hyperthyroidism
DESCRIPTION
caseTRANSCRIPT
I. INTRODUCTIONo Objectives
o Reason for choosing the study
II. Nursing History o History of Past Illnesso History of Present Illnesso Lifestyleo Family Health-Illness History
III.PHYSICAL EXAMINATION
o General Survey
o Vital Signs
o Physical Assessment
IV. DIAGNOSTICS AND LABORATORY PROCEDURES
V. THE PATIENT AND HIS ILLNESS
o Anatomy and Physiology
o Pathophysiology (Book-based)
o Synthesis of the Disease
VI. THE PATIENT AND HIS CARE
o Surgical Management
o Pharmacological Management
o Diet
o Activity and Exercise
VII. NURSING CARE PLANS
VIII. CONCLUSION
IX. RECOMMENDATION
X. BIBLIOGRAPHY
Thyroidectomy Page | 1
I. INTRODUCTION
Hyperthyroidism, often referred to as an overactive thyroid, is a condition in which the thyroid gland produces and secretes excessive amounts of the free (not protein bound, and circulating in the blood) thyroid hormones, triiodothyronine (T3) and/or thyroxine (T4). Thyroxine is a body chemical (hormone) made by the thyroid gland. It is carried around the body in the bloodstream. It helps to keep the body's functions (the metabolism) working at the correct pace. The thyroid gland is located in the neck. It controls important metabolic processes, such as growth and energy expenditure. An immune system abnormality called Graves' disease is the most common cause of hyperthyroidism. Other causes include local inflammation (thyroiditis), nodules or lumps.
The radioimmunoassay for T3 is now widely available and is a useful diagnostic tool for hyperthyroidism, especially in T3-thyrotoxicosis. It is an essential tool in the management of hyperthyroidism that persists after treatment with normal T4 serum levels or, in euthyroid cases, with low T4 serum levels. In these conditions, it reflects the metabolic state more accurately than serum levels of T4. A promising new test is the response of radioimmunoassayable TSH to protirelin (TRH) administration. An absent response indicates pituitary suppression and thyroid autonomy as seen in frank hyperthyroidism or euthyroid Graves disease, treated or untreated. It is safer and quicker than the conventional T3 suppression test of thyroid radioactive iodine uptake and may replace it at least partly in the future.(H Haibach, 1976)
Although existing treatments are effective, they are not directed at the root of the problem. Rather, they seek to knock the thyroid out of action, either by surgically removing it or destroying it with radioactive iodine. But most patients receiving these therapies may have to take replacement thyroid hormone for life. A third approach is the use of drugs to block the production of the excess hormone the abnormal gland produces. (Lawrence K. Altman, 1991)
Thyroidectomy Page | 2
Biochemical signs of hyperthyroidism, or even overt and possibly lethal clinical hyperthyroidism were reported in 2 severely iodine-deficient African countries (Zimbabwe and Democratic Republic of Congo, RDC) soon after the introduction of iodized salt. The 2 countries had access to iodized salt produced in Botswana, as well as 5 other countries in the region, namely Cameroon, Nigeria, Kenya, Tanzania, and Zambia. Therefore, a multicenter study was conducted in these 7 countries to evaluate whether the occurrence of iodine-induced hyperthyroidism (IIH) after the introduction of iodized salt was a general phenomenon or corresponded to specific local situations in the 2 affected countries. Two or 3 areas with a past history of severe iodine deficiency that had recently been supplemented with iodized salt were selected in each of the 7 countries. The prevalence of goiter was determined in 4423 schoolchildren in these areas and the concentration of urinary iodine in 2258. The study showed that iodine deficiency had been eliminated in all areas investigated, and that the prevalence of goiter had markedly decreased since the introduction of iodized salt.
30,000,000 people in the US and 200 million worldwide have a Thyroid Disorder. Of the 30 million people above about half are undiagnosed. 37,000 new cases of Graves' disease are diagnosed each year in the US. 80% of all cases of Graves' disease are diagnosed in females. 20% of Thyroid Storm cases end in death. 80% of all Thyroid Disease cases are diagnosed as Hypothyroidism and 20% Hyperthyroidism. 20% of people with Diabetes will experience an onset of a thyroid disorder. 50% of children with parents having a thyroid disorder may develop a thyroid disorder themselves by age 40.
Moreover, the Philippine Thyroid Disorder Prevalence Survey (PhilTiDeS) made the first national survey in the Philippines on the prevalence of thyroid disorders based on thyroid function tests on the non-pregnant population in 2001. The test revealed that more Filipino adults are affected with subclinical (no symptoms) forms of thyroid disorders than which have obvious symptoms. Among the 5,000 people recruited in the study, 4,897 qualified for the structured interview and physical assessment of the thyroid. After which, the respondents' blood samples were taken and tested for thyroid disorders. Upon analysis of data, it was found out that subclinical thyroid disorders are the more common case of the condition found in the Philippines' adult population.
Untreated hyperthyroidism can shorten your life, but it, in itself, is not going to kill you. The resulting conditions and diseases such as severe
Thyroidectomy Page | 3
thyroid storm or thyrotoxicosis could if not treated right away. Untreated hyperthyroidism will ruin your appearance, to be sure. They develop very unattractive bulging eyes (exophthalmos) or loose weight to an unhealthy and unattractive state. The thyroid hormones need to be balanced. If hyper or hypo types of thyroid disease develops, it only takes a quick blood test once or twice a year (for a lifetime basis, since it's not curable, only treatable) to test its level, and then one little pill every morning to solve the problem. Diet and exercise will keep it from getting worse. It is important to maintain regular, lifelong visits if a client have hyperthyroidism. Untreated or improperly treated, an overactive thyroid can lead to severe, even life-threatening problems. Complications include irregular heart rhythm (atrial fibrillation), congestive heart failure, miscarriage, osteoporosis and bone fractures (hyperthyroidism causes your bones to lose calcium faster than usual).
Reason for Choosing the Study
We have chosen this study for the intention of obtaining greater understanding about the disease and acquiring knowledge for the improvement of our skills and management if such condition will be encountered. The topics that will be discussed in this study are the development, diagnosis, and treatment of the condition hyperthyroidism. The researchers have made a comprehensive report to be able to determine the truthful information into what causes this condition and how it can lead to thyroidectomy (surgical removal of the thyroid gland). The study will help students that are in the medical field in knowing the proper management of patients under the condition and have an adequate overview of the general information about hyperthyroidism and thyroidectomy.
O bjectives
Define the anatomy and physiology of the Thyroid gland,
particularly those that are linked with the disease.
Define hyperthyroidism and thyroidectomy.
Identify the underlying causes of hyperthyroidism.
Enumerate the signs and symptoms of hyperthyroidism.
Explain the pathophysiologic nature and complications of
Hyperthyroidism.
Thyroidectomy Page | 4
Determine the prognosis of the disease with the following criteria:
duration of illness, onset, precipitating factors, environmental
factors, and lifestyle.
Interpret the findings from the Nursing Health Assessment and
laboratory examinations with their clinical significance.
Psychomotor:
Relate nursing concepts learned to manage preoperative,
intraoperative and postoperative care in thyroidectomy.
Develop nursing care plan related to the potential and existing
problems effective for the improvement of the management of
disease.
Select the appropriate, immediate nursing management for
hyperthyroidism and thyroidectomy.
Affective:
Express genuine concern for patients with hyperthyroidism.
Pay attention on the importance of developing a practice of
performing accurate and complete assessment findings.
Assert the role in the nursing profession of finding out appropriate
ways to promote a patient’s relief and recovery.
Integrate the knowledge acquired to co-student nurses, increase
awareness and help them for future encounters with a client having
the same condition.
II. Nursing History
A. Demographic Data
B. Socio-economic, Cultural and Environmental Factors
Thyroidectomy Page | 5
C. History of Past Illness
D. History of Present Illness
E. Lifestyle
E. Family Health-Illness Hi
II. PHYSICAL EXAMINATION
A.General Survey
A client diagnosed with hyperthyroidism often appears extremely
agitated and irritable especially when exposed to hot climate. Despite
a ravenous appetite, weight loss can be observed as a result of the
hypermetabolic state. One of the hallmarks when a assessing a patient
Thyroidectomy Page | 6
with hyperthyroidism is the presence of enlarged neck and protruding
eyes (exophthalmos). They markedly show hyperkinetic movements
and tremors are apparent even at rest.
B.Vital Signs
B lood P ressure :
o Increased systolic BP
o Widened pulse pressure
T emperature
o Low-grade fever
R espiratory R ate
o Increased RR
o Shortness of breath
P ulse R ate
o Rapid, bounding pulse (>100 bpm)
C.IPPA- Cephalocaudal Assessment
Skin
o Smooth, warm, moist skin
o Diaphoresis (excessive sweating)
Thyroidectomy Page | 7
Nails
o Brittle nails (that may separate from the nail beds)
o Clubbing of fingers
Hair
o Thinning of scalp hair (patches)
o Shiny hair
Eyes
o Protruding eyes (exophthalmos)
o Red, swollen eyes
o Elevated, retracted upper eye lids
o Dry and irritated cornea (due to inability to completely close the
enlarged eyes)
o Blurred or double vision
o Corneal ulcers or infections
o Increased tears
o Photophobia
Neck
o Enlarged thyroid gland (protrusion in the neck)
o Nodular thyroid gland
o Bruits heard on auscultation (due to the increased blood flow to the
thyroid gland)
Thyroidectomy Page | 8
Chest and Lungs
o Shortness of breath with or without exertion
o Rapid, shallow respirations
o Decreased vital capacity
Breast
o Enlarged breasts in men
Abdomen
o Enlarged spleen and/or liver
o Increased bowel sounds
Extremities
o Muscle weakness
o Palmar erythema
o Tremors
o unable to perform a full range of motion due to reported weakness
Extremities
o Osteoporosis
Thyroidectomy Page | 9
Thyroidectomy Page | 10
III. DIAGNOSTICS AND LABORATORY PROCEDURES
Diagnostic/
Laboratory
Procedure
Indications or Purpose Results Normal Values Analysis and Interpretation
1. Complete Blood Count
A. Hemoglobin
(hgb)
Hgb test measures the amount of
hemoglobin in the blood. Normal 12.5 - 15 g/dl Hemoglobin is normal.
