efeitos colaterais buy dilantin canada online emsam purchase where to buy cialis online in canada cymbalta online cheap buy benfotiamine online overnight is ondansetron generic for zofran lozol for sale online cymbalta patient medication guide ropa de culturismo y fitness buy bystolic for daily use the best online nonprescription pharmacy best place buy mentax pct mail-order naprosyn how to take alli weight loss pills canadian pharmacy no prescription overnight shipping avodart medication on line comprar cialis online paypal differin with paypal payment generic accutane, us, fast shipping what is the medicine decadron used for where can i get motilium from azulfidine mechanism of action amaryl online order cheap lithium batteries cr2032 sominex lawsuit canada how to take lipitor mg eurax cream wikipedia how much does accutane cost canada effects of viagra for men elavil apo-amitriptyline 10 mg does doxycycline 100mg treat canada bentyl walgreens mail order meds pletal cheap methotrexate 20 mg weekly compare prices femcare alphagan 0.1 price can you buy benicar generic olmesartan how long does it take for avodart to be effective can you buy gyne-lotrimin over the counter in germany prednisone prices vpxl noprescrition needed canada online pharmacy buy bactroban from india trazodone brands in india trazodone medicine sleep zyrtec lawsuit canada lilly cialis 10mgrezeptfrei purchase cialis toronto side effects of taking flagyl with alcohol aygestin mail order current ginseng prices 2012 acheter livres en ligne france order liv order anafranil 75 mg azithromycin and drinking alcohol pfizer pharmacy 1010 acquistare zithromax in italia micronized fenofibrate dose cipla pharma company hyderabad retail cost of micardis serious side effects of crestor toradol overnight shipping cheap acai spain buy doxazosin paypal accepted walmart pharmacy online pharmacy walmart pharmacy price check styplon australia price ortho tri cyclen on line in the usa boots chloroquine & proguanil tablets torsemide 5 mg tablet steroids online methylprednisolone buy cheap requip no prescription bulk cialis discount minipress mg viagra soft generic famvir buy on line non prescription suhagra pharmacy buy amlodipine besylate 10mg buy amaryllis betoptic results forum buy atorvastatin calcium online mail order generic metformin buy starlix online usa how to buy actoplus met in canada ebay alli weight loss pills lotrisone visa requip on line purchase elocom ma?? krem ordering pariet uk drugs similar to zanaflex what is montelukast tenormin cost in canada side effects of himalaya lasuna moduretic overnight delivery how to get viagra to work better zyrtec by mail cheap wellbutrin free delivery mirapex without a prescription no prescription amantadine menosan rx comprar levitra por internet buying diflucan aceon daily use reviews meri adalat movie buy flagyl er 750 mg zocor where to get non persciption augmentin generic differin gel reviews long term anxiety medication clindamycin phosphate gel clozaril online price is mail order zyloprim safe best prices advodart online no prescription promethazine no prescription reviews lopid billig kaufen propranolol phone orders how long does cardizem take to work atarax refill pack cheapest eurax effexor xr generic cost can you get micronase over the counter buy alli paypal accepted lexapro results forum levlen for purchase ampicillin sulbactam indication number of australian pharmacies order levitra super active online with visa buy nimotop with paypal can buy leukeran online pavitra rishta desi tashan 24 jan 2013 diovan without prescription pills costco pharmacy phenergan price original penegra online paroxetine drug in mexico pharmacy orlistat supplies suprax medication coupons maxalt tablets 10mg cheap allegra fexofenadine generic uk diclofenac misoprostol side effects biaxin for men sale in uk iv pain meds list any medicine for abortion in india buy amitriptyline online at canada pharmacy lipitor online prices augmentin 625mg tablets co-amoxiclav free printable coupon for alli malaseb shampoo active ingredients top specialty pharmacy drugs serophene online legally how many calories to eat a day to be healthy metformin cost ireland india tv show aap ki adalat cialis super active without a prescription sinequan suppositories buy order pet meds online canada can order bactrim online cheap propecia pills generic cialis online erythromycin ointment shoppers drug mart how to buy renagel in london nizagara without prescription pills desyrel fast canada buy zyloprim hong kong canadian cheap cephalexin 250 mg 500 capsules diovan medication on line generic xeloda new mexico pharmacy laws and regulations vermox roche precio argentina azithromycin oral suspension dosage for children lov cost antabuse is protonix available over the counter stilnox sleeping pills overdose lipothin next day pyridium canada overnight delivery online naprosyn purchase benemid canadian pharmacy buy loreal professional shampoo online india mail order coumadin online is it safe to split cialis pills purchase levlen lowest price plendil online pharmacy diclofenac gel 100 ml finast dose cheap generic indocin buy silagra from canada keppra cost usa himcocid order online vasotec not generic online pharmacy uk bupropion cymbalta to buy in england can you get finpecia viagra side effects delayed ejaculation genuine motrin best price cloridrato de ciprofloxacino dexametasona can order xenical online where can i buy nizoral mg prescription drug prednisolone cheapest amitriptyline tablets uk best price for real zovirax where to buy cheap generic snovitra super power is mirapex available over the counter cialis 20g wiki best price 100mg viagra vasotec reviews and dosage complications of quinine poisoning levitra online pharmacy uk buyers of viagra canada buy pills alli weight loss aid mexican pharmacy online no prescription cephalexin medication interactions what is the best online pharmacy tech program florida alligator attacks 2010 where to buy alli cheapest aurochem buildprop pvt ltd para que se usa la crema lotrisone cost of hydrea without insurance meclizine free shipping alesse next day shipping controlled drugs uk law online forum buy claritin cod accepted aciphex generic drug Purchase abilify 5mg online prescription cheapest propecia paypal aspirin mg price prevacid for infants with reflux buy meclizine online india buy prevacid lansoprazole where to buy leanspa acai berry which uk site to buy ditropan purchasing hyaluronic acid online uk can you take menosan daily pariet medication generic viagra canada patent expiration buying cleocin using paypal liquid viagra drink blue levitra by mail order online gasex with no prescription through aceon online low buy online cheap diflucan without cytotec in usa buying cleocin buy indinavir boots pharmacy can you buy viagra over the counter in amsterdam what does allegra fexofenadine symptoms can you order viagra online legally buy diflucan pills online cheap genuine prevacid online buy atorlip-20 mexican pharmacies best place buy robaxin pct canada pharmacies online that sell combivent side effects of minocin 100 mg cialis professional drug store online where to buy pletal cytoxan tablets online nootropil syrup dose can you order diakof prescription drugs online normoxic trimix diver iantd viagra professional 100mg cheap can you order periactin generic goes order viagra online canada voveran medication mexican pharmacy no prescription indocin genuine online pharmacy generic bentyl where purchase nizagara best online pharmacy generic doxycycline floxin australia pharmacy discount medications for seniors pastillas de ovulacion omifin brand lopid for sale rocaltrol costco ditropan online usa no prescription urispas sale buy lotrel pills in the canada onde comprar viagra em portugal max dose of lasix iv nizoral online order buy plendil lowest price buy antabuse cheap disulfiram alcoholism flomax ordering cheap bactrim 40 mg buy brand zithromax fincar from india low price atorlip-5 uk can you buy kamagra oral jelly over the counter in germany kamagra oral jelly drugs online purchases over counter prilosec same prescription cheap glucophage pills very cheap retino-a cream 0,05 wo kann ich in wien viagra kaufen can i get fucidin cream over the counter medrol brands india acquistare prednisone in italia prilosec online pharmacy naprosyn pills buy nexium prescription assistance buying lincocin in manchester Purchase amitriptyline 25mg is protonix over the counter pills proscar purchase cheap generic kamagra gold online in us asacol price indinavir non perscription countries low carbon alliance simon crowe to buy propranolol 20 mg ordering aciclovir usa best place to buy medrol online post cycle therapy cialis professional is generic plavix available in canada hyzaar medication ace inhibitor is viagra over the counter in uk pharmacy sarafem cheapest rate xanax order canada eldepryl without script enalapril dosage for adults hytrin medication where to buy where to buy tulasi plant in canada diclofenac gel no prescription reviews recommended levitra dose micardis hct price singulair 10mg tablet list all anti anxiety drugs where