Throidectomy

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Chapter I
INTRODUCTION

General Description of Disease Condition Requiring Surgical Procedure
Thyroidectomy is a surgical procedure in which all or part of the thyroid gland
is removed. The thyroid gland is located in the forward (anterior) part of the neck just
under the skin and in front of the Adam's apple. The thyroid is one of the body's
endocrine glands, which means that it secretes its products inside the body, into the
blood or lymph. The thyroid produces several hormones that have two primary
functions: they increase the synthesis of proteins in most of the body's tissues, and
they raise the level of the body's oxygen consumption.

All or part of the thyroid gland may be removed to correct a variety of
abnormalities. Before a thyroidectomy is performed, a variety of tests and studies are
usually required to determine the nature of the thyroid disease. Laboratory analysis
of blood determines the levels of active thyroid hormones circulating in the body. The
most common test is a blood test that measures the level of thyroid-stimulating
hormone (TSH) in the bloodstream. Sonograms and computed tomography scans
(CT scans) help to determine the size of the thyroid gland and location of
abnormalities. A nuclear medicine scan may be used to assess thyroid function or to
evaluate the condition of a thyroid nodule, but it is not considered a routine test. A
needle biopsy of an abnormality or aspiration (removal by suction) of fluid from the
thyroid gland may also be performed to help determine the diagnosis.

Continued treatment with antithyroid drugs may be the treatment of choice for
hyperthyroidism and goiter. Otherwise, no other special procedure must be followed
prior to the operation.

Relevant and Current Statistical Evidence or Critical Findings
Screening tests indicate that about 6% of the United States population has
some disturbance of thyroid function, but many people with mildly abnormal levels of
thyroid hormone do not have any disease symptoms. It is estimated that between 12
and 15 million people in the United States and Canada are receiving treatment for
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thyroid disorders as of 2002. In 2001, there were approximately 34,500
thyroidectomies performed in the United States. Females are somewhat more likely
than males to require a thyroidectomy. (Retrieved at
http://www.surgeryencyclopedia.com/St-Wr/Thyroidectomy.html; accessed on
January 22, 2011)

Recent Trends, Refinements, and/or Innovations in Treatment
1. Outpatient Thyroid Surgery Found To Be Safe, Cost Effective
Thyroid surgery, which has traditionally been an overnight hospital procedure,
can be done safely in an outpatient setting, and in fact is preferable because it is less
expensive, according to a new study published in the April issue of Otolaryngology-
Head and Neck Surgery. The study's authors found not only were complications low,
but conducting the procedure in an outpatient environment significantly lowered the
cost by several thousand dollars. (Retrieved at
http://www.medicalnewstoday.com/articles/67471.php; accessed on January 23,
2011)

2. 'Scarless' Thyroid Surgery Uses 3-D, High-Def Robotic Equipment
The scarless thyroid surgery is a new form of endoscopic surgery. The
technique uses the latest Da Vinci three-dimensional, high-definition robotic
equipment to make a two-inch incision below the armpit that allows doctors to
maneuver a small camera and specially designed instruments between muscles to
access the thyroid. The diseased tissue is then removed endoscopically through the
armpit incision. This technique safely removes the thyroid without leaving so much
as a scratch on the neck. The benefits of this new technique go beyond aesthetics.
Unlike other forms of endoscopic thyroid surgery, it doesn't require blowing gas into
the neck to create space to perform the operation. Those techniques can risk
complications if the gas is retained in the neck or chest after surgery, causing
significant discomfort and postoperative complications. There is a reduced likelihood
of laryngeal nerve damage and less risk of trauma to the parathyroid glands, which
are near the thyroid. There is also significant faster recovery time and less
discomfort on the part of the patients. (Retrieved at http://www.sciencedaily.com
/releases/2009/11/091124174735.htm; accessed on January 24, 2011)

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3. Differences in postoperative outcomes, function, and cosmesis: open
versus robotic thyroidectomy.
Robotic thyroidectomy using a gasless transaxillary approach, first described
in 2008, has become popular. This study compared outcomes, including
postoperative distress and patient satisfaction, for patients undergoing robotic
thyroidectomy with those for patients treated by conventional open thyroidectomy.
Methods: Of 84 prospectively enrolled patients, 41 underwent robotic thyroidectomy
(the robot group), and 43 received conventional open thyroidectomy (the open
group). All the patients were followed up for at least 3 months after surgery. Although
postoperative pain levels and complications were comparable in the two groups,
conventional open thyroidectomy requires a shorter operative time. The robotic
technique, however, offers several distinct advantages including very good to
excellent cosmetic results, reduced postoperative neck discomfort, and fewer
adverse swallowing symptoms. (Retrieved at:
http://web.ebscohost.com/ehost/detail?hid=107&sid=79aa1711-581b-4e56-8485-
4efd96144899%40sessionmgr104&vid=1&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d
%3d#db=a3h&AN=55216256; accessed on January 24, 2011)

