or case report

8/8/2019 Or Case Report

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I. Introduction

The thyroid is a highly vascular, butterfly-shaped endocrine gland composed of

two lobes connected by a narrow bridge called the isthmus. It is located on the anterior

aspect of the trachea adjacent to the second, third, and fourth tracheal cartilage rings.

The gland is responsible for regulating metabolism by secreting hormones. When

diseases affect the thyroid gland, its size or activity may become abnormal. These

diseases include thyroid cancer, goiter, and hyperthyroidism. Tumors and other

conditions can render some or all parts of the thyroid gland ineffective, but they can

often be treated medically. While in some cases, interventions other than surgery may

not be effective, and thus render the thyroid to be subjected for removal, a procedure

known as Thyroidectomy.

Thyroidectomy involves the surgical removal of all or a part of the thyroid gland.

Surgeons often perform a thyroidectomy when a patient has thyroid cancer or some

other condition of the thyroid gland such as hyperthyroidism. Thyroid lobectomy or the

removal of only a lobe of the thyroid is performed commonly for the treatment of some

thyroid nodules and carcinomas. Total thyroidectomy is indicated for certain carcinomas

and to relieve tracheal or esophageal compression. Infrequently, a portion of the gland

may be substernal, necessitating a more extensive procedure.

Thyroid tumors are rare in children and increase in frequency in each decade.

The variety of tumor are also related to age. Carcinomas are three times as frequent in

women as in men. In the past it was generally believed that thyroid tumors were more

frequent in areas of endemic goiter and reports from Columbia and Austria support this

association. More recent studies suggest that in iodine deficient countries, the number of

nodules is increased and as a consequence, the number of thyroid cancer cases

increase as well, which subsequently increase the number of individuals who are

indicated or qualified for thyroidectomy. Secondary non-thyroid cancers occur in slightly

increased frequency in patients who have had a primary thyroid cancer or tumors. While

this may in part be related to therapy, it is believed that it may also represent a common

genetic or environmental effect predisposing to tumors.

The article Dissection and hemostasis with hydroxilated polyvinyl acetal tampons

in open thyroid surgery is about the new technologies have been proposed and applied

in thyroid surgery, such as the mini-invasive video-assisted thyroidectomy (MIVAT) and


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the intraoperative monitoring of recurrent laryngeal nerve (RLN). In general the essential

objectives for thyroidectomy are: conservation of the parathyroid glands, avoidance of

injury to RNL, an accurate hemostasis and an excellent cosmesis. The thyroid has a rich

blood supply. Each must be securely occluded and divided to perform a safe and

expeditious operation. Theodor Kocher is credited with refining the technique of

thyroidectomy and reducing the incidence of postoperative hemorrhage. It is difficult to

estimate the real impact of bleeding, as main cause of intra-operative accidental lesions

of vital structures as RLN. However any surgeon who has routinely been practising

thyroid surgery, knows that even minor bleeding may greatly compromise the view of

surgical field and lead to severe difficulties in identifying the anatomical structures.

Furthermore, management of abnormal bleeding exposes the patient to the morbidity of

re-operation. In mini-invasive thyroidectomy intraoperative bleeding is a frequent cause

for conversion to open technique . Several devices and techniques, coming from general

surgery, are commonly used to control bleeding, during thyroid surgery. Haemostasis in

thyroid surgery is achieved by means of conventional clamp-and-tie technique,

diathermy, and haemostatic clips and, more recently, by ultrasonic coagulating-

dissection and electrothermal bipolar vessel sealing systems. They tested hydroxylated

polyvinyl acetal tampons (HPA), their efficacy for small bleeding control and tissue

dissection during several thyroid procedures.

The issue of a subtotal or partial versus total thyroidectomy is controversial.

Some practitioners prefer to perform a partial thyroidectomy whenever possible,

believing that they will leave behind enough thyroid tissue to prevent hypothyroidism,

since a total thyroidectomy has nearly 100% chance of causing hypothyroidism. The risk

of hypothyroidism is, however, quite high, and some experts say that more than 70% of

patients receiving a subtotal thyroidectomy will become hypothyroid. Since one of the

main reasons for subtotal thyroidectomy is to prevent hypothyroidism, and the goal is

achieved in only a minority of cases, experts increasingly believe that there is no added

benefit to subtotal thyroidectomy, and are more positively recommending a total

thyroidectomy.

Thyroid surgery is performed using general anesthesia by a majority of

surgeons in current practice. A study was conducted to analyze the utility and safety of

local anesthesia for thyroid surgery. Prospective data was collected during a 16 year

period by a single surgeon at a tertiary referral system. The results showed that


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thyroidectomy using local anesthesia appears safe and applicable to a wide range of

patients including those who pose a general anesthetic risk or require more complex

procedures, when performed by an experienced surgeon.

As with regards to the implication of the above information to the nursing

profession, nurses have an important duty of being the patients advocate. This meant

that one of the important roles of nurses is to ensure the protection and safety of the

patient. Clearly, the above information attests that in such cases of surgical interventions

as thyroidectomy, many of what is conventionally practiced may actually be

inappropriate. This is best exemplified by certain findings that not all patients who are to

undergo thyroid surgery require the induction of general anesthesia. As what the results

of an aforementioned said study suggest, local anesthesia may even be more

advantageous and safer for some patients. In line with this, nurses being the patients

advocate, should uphold what they think will yield to the greatest advantage for their

client even if this meant the negation of certain decisions made by the physician.

More and more of the population worldwide is gradually acquiring certain

disorders involving the thyroid gland. This imply that more than ever, we must duly

execute or perform one of our most crucial but basic function: health promotion through

the most feasible means which is via patient education, in order for the general

populace to be aware of their responsibility to uphold their own health and biological

status. In view of the surgical procedure, thyroidectomy may be a traumatic and

frightening experience for the patient. Nurses then have a great responsibility to ease

the anxiety of the patient. In such scenarios, as a nurse working towards the

achievement of rendering holistic care, it is ones duty to know how to handle clients is

such situations. Understanding the concepts and principles of this field of nursing can

provide a solid foundation for the nurse who works with such delicate patients.

Moreover, it is essential for any nurse to be aware of the assessment and technical skills

and nursing knowledge associated with the nursing management of patients who are to

undergo thyroidectomy.