to get albendazole generic brafix uk paypal antabuse pills side effects phone in order for cyklokapron discount card for benicar actoplus met 15 850 mg side effects when will generic viagra be available is the us buy propranolol pills in the india buy kamagra xr without prescription prandin side effects uk mailinorder colchinchin what is metoclopramide syrup for dogs buy allium bulbs plants pfizer celebrex coupons how to get promethazine codeine syrup prescription to buy brand viagra lotrisone shoppers drug mart +medications without prescriptions kamagra chewable next day use caverta coupon online restless legs quinine tonic water cheap noroxin 100 mg can you drug buy avapro online can i order metformin online best online no prescription pharmacies where to buy live fish online trazodone hcl 50 mg insomnia cheap florinef uk where to buy plavix in canada safely how much will nitrofurantoin cost citalopram online with out prescription provera us companies only new diet pill alli best drugstore foundation for combination acne prone skin best price entocort finast online pay paypal seroquel side effects australia buying antibiotics online para que se usa el remeron where is bora bora tahiti french polynesia pulmicort online order how to purchase anacin online generic name for bactroban zofran side effects children buy desyrel online no prescription us drugs from india safe countries como se usa el combivent asacol with paypal payment shallaki lawsuit canada inderal for men sale in uk yasmin saleh bin saaid cost of lipitor 20 mg viagra professional medication where to buy online atacand purchase how much is brand cialis tablets lincocin drug class pharmacy 4 u net kamagra generico warfarin alternatives 2011 uk what is ic ranitidine 150 mg buy myambutol boots can you buy cymbalta in mexico minocin how to take clozaril mg where can i get actoplus met from sublingual sale generic cialis prescription buy shatavari kalp glucophage lowest price online benefits of intrathecal delivery of baclofen neurontin retailers is rocaltrol legal in uk quiero comprar vasotec split cialis tablet prescription discount abilify buy generic midamor with bonus buy dipyridamole patch order ampicillin generic comprar urispas original med cab flonase us pharmacy online aricept adco diclofenac medication order viagra jellyfish from stings ventolin hfa price cipla india annual report 2012 ordering tadalis sx here in canada cheap propecia online no prescription nizagara order canada tadalafil other uses craigslist usa colorado excenel antibiotic for sale valacyclovir famciclovir or acyclovir citalopram manufacturers india acquisto dipyridamole sicuro online rheumatoid arthritis methotrexate side effects is it safe to order mentat ds syrup bactroban oint price cipro on line purchase cheap crestor buy online no prescription differin discontinued what is the generic name for carvedilol billig asacol online kaufen wellbutrin tablets uses alli capsules usa fastest brafix uk delivery codeine syrup for sale anafranil sold over counter non prescription lukol pharmacy what is the side effects of minocycline 100mg is zerit available over the counter biaxin drugs interactions levitra coupon card buy proventil usa erythromycin with no rx avalide dosage hypertension pariet 10 mg buy minocin without a prescription from canadian pharmacy canadian alliance physiotherapy regulators capricorn can i buy asthma inhalers over the counter teva viagra canada zyvox online ordering how to use zestril effects of alcohol and levothyroxine clonidine hydrochloride hot flashes methotrexate in croatia post cycle therapy diflucan seroquel over the counter australia why is amitriptyline discontinued in us use sildenafil women buy calcium carbonate boots pharmacy erection packs 2 pharmacies get baclofen toronto generic betapace for sale on line no prescription zyprexa sale order cipro online no script minocycline online bestellen medicine to gain weight for women tenormin pills sweat how to get xenical from gp where can i buy toporal xl viagra sublingual comprar blopress original en madrid purchasing inderal online uk ibuprofen gel how much is dostinex tablets levitra plus delivery london online torsemide purchase buy albenza no prescription fast delivery ciprofloxacina tablete prospect viagra paypal payment uk Purchase lotensin 10 mg actos comerciales argentina valtrex generico online effexor xr overnight delivery how much does tinidazole cost without insurance buying kamagra soft using paypal maximum recommended dosage of viagra which uk site to buy micronase canada drugs tricor with prescription what types of trimox are there brand name hytrin online ortho tri-cyclen mail order generic valtrex cost flonase medication class doxazosin mg tablet altace side effects in women strattera street prices gabapentin buy online no prescription order requip online uk champix dosage regimen where to buy cytotec in canada asacol overnight delivery where can i order famvir to buy cytoxan safe cialis super active no prescription pharmacy has best price zovirax protonix from india generic cardizem uk citalopram 20mg tablets price cost of bupropion diovan new zealand metformin overdose amount where to buy aleve drugs online nymphomax bonus pills canadian chinese alliance churches association ccaca c&ma buy cheap flomax cabergoline sex women valtrex for sale canada what does protonix do to you paypal motillium order valtrex mexico how to use benzac ac 5 where to buy albendazole generic average cost cialis daily use dose what does a lasix pill look like what does diamox do for you buy ciprofloxacin online canada lioresal medicine 1 hydrocortisone cream tamoxifen discount code buy atenolol online uk harga crestor 20 mg do you need rx seroflo buy blopress in australia xanax dosage erowid ordering low dose colospa sex and the city the man the myth the viagra music eulexin online store antabuse costco how much does viagra cost at walgreens can i get high on benadryl cost generic astelin diflucan 150 mg price danazol order in the us procardia online overnight can i take two 50mg viagra tablets where to buy malegra fxt drugs online best site to buy epivir-hbv what class of drugs is baclofen reviews on differin lotion kamagra fast uk delivery astelin online legally buy liposafe greece buy capoten visa elocon cream price in india renagel dose cat pharmacy rx world canada buy bentyl over the counter viagra professional generic india albendazole through high oral buy keppra from india drugstore makeup for indian skin no prescription reminyl best over the counter asthma medication zyloprim for men sale in uk buy nizagara usa buy over the counter ortho tri-cyclen online bringing medications back from mexico where can i buy generic lexapro prigily generico online levlen pills online in the canada how to take levitra plus mg canadian pharmacy fosamax biaxin mail order india reglan without self long term side effects of advair diskus fluconazole thrush breastfeeding places where ashwagandha is found minocycline 100 mg price nitroglycerin tablets 150 mg buy sertraline can you buy order online cheap tenormin online sale of amantadine metformin results forum retin-a 0,025 billig kaufen mycelex-g online forum original didronel online cipro drug in canada pharmacy benfotiamine buy online ireland motilium online canadian can you buy prazosin cheapest place get propecia glucophage pcos dosage buy online hytrin generic buy ginseng without a script natural fertility pills for women nymphomax 20mg tab boots aspirin and codeine tablets aldactone over the counter usa ordering trandate here in canada donde comprar metformina mexico cheap colospa 40 mg green pharmacy for high blood sugar ou acheter du clomid purchase liv 52 mail-order cipro worldwide pharmacy albendazole cheap neo medrol atarax uk sale epivir-hbv order minocin medication by mail otc inhalers for bronchitis buy alphagan bulk urinary tract infection doxycycline dosage no.1 online pharmacy himcolin from canada long time side effects entocort skelaxin no prrescription metformin 500 mg side effects women is it ok to buy pet meds online ophthacare prices usa fincar no prescription zoloft online uk pareque sirve la eritromicina how long for lipitor to take effect buy zoloft meds online india what does lipitor do to your muscles forum order cheapest alavert online best price for real chloromycetin cost comparison phenergan mg can you buy viagra over the counter cialis drugstore can you order claritin drugs zaditor uk next day delivery minocycline 100mg twice a day for acne buy hydrea uk buy birth control no prescription order alesse where is aravali range how to order alli in canada best pharmacy to order pletal accutane side effects forum methotrexate order metformin bc protection actos buy uk zyvox 1200 mg linezolid best drugstore brand mascara 2012 buying cytotec philippines periactin uk drugstore entocort online pharmacy buy ciplactin pills brand cialis tablets uses how to by estrace online ist viagra in spanien rezeptfrei order cardizem rx how much will prednisolone cost casodex online order best pharmacy to order finpecia half price hoodia buy zocor online no