B. Hematocrit (hct) A Hct test indicates whether you
have too few or too many red
blood cells.
Normal 36.0 - 46.0%
Indication of anemia due to
hematuria and decreased
erythropoietin production due to
the damage in the kidneys.
C. White Blood
Cells (WBC)
The WBC count determines the
total number of white cells
(leukocytes) in the blood sample.
Normal 4,500 – 12,000 / mm³ WBC is within normal value.
D. Red Blood Cells
(RBC)
RBC count signifies the number of
red blood cells in a volume of
blood.
Normal 4.0 – 6.0 million /
mm³ RBC is normal.
Thyroidectomy Page | 11
Diagnostic/
Laboratory
Procedure
Indications or Purpose Results Normal Values Analysis and Interpretation
Nursing Responsibilities:Before:
1. Explain the test procedure and purpose.2. Explain that slight discomfort may be felt when the skin is punctured.3. Obtain a history of the patient's complaint which includes a list of known allergens.4. Obtain a list of the patient's current medications, including herbs, nutritional supplements, and nutraceuticals.5. Note any recent procedures that can affect with test results.6. Encourage to avoid stress if possible because altered physiologic status influences and changes normal hematologic values.7. Be sensitive to social and cultural issues, as well as concern for modesty, is important in providing psychological support
before, during, and after the procedure.During:
1. Instruct the patient to follow and cooperate with the given directions.2. Instruct the patient to breathe normally and to avoid unnecessary movement.3. Observe standard precautions, and follow the general guidelines.4. Identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection.5. Perform a venipuncture and collect the specimen.6. Apply manual pressure and dressings over puncture site to stop bleeding7. Transport the specimen to the laboratory for processing and analysis.
After:1. Monitor the puncture site for oozing or hematoma formation.2. Evaluate test results in relation to the patient's symptoms and other tests performed.
Thyroidectomy Page | 12
Diagnostic/
Laboratory
Procedure
Indications or Purpose Results Normal Values Analysis and Interpretation
2. Blood Chemistry
A. Calcium To evaluate bone diseases
and the function of the
parathyroid glands.
Increased 8.5 – 10.5 mg/dl Hypercalcemia (chronically elevated blood
calcium) is most commonly caused by
hyperparathyroidism due to a benign parathyroid
tumor.
B. Fasting Blood
Glucose
To measure the amount of
a sugar called glucose in a
sample of your blood
Increased 70 – 100 mg/dL The excessive thyroid hormone causes increased
glucose production in the liver, rapid absorption
of glucose through the intestines, and
increased insulin resistance.
C. Total
Cholesterol Test
Measures all the
cholesterol in the blood.
Decreased 120 – 200
mg/dL
Cholesterol level is decrease in hyperthyroidism
due to increased bile excretion of cholesterol.
Nursing Responsibilities:Before: 1. Explain the test procedure and purpose. 2. Note any recent procedures and medications that can affect with test resultsDuring: 1. Instruct the patient to follow and cooperate with the given directions. 2. Note that the client may feel moderate pain when the needle is inserted to draw blood.After: 1. Apply pressure (with cotton or gauze) to the puncture site. 2. Monitor for hematoma formation. 3. Advise to resume normal activities and any medications that were withheld before the test.
Thyroidectomy Page | 13
Thyroidectomy Page | 14
Diagnostic/
Laboratory Procedure
Indications or
Purpose
Results Normal
Values
Analysis and Interpretation
3. Thyroid Function Tests
A. Thyroid-stimulating hormone (TSH)
assay
TSH blood test is used
to check for thyroid
gland problems.
Decreased 0.4-4.2 mU/L TSH is below normal that may
indicate hyperthyroidism
(overactive) and is producing
too much thyroid hormone.
Nursing Responsibilities:Before:
1. Explain the test procedure and purpose.2. Note those medications taken that may affect results.3. The client should be relaxed and recumbent for 30 minutes before the test.
During:1. Wrap an elastic band around your upper arm to stop the flow of blood.2. Put the needle into the vein and attach a tube to the needle to fill it with blood.3. Remove the band from your arm when enough blood is collected.4. Put a cotton ball over the needle site as the needle is removed and apply pressure on the site.
After:1. Monitor the puncture site for hematoma formation.
B. Radioactive Iodine Uptake Use to determine the
metabolic activity of
the thyroid gland and
may determine
whether the gland is
functioning normally.
Increased24 hours:
15 - 25%
RAIU test
is higher than normal
amounts of iodine in
the thyroid gland due
to hyperthyroidism.
Nursing Responsibilities:Before:
1. Explain the test procedure and purpose.2. Note that it is contraindicated in pregnant women and breastfeeding mothers.3. Instruct the patient not to eat for 2 hours before the test.4. Instruct not to take any antithyroid medicine for 5 to 7 days before the test.5. Inform to sign a consent form saying that the patient understand the risks of the test and agree to have it done.
During:1. Instruct to swallow a liquid or capsule containing radioactive iodine.2. Instruct the patient not to eat for 2 hours before the test.3. After six to 24 hours, the patient will return for a measurement of the radioactivity (uptake) and a picture of your thyroid using a device called a gamma probe.
Diagnostic/
Laboratory
Procedure
Indications or
Purpose
Results Normal Values Analysis and
Interpretation
Diagnostic Imaging
Studies
A. Thyroid Scan Injection of radioactive
isotopes used to
identify thyroid gland;
to evaluate the size,
position and
functioning of the
thyroid gland.
The scan show an
enlarged thyroid
gland and thyroid
appears lighter.
Hot nodules:
benign
The thyroid appears
the correct size,
shape, and in the
proper location. It
appears an even gray
color on the
computer image.
The thyroid gland is
enlarged as one of the
s/sx of
hyperthyroidism and
appears lighter due to
thyroid problem
Nursing Responsibilities:Before: 1. Explain the test procedure and purpose. 2. Explain the risks and side effects of the test. 3. Inform patient to sign the consent form. 4. Advise not to eat after midnight the night before the exam. 5. Note that radioactive substance needs time to be absorbed before the scan, wait for 4 to 6 hours if the substance is taken by mouth. 6. Instruct to remove dentures and all jewelry or other metals, because they may interfere with the image. During: 1. Instruct the patient to follow and cooperate with the given directions. 2. Administer a pill that contains radioactive iodine, and wait as the iodine collects in the thyroid. 3. Instruct to lie on his/her back on a movable table with the neck and chest under the scanner. 4. Advise to lie still to let the scanner get a clear image.After: 1. Explain the test result. 2. Advise to drink extra fluids and empty the bladder often to flush out the residual radionuclide.
Thyroidectomy Page | 15
B. Ultrasonography Provides the best
information about the
shape and structure of
nodules and may be
used to distinguish
cysts from solid
nodules, to determine if
multiple nodules are
present.
Degree of
inhomogeneity is
present with typical
features of
thyrotoxicosis.
Thyroid is of
normal size, shape,
and position.
Normal thyroid
appears
homogenous, with a
characteristic
echogenicity.
The result of the
ultrasound reveal
markedly increased
vascularity throughout
the thyroid gland.
Some degree of
inhomogeneity is also
present with typical
features of
thyrotoxicosis.
Nursing Responsibilities:Before: 1. Explain the test procedure and purpose.
2. Instruct to remove necklaces and other accessories that can block the throat.
During:
1. Instruct the patient to follow and cooperate with the given directions.
2. Instruct to remove the shirt and lie on his/her back.
3. Place a pillow or a pad under the back of the neck for this will tilt the head back and expose the throat.
4. Rub the gel onto the throat for this helps the ultrasound probe, or transducer, glide over the skin.
5. Run the transducer back and forth over the area where the thyroid is located (Images will be visible on a screen and used to have a clear
picture of the thyroid to evaluate).
After:
1. Examine the images.
Thyroidectomy Page | 16
2. Advise to resume normal activities as soon as it is over.
C. Magnetic Resonance Imaging
(MRI)
Used to visualize gland
size, location, identify
abnormalities.
Enlarged thyroid
gland
Thyroid is of normal
size, shape, and
position.
The thyroid gland is
enlarged because it
produces too much
hormone
(hyperthyroidism).
Nursing Responsibilities:Before: 1. Explain the test procedure and purpose. 2. Note any allergy history. 3. Inform to remove any metal objects, including jewelry, eyeglasses, dentures and hairpins that may affect the MRI images. 4. Advise to wear comfortable, loose-fitting clothing to the exam. 5. Patient may be asked not to eat or drink anything for 4 - 6 hours before the scan.
During: 1. Patient will be asked to remain perfectly still during the time the imaging takes place, but between sequences some minor movement may be allowed. 2.When MRI procedure begins, patient may breathe normally, however, for certain examinations it may be necessary for you to hold your breath for a short period of time.After: 1. Examine the images. 2. Advise to resume normal activities as soon as it is over.
Thyroidectomy Page | 17
Thyroidectomy Page | 18
Thyroidectomy Page | 19
IV. THE PATIENT AND HIS ILLNESS
A. Anatomy and Physiology
The Thyroid
Gland
The thyroid gland lies in the neck, in front of the upper part of the trachea. The thyroid gland is located adjacent to the cranial trachea. Close to the recurrent laryngeal nerve, carotid sheath and sternohyoid and sternothyroid muscles. The Parathyroid Glands are located dorsally to, or within the thyroid gland itself. It is supplied by the cranial thyroid artery which is a branch of the common carotid artery. A subsidiary supply is provided by the caudal thyroid artery. The cranial and caudal thyroid arteries are united by substantial anastamoses along their caudal edge. Venous drainage is provided by the internal jugular vein and lymph drains into the cranial deep cervical nodes.
Two types of hormones are produced, which are the iodine containing hormones; tri-iodothyronine(T3) and thyroxine (T4). Thyroid hormones regulate the basal metabolic rate and are important in the regulation of growth of tissues, particularly nervous tissue. Release stimulated by TSH from the pituitary.
.