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II. Clinical Intervention

2.1 Description of Prescribed Surgical Procedure

Thyroidectomy is an operative procedure done most commonly by a general

surgeon, or occasionally by an otolaryngologist, in the operating room of a hospital. The

operation begins when an anesthesiologist puts the patient to sleep. The

anesthesiologist injects drugs into the patient's veins and then places an airway tube in

the windpipe to ventilate (provide air for) the patient. The surgeon makes an incision in

the front of the neck where a tight-fitting necklace would rest. He locates and takes care

not to injure the parathyroid glands and the recurrent laryngeal nerves, while freeing the

thyroid gland from these surrounding structures. The blood supply to the portion of the

thyroid gland that is to be removed is clamped off. Then all or part of the gland is

removed. If cancer is present, all, or almost all, of the gland is removed. If other diseases

or a nodule is present, the surgeon may remove only part of the gland. The total amount

of thyroid gland removed depends upon the thyroid disease being treated. A drain (a soft

plastic tube that drains fluid out of the area) may be placed before the incision is closed.

The incision is closed either with sutures (stitches) or metal clips. A dressing is placed

over the incision and the drain, if one is used.

SURGICAL PROCEDURE OF TOTAL THYROIDECTOMY

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 hormone circulating in the body. Sonograms and computed

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

location of abnormalities. A thyroid nuclear medicine scan assesses the function of the

gland. A needle biopsy of an abnormality or aspiration (removal by suction) of fluid from

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

If the diagnosis is hyperthyroidism, the patient may be asked to take antithyroid

medication or iodides before the operation; or continued treatment with antithyroid drugs

may be the treatment of choice. Otherwise, no other special procedure must be followed

prior to the operation.


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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


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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 at the neck, around theshoulders, and at the sides.

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 the head 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


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Fig. 1.2b

Fig. 1.2c

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 and platysma. 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.


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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 (Kecht 1953;

Kreiner 1952; Arnold 1948; Schilling 1942). However it should be remembered that moredamage 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 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. (From Sabiston, D.C., Jr. [Ed]: Atlas of General Surgery

Philadelphia, WE.B. Sauders, 1995.)

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 thesuperior 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. (From Sabiston, D.C., Jr. [Ed]:

Atlas of General Surgery Philadelphia, WE.B. Sauders, 1995.)

Fig 1.13


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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 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. Sabiston, D.C., Jr. [Ed]: Atlas of General Surgery

Philadelphia, WE.B. Sauders, 1995.)

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. Sabiston, D.C., Jr. [Ed]:



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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 Istrhmus, and the specimen is divided, so that

the isthmus is included with the resected lobe. Sabiston, D.C., Jr. [Ed]: Atlas of

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

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 blood supply and ton protect the recurrent laryngeal nerve. It should be

based on the inferior thyroid artery or its major branches. Sabiston, D.C., Jr. [Ed]:



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Fig 1.17a

Fig 1.17b

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.)


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Fig 1.18

At the end of the resection the remnant of capsule and parenchyma is closed byindividual 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 1.22


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Thyroidectomy scar after two weeks.

2.2 Indications of Prescribed Surgical Treatment

General and/or specific indications

The surgical removal of part or all of the thyroid gland, thyroidectomy allows treatment of

hyperthyroidism, respiratory obstruction from goiter, and thyroid cancer. Total

thyroidectomy may be performed for certain types of thyroid cancers, such as papillary,

follicular, medullary, or anaplastic neoplasms. After this surgery, the patient requireslifelong hormone replacement therapy. Subtotal thyroidectomy is performed to correct

hyperthyroidism when drug therapy falls or radiation therapy is contraindicated, reduces

secretion of thyroid hormone. It also effectively treats diffuse goiter. About five sixths of

the gland is removed. After surgery, the remaining thyroid tissue usually supplies

enough thyroid hormone for normal function, thus hormone replacements may not be

necessary. Ideally, clients selected are young and fee of any condition that makes them

poor operative risks (e.g., diabetes, heart disease, renal disease, drug allergies).

Risks vs. Benefits

The benefit of thyroidectomy is to improved probability of curing the medical condition

but the doctors cannot guarantee that the patient will receive these benefit, only patient

can decide if the benefit are worth the risk.


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Before undergoing one of these procedures, understanding the associated risks is

essential. No procedure is completely risk-free. The following risks are well recognized,

but there may also be risks not included in this list that are unforeseen by the doctors.

Thyroidectomy is generally a very safe surgical procedure that carries a 1-in-1000 (or

less) risk of death. However, about 13 percent of patients do have major or minor

postoperative complications. These complications include:

Bleeding may occur during or after the procedure. Bleeding can be life-

threatening. If the bleeding occurs after the procedure, patient may need

additional treatment to stop the bleeding or to remove blood clots.

The patient may also need blood transfusions. The patient will sign a separate

consent authorizing transfusions if necessary. Separate information is available

regarding blood transfusion, products, and alternatives.

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.

The patient may develop infection of facial tissue or bone. Any infection might

require the patient to stay in the hospital a long time or require you to get

antibiotics through the veins at home for a long time.

There may be hoarseness or voice loss if the recurrent laryngeal nerve was

injured or destroyed during the operation; this is more likely to occur in patients

who have large goiters or cancerous tumors.

The patient may experience a life-threatening surge of thyroid hormones into the

blood. Only certain patients are at risk of this complication, and it rarely occurs if

preventive medications are given before surgery.

There may be 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.


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There may be injury to a portion of the superior laryngeal nerve. If this occurs,

patients who sing may not be able to hit high notes, and their voice may lose

some projection.

The patient may develop hypoparathyroidism; if the parathyroid glands aremistakenly 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.

The patient may experience irregular heartbeats.

The healing process may take longer than expected; there may be scarring.

You may develop an allergic reaction to drugs and/or equipment.

The procedure may fail to achieve the desired results.

As a result of this procedure, you may experience postoperative pain during the

healing period.

