52913971 thyroidectomy

5/23/2018 52913971 Thyroidectomy

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Throidectomy


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Chapter I

INTRODUCTION

General Description of Disease Condition Requiring Surgical ProcedureThyroidectomy is a surgical procedure in which all or part of the thyroid gland

is removed. The thyroid gland is located in the forward (anterior) part of the neck just

under the skin and in front of the Adam's apple. The thyroid is one of the body's

endocrine glands, which means that it secretes its products inside the body, into the

blood or lymph. The thyroid produces several hormones that have two primary

functions: they increase the synthesis of proteins in most of the body's tissues, and

they raise the level of the body's oxygen consumption.

All or part of the thyroid gland may be removed to correct a variety of

abnormalities. Before a thyroidectomy is performed, a variety of tests and studies are

usually required to determine the nature of the thyroid disease. Laboratory analysis

of blood determines the levels of active thyroid hormones circulating in the body. The

most common test is a blood test that measures the level of thyroid-stimulating

hormone (TSH) in the bloodstream. Sonograms and computed tomography scans

(CT scans) help to determine the size of the thyroid gland and location of

abnormalities. A nuclear medicine scan may be used to assess thyroid function or to

evaluate the condition of a thyroid nodule, but it is not considered a routine test. A

needle biopsy of an abnormality or aspiration (removal by suction) of fluid from the

thyroid gland may also be performed to help determine the diagnosis.

Continued treatment with antithyroid drugs may be the treatment of choice for

hyperthyroidism and goiter. Otherwise, no other special procedure must be followed

prior to the operation.

Relevant and Current Statistical Evidence or Critical Findings

Screening tests indicate that about 6% of the United States population has

some disturbance of thyroid function, but many people with mildly abnormal levels of

thyroid hormone do not have any disease symptoms. It is estimated that between 12

and 15 million people in the United States and Canada are receiving treatment for


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thyroid disorders as of 2002. In 2001, there were approximately 34,500

thyroidectomies performed in the United States. Females are somewhat more likely

than males to require a thyroidectomy. (Retrieved at

http://www.surgeryencyclopedia.com/St-Wr/Thyroidectomy.html; accessed on

January 22, 2011)

Recent Trends, Refinements, and/or Innovations in Treatment

1. Outpatient Thyroid Surgery Found To Be Safe, Cost Effective

Thyroid surgery, which has traditionally been an overnight hospital procedure,

can be done safely in an outpatient setting, and in fact is preferable because it is less

expensive, according to a new study published in the April issue of Otolaryngology-

Head and Neck Surgery. The study's authors found not only were complications low,

but conducting the procedure in an outpatient environment significantly lowered the

cost by several thousand dollars. (Retrieved at

http://www.medicalnewstoday.com/articles/67471.php; accessed on January 23,

2011)

2. 'Scarless' Thyroid Surgery Uses 3-D, High-Def Robotic Equipment

The scarless thyroid surgery is a new form of endoscopic surgery. The

technique uses the latest Da Vinci three-dimensional, high-definition robotic

equipment to make a two-inch incision below the armpit that allows doctors to

maneuver a small camera and specially designed instruments between muscles to

access the thyroid. The diseased tissue is then removed endoscopically through the

armpit incision. This technique safely removes the thyroid without leaving so much

as a scratch on the neck. The benefits of this new technique go beyond aesthetics.

Unlike other forms of endoscopic thyroid surgery, it doesn't require blowing gas into

the neck to create space to perform the operation. Those techniques can risk

complications if the gas is retained in the neck or chest after surgery, causing

significant discomfort and postoperative complications. There is a reduced likelihood

of laryngeal nerve damage and less risk of trauma to the parathyroid glands, which

are near the thyroid. There is also significant faster recovery time and less

discomfort on the part of the patients. (Retrieved at http://www.sciencedaily.com

/releases/2009/11/091124174735.htm; accessed on January 24, 2011)


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3. Differences in postoperative outcomes, function, and cosmesis: open

versus robotic thyroidectomy.

Robotic thyroidectomy using a gasless transaxillary approach, first described

in 2008, has become popular. This study compared outcomes, including

postoperative distress and patient satisfaction, for patients undergoing robotic

thyroidectomy with those for patients treated by conventional open thyroidectomy.

Methods: Of 84 prospectively enrolled patients, 41 underwent robotic thyroidectomy

(the robot group), and 43 received conventional open thyroidectomy (the open

group). All the patients were followed up for at least 3 months after surgery. Although

postoperative pain levels and complications were comparable in the two groups,

conventional open thyroidectomy requires a shorter operative time. The robotic

technique, however, offers several distinct advantages including very good to

excellent cosmetic results, reduced postoperative neck discomfort, and fewer

adverse swallowing symptoms. (Retrieved at:

http://web.ebscohost.com/ehost/detail?hid=107&sid=79aa1711-581b-4e56-8485-

4efd96144899%40sessionmgr104&vid=1&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d

%3d#db=a3h&AN=55216256;accessed on January 24, 2011)

4. (INSERT TITLE HERE)

Researchers at the National Institutes of Health have identified a compound

that prevents overproduction of thyroid hormone, a finding that brings scientists one

step closer to improving treatment for Graves' disease. Attacking the problem at its

root cause, lead researcher Susanne Neumann, Ph.D., and her colleagues at the

NIH's National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

have identified a chemical compound that binds to the receptors and acts as an

antagonist, keeping the stimulating antibodies from their work and potentially

allowing the thyroid cells to revert to normal function. (Retrieved at (complete URL);

accessed on January 25, 2011)

Implication of The Above Information for Nurses as a Productive

Member of Society

Nurses are health care providers and considered as productive member of

the society. Nurses should have a concrete background or knowledge on the current

illness condition of their patient in order to render adequate and appropriate nursing
http://web.ebscohost.com/ehost/detail?hid=107&sid=79aa1711-581b-4e56-8485-4efd96144899%40sessionmgr104&vid=1&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a3h&AN=55216256http://web.ebscohost.com/ehost/detail?hid=107&sid=79aa1711-581b-4e56-8485-4efd96144899%40sessionmgr104&vid=1&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a3h&AN=55216256http://web.ebscohost.com/ehost/detail?hid=107&sid=79aa1711-581b-4e56-8485-4efd96144899%40sessionmgr104&vid=1&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a3h&AN=55216256http://web.ebscohost.com/ehost/detail?hid=107&sid=79aa1711-581b-4e56-8485-4efd96144899%40sessionmgr104&vid=1&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a3h&AN=55216256http://web.ebscohost.com/ehost/detail?hid=107&sid=79aa1711-581b-4e56-8485-4efd96144899%40sessionmgr104&vid=1&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a3h&AN=55216256http://web.ebscohost.com/ehost/detail?hid=107&sid=79aa1711-581b-4e56-8485-4efd96144899%40sessionmgr104&vid=1&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a3h&AN=55216256


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interventions. To render effective nursing care, one must have first basic information

related to the disease condition such as its possible causes and possible nursing

interventions, medical or surgical treatments. For example in this case, a nurse with

adequate knowledge could support the doctors explanation to the patient what

happens in thyroidectomy and it could help them understand the required surgery

and its possible complications. The nurse would also know which appropriate and

inappropriate interventions should not be given to the patient. The nurse could also

render preoperative and postoperative teachings efficiently as well.

These current trends encompass the continuous advancements with regards

to the study at hand. As thyroidectomy continuous to be one of the most common

surgical procedures done in the country, it is evident that the need to expand our

knowledge is a must in order to render appropriate and efficient service to our

clientele. Through various readings, lectures, activities, hospital experience etc.,

these placed a challenged in us to improve our nursing skills and clinical

competence; in such a way that we would likely to offer the community the efficient

services it needs in the future. It relates its theories and principles with the human

being a complex individual. Learning its process is an intricate procedure that

sometimes we should deal with the actual setting first before realizing and

understanding its real course of action.