prescription canada cost of generic coreg arthrotec forte opinie elavil user reviews for migraine prevention acheter nootropil pas cher accutane online pharmacy reviews no prescription online pharmacy overnight delivery alli over the counter diet pills can you take meclizine to get high cheapest sarafem to buy doxazosin overnight delivery remeron mirtazapine reviews viagra generic price free coupon for aceon can you get pregnant while on provera 10mg buy lasix tablets us ranitidine drugs used buy cialis professional no prescription cleocin gel drugstore.com buy doxycycline 50mg buy vermox online from australia walmart pharmacy tulsa delaware thyroxine sodium tablets ip side effects difference between proscar and finasteride generic from finast order carafate us indian pharmacy generic cialis can i buy viagra from india acheter coumadin get brand amoxil las vegas can you buy antivert over the counter vertigo zoloft for sale usa long time side effects ophthacare where to get paroxetine pct how to take fincar para que sirve glucofage de 850 phone in order for periactin dosage of trazodone for depression how to purchase flonase online kamagra oral jelly by mail order generic drug for ciprofloxacin generic neurontin paypal methotrexate online sales paroxetine 20 mg filmomhulde tablet medicijnen nitrofurantoin refills clonidine medication opiate withdrawal cipro generic reviews price increase cafergot cipro delivered to your home order celexa 20 mg viagra prescription uk procardia medicine online ordering yasmin india ponstel without script generic uk paypal brand amoxil keftab uk brand name proventil hfa generic names bactrim tablets for purchase zithromax antibiotic wiki zyvox order trazodone from anti herpes anxiolytic buy online pravachol generic ponstel pharmacy prices list free samples ed medication bupron sr pas cher italie buy lopid bulk ventolin nebules side effects cheapest rogaine 2 pharmacy support worker uk amitriptyline hydrochloride 25 mg lipitor mg price actoplus met generic substitute drug cleocin gel tablets uk best viagra online site separating thalidomide enantiomers nolvadex clomid post cycle therapy discount code for maxalt best prices prescription precose mg 10 000 games free suhagra drug canadian pharmacy minocycline prescription buy online promethazine codeine syrup what is the best online pharmacy tech school side effects of oral prednisolone in children serevent brands india lithium cost per 100g cheap finasteride no prescription buy carbozyne online india kamagra gold without a prescription where to buy acai berry products in south africa buy generic zithromax azithromycin from india side effects of tegretol 100mg viagra super active online pharmacy uk over the counter allergy eye drops zaditor discount canadian pharmacy plendil where to buy alligator gar grow buy wellbutrin singapore how do xenical works buy online uk cheap nizoral cream carafate for dogs how to administer no rx zenegra online zoloft 50mg side effects how much does clomid cost in australia 2012 vasotec drug nutrient interactions amaryl coupon code paroxetine dose for premature ejaculation prednisone 10mg tabs pack 48;s methotrexate over the counter usa cialis soft without a prescription from uk legal buy amitriptyline online canada zyrtec for men sale in uk naproxen overdose treatment buy flagyl 500mg online no prescription where to buy retin a on line voltaren discounted us pharmacy online sarafem cephalexin 250 mg capsule for dogs can you buy viagra mexico where can i buy claritin d online prednisone india how to buy xanax can order tenormin online people pharmacy fosamax boots pharmacy jobs combivent overnight where can i purchase mevacor herbal viagra viagra alternative lamictal brands india how to get snovitra super power drug generic prometrium switzerland cytotec costco discount lioresal mg buy cymbalta from india best price for real stromectol atorvastatin and amlodipine combination shatavari women buy buy viagra generic viagra o generico do viagra funciona mesmo is there a generic available for aricept licensed online pharmacies in usa crestor generic launch grifulvin v where can i buy it buy pulmicort new zealand online comprar celebrex portugal zoloft free shipping generic from hyaluronic acid propranolol by mail cheap minipress usa what does nizoral look like retin-a 0,025 canada overnight delivery colchicine canadian online overnight pharmacy where does mobicity ship from buy clonidine next day why is allegra k so cheap best otc erection pills your-generic can i send medicine by mail where to alligator hunt in texas rumalaya 100mg buy can you only get astelin on prescription how to purchase cleocin online side effects of risperdal consta legal to buy floxin etodolac 500 mg price where do i dilantin in usa vasotec in canada where to get baby aspirin female viagra coupons zyvox sales 2014 order diet pills online canada purchase advair diskus in australia avapro billig kaufen overnight pharmacy augmentin buying plavix from canada no prescription buspar drugs mylan albuterol sulfate inhalation solution 0.083 walmart mail order prescriptions where to buy flonase generic canadian pharmacy generic l-tryptophan for sale on line is there a drug comparative to famvir us pharmacy online celexa alphagan no prrescription trandate next day paxil anxiety worse hydrochlorothiazide cost canadian billig cialis jelly online kaufen online tretinoin 0,05 india compare viagra prices online can keflex get you high is there a shortage of cialis alli 60 mg xenical 120mg purchase prevacid solutab duetact spain benfotiamine for sale australia speman tablets 150 mg viramune pharmacy over the counter proventil inhaler haldol visa accutane with prescription where can you buy alligator meat in michigan cozaar no prescription reviews viagra plus medication where to buy metronidazole dosage for trichomoniasis how to order terramycin best site to buy clonidine trial erection packs 1 cheap us pharmacy buy over the counter suhagra online haldol over the couter buy generic keppra cialis generics available at ordering buy ampicillin online trazodone hydrochloride 50 mg high tadacip 20 mg canada how to take flovent mg buy nolvadex 40mg los algodones pharmacies purple buy lotrel paypal major side effects of lasix bactrim for uti dosage 3 days buy inderal patch benzac online order where to buy ceftin online usa abc pharmacy canada review best place to buy starlix coming off depakote er fexofenadine dosage urticaria orlistat 60 uk rogaine without propecia how to get paxil online paxil 20mg tablet dapoxetine without rx buyers of clozaril canada zenegra for sale permethrin spray uk real brand viagra jennifer t alli reading order neurontin noprescrition needed canada online pharmacy buy pyridium from mexico online xanax street price .25 genuine low prices altace online albendazole in early pregnancy overnight doxcycline ordering low dose vermox how to buy liv 52 in london augmentin without a perscription starlix 60 mg tablet antibiotics for sale without prescription safe buy nymphomax online quinine tonic water leg cramps western drug cardura buy flonase cheap buy paroxetine online from india buy hoodia with no rx trandate pills diclofenac gel paypal lisinopril hctz generic name safe buy female viagra online revatio cost of crestor tablets 10mg benadryl medication reaction como comprar viagra en la farmacia vytorin 10/20 side effects comprar buspar pela internet buy tofranil 15mg online zestril low dose birth control codeine syrup with promethazine pills us pharmacy online lexapro us pharmacy online requip buy diflucan in uk side effects of too much levothyroxine medication cheap wellbutrin pharmacy buy generic sinequan with bonus finasteride buy online australia zoloft discount program buy lanoxin online phenergan dosage can order menosan canada cephalexin tablets pictures zebeta without prescription canada discount canadian pharmacy brand viagra lloyds pharmacy head office jobs over counter zovirax levofloxacin tablets cipla yasmin indian brasserie chelmsford where to buy atarax ointment zovirax side effects tablets orange jelly viagra augmentin pills side effects buy ciplox online at canada pharmacy cipro online services safe place order abana saw palmetto canada prescription prescription drug etodolac purchasing asacol online order crestor online no prescription order viagra jelly from pills safe to buy generic keftab from usa paroxetine mexico buy flagyl er australia capoten dosage generic topamax in usa prandin woldwide shipping imitrex generic kamagra reviews how often to use confidor how to order prednisolone online abilify common side effects buy clomid pills online non generic roxithromycin tenormin generic drug benicar dosage side effects antibiotics overnight delivery canadian pharmacy cialis finast mail order where to buy nolvadex in the us mixing wellbutrin and cold medicine ralista women buy side effects of bactrim ds antibiotic ephedraxin on line in the usa where to buy deltasone with echeck mirtazapine weight gain alternative brand finax buy buy effexor canada discount speman 40 mg dose cheap kamagra wholesale online is mail order combivent safe buy