2.3 Required Instruments, devices, supplies, equipment and fecilities.

(4) needle holders

(6) towel clips

(2) straight /mayo scissors

(1) Metzenbaum scissor

(1) iris scissor

(4) #3 knife handles

(6) 10 blades

(1) short plain forceps

(1) fine cushing forceps

(2) Kelly clamps

(2) Oschner

(12) mosquito clamps

(1) double-ended medium-small

Richardson retractor

(2) Army Navy retractor

(1) Cautery unit

(1) Penrose Drain

(1)Weitlaner

(2) lahey

(2) Gelpi


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(2) Debakey

(6) Curved Crile

(6) Allis

(2) Adson with Teeth

Retractors:

1.) Double-ended Richardson retractor= used to retract deep incisions

2.) Army-Navy retractor= used to retract shallow or superficial incisions

3.) Weitlaner= ends can be blunt or sharp; has rake tips; ratchet to hold tissue apart

4.) Gelpi= has single point tips; ratchet to hold tissue apart


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Clamping Instruments:

5.) Mosquito= used to clamp blood vessels

6.) Kelly= is used to clamp larger vessels and tissue. Available in short and long

sizes.

7.) lahey= thyroid forceps used to deliver the thyroid in thyroidectomy.
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8.) kocher=a heavy, straight hemostat with interlocking teeth on the tip

9.) crile=a clamp for temporary stoppage of blood flow.

10.) Towel Clips= used to hold towels and drapes in place.

Grasping Instruments:

11.) Babcock clamp= used to grasp delicate tissue
http://images.google.com.ph/imgres?imgurl=http://www.spectrumsurgical.com/images/forceps/crile.gif&imgrefurl=http://www.spectrumsurgical.com/catalog/forceps.htm&h=157&w=216&sz=5&hl=en&start=14&tbnid=9kuQ8d6Yq7cQlM:&tbnh=78&tbnw=107&prev=/images%3Fq%3Dcrile%26svnum%3D10%26hl%3Den%26lr%3Dhttp://images.google.com.ph/imgres?imgurl=http://www.bookstore.umn.edu/images/system/product/9547.jpg&imgrefurl=http://www.bookstore.umn.edu/viewProduct.cgi%3FcategoryID%3D392%26productID%3D9547&h=306&w=200&sz=3&hl=en&start=2&tbnid=fsAOSCcyr5f7LM:&tbnh=117&tbnw=76&prev=/images%3Fq%3Dkocher%26svnum%3D10%26hl%3Den%26lr%3D


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12.) Adson= a small thumb forceps with two teeth on one tip and one tooth on the other.

13.) Cushing Forceps

14.) Plain Tissue forceps= used to grasp tissue

15.) debakey forceps= nontraumatic forceps used to pick up blood vessels; also known

as magics.

.
http://images.google.com.ph/imgres?imgurl=http://www.universalsurgical.com/images/prod/full/DebakeyTissueForceps.jpg&imgrefurl=http://www.universalsurgical.com/products.asp%3FCat%3DTF&h=480&w=640&sz=12&hl=en&start=22&tbnid=NjR-8yroPilfBM:&tbnh=103&tbnw=137&prev=/images%3Fq%3Ddebakey%26start%3D20%26ndsp%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com.ph/imgres?imgurl=http://images.mercateo.com/images/products/mediprax/gr_100-30698.jpg&imgrefurl=http://www.mercateo.com/p/318-100(2d)30698/Adson_Pinzette_chirurgische_Form.html&h=399&w=200&sz=4&hl=en&start=6&tbnid=ObI71BGKCrcaWM:&tbnh=124&tbnw=62&prev=/images%3Fq%3Dadson%26svnum%3D10%26hl%3Den%26lr%3D


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16.) Allis= a straight grasping forceps with serrated jaws, used to forcibly grasp or retract

tissues or structures.

Dissecting/ Cutting Instruments:

17.) Mayo Scissors= used to cut heavy tissue

(curved and straight)

18.) Metzenbaums "Mets"= used to cut delicate tissues
http://images.google.com.ph/imgres?imgurl=http://www.wpi-europe.com/products/microdissection/images/501324.jpg&imgrefurl=http://www.wpi-europe.com/products/microdissection/haemostats.htm&h=187&w=400&sz=11&hl=en&start=12&tbnid=vwpVDGe_1RxbpM:&tbnh=58&tbnw=124&prev=/images%3Fq%3Dallis%2Bclamp%26svnum%3D10%26hl%3Den%26lr%3D


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19.) #3 knife handles

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
http://images.google.com.ph/imgres?imgurl=http://www.tedpella.com/dissect_html/1360.jpg&imgrefurl=http://www.tedpella.com/dissect_html/scissor1.htm&h=286&w=179&sz=12&hl=en&start=2&tbnid=ch7YG2mXgthCSM:&tbnh=115&tbnw=72&prev=/images%3Fq%3Dcurved%2Biris%26svnum%3D10%26hl%3Den%26lr%3Dhttp://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%3Fq%3Dtenotomy%26svnum%3D10%26hl%3Den%26lr%3D


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Suturing Instruments:

23.) Needle Holder= used to hold needles when suturing. They may also be placed on

the sewing category.

Equipments:

24.) Cautery Unit = This 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 a hand-

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.
http://rds.yahoo.com/_ylt=A0Je5xVcb2hFjlUA96WJzbkF;_ylu=X3oDMTBkaWRnNHZyBHBvcwMxMQRzZWMDc3I-/SIG=1f82g3s8t/EXP=1164558556/**http%3A//images.search.yahoo.com/search/images/view%3Fback=http%253A%252F%252Fimages.search.yahoo.com%252Fsearch%252Fima


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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.

27.) Penrose Drain= is 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.
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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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Conditions:

Before You Go

The Week Before Surgery:

You'll probably need to stop taking aspirin and ibuprofen; the doctor will tell you

when. If you're taking aspirin for your heart, don't stop without asking the doctor

first. Also ask whether you can take any over-the-counter medicines.

Your doctor will tell you whether you need to have blood drawn.

The Night Before Surgery:

Your physician may suggest you take a sleeping pill.

Just before surgery, you should not eat or drink anything (even water). Your

doctor will tell you when to begin fasting.

Call Your Doctor If...

You have a cold or flu or are running a high temperature. The operation may

need to be postponed.

The problems for which you are having the operation get any worse.

When You Arrive

Check with your doctor before taking insulin, diabetes pills, blood pressure

medicine, heart pills, or any other medication on the day of surgery.

Do not wear contact lenses to the hospital. You may wear glasses.

What to Expect While You're There

You may encounter the following procedures and equipment during your stay.

Taking Vital Signs: These include your temperature, blood pressure, pulse

(counting your heartbeats), and respirations (counting your breaths). A

stethoscope is used to listen to your heart and lungs. Your blood pressure is

taken by wrapping a cuff around your arm.