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Chapter II

ANATOMY AND PHYSIOLOGY

ANATOMY OF THE THYROID GLAND

A large, highly vascularendocrine gland situated in the base of the neck. The

thyroid consists of two lobes, one on each side of thetrachea,just below the larynx

or voice box. The two lobes are connected by a narrow band of tissue called the

isthmus. Internally, the gland consists of follicles, which produce thyroxine and

triiodothyronine hormones. Both thesehormones contain iodine.

The thyroid controls how quickly the body burns energy, makes proteins,

and how sensitive the body should be to other hormones. The thyroid participates in

these processes by producing thyroid hormones, principally thyroxine (T4) and

triiodothyronine (T3). These hormones regulate the rate of metabolism and affect the

growth and rate of function of many other systems in the body. Iodine is an essential

component of both T3 and T4. The thyroid also produces the hormone calcitonin,

which plays a role in calcium homeostasis. Thyroid hormones also help maintain

normal blood pressure, heart rate, digestion, muscle tone, and reproductive

functions.

The thyroid tissue is made up of two types of cells: follicular cells and

parafollicular cells. Most of the thyroid tissue consists of the follicular cells, whichsecrete iodine-containing hormones called thyroxine (T4) and triiodothyronine (T3).
http://www.daviddarling.info/encyclopedia/E/endocrine_glands.htmlhttp://www.daviddarling.info/encyclopedia/T/trachea.htmlhttp://www.daviddarling.info/encyclopedia/L/larynx.htmlhttp://www.daviddarling.info/encyclopedia/T/thyroxine.htmlhttp://www.daviddarling.info/encyclopedia/T/triiodothyronine.htmlhttp://www.daviddarling.info/encyclopedia/H/hormone.htmlhttp://www.daviddarling.info/encyclopedia/H/hormone.htmlhttp://www.daviddarling.info/encyclopedia/T/triiodothyronine.htmlhttp://www.daviddarling.info/encyclopedia/T/thyroxine.htmlhttp://www.daviddarling.info/encyclopedia/L/larynx.htmlhttp://www.daviddarling.info/encyclopedia/T/trachea.htmlhttp://www.daviddarling.info/encyclopedia/E/endocrine_glands.html


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The parafollicular cells secrete the hormone calcitonin. The thyroid needs iodine to

produce the hormones.

About 95 percent of the active thyroid hormone is thyroxine, and most of the

remaining 5 percent is triiodothyronine. Both of these require iodine for their

synthesis. Thyroid hormone secretion is regulated by a negative feedback

mechanism that involves the amount of circulating hormone, the hypothalamus, and

the anterior pituitary gland (adenohypophysis).

The thyroid is controlled by the hypothalamus and pituitary. The gland gets its

name from the Greek word for "shield", after the shape of the related thyroid

cartilage. Hyperthyroidism (overactive thyroid) and hypothyroidism (underactive

thyroid) are the most common problems of the thyroid gland.

The thyroid gland is butterfly-shaped organ and is composed of two cone-like

lobes or wings: lobus dexter (right lobe) and lobus sinister (left lobe), connected with

the isthmus. The organ is situated on the anterior side of the neck, lying against and

around the larynx and trachea, reaching posteriorly the oesophagus and carotid

sheath. It starts cranially at the oblique line on the thyroid cartilage (just below the

laryngeal prominence or Adam's apple) and extends inferiorly to the fourth to sixth

tracheal ring. It is difficult to demarcate the gland's upper and lower border with

vertebral levels as it moves position in relation to these during swallowing.

The normal thyroid gland is easily palpable. Palpation is carried out from

behind using the digits to feel for the cricoid cartilage and for the 1st tracheal ring

directly below it. The isthmus of the thyroid overlies the 2nd through the fourth

tracheal rings, to which the pretracheal fascia (a fibrous sheath that contains the

thyroid and allows it to glide smoothly over the nearby contents) firmly attaches

through suspensory ligaments (extensions of the fascia). This attachment allows the

thyroid to move with the larynx during swallowing, an important fact in palpating the

thyroid as it is appropriate to ask the patient to sip a glass of water while palpating

the gland, as to allow the inferior portion to be better felt when it elevates with the

larynx.


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The thyroid isthmus is variable in presence and size, and can encompass a

cranially extending pyramid lobe (lobus pyramidalis or processus pyramidalis),

remnant of the thyroglossal duct. The thyroid is one of the larger endocrine glands,

weighing 2-3 grams in neonates and 18-60 grams in adults, and is increased in

pregnancy.

The thyroid is supplied with arterial blood from the superior thyroid artery, a

branch of the external carotid artery, and the inferior thyroid artery, a branch of the

thyrocervical trunk, and sometimes by the thyroid ima artery, branching directly from

the aortic arch. The venous blood is drained via superior thyroid veins, draining in

the internal jugular vein, and via inferior thyroid veins, draining via the plexus

thyroideus impar in the left brachiocephalic vein. Lymphatic drainage passes

frequently the lateral deep cervical lymph nodes and the pre- and parathracheal

lymph nodes. The gland is supplied by sympathetic nerve input from the superior

cervical ganglion and the cervicothoracic ganglion of the sympathetic trunk, and by

parasympathetic nerve input from the superior laryngeal nerve and the recurrent

laryngeal nerve.

PHYSIOLOGY OF THE THYROID GLAND

The primary function of the thyroid is production of the hormones thyroxine

(T4), triiodothyronine (T3), and calcitonin. Up to 80% of the T4 is converted to T3 by

peripheral organs such as the liver, kidney and spleen. T3 is about ten times more

active than T4.

T3 and T4 Production and Action

Thyroxine (T4) is synthesised by the follicular cells from free tyrosine and on

the tyrosine residues of the protein called thyroglobulin (TG). Iodine is captured with

the "iodine trap" by the hydrogen peroxide generated by the enzyme thyroid

peroxidase (TPO) and linked to the 3' and 5' sites of the benzene ring of the tyrosine

residues on TG, and on free tyrosine. Upon stimulation by the thyroid-stimulating

hormone (TSH), the follicular cells reabsorb TG and proteolytically cleave the

iodinated tyrosines from TG, forming T4 and T3 (in T3, one iodine is absent

compared to T4), and releasing them into the blood. Deiodinase enzymes convert T4


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to T3. Thyroid hormone that is secreted from the gland is about 90% T4 and about

10% T3.

Cells of the brain are a major target for the thyroid hormones T3 and T4.

Thyroid hormones play a particularly crucial role in brain maturation during fetal

development. A transport protein (OATP1C1) has been identified that seems to be

important for T4 transport across the blood brain barrier. A second transport protein

(MCT8) is important for T3 transport across brain cell membranes.

In the blood, T4 and T3 are partially bound to thyroxine-binding globulin,

transthyretin and albumin. Only a very small fraction of the circulating hormone is

free (unbound) - T4 0.03% and T3 0.3%. Only the free fraction has hormonal activity.

As with the steroid hormones and retinoic acid, thyroid hormones cross the cell

membrane and bind to intracellular receptors (1, 2, 1 and 2), which act alone, in

pairs or together with the retinoid X-receptor as transcription factors to modulate

DNA transcription.