xeloda with paypal ponstel online in usa what is the standard dosage for viagra cialis tadalafil 20mg australia cialis pharmacy australia cane you buy steroids mexican pharmacies cheap nitroglycerin 100 mg shelf life of nitroglycerin pills dramamine patch over the counter comprar vpxl pela internet phenergan mist canada what over the counter cough syrup has promethazine and codeine cytotec generic for what does voltaren gel treat motilium online price provera 2.5 mg half price benfotiamine best place to buy viagra plus online what is ciprofloxacin used for in dogs buying nymphomax atacand cost without insurance how to buy provera online buy viagra from usa pharmacy zofran dosage rxlist where can i get viagra in chennai amantadine no prescription look genuine florinef best price how to make 1000x ampicillin stock lukol canada prescription buy serophene mexican pharmacies where can i buy hoodia gordonii pure price of effexor xr without insurance where can you buy acai berries in sydney pulmicort australia price hindi serial adalat wiki billig zestril online kaufen where can i get viramune pills lasix bodybuilding dosage best place buy serevent pct pariet pharmacy prices list bupropion order by phone positive cipro reviews crestor tablets 10mg side effects buy brand ashwagandha ebay.com pharmacy can you get cialis sublingual will generic premarin available mycelex-g from canada nolvadex tamoxifen citrate buy hydrea online forum purchase grifulvin v online como comprar finasteride over the counter equivalent to prednisone is mebendazole over the counter crestor usa price side effects of augmentin 375 buying etodolac from canada no prescription online pharmacy l-tryptophan buy prozac from canada generic luvox tablets sale didronel methotrexate combination hartley pharmacy new york amsterdam safe buy oxytrol online order antibiotics online fast worst pills best pills cymbalta eulexin pharmacy order calan online in us isoniazid online trandate without prescription canada achat de viagra au quebec vardenafil tablets 20 floxin for men sale in uk canadian online levitra purchase coreg 3.125 mg flagyl antibiotic sinus infection femara without a prescription from india cipla viagra online side effects of women taking male viagra dipyridamole tablets 40mg imuran without insurance costco alli weight loss pill colospa online pharmacy uk ordering tetracycline on line order voveran online with visa without script allopurinol online pharmacy letrozole nolvadex gyno what is the medication prilosec used for chinese drugstore hong kong legit periactin without a prescription glycomet without insurance buy malegra dxt in india online purchase viagra soft in us lexapro drug in mexico pharmacy cialis jelly prescription only a good web page to buy mircette with no script what is sinequan prescribed for buy allegra in uk cozaar drug classification generic rumalaya forte switzerland two types of asthma inhalers clonidine medicine side effects genuine keppra 100mg buy tramadol overnight cod kamagra drug in mexico pharmacy estrogen pills online uk buy brand cialis minomycin generic 2013 drugs roxithromycin tablets 150 nitrofurantoin monohydrate 100 mg oral cap to buy guaranteed deltasone online uroxatral 10 mg picture order prednisone online with visa long term side effects of lotrisone long term low dose prednisone for copd how much does arimidex cost benfotiamine drug schedule pharmacy that sells haldol what classification is desyrel bactroban 20 mg precio pyridium lawsuit cheap eldepryl usa atrovent 40 mg buy caverta 100 non prescription geriforte pharmacy female cialis discount code side effects of tetracycline in children organic india ashwagandha formula eulexin sale no script tadacip mg isoptin sr comprar ventolin online buying lamisil online which uk site to buy trazodone buy actos online canadian pharmacy furosemid rezeptfrei holland tamoxifen canada price get rogaine 2 las vegas comprar cordarone portugal dutas weight gain aceon mail order india revatio 20 mg cheap where to buy cialis online uk non persciption lotensin hyzaar canada no prescription requip can you get clomid in australia xenical for sale cheap price buy snovitra super power singapore low price fertomid uk allegra no prescription needed drugs s club 7 reach lyrics can you get viagra over counter canada kamagra chewable usa sale atacand generic cheap costs accutane medication guide maxaman from canada buy colchicine online no prescription united states buy adalat 1 pharmacy overnight feldene no prescription needed cost of doxycycline uk avalide generic name lioresal order in the us anafranil from india levaquin alcohol consumption vytorin prices i pill lipitor website donde puedo comprar lady era long time sex tablets for men what is the medication bactrim used for fucidin cream in canada doxycycline mono 100mg alcohol price increase baclofen fast zofran delivery buy proventil 100 generic zofran for sale on line ordering dutas here in canada generic brand viagra difference compare prices minomycin cheap delivery to us deltasone without cialis sales 2012 generic diltiazem hydrochloride extended release capsules usp gabapentin 100mg mexico benicar overnight delivery what is florinef used to treat buy ashwagandha plant delhi ortho tri cyclen no rx epivir-hbv india buy tamoxifen citrate no prescription mg motrin dosage for children chloroquine cost canada cheap prinivil free delivery yasmin online from uk acai now foods brahmi amla hair oil reviews calcium carbonate prices usa cost of bystolic 5mg over the counter zovirax ointment viagra south africa price alli tablets price generic shatavari us blood pressure drug brand names side effects of losartan hctz buy flonase paypal accepted confido drug class desyrel medication depression requip next day can you split crestor tablets entocort from usa depakote dosage pediatric sumycin online overnight shipping how to get free cialis samples where to buy differin 0.3 online mail order generic levaquin online sale of benicar salep chloramphenicol 1 hoodia prices cvs acheter voveran bentyl no prescription canada v t logistics lasix can take 2 unisom pills voltaren gel shortage novartis pictures of viagra fake logos no prescription zyprexa what is the drug amaryl used for duphalac drug class names of antibiotics in canada arava over the counter what is the prescription dosage for prilosec bactrim tablets uses genuine ampicillin best price ceftin delivery uk ordering advair diskus mexico roxithromycin mg order clonidine maximum dosage side effects from levaquin 500 mg compare prices pletal buy allopurinol cheap online no prescription grifulvin v tablets price beat way to order nexium alphagan canada prescription brahmin purses on sale zovirax ointment medication synthroid 0.1 mg tb aspirin limited india viagra sin receta en chile alavert d-12 coupons nootropil without script best site get mirapex femara generic us buy lipitor in canada no rx what does prednisone help in dogs over the counter drugs containing skelaxin pharmacy has best price prinivil what does fluoxetine hcl treat to buy cialis tablets trazodone shopping allegra dosage too high buy generic trandate online no prescription buy finasteride tablets what is the generic drug for depakote celexa drug schedule who is canadian health minister what kind of hair loss does propecia treat can you buy rumalaya allegra commercial girl bestbuy mexico glucophage 850 mg 100 film tablet fiyat how to use panax ginseng extractum purchase nitrofurantoin in canada generic rocaltrol in usa western drug aricept buspar precio mexico cheap fincar online sexual side effects of lexapro for women best online pharmacy generic cleocin gel chloramphenicol sold over counter eurax online in usa is there a drug comparative to eldepryl arimidex noprescrition needed uk online pharmacy buy estrace overseas buy fluoxetine quick tesco pharmacy summer placement deadline how to purchase finast online i pill rosuvastatin website viagra seller uk reglan 10 mg buy anacin no prescription celebrex discount coupons norvasc from india generic viagra online pharmacy no prescription accutane long term side effects information comprar ranitidine pela internet side effects of citalopram nhs viagra jelly next day delivery uk best site get leukeran ranitidine delivery where can i purchase phenergan levitra 10 mg costo what is the dose of augmentin for dogs pharmacy usa online cialis 10mg cost of viagra on private prescription buy benadryl 20 to buy bystolic isoniazid discount medications purchasing voveran online uk how much is entocort tablets apcalis sx with american express cialis super active online shipping my ralista coupons buy hydrochlorothiazide mg online for decadron online uk how to buy albendazole serophene order by phone rumalaya gel for sale philippines zerit stavudine order floxin canada best price himcocid can you buy clomid over counter dubai discount citalopram buy cafergot 50 generic brand for levaquin skelaxin online coupon code western drug imitrex brand name propecia online fml forte for sale australia avalide 100mg tablet order actonel online with visa menstrual cycle length clomiphene acheter metoclopramide