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Blood Tests: You may need blood taken for tests. It can be drawn from a vein in

your hand or from the bend in your elbow. Several samples may be needed.

Chest X-ray: The doctor will check this picture of your lungs and heart to make

sure you're ready for surgery.

Heart Monitor: Typically, three to five sticky pads are placed on different parts of

your body. Each pad has a wire that is hooked to a TV-type screen or to a small

portable box (telemetry unit) that shows a tracing of each heartbeat.

IV: A tube placed in your vein for giving medicine or liquids. It will be capped or

have tubing connected to it.

Pulse Oximeter: With a little clip connected to your ear, finger, or toe, this

machine measures the oxygen in your blood.

Pre-Op Preparations: Medical personnel may put a rolled sheet or small pillow

under your shoulders. This will lift your chin and extend your neck so your doctor

can see your thyroid better. Your arms will be tucked at your sides so that the

doctor can get close to you during surgery.

General Anesthesia: You'll be kept completely asleep throughout the operation.

The anesthetic is given either as a liquid in your IV or as a gas through a face

mask or tube placed in your mouth and throat.

2.4 Perioperative Tasks and Responsibilities of the Nurse

Pre-operative

The Preoperative phase begins when the decision to proceed with surgical interventions

is made and ends with the transfer of the patient onto the operating room table. The

scope of nursing activities during this period involves the following:

Circulating Nurse

Assessing the client

Delegating and monitoring unlicensed personnel

Ensuring all equipment is working properly


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Identifying and counting the sponges, sharps, and instruments prior

the surgery

Guaranteeing sterility of instruments and supplies

Assisting with positioning

Performing surgical skin preparation

Monitoring the room and team members for breaks in sterile

technique

Assisting anesthesia personnel with induction and physiologic

monitoring

Coordinating activities with other departments, such as laboratory

Obtain written consent

review the chart and confirm that all paperwork is in order

Preoperative teaching such as giving the patient a brief description of

what he or she will expect in the Operating Room in order to allay fear

and anxiety

Circulating Nurse

Gathering all equipment for the procedure

Perform the surgical hand scrub making sure that he or she upholds

the principles of sterile technique

Preparing all supplies and instruments using sterile technique

Intra-operative

The Intraoperative phase begins when the patient is transferred on to the Operating

Room table and ends with the admission of the patient to the Post Anesthesia Care Unit.

The scope of nursing activities during this phase includes:


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Circulating Nurse

Documenting care provided

Checks the time the operation began

Notes when, how and what specimen, if available, was removed from

the patients body

Minimizing conversation and traffic within the Operating room suite

Maintaining an accurate count of sponges, sharps, and instruments

on the sterile field

Scrub Nurse

Maintaining sterility within the sterile field

Handling the supplies and the instruments

Maintaining an accurate count of sponges, sharps, and instruments

on the sterile field.

Post-operative

The postoperative phase begins with the admission of the patient to the Post Anesthesia

Care Unit and ends with a follow-up evaluation by the physician. The scope of nursing

activities during this phase includes:

Circulating Nurse

Counting and ensuring the exact count of the sponges, sharps, and

instruments used in the surgery

Documenting the care provided

Instructing the patient to make an appointment to have the surgeon

remove the sutures between the fifth and seventh day after the

operation


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Incision care and activity guidelines are discussed

Scrub Nurse

Counting the exact count of the sponges, sharps, and instruments

used in the surgery

Washing of the instrument

2.5 Expected Outcomes of Surgical Treatment Performed

Physiologic Outcomes

The outcomes after surgery depend on the reason for thyroidectomy. If the thyroid was

removed to treat hyperthyroidism, the following symptoms should subside: Excessive

fatigue, Weight loss, Nervousness, Rapid heart beat, Excessive sweating, Feeling of

being hot, Tremors, and Menstrual cycle irregularities

If the thyroid was removed to treat a thyroid tumor, nodule, or excessive goiter, the

outcomes include: Removal of cancerous tissue from the body ,Improvement in

swallowing or airflow that may have been compromised by an oversized thyroid gland.

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

major or minor complications. Possible complications include:

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


35/65

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.

Wound infection

The patient may notify his physician if any of the following occurs: Numbness or tingling

around the lips or extremities, Twitching or spasms ,Excessive and progressive

fatigue ,Signs of infection, including fever and chills ,Redness, swelling, increasing pain,

excessive bleeding, or discharge from the incision site ,Cough, shortness of breath,

chest pain, or severe nausea or vomiting.

After Surgery:

The incision will be bandaged to keep the area clean and prevent infection. (A nurse

may briefly remove the bandage and check the stitches shortly after surgery.) Patient

needs to stay in bed until the doctor says it's safe to get up. As the patient begins

recovery, possibly expect the following:

Oxygen: At times during your stay, your body may need extra oxygen. It is given

either through a plastic mask over your mouth and nose or through nasal prongs.

If the oxygen dries out your nose or the nasal prongs bother you, tell your nurse,

but don't take off the oxygen on your own.

Deep Breathing and Coughing: These exercises help prevent a lung infection

after surgery. Deep breathing opens the tubes going to your lungs. Coughing

helps to bring up sputum from your lungs and keep them clear. You should deep

breathe and cough every hour while you are awake, including any time you

spend awake during the night.
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Take a deep breath and hold it as long as you can. Then push the air out of your

lungs with a deep strong cough. Put any sputum that you have coughed up into a

tissue. Take 10 deep breaths in a row every hour while awake. Remember to

follow each deep breath with a cough.

Incentive spirometer: This piece of equipment helps you take deeper breaths. Put

the plastic nozzle into your mouth, take a very deep breath, and hold it as long as

possible. Then blow as hard as you can into the mouthpiece. Take 10 deep

breaths in a row every hour while awake. Remember to follow each deep breath

with a cough.

Drains: Thin rubber tubes may be put into the area around your incision to drain

off excess fluid. They will be taken out when no longer needed.

Activity: You may need to rest in bed for a while. But even if you are confined to

bed, it's important to exercise your legs in order to stop blood clots from forming.

Lift one leg off the bed and draw big circles with your toes, then repeat with the

other leg. You can also try lying on your side and pretending to pedal a bike.

When you're told it's OK to get out of bed, make sure someone is with you the

first time you try. If you feel weak or dizzy, sit or lie down right away.