Ultrastructure and Histology
The gland consists of varying sized follicles, which are bounded by a single layer of cuboidal epithelial cells (follicular cells} and a basement membrane, surrounding a central lumen filled with a homogenous protein rich colloid (thyrogloblin). The apical surface of the cell membranes is covered with numerous micovilli to increase surface area. The follicular cells are connected by tight junctions, and have a dense capillary network. The colloid is a store of thyroid hormones prior to secretion. The
Thyroidectomy Page | 20
thyroid gland is the only endocrine gland to store its hormone in large quantities. In the active gland colloid is diminished and epithelial cells are tall and columnar.
Within the connective tissue close to the follicles are C-cells alternatively known as parafollicular cells. They are found in clusters in the interfollicular space and are also known as clear cells as their cytoplasm doesn't stain with H and E. They secrete calcitonin, a hormone which acts to lower plasma Ca2+ levels.
Thyroid Hormone Physiology
Follicular cells synthesize thyroglobulin in their golgi apparatus. This is a glycoprotein consisting of 70 linked tyrosine molecules, 10% of which are iodinated, and is stored in the colloid.
The thyroglobulin is then split to form the two amino acid derivative hormones produced in the thyroid gland which are triiodothyronine (T3) and thyroxine (T4). Thyroxine contains 4 iodine atoms, triiodothyronine contains 3. Creation of these two hormones is the only role of iodine in the body.
The majority (90%) of hormone produced by the follicular cells is T4. T4 can only be made in the thyroid gland. It can then be converted by other tissues into T3.
Iodine Uptake
Iodine circulates within the blood as iodide (I-). It is actively transported into the follicular cells by an Na+/I- symport in the basal membrane. This pump concentrates iodine in the colloid at a level up to 250x greater than the plasma level. This process is known as iodide trapping. The pump is activated by thyroid stimulating hormone (TSH) a hormone from the pituitary gland.
Any excess iodide is excreted via the kidneys.
Secretion of Thyroid Hormones
Colloid uptake into the follicular cells takes place by endocytosis. The intracellular vesicles containing the colloid then fuse with lysosomes, where enzymes split the thyroglobulin into T3 and T4. The hormones
Thyroidectomy Page | 21
diffuse across the basal plasma membrane into the interstitium (they are lipid soluble hormones).
Transport
Thyroid hormones are lipid soluble, thus need a transporting protein in order to travel in the blood. Half-life in the blood is 1 day for T3, 6 days for T4. 99% of thyroid hormones in circulation are bound. The primary transport protein for thyroid hormones is thyroid binding globulin (TBG). Synthesized in the liver, this protein binds 70-80% of the circulating thyroid hormones. The remainder are carried by thyroxine-binding prealbumin or albumin.
Degradation
Only free T3 and free T4 can enter cells to exert their actions. T4 is deiodinated to T3 in many cells of the body, particularly the liver and kidneys.
The thyroid secretes 90% T4, with 50% of this being deiodinated to T3. The remainder is converted to reverse T3 (rT3). This is an inactive form of T3, and so creation of it is a regulatory mechanism. More rT3 is created when the body needs to reduce the action of T3 and T4.
The hormones are further deiodinated to diiodothyronine and monoiodothyronine in the liver and kidneys. Iodine is recycled or excreted in the urine.
Thyroidectomy Page | 22
Regulation
The hypothalamus releases thyrotropin releasing hormone (TRH) which stimulates
the adenohypophysis (anterior pituitary gland) to release thyroid stimulating hormone (TSH). This water soluble hormone travels in the
blood to activate the thyroid gland by 5 actions:
1. Increased endocytosis and proteolysis of thyroglobulin from colloid2. Increased activity of the Na+/I- symport3. Increased iodination of tyrosine4. Increased size and secretory activity of thyroid follicular cells5. Increased number of follicular cells
Thyroid Hormone Actions
T3 and T4 have effects on all body systems and at all stages of life. These include: Development where thyroid hormones are vital during
Thyroidectomy Page | 23
the fetal period and the first few months after birth. T3 and T4 are the hormones for metamorphosis in frogs.
o Thyroid hormones also promote growth as they enhance amino acid uptake by tissues and enzymatic systems involved in protein synthesis thus promoting bone growth.
o They also help with metabolic actions such as carbohydrate metabolism, as thyroid hormones stimulate glucose uptake, glycogenolysis, gluconeogenesis.
o In fat metabolism they mobilise lipids from adipose stores and accelerate oxidation of lipids to produce energy (occurs within mitochondria), as well as increasing the size and number of mitochondria.
o Thyroid hormones also increase basal metabolic rate (BMR) in all tissues except brain, spleen and gonads. The results in increased heat production, increased oxygen consumption. This increased metabolic rate also results in increased utilisation of energy substrates causing weight loss.
o Some of thyroid hormones cardiovascular actions are to increase cardiac output, heart rate and contractility. They affect the respiratory system indirectly through increased BMR causing increased demand for oxygen and increased excretion of carbon dioxide.
o In the nervous system thyroid hormones are required for myelination of neurons during the development. They also enhance the sympathetic nervous system (by increasing epinephrine receptors).
o Reproductive system is affected by reduced levels of thyroid hormone causing irregular cycling and decreased libido.
o Finally, in the alimentary system, thyroid hormone increases appetite and feed intake, increases secretion of pancreatic enzymes and increases motility.
Thyroidectomy Page | 24
A. Pathophysiology (book-based)
i. Schematic Diagram
Thyroidectomy Page | 25
Hypothalamus secretes TRH
Modifiable Factors:*Diet – high iodine intake
*Drugs*Infection
Non-modifiable Factors:*Age
*Gender (Women)*Genetic Susceptibility
Signals Pituitary gland to release TSH
THYROID GLAND
Excess thyroid hormone (T3, T4)
Increased iodide uptake
Increased rate of thyroid gland metabolism
Hypervascularity
Increased basal metabolic rate
TRH, TSHSupression
Increased iodide oxidation by enzyme
peroxidase
Iodine incorporated tyrosine residue
Binds to throxine-binding globulin
Goiter
Opthalmopathy
Infiltrative changes
Enlargement of ocular muscles
Upper lid lag
Increased globe gaze, exopthalmos
A
0.5 cm0. 5 cm
Thyroidectomy Page | 26
Increased basal metabolic rate
Overstimulation of CNS
Emotional lability
Fatigue, restlessness
Insomnia
Decreased attention span
Reproductive
Increase in sex hormone-binding globulin
Increased estrone and
estradiol serum level
Oligomenorrhea, amenorrhea
Decreased libido
Cardiac
Increased beta-adrenergic receptors
Increased Heart rate & Contractility
Peripheral vasodilation due to
heat load
Increased volume & cardiac output
Increase BP, Palpitations and
tachycardia
Endocrine
Disruption of PTH Mechanism
Decreased PTH secretion
Hypercalcemia
Increased insulin degregation
Decreased sensitivity to
exogenous insulin
Gastrointestinal
Rate of glucose, fat, and protein use increases
Lipid are mobilized from adipose tissues
Increased catabolism of cholesterol by
the liver
Decreased blood
Heat Intolerance, diaphoresis,
Weight loss despite of ravenous appetite
Increase in motility and
gastrointestinal
Diarrhea and malabsorption
Increased born resorption
Hypermetabolic State
(Increased BMR)
Increased sensitivity of
neural synapses in
Hyperactive reflexes
A
ii. Synthesis of the Disease
2. Definition of the Disease
Hyperthyroidism is a condition in which an overactive thyroid gland
is producing an excessive amount of thyroid hormones that circulate in
the blood. ("Hyper" means "over" in Greek). Thyrotoxicosis is a toxic
condition that is caused by an excess of thyroid hormones from any cause.
Thyrotoxicosis can be caused by an excessive intake of thyroid hormone
or by overproduction of thyroid hormones by the thyroid gland. The most
common cause of hyperthyroidism is Grave’s disease which accounts to
75% of patients. Some people develop thyrotoxicosis due to inflammation
of the thyroid gland (thyroiditis), which can lead to excessive release of
thyroid hormone already stored in the gland (without the accelerated
hormone production that characterizes hyperthyroidism). Thyrotoxicosis
can also occur after ingestion of excessive amounts of exogenous thyroid
hormone in the form of thyroid hormone supplements, such
as levothyroxine.
3. Predisposing and Precipitating factors with rationale
Predisposing Factors
o Age - Hyperthyroidism can happen at any age, but it is more common in people aged 60 and older. Graves disease is more likely to occur between ages 40-60 years old.
o Gender - more women develop hyperthyroidism than men, with a ratio of approximately 4:1, an effect that is often said to be mediated in some way by more estrogen or less testosterone. There is a large body of evidence that moderate amounts of estrogen enhance immunologic reactivity. However, it is just as likely that the X-chromosome is the
Thyroidectomy Page | 27
source of the enhanced susceptibility rather than sex steroids since the susceptibility continues after the menopause.
o Genetic susceptibility- The diseases cluster in families. The concordance rate in monozygotic twins is 20 to 40 percent.
o Other Factors- If you had a diet that was deficient in iodine, then start taking iodine supplements, this can increase your risk of hyperthyroidism.
Precipitating Factors
o Drugs- Iodine and iodine-containing drugs such as amiodarone may
precipitate hyperthyroidism in a susceptible individual. Iodine is most
likely to precipitate thyrotoxicosis in an iodine deficient population
simply by allowing the TSHR-Abs to be effective in stimulating more
thyroid hormone to be formed. Whether there is any other
precipitating event is unclear. Iodine and amiodarone may also
damage thyroid cells directly and release thyroid antigens to the
immune system. Interferon alpha treatment of patients with hepatitis C
infection has been widely associated with the development of
autoimmune thyroiditis but Graves' disease may also be precipitated
presumably by influencing the immune repertoire. Alemtuzumab, a
monoclonal antibody against the T-cell antigen CD52 used for
treatment of multiple sclerosis, has been associated with a 10 to 15
percent incidence of new onset Graves’ disease
o Diet - Excess iodine ingestion- causes hyperthyroidism with a low
thyroid radioactive iodine uptake. The etiology may be that the excess
iodine provides substrate for functionally autonomous areas of the
thyroid to produce hormone. Hyperthyroidism usually persists as long
as excess iodine remains in the circulation.