T3 and T4 Regulation

The production of thyroxine and triiodothyronine is regulated by thyroid-

stimulating hormone (TSH), released by the anterior pituitary (that is in turn released

as a result of TRH release by the hypothalamus). The thyroid and thyrotropes form a

negative feedback loop: TSH production is suppressed when the T4 levels are high,

and vice versa. The TSH production itself is modulated by thyrotropin-releasinghormone (TRH), which is produced by the hypothalamus and secreted at an


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increased rate in situations such as cold (in which an accelerated metabolism would

generate more heat). TSH production is blunted by somatostatin (SRIH), rising levels

of glucocorticoids and sex hormones (estrogen and testosterone), and excessively

high blood iodide concentration.

Calcitonin

An additional hormone produced by the thyroid contributes to the regulation of

blood calcium levels. Parafollicular cells produce calcitonin in response to

hypercalcemia. Calcitonin stimulates movement of calcium into bone, in opposition to

the effects of parathyroid hormone (PTH). However, calcitonin seems far less

essential than PTH, as calcium metabolism remains clinically normal after removal of

the thyroid, but not the parathyroids.

Significance of Iodine

In areas of the world where iodine (essential for the production of thyroxine,

which contains four iodine atoms) is lacking in the diet, the thyroid gland can be

considerably enlarged, resulting in the swollen necks of endemic goitre.

Thyroxine is critical to the regulation of metabolism and growth throughout the

animal kingdom. Among amphibians, for example, administering a thyroid-blocking

agent such as propylthiouracil (PTU) can prevent tadpoles from metamorphosing

into frogs; conversely, administering thyroxine will trigger metamorphosis.

In humans, children born with thyroid hormone deficiency will have physical

growth and development problems, and brain development can also be severely

impaired, in the condition referred to as cretinism. Newborn children in many

developed countries are now routinely tested for thyroid hormone deficiency as part

of newborn screening by analysis of a drop of blood. Children with thyroid hormone

deficiency are treated by supplementation with synthetic thyroxine, which enables

them to grow and develop normally.

Because of the thyroid's selective uptake and concentration of what is a fairly

rare element, it is sensitive to the effects of various radioactive isotopes of iodine


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produced by nuclear fission. In the event of large accidental releases of such

material into the environment, the uptake of radioactive iodine isotopes by the thyroid

can, in theory, be blocked by saturating the uptake mechanism with a large surplus

of non-radioactive iodine, taken in the form of potassium iodide tablets. While

biological researchers making compounds labelled with iodine isotopes do this, in

the wider world such preventive measures are usually not stockpiled before an

accident, nor are they distributed adequately afterward. One consequence of the

Chernobyl disaster was an increase in thyroid cancers in children in the years

following the accident.

The use of iodized salt is an efficient way to add iodine to the diet. It has

eliminated endemic cretinism in most developed countries, and some governments

have made the iodination of flour mandatory. Potassium iodide and Sodium iodide

are the most active forms of supplemental iodine.


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Chapter III

CLINICAL INTERVENTION

Description of Prescribed Surgical Treatment Performed

Thyroidectomy is a surgical procedure in which all or part of the thyroid gland

is removed. Located in the forward (anterior) part of the neck just under the skin and

in front of the Adam's apple. The thyroid is one of the body's endocrine glands, it

secretes its products inside the body, into the blood or lymph. The thyroid produces

several hormones that have two primary functions: they increase the synthesis of

proteins in most of the body's tissues, and they raise the level of the body's oxygen

consumption.

Types of Thyroidectom :

1. Total Thyroidectomy (Complete Removal of the Thyroid) - This is the

most common type of thyroid surgery and preferred by most surgeons for cases of

hyperthyroidism, often used for thyroid cancer, and in particular, aggressive cancers,

such as medullary or anaplastic thyroid cancer. It is used for goiter and Graves.

2. Subtotal/Partial Thyroidectomy (Removal Half of the Thyroid Gland) - For

this operation, cancer must be small and non-aggressive -- follicular or papillary --

and contained to one side of the gland. When a subtotal or partial thyroidectomy is

performed, typically, surgeons perform a bilateral subtotal thyroidectomy which

leaves from 1 to 5 grams on each side/lobe of the thyroid.


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3. Thyroid Lobectomy (Removal of Only About a Quarter of the Gland)-

This is less commonly used for thyroid cancer, as the cancerous cells must be small

and non-aggressive.

Preparation and Positioning of the Patient

The patient may lie either in the half sitting position with slightly reclined head,

(Fig 1.1a) or be lying with the head hanging (Fig. 1.1b). The advantage of the lying

position is that the venous pressure is positive preventing an air embolus. The

pressure in the cervical veins in the sitting position is on average 2.4cm and, in the

lying position with the head hanging, 8.1 cm. however, it must not be overlooked that

a pressure in the venous system is dangerous even under positive pressure if the

vein is opened (Keminger and Maager 1969).

Fig. 1.1a

Fig. 1.1b

Skin preparation

Using iodine solution with soap and sterile water, begin at the anterior neck

extending upward to just below the infra-auricular border and lower lip, and down-

ward to 2.5 to 5 cm (1 to 2 inches) above the nipples; continue down to the table atthe neck, around the shoulders, and at the sides.


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Preparation of Surgical Instruments

Draping

Simple and effective draping of the head can be achieved with Kaspars goiter

towel (Fig.1.2a). The tapes are tied behind the patients neck (Fig. 1.2a). Before thehead and the lateral parts of the neck are covered with the goiter towel, the patients

body is covered with a sterile folded linen drape. Four towel clips are used to fix the

towels and ensure a rectangular operative field (Fig 1.2b). After the skin has been

incised, and the cervical fascia and the strap muscle have been dissected the

remaining free parts of the skin are covered with 2 further drapes (Fig. 1.2c). The

upper drape is folded over several times but the long one simple lay on.

Fig. 1.2a

Fig. 1.2b

Fig. 1.2c


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Operative Procedure

The Skin Incision

It should lay two fingers breadth above the suprasternal notch. The

incision should be carried out in one straight stroke through skin andplatysma. A band may be mark out the incision (Fig. 1.3a). Bleeding

intracutaneous vessels are clamped but if possible are not covered. The flap

of skin and platysma is elevated above and below.

Fig. 1.3a - Band being used for marking out incision

Fig. 1.3b Kochers Collar Incision

Operative Technique

The fascia is divided on both sides of veins, held up with the forceps, clamped

(Fig 1.4) and then divided between two clamps (Fig 1.5). The fascia bridges lying

between the veins are divided from left to right. Veins should also be dealt with along

the medial edge of both the sternocleidomastoid muscles. The upper fascia and

platysmal flap is elevated as far as the laryngeal eminence (Fig 1.6) and the superior

fascial flap is elevated using a pair of forceps. The superior stumps of the vein are

ligated and the superior stumps transfixed (Fig 1.7).


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Fig. 1.4

Fig 1.5

Fig. 1.6

The deep strap muscles are divided in the mid line with scissors or scalpel up

to the cricoid (Fig 1.7).

As rule the muscles should not be divided. Division of the sternohyoid and

sternothryroid muscles may lead to rapid tiring of the voice and reduction of its

range. However it should be remembered that more damage may caused by blunt

forceful retraction than by deliberate division.


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Fig 1.7

Fig 1.8

Division of the Isthmus

The division of the isthmus, beginning at its superior or inferior edge, thus

allowing the trachea to be located. It is elevated from the trachea by spreading

movements with artery forceps. (Fig 1.9), bringing the delicate connective tissue

sheath of the trachea into view.

Fig 1.9


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A voluminous, adenomatous, and parenchymatous isthmus is divided

between clamps with scissors from below upwards. A small artery usually runs along

the superior edge from one pole to the other, and this should also be clamped and

divided (Fig.1.10)

Fig. 1.10

Fig. 1.11a

Fig 1.11b


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Figures 1.11a and 1.11b, Babcock are applied to inferior and superior (not

shown) aspects of the thyroid lobe to facilitate medial retraction on the gland. This

exposes the area when the parathyroid glands and recurrent laryngeal nerve are

located.