Strict Intake/Output: Your doctor may need to know the amount of liquid you are

taking in versus the amount you lose in your urine. This is often called an "I&O."

Unless told otherwise, drink 6 to 8 large glasses of water each day. Keep a

record of exactly how much liquid you drink.

Your output of urine may have to be measured. Ask your doctor whether it's OK

to use the toilet.

Antibiotics: These medicines help prevent bacterial infection. They may be given

by IV, as a shot, or by mouth.

Pain Medicine: To ease pain after the operation, your doctor will probably

prescribe medication to be given by IV, as a shot, or by mouth. Tell the doctor or

your nurses if the pain won't go away or keeps coming back.


37/65

Anti-Nausea Medicine: This medicine calms your stomach and controls vomiting.

Your doctor may suggest you take it at the same time as your pain medicine,

which sometimes upsets the stomach.

Stool Softeners: These medications make bowel movements softer so you won't

need to strain.

Psychosocial Outcomes and Quality of Life

Follow-up monitoring for thyroid cancer can have profound effects on patients' lives, as

they are required to undergo levothyroxine withdrawal for 4-6 weeks prior to whole-body

scanning. This places the patient in the position of trying to maintain normal activity and

function while experiencing the well-documented effects of hypothyroidism, including

increased fatigue, memory loss, mood disturbances, decreased motor skills, and the

many other effects of thyroid dysregulation. The impact of this experience on work

performance, family relationships, and social life can be detrimental to the well-being of

these patients.

Although the significant effects of levothyroxine withdrawal have been documented for

some time, significant deficits in the health-related quality of life and psychometric

functionality of patients while on maintenance levothyroxine have recently been

reported. Although these deficits are less severe than those experienced during periods

of levothyroxine withdrawal, they can be significant, as levothyroxine supplementation

therapy typically continues for the remainder of a patient's life

2.6 Medical Management of Physiologic Outcomes

When the patient wake up from surgery, the patient will be transported to the recovery

room (PACU), where would spend about 30 minutes to an hour, until you are fully awake

and stable for transportation to his room.

The patient will be asked to speak to find out if your voice is hoarse. Many

patients, especially smokers, have a raspy or hoarse voice when they wake up from

anesthesia. Smokers have a tendency to cough.


38/65

The patient will notice a dressing wrapped around your neck and drain tubes

attached to your clothes or a necklace. These are usually removed the next day.

Instruct the patient do not pull on them or try to empty the attached plastic bulbs.

For 2 3 days after the surgery, it is not unusual to have pain or difficulty on

swallowing.

The nurses have standing orders to give you antibiotics, pain killers, thyroid

replacement hormone and medications for nausea and vomiting. If there are no

contraindications, the patient will also receive the usual home medications.

Most patients develop a transient hypocalcemia (low calcium) in the immediate

post-operative period. That is why calcium, phosphorus and magnesium levels will be

monitored every six hours and sometimes more frequently. If the patient develop

hypocalcemia, he will be given calcium by mouth and / or intravenously. Tingling

around the mouth and face, muscle spasms of the hands and feet, involuntary grimacing

and sometimes difficulty in breathing and gasping for air (stridor) are signs of

hypocalcemia.

If he feel up to it, he is allowed to stand up, walk and go to the bathroom, with

assistance and always, with someone present in the room. Do not attempt at walking or

going to the bathroom if the patient is alone in the room. the patient may be too groggy

from the pain killers or you may pass-out and fall down.

The day after surgery, the doctor will remove the drains and dressing. In

general, the wound is sealed with a thin clear acrylic layer (Dermabond) and the sutures

are buried under the skin. There is no need to apply antibiotic ointment on the wound.

The patient is allowed to take a shower without covering the wound. This acrylic film will

peel off in a couple of weeks. When the patient goes home, warn the patient to keep the

wound exposed and do not hide it with a dressing or scarf. A little antibiotic ointment

may be used at the site of the drains for a day or two. In general the drain wound heals

and stops oozing in 24 hours.


39/65


40/65

2.7 Nursing Management of Physiologic, Physical and Psychosocial Outcomes

Nursing Diagnosis Prioritization

Ineffective airway clearancerelated to bleeding and/ or laryngeal edema

1

Acute pain related to presence of surgical incision 2

Impaired skin and tissue integrity secondary to

surgery

3

Risk for Injury: Hemorrhage 4

Risk for infection related to invasive surgicalprocedure

5

Impaired verbal communication related to damage

and/or manipulation of laryngeal nerves secondary

to surgery

6

Knowledge deficit (postoperative care) 7


41/65

Problem # 1: Ineffective airway clearance related to bleeding and/ or laryngeal edema

Assessment Diagnosis Scientific

Explanation

Objectives Interventions Rationale Desired

Outcomes

S= the patient

may verbalize

dyspnea

Ineffective

airway

clearance

related to

If hemorrhage

(bleeding)

beneath the

neck wound

SHORT

TERM:

After 1 hour of

> establish rapport > to gain the trust

and cooperation of

the client

SHORT TERM:

The patient will

be able to


42/65

O= the patient

may manifest:

> presence of

surgical woundon the low

collar area of

neck

> adventitious

breath sounds

( wheezes,

crackles)

> changes in

respiratory

rate and

rhythm

> difficulty

vocalizing

> restlessness

bleeding and/

or laryngeal

edema

occurs, the

wound bulges

and the neck

swells, possibly

compressing

structures insidethe neck and

interfering with

breathing. This

is an

emergency.

Laryngeal

edema may also

occur due to

surgical

manipulation.

Bilateral

recurrent nerve

injury with acute

paralysis of both

vocal cords may

occur during

surgery which

nursing

interventions,

the patient will

be able to

maintain

airwaypatency.

LONG TERM:

After 3 days of

nursing

interventions,

the patient will

be able to

maintain vitalsigns,

respirations,

and breath

sounds within

normal limits.

> 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 minutes for 1 hour

immediately after

surgery

> keep dressing sizeminimized

> position patient on

back with head of

bed elevated 30 to

45 degrees

> to provide

baseline data and

note deviations

from normal

>to ascertain status

and note progress

> to identify signs of

bleeding

> to prevent

impaired view of

incision site

> to promote ease

in breathing

> to identify early

maintain

airway

patency.