Thyroidectomy Page | 28
o Smoking- Smoking greatly increased the risk for Graves'
ophthalmopathy. The effect of smoking was more pronounced in
Graves' patients (particulary in the patients with Graves
Opthalmopathy) than in other thyroid patients. Smoking among
patients with thyroid disease is associated with developing of anxiety
and fright, depression and problems with social relations sphere.
o Inflammatory Processes Nonautoimmune autosomal dominant hyperthyroidism-
manifests during infancy. It results from mutations in the TSH receptor gene that produce continuous thyroid stimulation.
Grave's disease- also known as toxic diffuse goiter enlargement of the thyroid gland and is the most common form of hyperthyroidism in about 75 percent of all cases affecting the entire thyroid gland. Grave's disease is considered an autoimmune disorder.
Plummer's disease- sometimes results from TSH receptor gene mutations causing continuous thyroid activation. Patients with toxic nodular goiter have none of the autoimmune manifestations or circulating antibodies observed in patients with Graves' disease. Also, in contrast to Graves' disease, toxic solitary and multinodular goiters usually do not remit.
Inflammatory thyroid disease (thyroiditis)- includes subacute granulomatous thyroiditis, Hashimoto's thyroiditis, and silent lymphocytic thyroiditis, a variant of Hashimoto's thyroiditis. Hyperthyroidism results from destructive changes in the gland and release of stored hormone, not from increased synthesis.
Signs and Symptoms
Exophthalmos The bulging develops because the tissues in the eyeballs swell, and
the number of cells in the eye increases - resulting in larger eyes which push forward from their orbits, usually cause by something wrong with the thyroid gland.
Thyroidectomy Page | 29
Sudden Weight loss It is important to maintain proper levels of thyroid hormone so that
the body can perform its natural functions. Hyperthyroid conditions can cause the metabolism to be higher, thus resulting in weight loss.
Heat Intolerance Metabolism and heart rate are increased. By burning up more "fuel"
and faster the body transforms the excess energy into heat.
Nervousness, Anxiety and Irritability The thyroid hormone essentially activates the entire body. Due to
the regional metabolic changes it speeds up your body's metabolism in a way that causes your entire sympathetic nervous system to be more active including mood swings and irritability
Tremors It is usually a fine shaking, tremor of the outstretched fingers. It is
caused by a heightened beta-adrenergic state, it also increases metabolism of dopamine which in effect creates hyperactive reflexes.
Increased Appetite Thyroid hormones stimulate the uptake of glucose, the level of
blood glucose increases rapidly after a meal but then falls rapidly again. Because of increased absorption of these nutrients, the hypothalamus is signaled to compensate by activating the hunger center again.
Hyperactivity Client’s emotions are adversely affected by the turbulent activity
within the body. Excessive hyperactivity in turn leads to extreme fatigue and depression, again followed by episodes of over activity.
Decreased in cholesterol level As an effect of increased in thyroid stimulating hormone, the body
uses more of its lipid deposition to use for energy. This too much uptake causes the liver to release more cholesterol therefore leads cholesterol depletion.
Thyroidectomy Page | 30
Hyperglycemia Although thyroxine is not a counterregulatory hormone,
hyperthyroidism can interfere with glucose metabolism. It is
associated with both increased sensitivity of pancreatic beta cells to
glucose, resulting in increased insulin secretion, and antagonism to
the peripheral action of insulin. The latter effect usually
predominates, leading to impaired glucose tolerance in untreated
patients
Thyroidectomy Page | 31
V. THE PATIENT AND HIS CARE
A. Surgical Management
ThyroidectomyThyroidectomy is the removal of all or part of your thyroid gland. Your thyroid is a butterfly-shaped gland located at the base of your neck. It produces hormones that regulate every aspect of your metabolism, from your heart rate to how quickly you burn calories. The surgical removal of part or all of the thyroid gland, thyroidectomy allows treatment of hyperthyroidism, respiratory obstruction from goiter, and thyroid cancer. Subtotal thyroidectomy, used to correct hyperthyroidism when drug therapy fails or radiation therapy is contraindicated, reduces secretion of thyroid hormone. It also effectively treats diffuse goiter. After surgery, the remaining thyroid tissue usually supplies enough thyroid hormone for normal function. Total thyroidectomy may be performed for certain types of thyroid cancers, such as papillary, follicular, medullary, or anaplastic neoplasms. After this surgery, the patient requires lifelong thyroid hormone replacement therapy.
Total Thyroidectomy or the Complete Removal of the Thyroid This is the most common type of Thyroid Surgery and most often used for thyroid cancer. In particular, it is advised for aggressive cancers, such as medullary or anaplastic thyroid cancer. It is also used for goiter and Graves' hyperthyroidism treatment. Post a complete removal of the thyroid gland, the patient has to be on constant medication and daily treatment is needed to keep the body's thyroid needs fulfilled.
Partial Thyroidectomy or Removal of Half of the Thyroid Gland Also known as Subtotal Thyroidectomy, this operation is generally advised for removal of small and non-aggressive cancer and is contained to one side of the gland. After a partial thyroidectomy, the patient's thyroid gland is able to function naturally and normally.
Thyroidectomy Page | 32
Thyroid Lobectomy or Removal of Only About a Quarter of the Gland A less used approach, this type of Thyroidectomy is advised for very small and non-aggressive cancers as well as in the case of not very severe hyperthyroidism or hypothyroidism. The gland resumes normal functioning
post surgery.
Indications for Surgery
a. Diagnosis of malignant tumor of the thyroid by FNA or prior biopsy
b. Vocal cord paralysis with an associated thyroid mass
c. Palpable fixation of a thyroid mass to surrounding tissues
d. Diagnosis of "follicular neoplasm" of the thyroid by FNA
e. Single solid nodule greater than 3.0 cm
f. Persistent reaccumulation of an apparent cystic mass despite
aspirations or persistent aspiration of blood from an apparently cystic
mass
g. Symptoms of airway or esophageal compression with associated thyroid
mass or goiter
h. Patient desires to have a goiter removed for aesthetic reasons
i. Patient desires to have a nodule removed regardless of presumed
pathology
j. As an adjunct to cervical esophageal surgery for improved access
k. While not an absolute indication for thyroid surgery, a nodule present
with a prior history of radiation to the neck strongly suggests an
aggressive course of treatment
l. Rapid growth of a solid thyroid mass
Thyroidectomy Page | 33
m. Patient desires surgery rather than medical therapy or radioiodine
treatment of Grave's disease
n. A relative indication for thyroidectomy is the finding of metastatic
thyroid disease in neck nodes without an obvious thyroid mass. The
decision to perform thyroid surgery in this setting depends on the
clinical situation under which the metastatic disease was found. If the
metastatic disease was encountered in a palpable node in the absence
of other head and neck cancer, thyroid surgery is indicated. When well-
differentiated thyroid cancer is seen pathologically in a neck dissection
specimen that also contains metastatic squamous cell cancer and there
is no evidence of a thyroid mass, thyroidectomy is unlikely to alter the
clinical course of the patient if radiation therapy is administered to the
neck postoperatively. Thyroidectomy may be considered at a later date
with sequential follow-up offered as an alternative employing
ultrasound imaging.
Positioning/Skin Preparation/Anesthesia
Thyroidectomy Page | 34
PositionThe patient is placed in a supine position with the neck extended with cloth roll or sand bag placed under the shoulders.
Anesthesia UsedThyroid surgery is more commonly performed with general anesthesia. Some surgeons are now using local anesthesia, plus a sedative, however, to perform thyroid surgery. The benefits of local anesthesia are that it is associated with a shorter hospital stay, shorter actual surgery time, and less vomiting and nausea after surgery. You will, however, be awake during the surgery, and able to interact with your surgeon.
Skin PreparationThe entire front of neck, from jaw line to nipples is cleaned with Betadine.
DrapingSterile sheets are draped above, below and on either sides of neck, keeping only neck portion visible
Instruments
Thyroidectomy Page | 35
Discussion of the Procedure
PREOPERATIVE CONSIDERATIONS
Explain to the patient that thyroidectomy will remove diseased thyroid tissue or, if necessary, the entire gland. Tell him that he’ll have an incision in his neck; that he’ll have a dressing, and possibly, a drain in place after surgery; and that he may experience some hoarseness and a sore throat from intubation and anesthesia. Reassure him that he’ll receive analgesics to relieve his discomfort.
If thyroidectomy is being performed to treat hyperthyroidism, ensure that the patient has followed his preoperative drug regimen, which will render the gland euthyroid to prevent thyroid storm during surgery. He probably will have received either
Thyroidectomy Page | 36
propylthiouracil or methimazole, usually staring 4 to 6 weeks before surgery. Expect him to be receiving iodine as well for 10 to 14 days before surgery to reduce the gland’s vascularity and thus prevent excess bleeding. He may also be receiving propanolol to block adrenergic effects. Notify the physician immediately if the patient has failed to follow his medication regimen.
Collect samples for serum thyroid hormone determinations to check for euthyroidism. If necessary, arrange for an electrocardiogram to evaluate cardiac status.
Ensure that the patient or a legally authorized representative has signed an informed consent form.
1. Skin Incision An incision is made in the skin two finger breadths above the sternal notch between the medial borders of the sternocleidomastoid muscles (two muscles make a V shape in front of the neck). The width of the incision may need to be extended for large masses, or for a lateral lymph node removal.
2. Subplatysmal Flaps Subcutaneous fat and Platysma (triangle sheet of muscle at both sides of the neck) are divided, and asubplatysmal dissection is made
Thyroidectomy Page | 37
above the incision up to the level of the thyroid cartilage above, and thesternal notch, but remaining superficial to the anterior jugular veins.
3. Separating the Strap Muscles and Exposing the Anterior Surface of the Thyroid The fascia between the sternohyoid, omohyoid and sternothyroid muscles (strap muscles ) is divided along the midline and the muscles retracted laterally. This is an avascular plane but care must be taken not to injure small veins crossing between the anterior jugular veins.
4. Identify the Middle Thyroid Vein. The thyroid gland is rotated medially (using the surgeons fingers). The important vascular structure to identify is the middle thyroid vein (it will be tightly stretched by the medial rotation of the gland), which is then ligated. This permits further mobilisation of the gland and moving the bulk of the lobe out the wound.