Fig. 1.12

Figure 1.12, downward traction on the superior Babcock clamp exposes the

superior pole vessels, including the branches of the superior thyroid artery. The

external laryngeal nerve courses along the cricothyroid muscle just medial to the

superior pole vessels. To avoid injury to this nerve, which controls tension of the

vocal cords, the superior pole vessels are divided individually as close as possible to

the point where they enter the thyroid.

Fig 1.13

Figure 1.13, as the thyroid is retracted medially; gentle dissection with a Hoyt

clamp is used to expose the parathyroid glands, inferior thyroid artery, and recurrent

laryngeal nerve. The recurrent nerve usually passes behind the inferior thyroid artery


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but occasionally lies anterior to it. They nerve can then be traced upward, and its

position in relation to the thyroid can be determined. Parathyroid glands that lie on

the thyroid surface can be mobilized with their vascular supply and thus preserved.

Fig 1.14

Figures 1.14, to perform total lobectomy, the branches of the inferior thyroid

artery are divided at the surface of the thyroid gland. The inferior thyroid veins can

now be ligated and divided. Superiorly, the connective tissue (ligament of Berry),

which binds the thyroid to the tracheal rings, is carefully divided. Division of ligament

allows the thyroid to be mobilized medially.

Fig. 1.15

Figure 1.15, the dissection of the thyroid from the trachea can be performed

with the cautery by division of the loose connective tissue between these structures.

Dissection is extended under the Isthmus, and the specimen is divided, so that the

isthmus is included with the resected lobe.


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Fig 1.16

Figure 1.16, subtotal lobectomy necessitates identification of the parathyroid

glands inferior thyroid artery, and recurrent laryngeal nerve, as previously described.

The line of resection is selected to preserve the parathyroid glands and their bloodsupply and to protect the recurrent laryngeal nerve. It should be based on the inferior

thyroid artery or its major branches.

Fig 1.17a

Fig 1.17b


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Figures 1.17 A and B, clamps are placed along the line of resection, and the

thyroids gland is divided. The divided tissue is ligated or suture-ligated with 3-0 silk.

The dissection is extended to the trachea. (Sabiston, D.C., Jr. [Ed]: Atlas of General

Surgery Philadelphia, WE.B. Sauders, 1995.)

Fig 1.18

At the end of the resection the remnant of capsule and parenchyma is closed

by individual horizontal suture (Fig 1.18) to achieve good homeostasis. This

procedure is facilitated by traction to the opposite side on the capsule sutures which

have been left long, and by lateral displacement of the common carotid artery with a

hook.

Before closing the neck it is advisable to increase positive pressure

respiration for a brief period to increase the pressure in the superior vena cava and

thus show any venous bleeding points or potential points of entry for air emboli which

have been overlooked. Then a pyramidal lobe if present is removed and aberrant

adenomas in the region of the upper and lower pole are looked for. The cavity is

drained for 24 hours by penrose drain (Fig. 1.19)

Fig 1.19


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Fig 1.20a

Wound closure is limited to suture of the strap muscles (Fig 1.19) and the

placing of skin clips (Fig 1.20a and b) which are removed 3 days later.

Fig. 1.20b

Fig 1.21

1.2 Indication of Prescribed Surgical Treatment

Thyroidectomy is usually performed for the following reasons:

1. As therapy for some individuals with thyrotoxicosis; those with Graves

disease; and others with a hot nodule or toxic nodular goiter.


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2. To establish a definitive diagnosis of a mass within the thyroid gland,

especially when cytologic analysis after fine needle aspiration (FNA) is either

non-diagnostic or equivocal.

3. To treat benign and malignant thyroid tumors.

4. To alleviate pressure symptoms or respiratory difficulties associated with a

benign or malignant process.

5. To remove an unsightly goiter (Figure 9).

6. To remove large substernal goiters, especially when they cause respiratory

difficulties.

7. Young patients and are free from any condition that makes them poor

operative risks (DM, heart disease, renal disease)

Specific:

o A small thyroid nodule or cyst

o A thyroid gland that is so overactive it is dangerous (thyrotoxicosis)

o Benign (noncancerous) tumors of the thyroid

o Cancer of the thyroid

o Thyroid swelling (nontoxic goiter) that makes it hard for you to breathe or

swallow

Thyroid surgery (Thyroidectomy) is a common operation, but one which needs

to be taken seriously because of the potential complications which may occur.

Commonly, this surgery is done because of suspected cancer. Patient risk factors,

appearance on ultrasound examination or needle biopsy results may cause your

surgeon to recommend surgical removal of the thyroid.

If there is a vocal cord paralysis or rapid growth of a solid mass also indicates

a cancer. Unfortunately, one of the forms of thyroid cancer, follicular carcinoma, can

appear benign on needle biopsy and may also be read as benign on frozen section

during surgery.

If the thyroid becomes so large that it compresses the trachea or

esophagus surgical removal is indicated. A thyroid cyst that recurs after a single or

repeated needle drainage is also an indication for removal. Rarely, a thyroiditis will

cause scaring in the neck which also compresses the airway. The thyroid must also


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be removed in this case. However, cases of thyroiditis have an increased

complication rate due to bleeding and scarring.

2 Risk and Benefits of Undergoing Treatment

Risk Benifits

1. Hypoparathyroidism or recurrent

lesion, have not been investigated

systematically.

2. Recurrent laryngeal nerve injuries.

3. Cervical hematomas.

1. As therapy for some individuals

with thyrotoxicosis; those with Graves

disease; and others with a hot nodule or

toxic nodular goiter.

2. To establish a definitive diagnosis

of a mass within the thyroid gland,

especially when cytologic analysis after

fine needle aspiration (FNA) is either

non-diagnostic or equivocal.

3. To treat benign and malignant

thyroid tumors.

4. To alleviate pressure symptoms

or respiratory difficulties associated with

a benign or malignant process.

5. To remove an unsightly goiter.

3 Risks and Benefits of Not Undergoing Treatment

Risk Benefits

1. A small thyroid nodule or cyst.

2. A thyroid gland that is so

overactive it is dangerous

(thyrotoxicosis).

1. The patient may have decreased

risk of developing any

postoperational complications.


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Page | 26

3. Benign (noncancerous) tumors of

the thyroid

4. Cancer of the thyroid

5. Thyroid swelling (nontoxic goiter)

that makes it hard for you to breathe or

swallow

1.3 Required Instruments, Devices, Supplies, Equipment and Facilities

Retractors:

1.) DOUBLE-ENDED RICHARDSON RETRACTOR used to retract deep

incisions

2.) ARMY-NAVY RETRACTORused to retract shallow or superficial incisions


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3.) WEITLANERends can be blunt or sharp; has rake tips; ratchet to hold

tissue apart

4.) GELPIhas single point tips; ratchet to hold tissue apart

Clamping Instruments:

5.) MOSQUITOused to clamp blood vessels

6.) KELLY is used to clamp larger vessels and tissue. Available in short and

long sizes.


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7.) LAHEYthyroid forceps used to deliver the thyroid in thyroidectomy.

8.) KOCHERa heavy, straight hemostat with interlocking teeth on the tip

9.) CRILEa clamp for temporary stoppage of blood flow.

10.) TOWEL CLIPSused to hold towels and drapes in place.
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Grasping Instruments:

11.) BABCOCK CLAMPused to grasp delicate tissue

12.) ADSONa small thumb forceps with two teeth on one tip and one tooth on

the other.