4. (INSERT TITLE HERE)
Researchers at the National Institutes of Health have identified a compound
that prevents overproduction of thyroid hormone, a finding that brings scientists one
step closer to improving treatment for Graves' disease. Attacking the problem at its
root cause, lead researcher Susanne Neumann, Ph.D., and her colleagues at the
NIH's National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
have identified a chemical compound that binds to the receptors and acts as an
antagonist, keeping the stimulating antibodies from their work and potentially
allowing the thyroid cells to revert to normal function. (Retrieved at (complete URL);
accessed on January 25, 2011)

Implication of The Above Information for Nurses as a Productive
Member of Society
Nurses are health care providers and considered as productive member of
the society. Nurses should have a concrete background or knowledge on the current
illness condition of their patient in order to render adequate and appropriate nursing
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interventions. To render effective nursing care, one must have first basic information
related to the disease condition such as its possible causes and possible nursing
interventions, medical or surgical treatments. For example in this case, a nurse with
adequate knowledge could support the doctors explanation to the patient what
happens in thyroidectomy and it could help them understand the required surgery
and its possible complications. The nurse would also know which appropriate and
inappropriate interventions should not be given to the patient. The nurse could also
render preoperative and postoperative teachings efficiently as well.

These current trends encompass the continuous advancements with regards
to the study at hand. As thyroidectomy continuous to be one of the most common
surgical procedures done in the country, it is evident that the need to expand our
knowledge is a must in order to render appropriate and efficient service to our
clientele. Through various readings, lectures, activities, hospital experience etc.,
these placed a challenged in us to improve our nursing skills and clinical
competence; in such a way that we would likely to offer the community the efficient
services it needs in the future. It relates its theories and principles with the human
being a complex individual. Learning its process is an intricate procedure that
sometimes we should deal with the actual setting first before realizing and
understanding its real course of action.














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Chapter II
ANATOMY AND PHYSIOLOGY


ANATOMY OF THE THYROID GLAND
A large, highly vascular endocrine gland situated in the base of the neck. The
thyroid consists of two lobes, one on each side of the trachea, just below the larynx
or voice box. The two lobes are connected by a narrow band of tissue called the
isthmus. Internally, the gland consists of follicles, which produce thyroxine and
triiodothyronine hormones. Both these hormones contain iodine.

The thyroid controls how quickly the body burns energy, makes proteins,
and how sensitive the body should be to other hormones. The thyroid participates in
these processes by producing thyroid hormones, principally thyroxine (T4) and
triiodothyronine (T3). These hormones regulate the rate of metabolism and affect the
growth and rate of function of many other systems in the body. Iodine is an essential
component of both T3 and T4. The thyroid also produces the hormone calcitonin,
which plays a role in calcium homeostasis. Thyroid hormones also help maintain
normal blood pressure, heart rate, digestion, muscle tone, and reproductive
functions.

The thyroid tissue is made up of two types of cells: follicular cells and
parafollicular cells. Most of the thyroid tissue consists of the follicular cells, which
secrete iodine-containing hormones called thyroxine (T4) and triiodothyronine (T3).
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The parafollicular cells secrete the hormone calcitonin. The thyroid needs iodine to
produce the hormones.

About 95 percent of the active thyroid hormone is thyroxine, and most of the
remaining 5 percent is triiodothyronine. Both of these require iodine for their
synthesis. Thyroid hormone secretion is regulated by a negative feedback
mechanism that involves the amount of circulating hormone, the hypothalamus, and
the anterior pituitary gland (adenohypophysis).

The thyroid is controlled by the hypothalamus and pituitary. The gland gets its
name from the Greek word for "shield", after the shape of the related thyroid
cartilage. Hyperthyroidism (overactive thyroid) and hypothyroidism (underactive
thyroid) are the most common problems of the thyroid gland.

The thyroid gland is butterfly-shaped organ and is composed of two cone-like
lobes or wings: lobus dexter (right lobe) and lobus sinister (left lobe), connected with
the isthmus. The organ is situated on the anterior side of the neck, lying against and
around the larynx and trachea, reaching posteriorly the oesophagus and carotid
sheath. It starts cranially at the oblique line on the thyroid cartilage (just below the
laryngeal prominence or Adam's apple) and extends inferiorly to the fourth to sixth
tracheal ring. It is difficult to demarcate the gland's upper and lower border with
vertebral levels as it moves position in relation to these during swallowing.

The normal thyroid gland is easily palpable. Palpation is carried out from
behind using the digits to feel for the cricoid cartilage and for the 1st tracheal ring
directly below it. The isthmus of the thyroid overlies the 2nd through the fourth
tracheal rings, to which the pretracheal fascia (a fibrous sheath that contains the
thyroid and allows it to glide smoothly over the nearby contents) firmly attaches
through suspensory ligaments (extensions of the fascia). This attachment allows the
thyroid to move with the larynx during swallowing, an important fact in palpating the
thyroid as it is appropriate to ask the patient to sip a glass of water while palpating
the gland, as to allow the inferior portion to be better felt when it elevates with the
larynx.