where to buy liquid arimidex difference between proscar finasteride how to use orlistat where to buy ditropan ointment buy non generic cialis what are side effects of allopurinol best otc diet pills that work evista cause weight gain where to buy arimidex in australia pulmicort non perscription countries where to alesse bentyl medication online shortage of doxycycline ampicillin purchase in canada no prescription ou acheter cialis forum generic lasuna cost order pravachol online with visa tegretol carbamazepine side effects why has duetact been discontinued control sex pill for men metformin medicine pcos medrol dosage instructions differin cream 0.1 anti aging baclofen online store zyrtec for purchase where to get accutane in canada diltiazem limited india order online no script cheap cipro how to get amaryllis to bloom to buy tofranil aristocort tablets online how much is imitrex tablets side effects of p57 hoodia cactus slimming capsule snafi reviews generic trental buy valtrex mg online where do you buy nizoral shampoo generic bupropion xl reviews name brand lotrisone canada olanzapine on line purchase what is the generic for tenormin buy septilin mg online very cheap celexa how to get seroquel xr voveran sr drugs online purchases reputable indian pharmacies can motilium stop norovirus side effects of diltiazem cd 120 mg how to buy drugs online no prescription nolvadex available over counter pilex cream price pilex 100 tableta online rx pharmacy reviews buy abilify pills in the canada elocon 40 mg dose buy clozaril online reviews order elocon cream kill canadian companies selling viagra levlen side effects headache metoprolol iv for hypertension metformin 850 mg prices cardizem recommended dosage rogaine before and after men buspar online purchase rectal chlamydia symptoms men amantadine 1500 mg capsules reglan for sale usa sirius viagra commercial clarithromycin dose bnf where can i buy cialis 5 mg levlen ed buy online bbc formula 1 is mail order avapro safe pain meds uk farmacia online viagra generico bayer 20 mg what is it for what is procardia used to treat fastest viagra plus uk delivery can you take ditropan daily levitra professional pharmacy coupons how to get diflucan artane recreational dose metformin pills for sale how much does cialis cost at walmart nitroglycerin limited india 100 mg aciclovir suppliers of female cialis in us tetracycline online from usa doxycycline hyclate uses for sinus infection overnight pharmacy fedex buy bupron sr celebrex order online no prescription olanzapine 20 mg tablet where do i arimidex in canada where to buy retino-a cream 0,05 cheap tamoxifen online prometrium bonus pills cardizem cheap us pharmacy after accutane acne came back flomax mr kapsul is procardia legal in uk buy lamictal online india albenza online prescription how to purchase robaxin online unique hoodia customer reviews purchase frumil lowest price nizagara now co uk buy imitrex uk buy generic paxil online with prescription where can i buy yasmin birth control pills zyban italiano acquistare imitrex in italia what does flonase fluticasone seasonal order etodolac acai for purchase trazodone tablets ndc accutane price in india ovulation calculator after taking clomid; albendazole dosage pediatric over the counter diclofenac topical cialis sublingual for men in usa where to get lipitor generic cialis and levitra combination can buy propranolol online abilify price without insurance antipsychotic domperidone dosage for breastfeeding zovirax reviews capoten india angiotensin losartan revatio online pharmacies with out prescription buy rumalaya forte 100 minocycline australia azithromycin tablets 250 mg used for pain pills for dog arthritis kytril canada prescription zofran online price canadian drug pharmacy promo code how much is diflucan cost requip side effects depression anxiety test price of mentat in india ortho tri-cyclen drugs com can i buy prednisone in mexico ordering calan view topic yourdomain lotensin pharmacy order cheap genuine vantin online tenormin 25 mg side effects cialis generic 2013 drugs combivent without a script clomid recommended dosage for men kamagra soft online bestellen generic lariam suhagra side effects long term use buy tadapox 50 toprol xl delivery doxazosin generic release date viagra alternative viagra levitra zantac printable coupons 2011 buy aciclovir with next day is reliable rx pharmacy reliable how to get viagra free post cycle therapy wellbutrin proventil discounts buy pravachol online at canada pharmacy buy propecia tablets mexico what is the use of himalaya confido tablet promethazine dm reviews vermox pill shop discount code when do you start testing for ovulation after taking clomid prescription levitra plus cardizem gtt dose nitrofurantoin drug class mifepristone and misoprostol buy from england what does naprosyn crestor pharmacy canada himplasia online pay paypal how long does it take for haldol to leave the system sertralina 50mg efeitos is generic clozaril available in usa pharmaceutical companies london no rx alphagan online how much does viagra sell for on the street amantadine 5mg tablets comprar gasex original mircette to purchase without a prescription what does calcium carbonate can you get high off anafranil best site to buy prazosin vente de ciplox au quebec distributor of wellbutrin in dubai can you buy grifulvin v over the counter women viagra fast uk elavil low cost elie saab allegra sale can order dostinex online get augmentin las vegas cleocin gel australia culturismo y fitness methylprednisolone infusion spinal cord injury what is the maximum dosage for celebrex max menzies chatswood solicitor prometrium online forum new houses to buy liverpool lexapro 20 mg side effects is it illegal to order generic zenegra purchase cipro buy lamisil online at canada pharmacy viagra non generico generic mevacor in usa the online drugstore trazodone does viagra work on women buy once online cheapest lamisil prices generic wellbutrin price order keftab tablets brahmi generic can order eldepryl canada zanaflex generic availability prescription strength pyridium hydrochlorothiazide dose cialis pas cher paris farmacia online usa grifulvin v cost arimidex tablets used order erection packs 2 levitra cheap viagra australia paypal buy champix online no prescription acheter alli( 120 mg ) comprar atorlip-20 portugal canadian alliance of dance artists ontario director amoxil india sale where to get celebrex how to get propecia in canada overseas pharmacy no prescription xanax cheap lipothin sumycin online ordering original xeloda online cefixime 100 mg dosage buy retin a amazon where can i buy lithium chloride is tylenol better than aleve top 10 online fincar sites new alliance east longmeadow erythromycin stearate 500mg tabs triamterene 37.5mg hctz billig viagra kaufen viagra buy online no prescription is albuterol sulfate inhaler a steroid best site get wellbutrin sr luvox sale no prescription viagra sale abortion pills for sale online glucophage generic name metformin where to buy fertility drugs where to buy motilium ointment prilosec otc boots how much do xanax cost in mexico where to get sumycin pct donde puedo comprar viagra en argentina fort knox ireland hospital pharmacy dilantin drug test generic feldene in usa amitriptyline and alcohol use buy ciprofloxacin online no prescription uk overnight glucophage regular ovulation clomid twins cheap replacement for tricor arjuna generic wikipedia drugs severe anxiety treatment etodolac 400 buy cheap ginseng korea how to take robaxin penciclovir acyclovir and famciclovir elavil tablets pictures wellbutrin sr by mail will florinef cause weight gain xenical prix en parapharmacie side effects of anxiety pills adderall weight loss 2012 buy atarax 25 mg digoxin dosage recommended cialis soft no prescription fedex ups purchase cialis super active in mexico order buy floxin online canadian pharmacy moduretic proscar 5 mg precio mexico side effects of risperdal medication what is cipro medication best site get benzac proscar propecia better post cycle therapy biaxin can you buy imitrex in ireland purchase abana 1 online pharmacy roxithromycin no prescription needed canadian online pharmacy tricor western australia oder mg tablets of viagra soft discount pharmacy brisbane qld safe zoloft buy purchase ditropan online twitter search what is prednisone 5mg buy allopurinol with visa pletal rx amitriptyline limited india canadian buy discount ceftin fast methotrexate deleviery buy abilify 2 mg online buy avapro with e check comprar generico do viagra no brasil cephalexin monohydrate dosage for dogs where to get zenegra pct rumalaya forte medication order buy alphagan online usa prescription aldactone online cheap prescription buy diltiazem hydrochloride 60 mg tablets letrozole bodybuilding reviews femara generic cost procardia no prescription needed top 10 online sinemet sites amoxil shopping can you get high off meloxicam female viagra order by phone buy allegra with generic pharmacy bactroban no prescription needed online buy prevacid online canada
You are here: صفحه اصلي آموزش بیماران شرایط بالینی خاص مراقبت از لوله تراکئوستومی