Thyroidectomy Page | 38
5. Identify the Superior Laryngeal Artery and the External Laryngeal Nerve. Identify the superior laryngeal artery as close to the superior pole of the thyroid parenchyma as possible. Great care should be taken while ligating the superior laryngeal artery so as to avoid injury to the external laryngeal nerve. In some patients the external branch of the superior laryngeal nerve lies on the anterior surface of the thyroid lobe.
6. Identifying The Inferior Parathyroid Gland The inferior parathyroid glands are normally located between the lower pole of the thyroid and the isthmus, most commonly on the anterior or the posterolateral surface of the lower pole of the thyroid. Care must be taken to preserve it in situ and to avoid damaging its inferior thyroid artery.
7. Dividing The Thyroid Isthmus. When doing a thyroid lobectomy, the isthmus, which
is crossing between the two thyroid lobes, is divided.
Thyroidectomy Page | 39
8. Removing The Thyroid Gland.
The incision is closed in three layers: platysma, subcutaneous tissue, and skin Surgeons typically close
the Platysmal layer using buried interrupted 3-0 Monocryl sutures. This is followed by additional buried interrupted 3-0 Monocryl sutures in the
subcutaneous skin. A final 4-0 Monocryl suture is used in a subcuticular fashion followed by Dermabond. A Queen Anne dressing is applied.
POST-OPERATIVE CONSIDERATIONS
Keep the patient in high Fowler’s position to promote venous return from the head and neck and to decrease oozing into the incision. Check for laryngeal nerve damage by asking the patient to speak as soon as he awakens from anesthesia.
Watch for signs of respiratory distress. Tracheal collapse, tracheal mucus accumulat5ion, laryngeal edema, and vocal cord paralysis can all cause respiratory obstruction, with sudden stridor and restlessness. Keep a tracheotomy tray at the patient’s bedside for 24 hours after surgery, and be prepared to assist with emergency tracheotomy, if necessary.
Thyroidectomy Page | 40
Assess for signs of hemorrhage, which may cause shock, tracheal compression, and respiratory distress. Check the patient’s dressing and palpate the back of his neck, where drainage tends to flow. Expect about 50 ml of drainage in the first 24 hours; if you find no drainage, check for drain kinking or the need to reestablish suction. Expect only scant drainage after 24 hours.
Assess for hypocalcemia, which may occur when the parathyroid glands are damaged. Test for Chvostek’s and Trousseau’s signs, indicators of neuromuscular irritability from hypocalcemia. Keep calcium gluconate available for emergency IV administration.
Be alert for signs of thyroid storm, a rare but serious complication. As ordered, administer a mild analgesic to relieve a sore neck or throat.
Reassure the patient that his discomfort should resolve within a few days.
If the patient doesn’t have a drain in place, prepare him for discharge the day following surgery as indicated. However, if a drain is in place, the physician will usually remove it, along with half of the surgical clips, on the second day after surgery; the remaining clips, the following day, before discharge.
Nursing Responsibilities
SCRUB NURSEPre-operative Responsibilities1. Assist with the preparation of the room for the designated surgical procedure, including gathering supplies for the procedure.2. Scrub, dry hands, gown, and glove.3. Assist person scrubbed in first position with:
a. Setting up back table, mayo, and basinsb. Arrangement of instrumentsc. Preparation of suture and needlesd. Preparation and counting spongese. Arrangement and preparation of other necessary itemsf. Gowning and gloving surgeon and assistantsg. Assist with drapingh. Arrangement of sterile field
Intra-operative Responsibilities
Thyroidectomy Page | 41
1. During the procedure, progress from double-scrubbed position. Train self to keep eyes on field, and learn steps of procedure.2. Begin developing methods of anticipating needs of surgeon andassistant.3. After closing the skin:
a. Assist with care of instruments and counts if necessaryb. Care of specimenc. Assist with dressing of wound
Post-operative Responsibilities1. After the completion of the Procedure:
a. Assist with the gathering of all materials used during theprocedure
b. Discard items as necessary being careful to discard sharp itemsin designated placesc. Return all items to respective aread. Assist with cleaning of roome. Clean the materials used properly and arrange them after drying
2. Perform any duties which will speed up the surgical procedure tofollow in that room.
CIRCULATING NURSEPre-operative Responsibilities1. Care for the patient before surgery by:
a. Greeting patient and assist nurse with identificationb. Checking patient's chart, preparation, etc.
2. Prepare the room by:a. Obtaining instruments, supplies, and equipment for the designated operative procedureb. Opening unsterile suppliesc. Assisting in gowningd. Observing breaks in sterile techniquee. Assisting anesthesiologist as necessaryf. Assisting with skin preparation and positioningg. Assisting with forming of the sterile field
3. Count the instruments, sharps and sponges before the procedureand confirm with scrub nurse.
Intra-operative Responsibilities 1. During the Procedure:
a. Remain in room and dispense materials as necessaryb. Observe procedure as closely as possible
Thyroidectomy Page | 42
c. Begin establishing method of anticipating needs of surgical teamd. Care of specimen as indicatede. Care of operative records as indicatedf. Assist with application of dressingg. Monitor the instruments, sharps and sponges used and take noteof additional instruments.
2. Before the closing of the organ or peritoneum, count all instruments,sharps and sponges and confirm with scrub nurse.3. Inform the surgeon and assistant surgeon of a report of theinstruments.
Post-operative Responsibilities1. Properly document all the necessary information on the patient’schart.2. Assist in the cleaning of the operating room as necessary
Thyroidectomy Page | 43
B. P harmacological M anagement
Generic Name (Brand Name)
Mechanism of Action
Indications Side Effects/ Adverse Reaction
Contraindications
PROPYLTHIOURA
CIL
HyperthyroidismAdult: PO 300–450
mg/d divided q8h, may need 600–1200 mg/d
initiallyGeriatric: PO 150–300
mg/d divided q8hChild: PO 6–10 y, 50–150 mg/d; >10 y, 150–
300 mg/d or 150 mg/m2/d
Neonates: PO 5–10 mg/kg/d
Thyrotoxic CrisisAdult: PO 200 mg q4–
6h until full control achieved
As an anti-thyroid
drug, PTU inhibits
iodine and
peroxidase from
their normal
interactions with
thyroglobulin to
form T4 and T3.
This action
decreases
production of
thyroid hormone.
PTU also interferes
with the conversion
of T4 to T3, and,
since T3 is more
potent than T4, this
also reduces the
PTU is used to
manage
hyperthyroidism
associated with
Graves' disease in
patients who did not
tolerate methimazole,
and are not able to
receive surgery or
radioactive iodine
therapy. It also is
used to decrease
symptoms of
hyperthyroidism in
preparation for
surgical removal of
the thyroid gland or
before radioactive
iodine therapy in
patients who did not
The most common
side effects are
related to the skin
and
include rash, itchin
g, hives,
abnormal hair loss,
and skin
pigmentation. Other
common side effects
are
swelling, nausea, vo
miting, heartburn,
loss of taste, joint or
muscle aches,
numbness
and headache.
May also cause
agranulocytosis
Contraindicated
with allergy to
antithyroid
drugs,
pregnancy
Use cautiously
with lactation
Thyroidectomy Page | 44
activity of thyroid
hormones.
.
tolerated
methimazole.
.
Thyroidectomy Page | 45
NURSING RESPONSIBILITIES Before the administration of drug
Check for medical order
Determine if patient is allergic to the drug
Caution patient on taking blood thinners such as warfarin as this
may cause drug interaction and may potentiate the effect leading to
bleeding.
Instruct patient to avoid use of OTC drugs for asthma, or cough
treatment without checking with the physician because they may
contain iodide.
Give at the same time each day with relation to meals.
If drug is being used to improve thyroid state before radioactive
iodine (RAI) treatment, discontinued 3 or 4 d before treatment to
prevent uptake interference. PTU therapy may be resumed if
necessary 3–5 d after the RAI administration.
Explain possible side effects
During drug administration
Maintain aseptic technique
Check medication, right route, dosage, storage, etc
Stay with the patient while he takes in the drug
Do not exceed the recommended dosage
After the administration of drug
Monitor any untoward effects of the drug
Instruct SO’s to report to the attending nurse if any unusual effects
occur
Arrange for regular, periodic blood test to monitor bone marrow
depression and bleeding tendencies.
Advise patient that drug must not be discontinued unless the
physician told so and it must be taken for a prolonged period to
achieve the desired effects.
Report and record as appropriate.Thyroidectomy Page | 46
Thyroidectomy Page | 47
Generic Name (Brand Name)
Mechanism of Action
Indications Side Effects/ Adverse Reaction
Contraindications
METHIMAZOLE
(Tapazole)
Hyperthyroidism
Adult: PO 5–15 mg
q8h
Child: PO 0.2–0.4
mg/kg/d divided q8h
Thioamide with
actions and uses
similar to those of
propylthiouracil but
10 times as potent.
Actions are less
consistent, but effects
appear more
promptly than with
propylthiouracil.
Inhibits synthesis of
thyroid hormones as
the drug accumulates
in the thyroid gland.
Does not affect
existing T3 or
T4 levels.
For
Hyperthyroidism
and prior to
surgery or
radiotherapy of the
thyroid; may be
used cautiously to
treat
hyperthyroidism in
pregnancy. Long-
term use of
methimazole may
lead to a remission
of the
hyperthyroidism
GI: hepatotoxicity (rare).
Endocrine: Hypothyroidi
sm.
Hematologic: Leukopeni
a, agranulocytosis,
granulocytopenia,
thrombocytopenia,
pancytopenia, and
aplastic anemia.
Musculoskeletal
:Arthralgia.
CNS: Peripheral
neuropathy, drowsiness,
neuritis, paresthesias,
vertigo.
Skin: Rash, alopecia,
skin hyperpigmentation,
urticaria, and pruritus.
Urogenital: Nephrotic
syndrome.
It is
contraindicate
d in the
presence of
hypersensitivit
y to the drug
or any of the
other product
components.