13.) CUSHING FORCEPS

14.) PLAIN TISSUE FORCEPSused to grasp tissue.

15.) DEBAKEY FORCEPSnontraumatic forceps used to pick up blood vessels;

also known as magics.

.
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16.) ALLISa straight grasping forceps with serrated jaws, used to forcibly grasp

or retract tissues or structures.

Dissecting/ Cutting Instruments:

17.) MAYO SCISSORSused to cut heavy tissue.

18.) METZENBAUMS "Mets"used to cut delicate tissues.

19.) #3 KNIFE HANDLES -
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20.) BLADES NO. 10 the flat part of a tool or weapon that (usually) has a

cutting edge.

21.) TENOTOMY The surgical division of a tendon for relief of a deformity

caused by congenital or acquired shortening of a muscle, as in clubfoot or

strabismus

22.) CURVED IRIS

Suturing Instruments:

23. ) NEEDLE HOLDERused to hold needles when suturing. They may also be

placed on the sewing category.
http://images.google.com.ph/imgres?imgurl=http://www.muromachi.com/fst/Scissors/image/14064-11.GIF&imgrefurl=http://www.muromachi.com/fst/Scissors/14064-11.htm&h=307&w=182&sz=13&hl=en&start=8&tbnid=tqIUuswKp9jKyM:&tbnh=117&tbnw=69&prev=/images?q=tenotomy&svnum=10&hl=en&lr=http://images.google.com.ph/imgres?imgurl=http://www.muromachi.com/fst/Scissors/image/14064-11.GIF&imgrefurl=http://www.muromachi.com/fst/Scissors/14064-11.htm&h=307&w=182&sz=13&hl=en&start=8&tbnid=tqIUuswKp9jKyM:&tbnh=117&tbnw=69&prev=/images?q=tenotomy&svnum=10&hl=en&lr=http://images.google.com.ph/imgres?imgurl=http://www.muromachi.com/fst/Scissors/image/14064-11.GIF&imgrefurl=http://www.muromachi.com/fst/Scissors/14064-11.htm&h=307&w=182&sz=13&hl=en&start=8&tbnid=tqIUuswKp9jKyM:&tbnh=117&tbnw=69&prev=/images?q=tenotomy&svnum=10&hl=en&lr=http://images.google.com.ph/imgres?imgurl=http://www.muromachi.com/fst/Scissors/image/14064-11.GIF&imgrefurl=http://www.muromachi.com/fst/Scissors/14064-11.htm&h=307&w=182&sz=13&hl=en&start=8&tbnid=tqIUuswKp9jKyM:&tbnh=117&tbnw=69&prev=/images?q=tenotomy&svnum=10&hl=en&lr=


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Equipments:

24.) CAUTERY UNITThis may be a separate apparatus or it may be part of an

electrosurgery system. It employs a probe with a hot metal tip or wire which is used

to stop bleeding and in some cases for cutting. In its very simplest form it may be ahand-held unit containing a large electrical cell which heats up a small wire loop at its

tip on pressing a button. Such a unit may be used to remove very small polyps and

to stop bleeding. Larger units use a low voltage source from a transformer connected

to the cautery probe via a flexible lead.

Supplies:

25.) BASIN SET

26.) SUCTION TUBING An apparatus for removing fluid from a body cavity,

consisting usually of a hollow needle and a cannula, connected by tubing to

a container in which a vacuum is created by a syringe or a suction pump.
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27.) PENROSE DRAINis a surgical device placed in a wound to drain fluid. It

consists of a soft rubber tube placed in a wound area to prevent the build up

of fluid.

28.) ELECTROSURGICAL PENCIL A novel dual mode electrosurgical

pencil is provided for conventional tissue cutting/coagulation use in a first

mode of operation, and gas-enhanced coagulation by fulguration in a

second mode of operation.

29.) STERI STRIPS

30.) ADENOID SUCTION
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1.4 Perioperative Tasks and Responsibilities of The Nurse

DUTIES OF SCRUB NURSE

Ensures that the circulating nurse has checked the equipment.

Ensures that the theater has been cleaned before the trolley is set. Prepares the instruments and equipment needed in the operation.

Uses sterile technique for scrubbing, gowning and gloving.

Receives sterile equipment via circulating nurse using sterile technique.

Performs initial sponges, instruments and needle count, checks with

circulating nurse.

When Surgeon Arrives After Scrubbing: Perform assisted gowning and gloving to the surgeon and assistant

surgeon as soon as they enter the operation suite.

Assemble the drapes according to use. Start with towel, towel clips, draw

sheet and then lap sheet. Then, assist in draping the patient aseptically

according to routine procedure.

Place blade on the knife handle using needle holder, assemble suction tip

and suction tube. Bring mayo stand and back table near the draped patient after draping is

completed.

Secure suction tube and cautery cord with towel clips or allis.

Prepares sutures and needles according to use.

During an Operation

Maintain sterility throughout the procedure. Awareness of the patients safety.

Adhere to the policy regarding sponge/ instruments count/ surgical

needles.

Arrange the instrument on the mayo table and on the back table.

Before the Incision Begins

Provide 2 sponges on the operative site prior to incision.


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Passes the 1st knife for the skin to the surgeon with blade facing

downward and a hemostat to the assistant surgeon.

Hand the retractor to the assistant surgeon.

Watch the field/ procedure and anticipate the surgeons needs. Pass the instrument in a decisive and positive manner.

Watch out for hand signals to ask for instruments and keep instrument as

clean as possible by wiping instrument with moist sponge.

Always remove charred tissue from the cautery tip.

Notify circulating nurse if you need additional instruments as clear as

possible.

Keep 2 sponges on the field. Save and care for tissue specimen according to the hospital policy.

Remove excess instrument from the sterile field.

Adhere and maintain sterile technique and watch for any breaks.

End of Operation

Undertake count of sponges and instruments with circulating nurse.

Informs the surgeon of count result. Clears away instrument and equipment.

After operation: helps to apply dressing.

Removes and siposes of drapes.

De-gown.

Prepares the patient for recovery room.

Completes documentation.

Hand patient over to recover room.

Scrub Duties

Perform surgical hand scrub.

Gown and glove using closed glove technique.

Regown and glove when breaks in technique occur.

Assist the 1st scrub in setting up case (back table, mayo stand and O.R.

basins).The tasks include:

o Arrange instruments and supplies (back table, mayo stand and O.R.).


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o Count needles, instruments and sponges.

o Check instruments for proper functions.

o Prepare irrigating solution.

o Draw medications properly.

o Gown and glove surgeon and assistant.

o Assist with draping.

o Prepare electric cautery, suction and light handles for proper use.

o Prepare necessary sutures.

o Pass instruments to surgeon and assistant.

o Retract, sponge, and suction during case as necessary.

o Proper identification and handling of specimen.

o Prepare instruments for decontamination at completion of case.

o Dispose of sharps properly.

o Discard soiled drapes and trash properly.

o Transport soiled drapes and trash properly.

o Anticipate the surgeon and assistant needs.

o Anticipate the operative procedure needs.

DUTIES OF CIRCULATING NURSE

Before an Operation

Checks all equipment for proper functioning such as cautery machine,

suction machine, OR light and OR table.

Make sure theater is clean.

Arrange furniture according to use.

Place a clean sheet, arm board (arm strap) and a pillow on the OR table.

Provide a clean kick bucket and pail.

Collect necessary stock and equipment.

Turn on aircon unit.

Help scrub nurse with setting up the theater.

Assist with counts and records.

During the Induction of Anesthesia

Turn on OR light.


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Assist the anesthesiologist in positioning the patient.

Assist the patient in assuming the position for anesthesia.