LONG TERM:

The patient will

be able to

maintain vital

signs,

respirations,

and breath

sounds within

normal limits.


43/65

> cyanosis may cause

obstruction of

the airway

because of the

adduction of the

true vocal cords.

> monitor for signs of

respiratory distress

or obstructed airway

qh : stridor,

wheezing, coarse

airway crackles,dyspnea, cyanosis,

labored respirations

> teach and assist

patient to turn,

cough, and deep

breathe q2h and prn

>if indicated, keep

suction equipment at

bedside; gently

signs of respiratory

distress caused by

tracheal edema

> to prevent

pulmonary

complications and

to take advantage

of gravity

decreasing

pressure on the

diaphragm and

enhancing drainage

of / ventilation todifferent lung

segments

> to clear airway

when secretions are

blocking airway


44/65

suction oropharynx

only when necessary

> keep environment

allergen free

> have tracheostomytray 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

> to maintain patent

airway

> to use if patient

experiences severerespiratory distress

> to mobilize

secretions

> to prevent fatigue

> Hoarseness and

sore throat

secondary to

edema or damage

to laryngeal nerve

may last several

days. Increased

difficulty may


45/65

> evaluate changes

in sleep pattern

> observe for signs/

symptoms of

infection

> note physician if

dressing requires

reinforcement more

than one time

indicate impending

obstruction

> to assess

changes

>to identifyinfectious process/

promote timely

intervention

> to promote timely

intervention/revision

in plan of care


46/65

Problem # 2: Acute pain related to presence of surgical incision


Explanation


Outcomes

S = Patient

may report

pain on the

operative site

O = Patient

may

manifest:

> presence of

surgical

wound on the

low collar

area of neck

>facial

grimaces

>restlessness

Acute pain

related to

presence of

surgical

incision

Patient experiences

pain due to the

operative

procedure done. As

the anesthetic

agent wear off,

sensation returns

and pain of the

incision, retraction

of muscles, and

other manipulations

done on the body

come into

awareness. The

weight of the head

also creates stress

on the operative

area. The injured

tissue releases

SHORT TERM:

After 5 hours of

nursing

interventions,

the patient will

be able to

demonstrate

use of

relaxation skills

and diversional

activit ies as

indicated for

individual

situation.

LONG TERM:

> establish rapport

> monitor vital

signs

> perform a

comprehensive

assessment of pain

to include location,

characteristics,

onset/duration,

frequency, quality,

severity(0 to 10),

and precipitating or

aggravating factors

> note location of

surgical procedures

> to gain the trust

and cooperation of

the client

>to provide baseline

data

> to assess etiology/

precipitating

contributory factors

> this can influence

the amount of pain

experienced

SHORT

TERM:

The patient

will be able

to

demonstrate

use of

relaxation

skills and

diversional

activities as

indicated for

individual

situation.

LONG

TERM:


47/65

>irritability

>reduced

interaction

with people

>change inrespiration,

blood

pressure, and

pulse

pain substances

such as

prostaglandins,

histamine and

bradykinin. These

substancestransmit 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

transmitted back to

the site of injury

then through the

spinal cord. In the

spinal cord and in

the brain, many

chemicals such as

After 2 days of

nursing

interventions,

the patient will

be able to

report feeling ofwell-being and

comfort.

> observe body

language for

evidence of pain

> prevent flexion orextension of head

and neck

>place patient in

semi-fowlers

position with

support of

head/neck with

sandbags or small

pillows

> control

environmental

temperature

> provide quiet

environment

> to ensure comfort

despite impaired

communication

>to prevent tension

on sutures

>to prevent

hyperextension of

neck and protect

integrity of suture

line

> cool surroundings

aid in minimizing

dermal discomfort

> to assist client for

alleviation of pain

The patient

will be able

to report

feeling of

well-being

and comfort.


48/65

endorphins,

serotonin and

adrenaline are

involved in

modulation and

transmission ofpain.

> instruct patient to

use hands to

support head

during movement

> encourage

adequate rest

periods

> encourage use of

relaxation

techniques such as

soft music, reading,

focused breathing

>encourage

diversional

activities such asTV/radio,

socialization with

others

> take time to listen

and maintain

> to prevent tension

on sutures


> promotes rest,

redirects attention

> to control pain


49/65

frequent contact

with patient

>provide cool

liquids by mouth orsoft foods, such as

ice cream/popsicles

> monitor

effectiveness of

pain medications

> administer

analgesic throat

spray or lozenges

as ordered and as

patient desires

> helpful in

alleviating anxiety

and refocusingattention, which may

relieve pain

>to soothe sore

throat; soft foods

may be tolerated

better if patient

experiences difficulty

swallowing

> to promote timely


of plan of care

>Pharmacologicalmeans to minimizepain

Problem # 3: Impaired skin and tissue integrity secondary to surgery


50/65


Explanation


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

deeper

structures. Then,

all or part of the

thyroid gland will

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

> 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

> note odors and

drains emitted from

the skin/ area of injury

> to gain the trust

and cooperation of

the client

> to provide baseline

data

> to provide

comparative baseline

> to assess extent of

involvement

> to assess early

progression of wound

healing or

development of

hemorrhage or

infection

SHORT

TERM:

The patient

will be able to

verbalize

understanding

of condition

and causative

factors.

LONG TERM:

The patient

will be able to

display


51/65

be cut free from

surrounding

tissues and

removed. After

the thyroid gland

is removed, oneor 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

closed with

sterile paper

tapes. The

incision can be

an entry for

bacteria.

be able to

display

progressive

improvement

in wound

healing.

> 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,

support incision, and

prevent infection

> use appropriate

wound coverings

> avoid use of plastic

material and remove

wet/wrinkled linens

promptly

> to identify

contribution factors

> to promote timely


of plan of care

> to assist bodys

natural process of

repair

> to protect the

wound and/or

surrounding tissues

> to prevent skin

breakdown due to

progressive

improvement

in wound

healing.