قطب علمی آموزش الکترونیکی دانشگاه علوم پزشکی شیراز

مراقبت از لوله تراکئوستومی

چاپ
Untitled document
tracheostomy

تراکئوستومی باز کردن یک راه هوایی در لوله تراشه است که شما آنرا به صورت یک حفره در زیر گلو مشاهده می کنید.


 

 

 

 

 

 

 

 

در این مبحث به این سؤالات شما پاسخ داده می‌شود:

  1. تراکئوستومی چیست؟
  2. تراکئوستومی چه مزایایی دارد؟
  3. ساکشن تراکئوستومی چگونه است؟
  4. چه وسایلی جهت ساکشن تراکئوستومی مورد نیازند؟
  5. چه مواردی در مورد بیماران تراکئوستومی شده، باید رعایت شوند؟

 

     1.  تراکئوستومی چیست؟

تراکئوستومی باز کردن یک راه هوایی در لوله تراشه است که شما آنرا به صورت یک حفره در زیر گلو مشاهده می‌کنید.

 تراکئوستومی بر حسب نیاز بیمار ممکن است :                                                               

 الف) دائم       ب) موقت باشد.

  

2.  تراکئوستومی چه مزایایی دارد؟

1- راه هوایی مطمئنی است، برای خروج ترشحات مجاری تنفسی بیمار.

2- در بیمارانی که مدت طولانی از دستگاه تهویه مکانیکی استفاده می‌کنند و راه هوایی مطمئنی برای تنفس ندارند استفاده می‌شوند.

3- از ورود مواد خارجی، ترشحات دهانی یا محتویات معده به ریه در بیمارانی که کاملاً هوشیار نیستند پیشگیری می‌کند.

تراکئوستومی با یک نوار باریک به دور گردن بسته می‌شود و یک کاف به آن متصل می‌باشد که باید پر از هوا باشد تا از خروج آن جلوگیری کند و مانع ورود ترشحات از دهان و معده به ریه می‌شود. در زیر لوله تراکئوستومی یک عدد گاز قرار دهید تا باعث جذب ترشحات تراکئوستومی شود این گاز از ایجاد عفونت نیز پیشگیری می‌کند.

توجه :

گازی که در زیر تراکئوستومی قرار می‌گیرد را قیچی نکنید زیرا ممکن است پرزها وارد تراکئوستومی شده و ایجاد آبسه در مجاری تنفسی کند.

 با توجه به اینکه در بیماران تراکئوستومی شده، هوا از روی تارهای صوتی عبور نمی‌کند صحبت کردن آن‌ها بدون صدا می‌باشد. شما می‌توانید از طریق لب خوانی یا از طریق نوشتن مطالب با وی ارتباط برقرار کنید.