Anticipate the anesthesiologists needs.

If spinal anesthesia is contemplated:o Place the patient in quasi fetal position and provide pillow.

o Perform lumbar preparation aseptically.

o Anticipate anesthesiologists needs.

After the Patient is Anesthetized

Reposition the patient per anesthesiologists instruction.

Attached anesthesia screen and place the patients arm on the armboards.

Apply restraints on the patient.

Expose the area for skin preparation.

Catheterize the patient as indicated by the anaesthesiologist.

Perform skin preparation.

During Operation Remain in theater throughout operation.

Focus the OR light every now and then.

Connect diatherapy, suction, etc.

Position kick buckets on the operating side.

Replenishes and records sponge/ sutures.

Ensure the theater doors remain closed and patients dignity is upheld.

Watch out for any break in aseptic technique.

End of Operation

Assist with final sponge and instruments count.

Signs the theater register.

Ensures specimen are properly labeled and signed.

After an Operation Hands dressing to the scrub nurse.


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Helps remove and dispose of drapes.

Helps to prepare the patient for the recovery room.

Assist the scrub nurse, taking the instrumentations to the service

(washroom). Ensures that the theater is ready for the next case.

Circulating Duties

Clean operating room and discard suction prior to case.

Gather all supplies, instruments and equipment necessary for case.

Arrange O.R. furniture properly.

Open and flip sterile supplies for the surgical procedure. Assist with IV therapy.

Assist the anaesthesiologist.

Assist with the skin preparation.

Tie gowns of the scrub nurse and surgeon.

Provide scrub personnel with sitting stools and foot stools as necessary.

Turn and help adjust lights as necessary.

Supply the scrub nurse with necessary supplies.

Receive and label specimen properly.

Log and deliver specimen to pathology properly.

Help apply wound dressing.

1.5 Expected Outcome of Surgical Treatment Performed

After a thyroidectomy, the patient may experience neck pain and a hoarse or

weak voice. This doesn't necessarily mean there's permanent damage to the nervethat controls the vocal cords. These symptoms are often temporary and may be due

to irritation from the breathing tube (endotracheal tube) that's inserted into the

windpipe (trachea) during surgery, or as a result of nerve irritation but not

permanent damage caused by the surgery.

The long-term effects of thyroidectomy depend on how much of the thyroid is

removed. If only part of the thyroid is removed, the remaining portion typically takes


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over the function of the entire thyroid gland, and the patient doesn't need thyroid

hormone therapy.

If the entire thyroid is removed, the body can't make thyroid hormone and may

develop signs and symptoms of underactive thyroid (hypothyroidism). As a result,

the patient need to take a pill every day that contains the thyroid hormone thyroxine

(levothyroxine). This hormone replacement is identical to the hormone normally

made by the thyroid gland and performs all of the same functions. The Doctor will

determine the amount of thyroid hormone replacement the patient need based on

blood tests.

The patient may experience some short-term, less serious side effects after

surgery. These can include:

Pain when swallowing, or in the neck areapain can come from the

Tracheal tube after surgery or from the surgery itself. This should subside

within a few days; an over-the-counter non-steroidal pain reliever, like

ibuprofen, can relieve discomfort.

Neck tension and tendernessthere will be a tendency to hold the head

stiffly in one position after surgery, and this can cause neck and muscle

tension. It's good to do gentle stretching and range of motion exercises to

prevent muscle stiffness in the neck area. Simply turning the head to the

right, then rolling the chin across the chest until the head is facing left can

help loosen tight muscles.

Voice problems the voice may be hoarse, whispery, or tired. Some

people find that periods of hoarseness can last as long as two to three

months.

Irritated windpipe if the patient had a Tracheal tube during general

anesthesia, it can irritate the windpipe and may make the patient feel as if

he have something stuck in his throat. This feeling usually goes away

within five days.

Thyroidectomy is generally a safe surgical procedure. However, some people

have major or minor complications. Possible complications include:


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Hemorrhage (bleeding) beneath the neck wound if this occurs, the wound

bulges and the neck swells, possibly compressing structures inside the neck and

interfering with breathing. This is an emergency.

Thyroid storm. If a thyroidectomy is done to treat a very overactive gland

(thyrotoxicosis), there may be a surge of thyroid hormones into the blood. This is a

very rare complication because medications are given before surgery to prevent this

problem.

Injury to the recurrent laryngeal nerve because this nerve supplies the

vocal cords, injury can lead to vocal cord paralysis and can produce a husky voice.

In rare cases, if both vocal cords are paralyzed, the opening of the throat may be

obstructed, causing breathing problems.

Injury to a portion of the superior laryngeal nerve If this occurs, patients

who sing may not be able to hit high notes, and the voice may lose some projection.

Hypoparathyroidism. If the parathyroid glands are mistakenly removed or

unintentionally damaged during a thyroidectomy, the patient may suffer from

hypoparathyroidism, a condition in which the levels of parathyroid hormone (a

hormone that helps regulate body calcium) are abnormally low.

Hypothyroidism: Transient hypothyroidism is seen in 2% to 4% of all

patients after thyroidectomy and in 20% to 22% of those who undergo total or

repeated thyroidectomy. Permanent hypothyroidism occurs in under 0.6% of

patients.

Wound infection.

1.6 Medical Management of Physiologic Outcomes

Usual Postoperative Course. Outpatient procedures are appropriate for

solitary benign nodules and have been performed for thyrotoxicosis and thyroid

cancer in some centers; otherwise, the hospital stay is 1 to 2 days.


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Special monitoring required. Respiratory status should be carefully

monitored if early postoperative stridor or difficulty in clearing secretions occurs.

Patients with thyrotoxicosis who receive appropriate preoperative preparation should

undergo routine monitoring.

Patient activity and positioning. The head should be elevated 30 to 45

degrees (Semi-Fowler) when client is conscious unless client is hypotensive to

minimize edema and venous oozing. Support head and neck with pillows. Full

activity is resumed the morning after operation.

Neck Exercises.First, teach the client how to support the weight of the head

and neck when sitting up in bed. Show the client how to place the hands at the back

of the head when flexing the neck or moving. The client will probably be able to

perform this maneuver by the first postoperative day. Second, as the wound heals

(about the 2nd to 4thpostoperative day); demonstrate range-of-motion exercises to

prevent contractures. With the surgeons permission, teach the client to flex the head

forward and laterally, to hyperextend the neck, and to turn the head from side to

side. Have the client perform these exercises several times every day.

Medications.Give meperidine (Demerol) or morphine sulfate every 1-2 hours

as needed for pain in throat area. Give continuous mist inhalation until chest is clear.

If a total thyroidectomy has been performed, explain self-administration of thyroid

replacement medications (T4) used to treat hypothyroidism: Levothyroxine sodium

(Synthroid, Levothroid, Levoxine). Teach client the medication regimen and the need

for lifelong replacement therapy.

Alimentation: Full liquids are permitted on the day of operation and a soft

diet can be started on afternoon of day 2.

Drains:Closed suction drains are removed on the first postoperative day.


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Postoperative Complications

In the Hospital

Hemorrhage:Although it is extremely rare (less than 0.5%), a hematoma in

the area of resection may cause airway obstruction early in the postoperative period.Removal of the skin and strap muscle sutures and evacuation of the hematoma in

the recovery room is preferable to tracheostomy. Patients are then returned to the

operating room for irrigation of the operative site, control of hemorrhage, and

repeated closure of the wound.