52/65

> provide good

nutrition with

adequate protein and

calorie intake, and

vitamin/ mineral

supplements asindicated

> encourage

adequate rest and

sleep

>encourage early

ambulation and

mobilization

> provide position

changes

> practice aseptic

moisture

> to provide a

positive nitrogen

balance to aid inhealing and to

facilitate healing


> to promote

circulation and

reduce risks

associated with

immobility

> to prevent


53/65

technique in

cleansing/dressing

and medicating

lesions

> instruct proper

disposal of soiled

dressing

>refer to dietician as

appropriate

excessive tissue

pressure

> to reduce risk of

cross-contamination

> to prevent spread

of infectious agent

> to enhance healing

Problem # 4: Risk for Injury: Hemorrhage


Explanation

Objectives Nursing Interventions Rationale Desired

Outcomes


54/65

S:

O:

Risk for Injury:Hemorrhage

Increasedvascularity from thehyperthyroidismincreases the riskof postoperativehemorrhage.

Short term:

After 2 hours ofnursinginterventions,the bleeding willbe minimized.

Long Term:

After 3 days ofnursinginterventions,bleeding will becontrolled andthe patient willnot manifestexcessivebleeding thatmay lead toshock.

> Monitor vital signsfrequently.

> Note signs of upperairway obstructionand difficulty

swallowing.

> Check dressingfrequently, especiallyposterior portion.

> Prepare atracheostomy tray atthe patients bedsidefor 24 hours aftersurgery.

> Increased pulse,decreased bloodpressure areindicators of possible bleeding.

> May indicatedeveloping

sequesteredbleeding.

> If bleedingoccurs, anteriordressing mayappear dry as bloodpools dependently.

> To assist withemergencytracheotomy if respiratory distressis imminent due tohemorrhage.

Short term:

The bleedingwill beminimized.

Long Term:

The bleedingwill becontrolled andthe patientshall not havemanifestedexcessivebleeding thatmay lead toshock.

Problem # 5: Risk for infection related to invasive surgical procedure


Explanation


Outcomes


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S=

O=

Risk for

infection

related to

invasive

surgical

procedure

The patient is at

risk of acquiring

infection due to

the breakage on

the continuity of

the first line ofdefense, which is

the skin. The

patient had

undergone an

invasive

procedure,

thyroidectomy. If

there is a

breakage in the

skin, pathogens

will easily be able

to invade the

body system.

SHORT

TERM:

After 2 hours

of nursing

interventions,

the patient will

be able to

verbalize

understanding

on the health

teachings

given.

LONG TERM:

After 2 days

of nursing

interventions,

the patient

and SO will

be able to

> establish rapport

> monitor vital signs

and breath sounds

q4h to 8h

>note risk factors for

occurrence of infection

such as impaired skin

integrity

>observe for localized

signs of infection or

impaired healing:

redness, swelling, foul

drainage, fever

>stress proper hand

washing techniques to

client

> to gain the trust

and cooperation of

the client

> to provide

baseline data and

note deviations from

normal

> to assess

causative factors

> to assess

causative factors

> to promote a first-

line defense against

nosocomial

infections or cross

contamination

> to prevent

SHORT TERM:

The patient will

be able to

verbalize

understanding

on the health

teachings

given.

LONG TERM:

The patient and

SO will be able

to effectively

demonstrate


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effectively

demonstrate

techniques,

lifestyle

changes to

prevent riskfor infection.

> monitor visitors

>change dressings

daily and prn when

wet

>prevent stress on

incision line, cleanse

site daily as ordered,

and apply dry, sterile

dressing

> use only necessary

dressing and tape

> remove tape toward

incision

exposure of client

> to prevent the

occurrence of

infection

> to promoteincision healing

>to allow visibility

around surgical sign

> to prevent stress

on suture line and

possible interruption

of wound healing

> premature

discontinuation of

treatment when

techniques,

lifestyle

changes to

prevent risk for

infection.


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> emphasize necessity

of taking antibiotics as

directed

> administer prophylactic antibiotics

as ordered

client begins to feel

well may result in

return of infection

>To prevent

occurrence of

infection

Problem # 6: Impaired verbal communication related to damage and/or manipulation of laryngeal nerves secondary to surgery


Explanation


Outcomes


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S= the patient

may verbalize

dyspnea

O= the patientmay manifest:

> presence of

surgical

wound on the

low collar area

of neck

>impaired

articulation

>inability to

speak

>use of

nonverbal

cues/ gestures

>difficulty

Impaired verbal

communication

related to

damage and/or

manipulation of

laryngealnerves

secondary to

surgery

Injury that

results from

severing,

clamping,

compressing, or

stretching either

the recurrent

laryngeal nerveor superior

laryngeal nerve

during thyroid

surgery may

result in severe

untoward

sequelae for the

patient. The

recurrent

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

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, the

patient will be

able to

communicate

verbally without

> establish rapport

> monitor vital

signs

> monitor voice

quality q2h

> monitor for

edema at surgical

incision and glottis

> note presence of

draining tubes that

blocks speech

>if indicated

provide alternative

means of

communication

> 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

> to assess

causative factors

>to minimize

patients need to

speak

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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speaking or

verbalizing

paramedian

position, thus

immediate

hoarseness

occurs. The

voice may never

recover its

timbre andfocus, 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

voice change. such as use of

pad and pencil or

slate board

>keep call bell

within reach at all

times

> reduce

environmental

stimuli

> validate

meaning of

nonverbal

communication

> report increasing

hoarseness to

physician

> anticipate

patients needs as

>to minimize

patients need to

speak

> to lessen anxiety

which may worsen

problem

> because they

may be wrong

> to promote timely

intervention /

revision in plan of

care

>to minimize

patients need to

speak


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affects voice

pitch. Since the

cord is unable to

lengthen and

tense, the voice

is low in pitch

and breathy in

quality.

indicated

Problem # 7: Knowledge deficit (postoperative care)


Explanation


Outcomes

S = the patient

may verbalize

Knowledge

deficit

The patient may

need hormone

SHORT TERM: > establish > to gain the trust

and cooperation of

SHORT


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request for

information

O= the patient

may manifest:

> hostility

> anxiety

> apathetic

>

development

of preventable

complication

(postoperative

care)

replacement for

hypothyroidism.

This drug therapy is

important to the

satisfactory

recovery of thepatient and

adequate

knowledge can

enhance

cooperation.

After 2 hours of

nursing

interventions,

the patient will

be able to

verbalizeexpectations of

postoperative

needs.