نکته مهم 1: در صورتی که کاف تراکئوستومی پر از هوا نباشد هنگام تغذیه ممکن است بیمار آسپيره کند، یعنی مواد غذایی و ترشحات ناحیه دهان وارد مسیر راه هوایی شود.

 

نکته مهم 2 : وقتی کاف به حد لازم پر از هوا نباشد تنفس بیمار صدایی خرخر مانند می‌دهد. در صورت مشاهده این حالت با پزشک و پرستار خود مشورت کنید.

    

  3.  ساکشن تراکئوستومی چگونه است؟ 

در بیمارانی که تراکئوستومی شده‌اند مکانیسم سرفه ضعیف است. این بیماران برای دفع ترشحات دستگاه تنفس دچار مشکل هستند و نیاز به ساکشن دارند.

زمانی باید بیمار را ساکشن کنید که صدای غیر طبیعی در ریه ها شنیده شود یا اینکه شما ترشحات را مشاهده نمایید.

 توجه داشته باشید که ساکشن کردن غیر ضروری علاوه بر آنکه خطر عفونت را بالا می‌برد باعث آسیب به دستگاه تنفسی بیمار می‌شود.

 

 4.  چه وسایلی جهت ساکشن تراکئوستومی مورد نیازند؟

سرنگ 5 سی سی حاوی سرم شستشو – گاز استریل – ماسک – دستگاه ساکشن – دستکش استریل – سر ساکشن سفید (ترجیحاً رنگ سفید) – آمبوبگ – لوله رابط ساکشن – کپسول اکسیژن.

قبل از انجام ساکشن حتماً از دستگاه بخور و فیزیوتراپی قفسه سینه استفاده کنید. این کار باعث رقیق‌تر شدن و کنده شدن ترشحات از مسیر راه هوایی می‌شود و عمل ساکشن کردن به طور موثرتری انجام می‌پذیرد.


قبل از انجام عملیات با بیمار صحبت کنید و بگویید امکان دارد حین ساکشن کردن احساس ناخوشایندی داشته باشد. او را به آرامش دعوت کنید سپس دست خود را بشویید و ماسک بزنید. حدود 5-3 دقیقه به بیمار اکسیژن با غلظت 10 لیتر بدهید این کار باعث می‌شود بیمار حین ساکشن کردن دچار کمبود اکسیژن نشود.

 سپس دستگاه ساکشن را روشن کنید و روی دور متوسط تنظیم نمایید (دور دستگاه نباید بیش از 120 میلی متر جیوه باشد) لوله رابط ساکشن را به دستگاه ساکشن وصل نمایید و سر ساکشن را بدون آنکه از پوشش کامل خارج کنید به لوله رابط ساکشن وصل کنید سپس بیمار را در وضعیت نیمه نشسته قرار دهید دستکش استریل بپوشید و سر ساکشن را بدون آنکه با جایی تماس پيدا کند از پوشش خارج کنید. سر ساکشن را حدود 10 تا 15 سانتی متر وارد تراکئوستومی کرده و با یک چرخش 360 درجه به آرامی بین انگشت شست و اشاره چرخانده و آنرا از تراکئوستومی خارج نمایید.


این عملیات نباید بیش از 10 تا 15 ثانیه طول بکشد بسته به میزان ترشحات بیمار این عمل را چندین بار تکرار نمایید. دقت کنید در بین هر بار ساکشن کردن به بیمار 5-3 دقیقه اکسیژن با غلظت 10 لیتر بدهید و لوله ساکشن را با سرم، شستشو بشویید.

 

 

   5.  چه نکاتی در هنگام تراکئوستومی باید رعایت شود؟

  1. اگر ترشحات بیمار غلیظ بود و یا به صورت تکه های خلط جامد در آمده است بهتر است مدت زمان بیشتری از بخور استفاده نمایید. اگر ترشحات به خوبی خارج نشد، از یک نفر کمک بخواهید و نفر دوم حدود 2 سی سی سرم شستشو استریل را در تراکئوستومی بریزد و چندین بار آمبو بزند سپس شما ساکشن کنید. این کار باعث کنده شدن ترشحات می‌شود. این عمل را از پرسنل پرستاری بخش سؤال نمایید که به شما آموزش دهند.
  2. در صورتی که گاز زیر تراکئوستومی آلوده به ترشحات گردید و مرطوب شد، چندین بار در روز باید تعویض شود.
  3. در صورت آلوده شدن بند تراکئوستومی به ترشحات با رعایت اصول ایمنی آن را تعویض نمایید.
  4. بند تراکئوستومی را طوری ببندید که دو انگشت به راحتی از زیر آن رد شود.

قبل از هر بار تغذیه چک کنید کاف تراکئوستومی پر از هوا باشد.

 

  1. مراقب باشید کاف را قیچی نکنید. در صورت قیچی شدن یا سوراخ شدن کاف با یک فرد کارشناس تماس بگیرید و مراقب باشید تراکئوستومی از جای خود خارج نشود.
  2. در حین استراحت کردن احیاناً پتو، ملحفه و ... روی تراکئوستومی بیمار را مسدود نکند.
  3. از ارتباط بیمار با افرادی که مبتلا به سرما خوردگی یا دیگر عفونت‌های دستگاه تنفسی هستند جلوگیری کنید.
  4. مراقب باشید محل استراحت بیمار عاری از گرد و خاک باشد و اگر مگسی وجود دارد از پشه بند و یا پارچه توری برای جلوگیری از وارد شدن پشه و مگس در لوله تراکئوستومی استفاده کنید.
  5. هیچ شی ء خارجی را هرگز وارد تراکئوستومی نکنید.
  6. هنگامی که بیمار سرفه می‌کند آمبو نزنید این عمل باعث آسیب شدید به بافت ریه می‌شود.

 

      توجه کنید:

        در صورتی که ترشحات مسیر تراکئوستومی را مسدود کند بیمار دچار کمبود اکسیژن و نهایتاً خفگی می‌شود. پس در این رابطه دقت کافی داشته باشید.

        در صورتی که لوله تراکئوستومی به هر دلیلی از جای خود خارج شد برای جاگذاری آن اقدام نکنید. بلکه بلافاصله به بیمار از مسیر تراکئوستومی اکسیژن بدهید و با پزشک معالجتان تماس حاصل نمایید.

دقت کنید هر بار ساکشن نباید بیشتر از 10 ثانیه طول بکشد زیرا ممکن است بیمار با کمبود اکسیژن مواجهه شود.

کمبود اکسیژن به هر دلیلی می‌تواند اثرات جبران ناپذیری بر مغز بیمار بگذارد.

 

   6. چه مواردی در مورد بیماران تراکئوستومی شده، باید رعایت شوند؟

توجه داشته باشید:

  1. دستگاه تنفس بیمار بسیار حساس و آسیب پذیر است پس لطفاً نکات استریل را به دقت رعایت نمایید.
  2. هیچ گاه به صرف اینکه ترشحات بیمار بسیار زیاد است بیشتر از 10 ثانیه سر ساکشن را در راه هوایی بیمار نگه ندارید.

بین هر مرحله از عمل ساکشن به مدت 5-3 دقیقه اجازه دهید بیمار به صورت طبیعی تنفس کندو اکسیژن با درصد بالا دریافت نماید.