Hypothyroidism: Transient hypothyroidism is seen in 2% to 4% of all

patients after thyroidectomy and in 20% to 22% of those who undergo total or

repeated thyroidectomy. Permanent hypothyroidism occurs in under 0.6% of

patients. Symptomatic hypocalcemia (less than 7.5mg/dl) is characterized by

anxiety, perioral or finger tingling, and a positive Chvosteks sign, and usually

develops 16 to 24 hours after surgery. Intravenous calcium is given to relieve acute

symptoms in the hospital and oral calcium therapy is prescribed at the time of

discharge.

Recurrent laryngeal nerve injury: Paralysis of one vocal cord causes

hoarseness and difficulty in clearing secretions. This almost always is related to

traction on the recurrent nerve and may also resolve over a period of days to

months. Permanent recurrent nerve palsy occurs in as many as 4.5% of all

thyroidectomies, usually resulting from intended sacrifice of a nerve involved with

carcinoma.

Thyroid storm: Thyroid storm should not occur after surgery for

thyrotoxicosis in adequately prepared patients, but it may be seen in patients with

untreated thyrotoxicosis who are undergoing other operations. Symptoms of tremor,

agitation, tachycardia, and hyperthermia are treated with intravenous fluids,

propranolol, potassium iodide, and steroids.

After Discharge

Recurrent benign nodule or goiter:Recurrence of a benign nodule or goiter

can be prevented by the lifelong administration of thyroid hormone.


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Recurrent thyroid cancer:To decrease the incidence of recurrent cancer in

the neck, lungs, or bone, thyroid hormone replacement is delayed until radioactive

iodine is administered.

Late or recurrent hyperthyroidism: Annual thyroid function tests are

indicated in patients who are receiving thyroid hormone after operation for goiter or

cancer and in those who are originally euthyroid after operation for Graves disease.

Permanent hypothyroidism:Vitamin D is added to calcium replacement

to enhance absorption. In serial parathyroid hormone levels begin to raise, first the

vitamin D and then the calcium supplement should be tapered.


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Page | 44

1.7 Nursing Management of Physiologic, Physical, and Psychosocial Outcomes

Problem #1: Acute Pain

Assessment DiagnosisScientific

ExplanationPlanning Intervention Rationale

Expected

outcome/

Evaluation

S > Patient

may report

pain on the

operative site

O > Patient

may manifest:

- facial

grimaces

- restlessness

- irritability

- reduced

interaction with

people

Acute pain Patient

experiences

pain due to the

operative

procedure done.

As the

anesthetic agent

wear off,

sensation

returns and pain

of the incision,

and other

manipulations

done on the

body comes into

Short term:

After 5 hours of

nursing

interventions,

the patient will

be able to

demonstrate

use of

relaxation skills

and diversional

activities as

indicated for

individual

situation.

> Establish rapport

> Monitor vital

signs

> Perform a

comprehensive

assessment of pain

to include location,

characteristics,

onset/duration,

frequency, quality,

> To gain the trust

and cooperation of

the client

>To provide baseline

data.

> To assess etiology/

precipitating

contributory factors

Short term:

The patient

shall have

demonstrated

use of

relaxation skills

and diversional

activities as

indicated for

individual

situation.

Long term:

The patient

shall have


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Page | 45

- change in

respiration,

blood

pressure, and

pulse

awareness. The

injured tissue

releases pain

substances

such as

prostaglandins,

histamine and

kinin. These

substances

transmit pain

impulse to the

spinal cord.

From the spinal

cord, the pain

message is sent

to the brain

where it is

processed and

is perceived as

pain. The

message is

Long term:

After 4 days of

nursing

interventions,

the patient will

report feeling of

well-being and

comfort.

severity (1 to 10),

and precipitating or

aggravating factors

> Note location of

surgical

procedures

> Observe body

language for

evidence of pain

> Provide quiet

environment

> Encourage

adequate rest

periods

> This can influence

the amount of pain

experienced

> To ensure comfort

despite impaired

communication

> To assist client for

alleviation of pain

> To prevent fatigue

reported

feeling of well-

being and

comfort.


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Page | 46

transmitted back

to the site of

injury then

through the

spinal cord. In

the spinal cord

and in the brain,

many chemicals

such as

endorphins,

serotonin and

adrenaline are

involved in

modulation and

transmission of

pain.

> Encourage use of

relaxation

techniques such as

soft music, focused

breathing

> Take time to

listen and maintain

frequent contact

with patient

>Administer

analgesic

medications as

ordered.

> Monitor

effectiveness of

pain medications

> Promotes rest,

redirects attention

> Helpful in

alleviating anxiety

and refocusing

attention, which may

relieve pain

>To provide

pharmacologic

treatment of pain.,

> To promote timely

intervention/revision

of plan of care


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Page | 47

Problem # 2: Ineffective Airway Clearance Related to Bleeding and/ or Laryngeal Edema


ExplanationObjectives Interventions Rationale

Desired

Outcomes

S > the patient

may verbalize

dyspnea

O > the patient

may manifest:

- presence of

surgical

wound on the

low collar area

of neck

- adventitious

breath sounds

( wheezes,

crackles)

- changes in

respiratory

rate and

Ineffective

airway

clearance

related to

bleeding and/

or laryngeal

edema

If hemorrhage

(bleeding)

beneath the

neck wound

occurs, the

wound bulges

and the neck

swells, possibly

compressing

structures inside

the neck and

interfering with

breathing. This

is an

emergency.

Laryngeal

edema may also

occur due to

Short Term:

After 1 hour of

nursing

interventions,

the patient will

be able to

maintain

airway

patency.

Long Term:

After 3 days of

nursing

interventions,

the patient will

be able to

maintain vital

signs,

> Establish rapport

> Monitor vital signs,

level of

consciousness,

orientation

> Auscultate breath

sounds and assess

air movement

> Check dressing

site for profuse

bleeding (side of

neck and back of

head) every 15

> To gain the trust

and cooperation of

the client

> To provide

baseline data and

note deviations

from normal

>To ascertain

status and note

progress

> To identify signs

of bleeding

Short Term:

The patient will

be able to

maintain

airway

patency.

Long Term:

The patient will

be able to

maintain vital

signs,

respirations,

and breath

sounds within

normal limits.


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Page | 48

rhythm

- difficulty

vocalizing

- restlessness

- cyanosis

surgical

manipulation.

Bilateral

recurrent nerve

injury with acute

paralysis of both

vocal cords may

occur during

surgery which

may cause

obstruction of

the airway

because of the

adduction of the

true vocal cords.

respirations,

and breath

sounds within

normal limits.

minutes for 1 hour

immediately after

surgery

> Keep dressing size

minimized

> Position patient on

back with head of

bed elevated 30 to

45 degrees

> Monitor for signs of

respiratory distress

or obstructed airway

q 1 : stridor,

wheezing, coarse

airway crackles,

dyspnea, cyanosis,

labored respirations

> To prevent

impaired view of

incision site

> To promote ease

in breathing

> To identify early

signs of respiratory

distress caused by

tracheal edema


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Page | 49

> Teach and assist

patient to turn,

cough, and deep

breathe q2h and prn

> If indicated, keep

suction equipment at

bedside; gently

suction oropharynx

only when necessary

> Keep environment

> To prevent

pulmonary

complications and

to take advantage

of gravity

decreasing

pressure on the

diaphragm and

enhancing drainage

of / ventilation to

different lung

segments

> To clear airway

when secretions

are blocking airway

> To maintain


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Page | 50

allergen free

> Have

tracheostomy tray

and oxygen

immediately

available at bedside

> Encourage use of

warm versus cold

liquids as

appropriate

> Provide

opportunities for rest

> Encourage voice

rest, but do assess

speech and

swallowing

periodically

patent airway

> To use if patient

experiences severe

respiratory distress

> To mobilize

secretions

> To prevent

fatigue

> Hoarseness and

sore throat

secondary to

edema or damage

to laryngeal nerve


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Page | 51

> Evaluate changes

in sleep pattern

> Observe for signs/

symptoms of

infection

> Note physician if

dressing requires

reinforcement more

than one time

may last several

days. Increased

difficulty may

indicate impending

obstruction

> To assess

changes

> To identify

infectious process/

promote timely

intervention

> To promote

timely intervention /

revision in plan of

care


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Page | 52

Problem #3: Altered Tissue Perfusion r/t Excessive Blood Loss Secondary to Surgery