LONG TERM:

After 2 days of

nursing

interventions,

the patient willbe able to

demonstrate

increase interest

or assume

responsibility for

own learning

rapport

> monitor vital

signs

>discuss need for

adequate rest

>discuss

necessity for well-

balanced

nutritious diet

> provide

information about

possibility of

changes in voice

the client

>to provide

baseline data and

note deviationsfrom normal

>to promote healing

> to regain/maintain

adequate weight

and promote

healing

> possible

alteration in vocal

cord function may

cause changes in

TERM:

The patient

will be able to

verbalize

expectations

of

postoperative

needs.

LONG TERM:

The patient

will be able to

demonstrate

increase

interest or

assume

responsibility

for own

learning and


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and begin to

look for

information and

ask questions.

> give information

about the use of

loose fitting

scarves to cover

the scar. Avoid

the use of jewelry

>apply cold

cream after

sutures have

been removed

>observe for

signs of

hypothyroidism

pitch and quality of

voice, which may

be temporary or

even permanent

> covers the

incision without

aggravating the

healing/precipitating

infections of the

suture line

>moistens tissues

and may help to

minimize scarring

> possibility of

occurrence

increases with time

begin to look

for

information

and ask

questions.


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III. Conclusion

The thyroid gland is one of the primary endocrine organs whose functions are

necessary for a healthy and normal way of life. Unfortunately, diseases causing

impairments, dysfunction and the like that involve the delicate structures of the thyroid

gland are inevitable and therefore cause alterations and distortions to the functions of

not only the thyroid but involving also neighbouring organs such as the parathyroid

glands and the trachea. And so to, avoid such problems, thyroidectomy, or the removal

of all or a portion of the thyroid gland may be necessary.

Based from the opportunity to observe a thyroidectomy procedure, the

researchers now appreciate the delicacy of a thyroidectomy. For other student-nurses

who have not yet gained clinical experience in a real operating room set up, such a

procedure can be viewed as being just a thyroid surgery, one that does not strike much

interest compared to the complexity of other operations such as IM nailing, craniotomy

or a kidney transplant.

A thyroid surgery may seem like a simple slicing of the neck and removal of the

thyroid; nevertheless, considering its complications and risks, it is far from simple. One

must always remember that a responsible and a knowledgeable nurse ought never to

view the perplexity of a procedure since regardless of how simple or how complex a

procedure may be, one minor misstep could instantly jeopardize the patients life.

Instead, every nurse should always attempt to give her best efforts in any intervention

she assists in.

The group would definitely recommend the procedure to patients who are in need

of surgical interventions for the thyroid gland in order for them to be able to do and

perform their usual activities and live a normal way of life. The procedure may have been

considered delicate, but with skilful surgeons, patients are surely in good hands and will

be able to achieve the desired outcomes of the surgery.


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IV. References

Books:

Black, Joyce and Jane Hokanson Hawks, Medical-Surgical Nursing,7 th Edition,

Elsevier (Singapore) PTE LTD Health Sciences Asia, Singapore, 2005

Kozier, Barbara et.al, Fundamentals of Nursing 7th Edition, Pearson Education

Inc., Singapore, 2004

Naumann, H. (1984) Head and Neck Surgery. Germany, Georg Thieme Verlag.

Sabiston, D. (1997) Textbook of Surgery: The Biological Basis of Modern

Surgical Practice. 15th ed. Philadelphia, W.B. Saunders Company.

Websites:

http://www.healthscout.com/ency/68/23/main.html#DescriptionofThyroidecto

my

http://www.healthsquare.com/mc/fgmc9008.htm

http://www.surgery.com/procedure/thyroidectomy/demographics

http://emedicine.medscape.com/article/835535-overview

http://en.wikipedia.org/wiki/Thyroidectomy

http://www.mayoclinic.com/health/thyroidectomy/AN01228

http://www.debakeydepartmentofsurgery.org/home/content.cfm?

proc_name=thyroidectomy&content_id=274

http://www.um-endocrine-surgery.org/thyroid.html

http://www.um-endocrine-surgery.org/paraop.html#link2

http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?

requestURI=/healthatoz/Atoz/ency/thyroidectomy.jsp

www.medterms.com /script/main/art.asp?articlekey=5783
http://www.healthscout.com/ency/68/23/main.html#DescriptionofThyroidectomyhttp://www.healthscout.com/ency/68/23/main.html#DescriptionofThyroidectomyhttp://www.healthsquare.com/mc/fgmc9008.htmhttp://www.surgery.com/procedure/thyroidectomy/demographicshttp://en.wikipedia.org/wiki/Thyroidectomyhttp://www.mayoclinic.com/health/thyroidectomy/AN01228http://www.debakeydepartmentofsurgery.org/home/content.cfm?proc_name=thyroidectomy&content_id=274http://www.debakeydepartmentofsurgery.org/home/content.cfm?proc_name=thyroidectomy&content_id=274http://www.um-endocrine-surgery.org/thyroid.htmlhttp://www.um-endocrine-surgery.org/thyroid.htmlhttp://www.um-endocrine-surgery.org/paraop.html#link2http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/thyroidectomy.jsphttp://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/thyroidectomy.jsphttp://www.medterms.com/script/main/art.asp?articlekey=5783http://www.medterms.com/script/main/art.asp?articlekey=5783http://www.healthscout.com/ency/68/23/main.html#DescriptionofThyroidectomyhttp://www.healthscout.com/ency/68/23/main.html#DescriptionofThyroidectomyhttp://www.healthsquare.com/mc/fgmc9008.htmhttp://www.surgery.com/procedure/thyroidectomy/demographicshttp://en.wikipedia.org/wiki/Thyroidectomyhttp://www.mayoclinic.com/health/thyroidectomy/AN01228http://www.debakeydepartmentofsurgery.org/home/content.cfm?proc_name=thyroidectomy&content_id=274http://www.debakeydepartmentofsurgery.org/home/content.cfm?proc_name=thyroidectomy&content_id=274http://www.um-endocrine-surgery.org/thyroid.htmlhttp://www.um-endocrine-surgery.org/paraop.html#link2http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/thyroidectomy.jsphttp://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/thyroidectomy.jsphttp://www.medterms.com/script/main/art.asp?articlekey=5783


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www.yoursurgery.com /ProcedureDetails.cfm?BR=6&Proc=52
http://www.yoursurgery.com/ProcedureDetails.cfm?BR=6&Proc=52http://www.yoursurgery.com/ProcedureDetails.cfm?BR=6&Proc=52http://www.yoursurgery.com/ProcedureDetails.cfm?BR=6&Proc=52

or case report

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