Pregnancy
(category D),
Use cautiously
in lactating
women
Thyroidectomy Page | 48
Thyroidectomy Page | 49
NURSING RESPONSIBILITIES Before the administration of drug Check for medical order Determine if patient is allergic to the drug Caution patient about taking anticoagulant as this can reduce
anticoagulant effects of warfarin; may increase serum levels of digoxin; may alter theophylline levels;
Instruct patient to avoid use of OTC drugs for asthma, or cough treatment without checking with the physician because they may contain iodide.
Give at the same time each day with relation to meals. Explain possible side effects
During drug administration Maintain aseptic technique Check medication, right route, dosage, storage, etc Stay with the patient while he takes in the drug Do not exceed the recommended dosage
After the administration of drug Instruct patient to be aware that skin rash or swelling of cervical
lymph nodes may indicate need to discontinue drug and change to another antithyroid agent.
Ask the patient to notify physician promptly if the following symptoms appear: Bruising, unexplained bleeding, sore throat, fever, jaundice. Drug-induced jaundice may persist up to 10 wk after withdrawal of drug.
Closely monitor PT and INR in patients on oral anticoagulants. Anticoagulant activity may be potentiated.
Report and record as appropriate.
Thyroidectomy Page | 50
Generic Name
(Brand Name)
Mechanism of
Action
Indications Side Effects/ Adverse
Reaction
Contraindication
s
CARBIMAZOLE
( Neo-Mecrazole)
DOSAGE: 5–40 mg daily
ROUTE: PO
Carbimazole is an
antithyroid agent
that decreases the
uptake and
concentration of
inorganic iodine by
thyroid, it also
reduces the
formation of di-
iodotyrosine and
thyroxine. Once
converted to its
active form of
methimazole, it
prevents the thyroid
peroxidase enzyme
from coupling and
iodinating the
tyrosine residues on
For the
treatment of
hyperthyroidism
and
thyrotoxicosis. It
is also used to
prepare patients
for
thyroidectomy.
It reduces the
amount of
thyroid
hormone.
Sore throat,
fever, uneasiness,
nausea,
loss of taste,
headache, joint pain
and hair loss, Feeling
sick, Dizziness.
Skin rashes
Itching, Bruising,
Stomach upset,
Painful joints,
Liver problems
(jaundice)
Blood disorders,
Muscle pain
Contraindicated in
patients with
goiter and
hypersensitivity.
Should not be
used during
pregnancy
Pregnancy
category (D)
Caution should be
exercised in patients
with history of liver
disease and during
pregnancy and
breast-feeding.
Thyroidectomy Page | 51
thyroglobulin, hence
reducing the
production of the
thyroid hormones T3
and T4.
Thyroidectomy Page | 52
NURSING RESPONSIBILITIES
Before the administration of drug
Check for medical order
Determine whether patient is sensitive to other corticosteroids
Do not give drug to nursing mothers; drug may be secreted in
breast milk.
Ensure patient is not pregnant before giving this drug; advise
patient to use barrier contraceptives.
Explain possible side effects
During drug administration
Maintain aseptic technique
Check medication, right route, dosage, storage, etc
Stay with the patient while he takes in the drug
Do not exceed the recommended dosage
After the administration of drug
Monitor any untoward effects of the drug
Instruct SO’s to report to the attending nurse if any unusual effects
occur
Arrange for regular, periodic blood test to monitor bone marrow
depression and bleeding tendencies.
Advise patient that drug must not be discontinued unless the
physician told so and it must be taken for a prolonged period to
achieve the desired effects.
Report and record as appropriate.
Thyroidectomy Page | 53
Thyroidectomy Page | 54
Generic Name
(Brand Name)
Mechanism of
Action
Indications Side Effects/ Adverse
Reaction
Contraindication
s
LITHIUM CARBONATE( lithobid, carbolith,
lithizine)
ManiaAdult: PO Loading
Dose 600 mg t.i.d. or 900 mg sustained-
release b.i.d. or 30 mL (48 mEq) of solution
t.i.d. PO Maintenance Dose 300 mg t.i.d. or
q.i.d. or 15–20 mL (24–32 mEq) solution in 2–4 divided doses (max: 2.4
g/d)
Child: PO 15–60 mg/kg/d in divided
doses
The lithium ion
behaves in the body
much like the sodium
ion; but its exact
mechanism of action
is unclear. Competes
with various
physiologically
important cations:
Na+, K+, Ca++, Mg++;
therefore, it affects
cell membranes, body
water, and
neurotransmitters. At
the synapse, it
accelerates
catecholamine
destruction, inhibits
the release of
neurotransmitters
and decreases
sensitivity of
Control and
prophylaxis of
acute mania and
the acute manic
phase of mixed
bipolar disorder.
Pre-operative
drug for Grave’s
disease to
control
hyperthyroidism
and attain
euthyroid state.
.
CNS: Dizziness, headache,
lethargy, drowsiness, fatigue, slurred speech,
psychomotor retardation, giddiness, incontinence, restlessness, seizures,
confusion, blackout spells,
disorientation, recent memory loss, stupor, coma, EEG changes.
CV: Arrhythmias, hypotension,
vasculitis, peripheral circulatory collapse, ECG
changes.
Special Senses: Impaired vision,
transient scotomas, tinnitus.
Endocrine: Diffuse thyroid enlargement,
hypothyroidism,
Body as a Whole: Edema, weight
Significant
cardiovascular or
kidney disease,
brain damage,
severe
debilitation,
dehydration or
sodium depletion;
patients on low-
salt diet or
receiving
diuretics;
pregnancy,
especially first
trimester
(category D),
lactation, children
<12 y.
Thyroidectomy Page | 55
postsynaptic
receptors.
gain (common) or loss, exacerbation of psoriasis;
flu-like symptoms.
Thyroidectomy Page | 56
NURSING RESPONSIBILITIES Before the administration of drug
Check for medical order
Determine if patient is allergic to the drug
Explain possible side effects
During drug administration
Maintain aseptic technique
Check medication, right route, dosage, storage, etc
Stay with the patient while he takes in the drug
Do not exceed the recommended dosage
After the administration of drug
Monitor response to drug. Usual lag of 1–2 wk precedes response to
lithium therapy. Keep physician informed of progress.
Lab test: Periodic lithium levels (draw blood sample prior to next dose or
8–12 h after last dose); periodic thyroid function tests.
Monitor for S&S of lithium toxicity (e.g., vomiting, diarrhea, lack of
coordination, drowsiness, muscular weakness, slurred speech when level
is 1.5–2.0 mEq/L; ataxia, blurred vision, giddiness, tinnitus, muscle
twitching, coarse tremors, polyuria when >2.0 mEq/L). Withhold one
dose and call physician. Drug should not be stopped abruptly.
Monitor older adults carefully to prevent toxicity, which may occur at
serum levels ordinarily tolerated by other patients.
Be alert to and report symptoms of hypothyroidism.
Weigh patient daily; check ankles, tibiae, and wrists for edema. Report
changes in I&O ratio, sudden weight gain, or edema.
Report early signs of extrapyramidal reactions promptly to physician.
Report and record as appropriate.
Thyroidectomy Page | 57
Generic Name
(Brand Name)
Mechanism of
Action
Indications Side Effects/ Adverse
Reaction
Contraindication
s
DEXAMETHASONE(decadron)
Cerebral EdemaAdult: IV 10 mg
followed by 4 mg q4h, reduce dose after 2–4 d then taper over 5–7 dChild: PO/IV/IM 1–2 mg/kg loading dose, then 1–1.5 mg/kg/d
divided q4–6h (max: 16 mg/d)
ShockAdult: IV 1–6 mg/kg as a single dose or 40 mg
repeated q2–6h if needed
Dexamethasone Suppression Test
Adult: PO 0.5 mg q6h for 48 h
Long-acting synthetic
adrenocorticoid with
intense
antiinflammatory
(glucocorticoid)
activity and minimal
mineralocorticoid
activity. Antiinflam
matory
action: Prevents
accumulation of
inflammatory cells at
sites of infection;
inhibits phagocytosis,
lysosomal enzyme
release, and synthesis
of selected chemical
mediators of
inflammation;
reduces capillary
dilation and
permeability.
It can be used in
the treatment of
hypethyroidism.
At high does it
reduce the
peripheral
conversion of T4
(tetraiodo-
thyronine) to T3
(triiodothyronin
e).
.
Aerosol therapy: Nasal irritation, dryness, epistaxis, rebound
congestion, bronchial asthma, anosomia, perforation of nasal
septum.Systemic Absorption—
CNS: Euphoria, insomnia, convulsions, increased ICP, vertigo,
headache, psychic disturbances.
CV: CHF, hypertension, edema.Endocrine: Menstrual
irregularities, hyperglycemia; cushingoid state; growth suppression in
children; hirsutism.Special
Senses: Posterior subcapsular
cataract, increased IOP, glaucoma,
exophthalmos. GI: Peptic ulcer with possible
perforation, abdominal distension, nausea, increased appetite,
heartburn, dyspepsia, pancreatitis, bowel
Systemic fungal infection, acute
infections, active or resting
tuberculosis, vaccinia, varicella, administration of live virus vaccines (to patient, family members), latent
or active amebiasis.
Ophthalmic use: Primary open-angle glaucoma, eye
infections, superficial ocular herpes simplex,
keratitis and tuberculosis of eye.
Safe use during pregnancy (category
C), lactation, or in children is not established.
Thyroidectomy Page | 58
perforation, oral candidiasis.
Thyroidectomy Page | 59
NURSING RESPONSIBILITIES Before the administration of drug
Check for medical order
Determine if patient is allergic to the drug
Instruct patient to avoid use of OTC checking with the physician
Explain possible side effects
During drug administration
Maintain aseptic technique
Check medication, right route, dosage, storage, etc
Stay with the patient while he takes in the drug
Do not exceed the recommended dosage
After the administration of drug
Monitor for S&S of a hypersensitivity reaction (see Appendix F). The
acetate and sodium phosphate formulations may contain bisulfites,
parabens, or both; these inactive ingredients are allergenic to some
individuals.
Intruct patient to Report lack of response to medication or malaise,
orthostatic hypotension, muscular weakness and pain, nausea, vomiting,
anorexia, hypoglycemic reactions mental depression to physician. These
symptoms may signal hypoadrenocorticism.