ExplanationPlanning Intervention Rationale

Expected

outcome/

Evaluation

S >

O > The patient

may manifest:

- Generalized

weakness

- Paleness and

pallor

- Altered BP

- Dizziness

- Vomiting

- Headache

- Body malaise

-Hypoventilation

- Cold skin

Altered

Tissue

Perfusion r/t

excessive

blood loss

secondary

to surgery

The decreased

in hemoglobin

concentration in

the blood of

client may lead

to tissue

perfusion

ineffective. The

level of the

hemoglobin of

the patient may

give the

outcome of

decrease in

oxygen

resulting in

failure to

Short term:

After 3 hours of

nursing

interventions,

the patient will

be able to

demonstrate

measures to

improve

circulation.

Long term:

After 3 days of

nursing

interventions,

the patient will

be able to

> Establish rapport.

> Monitor and

record vital signs

> Instruct patient to

have complete bed

rest.

> Stress out the

importance of

compliance to the

therapeutic

> To gain trust and to

have a good

relationship to the

patient and to the

SO.

> To have a baseline

data.

> To prevent further

complications.

> Compliance to and

of the patient to the

regimen will result in

effective treatment

Short term:

The patient

shall have

demonstrated

measures to

improve

circulation.

Long term:

The patient

shall able to

demonstrate

increased

perfusion as

individually

appropriate.


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Page | 53

nourish the

tissues at the

capillary level.

This may exist

without

decreased

cardiac output:

however, there

may be a

relationship

between

cardiac output

and tissue

perfusion.

demonstrate

increased

perfusion as

individually

appropriate

regimen to hasten

healing process.

> Encourage

relaxation

technique such as

deep breathing

exercise.

> Provide

environment

conducive for

resting.

> Encourage

expression and

verbalization of

feelings.

>Administer IV

fluids as ordered.

and faster healing

process.

> To prevent

aspiration.

> For patient

comfortability.

> To know what the

patient is trying to

voice out and what

the patient feelings.

> To maintain

electrolyte balance.


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Page | 54

>Evaluate nursing

interventions given.

> To identify what

needs to be

reinforced and

assess effectiveness

of interventions

given.


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Page | 55

Problem # 4: Impaired Verbal Communication Related to Damage and/or Manipulation of Laryngeal Nerves Secondary to

Surgery



Desired

Outcomes

S > the

patient may

verbalize

dyspnea

O > the

patient may

manifest:

- presence of

surgical

wound on the

low collar

area of neck

- impaired

articulation

- inability to

speak

Impaired

verbal

communication

related to

damage and/or

manipulation

of laryngeal

nerves

secondary to

surgery

Injury that

results from

severing,

clamping,

compressing, or

stretching either

the recurrent

laryngeal nerve

or superior

laryngeal nerve

during thyroid

surgery may

result in severe

untoward

sequelae for the

patient. The

recurrent

Short Term:

After 4 hours of

nursing

interventions,

the patient will

be able to use

alternative

communication

methods in

which needs

can be

expressed.

Long Term:

After 6 days of

nursing

interventions,

> Establish

rapport

> Monitor vital

signs

> Monitor voice

quality q2h

> Monitor for

edema at surgical

incision and

glottis

> To gain the trust

and cooperation of

the client

> To provide

baseline data and

note deviations

from normal

> To evaluate

damage to

laryngeal nerves

> To assess

contributing factors

Short Term:

The patient will

be able to use

alternative

communication

methods in

which needs

can be

expressed.

Long Term:

The patient will

be able to

communicate

verbally

without voice

change.


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Page | 56

- use of

nonverbal

cues/

gestures

- difficulty

speaking or

verbalizing

laryngeal nerve

lies adjacent to

the postero-

medial aspect of

the thyroid.

Unilateral

recurrent

laryngeal nerve

injury causes

the ipsilateral

vocal cord to

remain in the

median or

paramedian

position, thus

immediate

hoarseness

occurs. The

voice may never

recover its

timbre and

the patient will

be able to

communicate

verbally without

voice change.

> Note presence

of draining tubes

that blocks

speech

>If indicated

provide

alternative means

of communication

such as use of

pad and pencil or

slate board

>Keep call bell

within reach at all

times

> reduce

environmental

stimuli

> To assess

causative factors

>To minimize

patients need to

speak

>To minimize

patients need to

speak

> To lessen anxiety

which may worsen

problem


57/64

Page | 57

focus, even

though effective

phonation can

eventually be

achieved.

Bilateral

recurrent nerve

injury with acute

paralysis of both

vocal cords

adducts the true

vocal cords.

Permanent

debilitating

hoarseness may

follow.

Damage to the

superior

laryngeal nerve

affects voice

> validate

meaning of

nonverbal

communication

> report

increasing

hoarseness to

physician

> anticipate

patients needs as

indicated

> because they

may be wrong

> to promote timely

intervention /

revision in plan of

care

>to minimize

patients need to

speak


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Page | 58

pitch. Since the

cord is unable to

lengthen and

tense, the voice

is low in pitch

and breathy in

quality.


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Page | 59

Problem # 5: Impaired Skin and Tissue Integrity Secondary to Surgery



Desired

Outcomes

S >

O > the

patient may

manifest:

- presence of

surgical

wound on the

low collar

area of neck

- damaged

tissue

Impaired

skin and

tissue

integrity

secondary

to surgery

In

thyroidectomy,

an incision will

be made through

the skin in the

low collar area of

the neck. Next, a

vertical cut will

be made through

the strap-like

muscles located

just below the

skin, and these

muscles will be

spread aside to

reveal the

thyroid gland

and other

Short Term:

After 2 hours

of nursing

interventions,

the patient will

be able to

verbalize

understanding

of condition

and causative

factors.

Long Term:

After 3 days of

nursing

interventions,

the patient will

be able to

> Establish rapport

> Monitor vital signs

> Record size (depth,

width), color, location,

temperature, texture,

consistency of

wound/ lesion if

possible

>Inspect surrounding

skin for erythema,

induration,

maceration

> To gain the trust

and cooperation of

the client

> To provide

baseline data

> To provide

comparative baseline

> To assess extent

of involvement

Short Term:

The patient will

be able to

verbalize

understanding

of condition

and causative

factors.

Long Term:

The patient will

be able to

display

progressive

improvement

in wound

healing.


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Page | 60

deeper

structures. Then,

all or part of the

thyroid gland will

be cut free from

surrounding

tissues and

removed. After

the thyroid gland

is removed, one

or two stitches

will be used to

bring the neck

muscles

together again.

Then the deeper

layer of the

incision will be

closed with

stitches, and the

skin will be

display

progressive

improvement

in wound

healing.

> Note odors and

drains emitted from

the skin/ area of injury

> Assess adequacy

of blood supply and

innervation of the

affected tissue

> Inspect skin on a

daily basis, describing

lesions and changes

observed

> Keep the area

clean/dry, carefully

dress wounds,

> To assess early

progression of

wound healing or

development of

hemorrhage or

infection

> To identify

contribution factors

> To promote timely

intervention/revision

of plan of care

> To assist bodys

nat

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