  1. در صورت مشاهده ترشحات خونی همراه با عملیات ساکشن 2 سی سی آب مقطر استریل وارد تراکئوستومی نمایید با انجام این کار خونریزی کنترل می‌شود در این صورت از ادامه ساکشن خودداری نمایید زیرا بافت سیستم تنفسی آسیب دیده است. در صورت تکرار خونریزی حتماً با پزشک معالجتان مشورت نمایید.
  2. بین هر بار ساکشن حتماً به بیمار اکسیژن با درصد بالا بدهید.
  3. بعد از اتمام عملیات ساکشن 10 دقیقه به بیمار اکسیژن با درصد بالا بدهید. بعد از آنکه متوجه شدید وضعیت تنفس بیمار کاملاً مطلوب است می‌توانید اکسیژن را قطع کنید.
  4. سر ساکشن ها یک‌بار مصرف هستند بعد از هر بار استفاده باید دور انداخته شوند.
  5. هیچ گاه سر ساکشن را بیش از 10 تا 15 سانتی متر وارد لوله تراکئوستومی نکنید این عمل باعث آسیب به بافت ریه و خونریزی آن می‌شود.
  6. ساکشن را ترجیحاً بهتر است قبل از وعده غذایی، قبل از خواب و بعد از خواب انجام دهید. اما دقت داشته باشید که عملیات ساکشن زمان مشخصی ندارد و در واقع بر حسب نیاز بیمار است.
  7. هرگز سر ساکشنی که وارد دهان بیمار کرده‌اید را وارد تراکئوستومی نکنید زیرا بلافاصله باعث انتشار عفونت می‌شود.
  8. بعد از هر بار ساکشن مقداری سرم شستشو وارد لوله رابط ساکشن کنید تا ترشحات کاملاً از لوله پاک شود و دستگاه ساکشن برای استفاده مجدد آماده گردد.
  9. بعد از اتمام عملیات ساکشن سر لوله رابط را با یک گاز استریل بپوشانید.
  10. در صورتی که ترشحات بیمار زیاد است یا به راحتی خارج نمی‌شود و یا به صورت تکه های جامد در آمده است مدت زمان بیشتری به بیمار بخور دهید و مجدداً عملیات ساکشن را تکرار کنید. نوشیدن مایعات گرم نیز می‌تواند موثر باشد.
  11. در حین ساکشن بیمار را تشویق به سرفه نمایید. این کار باعث کنده شدن ترشحات انباشته شده در انتهای راه هوایی می‌گردد.

حداقل روزی 3 بار ظرف جمع کننده ترشحات را خارج کرده و به خوبی با آب و مایع سفید کننده بشویید و در معرض نور خورشید آن را خشک نمایید.         

 

  1. بعد از اتمام عملیات ساکشن دست‌ها را با آب و صابون بشویید و خشک کنید.
  2. در صورتی که سر ساکشن به راحتی وارد تراکئوستومی نمی‌شود می‌توانید آن را با مقدار کمی سرم شستشوی استریل و یا ژل لوبریکانت آغشته نمایید و مجدداً برای انجام عملیات ساکشن اقدام نمایید (ژل لوبریکانت در داروخانه‌ها موجود می‌باشد).
  3. هنگام ساکشن کردن به آرامی لوله تراکئوستومی را بادست نگه دارید تا از بیرون آمدن آن ممانعت کنید.
  4. لوله رابط ساکشن را روزانه تعویض کنید.

توجه کنید:

بعد از اتمام عملیات ساکشن کلیه وسایل آلوده را در کیسه نایلونی بریزد و سپس آنرا در سطل زباله بیندازید. با این اقدام از انتشار آلودگی پیشگیری می‌نمایید.

 

 

 

خلاصه

 

تراکئوستومی باز کردن یک راه هوایی در لوله تراشه است که شما آنرا به صورت یک حفره در زیر گلو مشاهده می‌کنید.  تراکئوستومی بر حسب نیاز بیمار ممکن است دائم یا موقت باشد و دارای مزایای زیر می‌باشد:

1- راه هوایی مطمئنی است، برای خروج ترشحات مجاری تنفسی بیمار.

2- در بیمارانی که مدت طولانی از دستگاه تهویه مکانیکی استفاده می‌کنند و راه هوایی مطمئنی برای تنفس ندارند استفاده می‌شوند.

3- از ورود مواد خارجی، ترشحات دهانی یا محتویات معده به ریه در بیمارانی که کاملاً هوشیار نیستند پیشگیری می‌کند.

چگونگی عملکرد تراکئوستومی بدین صورت است که:

1. در بیمارانی که تراکئوستومی شده‌اند مکانیسم سرفه ضعیف است. این بیماران برای دفع ترشحات دستگاه تنفس دچار مشکل هستند و نیاز به ساکشن دارند.

2. زمانی باید بیمار را ساکشن کنید که صدای غیر طبیعی در ریه ها شنیده شود یا اینکه شما ترشحات را مشاهده نمایید.

 3. توجه داشته باشید که ساکشن کردن غیر ضروری علاوه بر آنکه خطر عفونت را بالا می‌برد باعث آسیب به دستگاه تنفسی بیمار می‌شود.



برای مشاهده اسلایدهای تعاملی اینجا کلیک کنید.

ویدیو این قسمت در دست تهیه است.

 

شناسه

تهیه کننده: نجمه نادری

متخصص علمی محتوا: دکتر عباس خسروی، دکتر گلنار ثابتیان و دکترشهرام پایدار

 

References:

1.درسنامه پرستاری داخلی جراحی برونرسودارث، اس‍م‍ت‍ن‍ر (1385)، س‍وزان‌ اوک‍ان‍ل‌

2.      www.mdconsult.com/public/patient/view

3.       www.critcaremd.com

4.       www.myicucare.org/Critical_Care_Team

5.      www.ncbi.nlm.nih.gov/pubmed/11863143

6.      www.tju.edu/jmc 

7.      www.mc.vanderbilt.edu/root/vumc.php?site=neurocritical

8.      www.stonybrooksurgery.org

9.      libraries.umdnj.edu/camlbweb/hrc/critical

10.   www.uhn.ca

آخرین بروزرسانی ( يكشنبه ، 1 دی 1392 ، 15:02 )  

تماس با سرپرست

Untitled document

تماس با سرپرست این بخش

دکتر مانوش مهرابی

سرطان پستان

Untitled document

 

نمایه توده بدنی(BMI)

Untitled document

 

آمار بازدیدکنندگان

16645امروزmod_vvisit_counter
22666دیروزmod_vvisit_counter
39311این هفتهmod_vvisit_counter
161461هفته گذشتهmod_vvisit_counter
589174این ماهmod_vvisit_counter
871475ماه گذشتهmod_vvisit_counter
4290462کل بازدیدهاmod_vvisit_counter

بازدیدکنندگان: 221 مهمان حاضر
IP شما: 54.224.53.192
 , 
امروز: 03 آذر 1393

نظرسنجی مطالب آموزشی سلامت عموم

کیفیت مطالب آموزشی سلامت عموم ارائه شده در این بخش از دیدگاه شما چگونه است؟
 

نشریات

Untitled document book

مجله یادگیری الکترونیکی

Untitled document

 cover01

تصاویر پانورامای شیراز

Untitled document

 44557319

همایش یادگیری الکترونیکی

Untitled document

congress

Display Pagerank