Note: Hiccups that occur for several hours following each dose may be a
complication of high-dose oral dexamethasone.
Advise patient that drug must not be discontinued unless the physician
told so and it must be taken for a prolonged period to achieve the
desired effects.
Report and record as appropriate.
Thyroidectomy Page | 60
Thyroidectomy Page | 61
Generic Name
(Brand Name)
Mechanism of
Action
Indications Side Effects/ Adverse
Reaction
Contraindication
s
PROPANOLOL(inderal,detensol)
Adult: PO 40 mg b.i.d., usually need 160–480 mg/d in
divided doses; InnoPran
XL dose 80 mg q hs, may increase to 120
mg hsChild: PO 1
mg/kg/d in 2 divided doses (1–5 mg/kg/d)
Competitively blocks beta-adrenergic receptors in the
heart and juxtaglomerular
apparatus, decreasing the influence of the
sympathetic nervous system on these
tissues, the excitability of the
heart, cardiac workload and oxygen
consumption, and the release of rennin and lowering BP; has
membrane-stabilizing(local
anesthetic)effects that contribute to its
anti arrhythmic action; acts in the
CNS to reduce sympathetic outflow and vasoconstrictor
Management of
cardiac
arrhythmias,
myocardial
infarction,
tachyarrhythmia
s associated
with digitalis
intoxication,
anesthesia, and
thyrotoxicosis,.
.
CV: Palpitation, profound bradycardia, AV
heart block, cardiac standstill, of hands. Special
Senses:Dry eyes (gritty sensation), visual
disturbances, conjunctivitis, tinnitus, hearing loss, nasal stuffiness. GI: Dry mouth, cheilostomatitis, nausea,
vomiting, heartburn, diarrhea, constipation, flatulence, abdominal
cramps, mesenteric arterial thrombosis, ischemic colitis,
pancreatitis.Hematologic: Transient
eosinophilia, thrombocytopenic or nonthrombocytopenic
purpura,agranulocytosis.
Metabolic: Hypoglycemia, hyperglycemia, hypocalcemia
(patients with hyperthyroidism).
Respiratory: Dyspnea, laryn
Greater than first-
degree heart block;
CHF, right
ventricular failure
secondary to
pulmonary
hypertension;
ventricular
dysfunction; sinus
bradycardia,
cardiogenic shock,
significant aortic or
mitral valvular
disease; bronchial
asthma or
bronchospasm,
severe COPD,
pulmonary edema,
allergic rhinitis
during pollen
Thyroidectomy Page | 62
tone. gospasm, bronchospasm. season; .
Thyroidectomy Page | 63
NURSING RESPONSIBILITIES Before the administration of drug
Check for medical order
Determine if patient is allergic to the drug Be consistent with regard to giving with food or on an empty
stomach to minimize variations in absorption. Take apical pulse and BP before administering drug. Withhold drug
if heart rate <60 bpm or systolic BP <90 mm Hg. Consult physician for parameters.
Ensure that sustained release form is not chewed or crushed. Must be swallowed whole.
Instruct patient to avoid use of OTC checking with the physician Explain possible side effects
During drug administration
Maintain aseptic technique
Check medication, right route, dosage, storage, etc
Stay with the patient while he takes in the drug
Do not exceed the recommended dosage
After the administration of drug
Monitor response to drug.
Lab tests: Obtain periodic hematologic, kidney, liver, and cardiac functions when propranolol is given for prolonged periods.
Instruct patient no to discontinue drug abruptly; can precipitate withdrawal syndrome (e.g., tremulousness, sweating, severe headache, malaise, palpitation, rebound hypertension, MI, and life-threatening arrhythmias in patients with angina pectoris).
Report and record as appropriate.
Thyroidectomy Page | 64
Thyroidectomy Page | 65
C. D iet
Thyroidectomy Page | 66
PRE-OP
NPO
POST-OP
Clear
Liquid diet
Soft diet
Type of diet wherein the client is not
allowed to eat anything for a certain period of time, either fluids or foods.
Medical instruction meaning, to
withhold oral food and fluids from a patient
for various reason
A clear liquid diet consists
of clear liquids, such
as water, broth and
plain gelatin, that are easily digested and
leave no undigested residue in
your intestinal tract.
It is necessary that NPO order
be carried out to assure accuracy
of findings of tests.
A clear liquid
diet may be
prescribed after
surgery to help
maintain
adequate
hydration,
provides some
important
electrolytes,
such as sodium
and potassium,
and gives some
energy at a time
when a full diet
isn't possible or
recommended.
This was
Plain water, Fruit juices without pulp, such as apple juice,
grape juice or cranberry juice,
Strained lemonade or fruit punch, Clear,
fat-free broth (bouillon or
consomme). Clear sodas, Plain gelatin,
Honey, Ice pops without bits of fruit or fruit pulp, Tea or coffee without milk
or cream
Use more sauces
Thyroidectomy Page | 67
Type of DietGeneral
DescriptionIndication of
PurposeExamples of Allowed
Foods
Diet as Tolerated (DAT)
This diet incorporates food that are moderately low in fiber have a soft texture and moderately
seasoned The diet is
individualized to meet the needs of the patient and varies from
smooth creamy foods.
Diet as tolerated means
to eat what your stomach can tolerate.
The doctor will give you a list of food that
you can eat and will say to eat them as often
as you can tolerate them.
ordered to provide a transitional diet between liquids and regular food for patient who undergone surgery.
This particular diet is only giver when client can now tolerate any
food she/he desires that is
nutritious, if this will not lead to
any complications and if the client needs further
monitoring for lab test
and gravies – moist food is easier to swallow than dry
water, juice, mashed vegetables and potatoes, ice cream, pudding,
milk shakes, eggs, broth, pasta, chile, bean, tender meats,
fish and gelatin.
Vegetables, fruits, grains, meat,
NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER
Before the Procedure
Check the doctor’s order.
Check the right client.
Be sure that the diet is properly instructed.
Explain the reason for type of diet
During the Procedure
Thyroidectomy Page | 68
Monitor if the client complies with the given diet.
Be sure patient is taking or eating food he/she can tolerate
After the Procedure
Assess for patient’s condition; how he responded to the diet.
Thyroidectomy Page | 69
D . A ctivity/ E xercise
Type of Activity
General Desription Indications or Purposes
Semi-
fowler’s
Position
May sit up
on bed &
ambulate
Placement of the patient in an inclined position,
with the upper half of the body raised by elevating
the head of the bed approximately 30 degrees.
The patient may sit up on bed in ambulatory state
slowly and gradually, walking and moving from
one place to another.
To reduce swelling and edema in neck area. Sandbags or pillows used to support clients head or neck. To prevent hyperextension of the neck and protects integrity of the suture line.
To facilitate gradual return of patient in normal activities of
daily living.light activity, such as walking,
is fine. However, there should be no strenuous
activity (exercising, etc) for 2 weeks following the surgery.
NURSING RESPONSIBILITIES
Educate client regarding his activity
Assisting client to his bathroom privileges
Explain the purpose of restrictions in activity and position in bed as
ordered.
Assist the patient to maintain the prescribed position.
Encourage the patient to adhere to ordered activity.
Accomplish necessary documentation of patient’s reaction to the
ordered activity restrictions.
Thyroidectomy Page | 70
Thyroidectomy Page | 71
VI. NURSING CARE PLAN
Deficient Knowledge
CUESNURSING DIAGNOSI
S
SCIENTIFIC EXPLANATION
OBJECTIVESNURSING
INTERVENTIONS
RATIONALE
The patient may manifest the following:
o inappropriate or exaggerated behavior
o unfamiliarity to disease condition
o inaccurate follow through of instruction
o incompliance to the treatment regimen
Deficient Knowledge r/t unfamiliarity with information resources
Deficient
Knowledge is
the absence or
deficiency of
cognitive
information
necessary for
the client/SOs to
make informed
choices
regarding the
condition,
treatment or
lifestyle
Short Term:
After 2 hours of nursing interventions, the pt. will be able to Exhibit increased interest/assume responsibility for own learning and begin to look for information and ask question.
Long Term:
After 2 days of Nursing Interventions, the pt. will be able to initiate necessary
Ascertain level of knowledge, including anticipatory needs.
Determine client’s ability to learn
Noted personal factors
Determine Barriers to
To know what is the level of understanding of the person to know what information should be reinforced.
Right timing is important in giving information, knowing the client’s ability gives the nurse idea on what way will he/she present the information.
Personal Factors are important in learning, because learning is individualized
Thyroidectomy Page | 72
changes. lifestyle changes and participate in treatment regimen.
learning
Identify motivating factors for the individual
Provide information relevant to the situation
Determine patient’s most urgent need
Recognize level of achievement, time factors, and short
term and long term goals.
To make some techniques to avoid being affected by those barriers
This will help the individual to learn
To let the client know about the present situation.
Knowing to prioritize the patient’s learning needs increases the effectivity of the teaching plan
To know what are the purpose of the patient teaching
Thyroidectomy Page | 73
Risk for Injury (tetany)
Thyroidectomy Page | 74
Thyroidectomy Page | 75
CUESNURSING DIAGNOSI
S
SCIENTIFIC EXPLANATION
OBJECTIVESNURSING
INTERVENTIONS
RATIONALE
Patient may
experience:
o Tingling
sensation
around the
mouth
o muscle aches
o weakness or
o twitching,
o difficulty
swallowing
Injury, risk for (tetany)
Risk factors may include: chemical imbalance: excessive CNS stimulation
Temporary post-
thyroidectomy
hypocalcaemia
is a relatively
common
complication,
due to removal,
injury or
devascularizatio
n of the
parathyroid
glands. It may
also be
secondary to
hungry bones
due to
postoperative
reversal of
thyrotoxic
osteodystrophy,
reactive
After 2 hours of nursing interventions, The client will be able to:o Verbalize
understandin
g
of individual
factors that
contribute
to possibility
of injury and
take steps to
correct
o Be free from
injury
associated
with calcium
deficit, as
evidenced by
no falls or
near falls and
no pathologic
fractures.
1. Monitor vital signs
2. Evaluate reflexes
periodically, observe for
neuromascular irritability.
(e,g., twitching, numbness,
paresthesias, positive
Chvostek;s and
trousseau’s signs, seizure
activity.)
3. Keep side rails raised and
padded, bed in low position, and airway at bedside. Avoid
use of restraints.
4. Monitor serum calcium levels
1. Manipulate of gland during
subtotal thyroidectomy may result in increased
hormone release, causing
thyroid storm and altered vital signs
2. Reduces potential for
injury if seizures occur.
3. Reduces potential for
injury if seizures occur.
4. Patients with levels less
Risk for Bleeding
Thyroidectomy Page | 76
Risk for Impaired Verbal Communication r/t: Vocal cord injury/laryngeal nerve damage
CUESNURSING
DIAGNOSISSCIENTIFIC
EXPLANATIONDESIRED
OUTCOMES
NURSING INTERVENTIO
NSRATIONALE
Patient may
experience
Hoarsnessn
ess
sorethroat
Difficulty in
forming
words/sent
ences
Difficulty
expressing
thoughts
verbally
Difficulty in
comprehen
ding/
maintainin
g usual
Impaired
Verbal
Communication
r/t: Vocal cord
injury/laryngea
l nerve damage
Thyroidectomy is
a surgical
procedure. Apart
from rare
hemorrhagic or
infectious
complications,
thyroid surgery
may also induce
voice disorders
which are
generally
transient but
sometimes
permanent. They
usually occur as a
result of a nerve
lesion (recurrent
or external
After 4 hours
of nursing
interventions,
the patient
will be able
to:
o Verbalize
or indicate
an
understand
ing of the
communica
tion
difficulty
and plans
for ways of
handling
1. Assess speech
periodically;
encourage
voice rest.
2. Keep
communicatio
n simple; ask
yes/no
questions.
3. Provide
alternative
1. Hoarseness
and sore
throat may
occur
secondary to
tissue edema
or surgical
damage to
recurrent
laryngeal
nerve and
may last
several days.
2. Reduces
demand for
response;
Thyroidectomy Page | 77
communica
tion
pattern.
laryngeal nerves).
Due to the
proximity of the
organs, the
surgery may
bring accidental
damage to the
adjacent organs
which includes
the larynx nerve.
Permanent nerve
damage can occur
(rare) that causes
paralysis of vocal
cords and/or
compression of
the trachea.
o Establish
method of
communica
tion in
which
needs can
beundersto
od
methods of
communicatio
n as
appropriate,
e.g., slate
board,
letter/picture
board..
4. Anticipate
needs as
possible. Visit
patient
frequently.
5. Post notice of
patient’s voice
limitations at
central station
and answer
call bell
promptly.
6. Maintain quiet
promotes
voice rest.
3. Facilitates
expression of
needs and to
easily
understand
the patient.
4. Reduces
anxiety and
patient’s need
to
communicate.
5. Prevents
patient from
straining
voice to make
needs
known/summ
Thyroidectomy Page | 78
environment on assistance.
6. Enhances
ability to hear
whispered
communicatio
n and reduces
necessity for
patient to
raise/strain
voice to be
heard.
Thyroidectomy Page | 79
Thyroidectomy Page | 80
Risk for Ineffective airway clearance: risk factors may include tracheal obstruction –edema, hematoma, laryngeal spasm
Thyroidectomy Page | 81
Thyroidectomy Page | 82
CUESNURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
DESIRED
OUTCOMES
NURSING
INTERVENTIO
NS
RATIONALE
Patient may experience:
Changes in
respiratory
rate/
rhythm
Diminished
/
adventitiou
s breath
sounds
(rhonchi)
Orthopnea
Cyanosis
Risk for Ineffective
airway clearance: risk
factors may include tracheal
obstruction –edema,
hematoma, laryngeal
spasm
Respiratory
distress may be
experienced by
a post-operative
thyroidectomy
patient due to
possible airway
obstruction and
tracheal
compression or
closure of glottis
from laryngeal
nerve damage
brought by the
trauma during
surgery or
pressure from
swelling after
surgery.
After 4 hours of nursing
interventions, the patient will be able
to:
o Expectorate sputum effectively
o Demonstrate controlled coughing techniques.
o Demonstrate behaviors to improve or maintain clear airway.
1. Monitor respiratory rate, depth, and work of breathing.
2. Auscultate breath sounds, noting presence of rhonchi.
3. Assess for dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice.
4. Caution patient to avoid bending neck; support
Respirations may remain somewhat rapid, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage.
Rhonchi may indicate airway obstruction/accumulation of copious thick secretions.
Indicators of tracheal obstruction/laryngeal spasm, requiring prompt evaluation and intervention.
Reduces likelihood of tension on surgical wound.
Acute Pain
Thyroidectomy Page | 83
Thyroidectomy Page | 84
CUESNURSING
DIAGNOSISSCIENTIFIC
EXPLANATIONDESIRED
OUTCOMES
NURSING INTERVENTIO
NSRATIONALE
Patient may manifest the following:
o Episodes of pain, verbal reports, swelling, and bruising around the wound area.
o During the first few days, eating and drinking can be associated with some discomfort and pain.
Acute PainMay be related to: Surgical
interruption/manipulation of tissues/muscles
Postoperative edema/ presence of surgical incision
Possibly evidenced by Reports of
pain
Narrowed focus; guarding behavior; restlessness
Autonomic responses
Complex
responses of
tissue and nerve
endings due to
trauma from
surgery(incision
) and cause
hypersensitivity
to the central
nervous system
that causes
unpleasant
physical and
emotional
reactions and
responses.
After 4 hours of nursing interventions, the patient will be able to:o Report
pain is relieved or controlled
o Verbalize non-pharmacological methods that provides relief
o Demonstrate use of relaxation skills and diversional activities.
o Follow prescribed pharmacological regimen.
1. Assess verbal/nonverbal reports of pain, noting location, intensity (0–10 scale), and duration.
2. Monitor vital signs
3. Place in semi-Fowler’s position and support head/neck with sandbags or small pillows.
4. Maintain head/neck in neutral position and support during position changes. Instruct patient to use hands to support neck during movement
Useful in evaluating pain, choice of interventions, effectiveness of therapy.
Usually altered in acute pain
Prevents hyperextension of the neck and protects integrity of the suture line.
Prevents stress on the suture line and reduces muscle tension.
VIII. CONCLUSION
Hyperthyroidism has been described in the literature as the
overfunctioning of the thyroid gland. In the clinical findings, amongst the
etiologies include: infections, autoimmune deficiencies, age, gender,
lifestyle and genetic predispositions. As we all know, the thyroid gland
plays a very intricate role in certain body processes like metabolism and
hormone regulations. Any malfunctions may digress the body’s homeostasis
leading to chain of inflammatory processes although the progression of the
disease varies with age, diet and life-style related factors.
In the recent years, the incidence of hyperthyroidism has decline in
many industrialized countries as a result of breakthroughs in medicine.
These had lead to increased recognition and treatment of the disease’s risk
factors. As a student nurse, we also play a very vital role throughout the
course of the disease. Patient education is focused on prevention,
recognition of clinical manifestations and early treatment of
hyperthyroidism. Information-dissemination may help our patients be
aware of the classic signs and symptoms of hyperthyroidism, which
therefore can help them detect the disease as early as possible and avoid
the risk factors. Our primary goal here is to restore the normal functioning
of the thyroid gland hence prompt recognition of the cause allows early
treatment and management. Better prognosis is achieved if the condition
will be given an immediate attention.
Thyroidectomy Page | 85
As part of the treatment, thyroidectomy may be necessary if the
disease has progressed to advanced stage. Critical care should be observed
as the client might experience discomforts after the surgery. The
complications post-operatively put the patient in danger if not
distinguished immediately. It is very important that the student nurses are
equipped with adequate knowledge to attend to the immediate needs of the
patient.
IX. RECOMMENDATION
This case study is recommended to the following:
A. To the Philippine Government, they may be aware of the incidence
of the disease condition in our country and that they may help
those who are less fortunate by making the health care services
more affordable and acceptable;
B. To the Department of Health, that they may implement the
effective treatment of hyperthyroidism and that they may have
proper information dissemination about the disease condition;
C. To the health care providers, particularly physicians and nurses,
that they may have the proper knowledge and skills regarding this
medical condition, its management and as well as its treatment;
D. To the medical interns and student nurse, that they become aware
of the current trends and issues in both medicine and nursing field
about hyperthyroidism, its new innovation and treatment as well;
Thyroidectomy Page | 86
E. To those support groups who are willing to extend their hand for
those unlucky few, that they may give adequate needs in order to
cure the disease condition;
F. To the families who have a member who is suffering from the
disease condition, that they may become aware and conscious
with this kind of condition;
G. And to the Filipino people, that they may have background
regarding the treatment for thyroid diseases in different ages of
patient.
X. BIBLIOGRAPHY
Bahn RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of
thyrotoxicosis: Management Guidelines of the American Thyroid
Association and American Association of Clinical
Endocrinologists. Endocr Pract. 2011;17:457-520.
Davies TF, Larsen PR. Thyrotoxicosis. In: Kronenberg HM, Melmed S,
Polonsky KS, Larsen PR, eds. Williams Textbook of Endocrinology .
11th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 11.
Ladenson P, Kim M. Thyroid. In: Goldman L, Ausiello D, eds. Cecil
Medicine . 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 244
Thyroidectomy Page | 87
Halsted WS. The operative story of goiter. The authors operation. Johns
Hopkins Rep. 1920;19:71- 257.
Hoffman HT, Rojeski M, Funk GF, McCulloch TM. The solitary thyroid
nodule. In Gates GA, ed. Current Therapy in Otolaryngology. St. Louis,
Mo: Mosby: 1994:319-323.
Karlan MS, Catz B, Dunkelman D, Uyeda RY, Gleischman S. A safe
technique for thyroidectomy with complete nerve dissection and
parathyroid preservation. Head Neck. 1984;6:1014- 1019.
https://wiki.uiowa.edu/display/protocols/Thyroidectomy+and+Thyroid+Lob
ectomy
http://khalidalomari.weebly.com/anatomical-steps-of-
thyroidectomy.html
Thyroidectomy Page | 88