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The thyroid isthmus is variable in presence and size, and can encompass a
cranially extending pyramid lobe (lobus pyramidalis or processus pyramidalis),
remnant of the thyroglossal duct. The thyroid is one of the larger endocrine glands,
weighing 2-3 grams in neonates and 18-60 grams in adults, and is increased in
pregnancy.

The thyroid is supplied with arterial blood from the superior thyroid artery, a
branch of the external carotid artery, and the inferior thyroid artery, a branch of the
thyrocervical trunk, and sometimes by the thyroid ima artery, branching directly from
the aortic arch. The venous blood is drained via superior thyroid veins, draining in
the internal jugular vein, and via inferior thyroid veins, draining via the plexus
thyroideus impar in the left brachiocephalic vein. Lymphatic drainage passes
frequently the lateral deep cervical lymph nodes and the pre- and parathracheal
lymph nodes. The gland is supplied by sympathetic nerve input from the superior
cervical ganglion and the cervicothoracic ganglion of the sympathetic trunk, and by
parasympathetic nerve input from the superior laryngeal nerve and the recurrent
laryngeal nerve.

PHYSIOLOGY OF THE THYROID GLAND
The primary function of the thyroid is production of the hormones thyroxine
(T4), triiodothyronine (T3), and calcitonin. Up to 80% of the T4 is converted to T3 by
peripheral organs such as the liver, kidney and spleen. T3 is about ten times more
active than T4.

T3 and T4 Production and Action
Thyroxine (T4) is synthesised by the follicular cells from free tyrosine and on
the tyrosine residues of the protein called thyroglobulin (TG). Iodine is captured with
the "iodine trap" by the hydrogen peroxide generated by the enzyme thyroid
peroxidase (TPO) and linked to the 3' and 5' sites of the benzene ring of the tyrosine
residues on TG, and on free tyrosine. Upon stimulation by the thyroid-stimulating
hormone (TSH), the follicular cells reabsorb TG and proteolytically cleave the
iodinated tyrosines from TG, forming T4 and T3 (in T3, one iodine is absent
compared to T4), and releasing them into the blood. Deiodinase enzymes convert T4
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to T3. Thyroid hormone that is secreted from the gland is about 90% T4 and about
10% T3.

Cells of the brain are a major target for the thyroid hormones T3 and T4.
Thyroid hormones play a particularly crucial role in brain maturation during fetal
development. A transport protein (OATP1C1) has been identified that seems to be
important for T4 transport across the blood brain barrier. A second transport protein
(MCT8) is important for T3 transport across brain cell membranes.

In the blood, T4 and T3 are partially bound to thyroxine-binding globulin,
transthyretin and albumin. Only a very small fraction of the circulating hormone is
free (unbound) - T4 0.03% and T3 0.3%. Only the free fraction has hormonal activity.
As with the steroid hormones and retinoic acid, thyroid hormones cross the cell
membrane and bind to intracellular receptors (1, 2, 1 and 2), which act alone, in
pairs or together with the retinoid X-receptor as transcription factors to modulate
DNA transcription.



T3 and T4 Regulation
The production of thyroxine and triiodothyronine is regulated by thyroid-
stimulating hormone (TSH), released by the anterior pituitary (that is in turn released
as a result of TRH release by the hypothalamus). The thyroid and thyrotropes form a
negative feedback loop: TSH production is suppressed when the T4 levels are high,
and vice versa. The TSH production itself is modulated by thyrotropin-releasing
hormone (TRH), which is produced by the hypothalamus and secreted at an
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increased rate in situations such as cold (in which an accelerated metabolism would
generate more heat). TSH production is blunted by somatostatin (SRIH), rising levels
of glucocorticoids and sex hormones (estrogen and testosterone), and excessively
high blood iodide concentration.

Calcitonin
An additional hormone produced by the thyroid contributes to the regulation of
blood calcium levels. Parafollicular cells produce calcitonin in response to
hypercalcemia. Calcitonin stimulates movement of calcium into bone, in opposition to
the effects of parathyroid hormone (PTH). However, calcitonin seems far less
essential than PTH, as calcium metabolism remains clinically normal after removal of
the thyroid, but not the parathyroids.

Significance of Iodine
In areas of the world where iodine (essential for the production of thyroxine,
which contains four iodine atoms) is lacking in the diet, the thyroid gland can be
considerably enlarged, resulting in the swollen necks of endemic goitre.

Thyroxine is critical to the regulation of metabolism and growth throughout the
animal kingdom. Among amphibians, for example, administering a thyroid-blocking
agent such as propylthiouracil (PTU) can prevent tadpoles from metamorphosing
into frogs; conversely, administering thyroxine will trigger metamorphosis.

In humans, children born with thyroid hormone deficiency will have physical
growth and development problems, and brain development can also be severely
impaired, in the condition referred to as cretinism. Newborn children in many
developed countries are now routinely tested for thyroid hormone deficiency as part
of newborn screening by analysis of a drop of blood. Children with thyroid hormone
deficiency are treated by supplementation with synthetic thyroxine, which enables
them to grow and develop normally.

Because of the thyroid's selective uptake and concentration of what is a fairly
rare element, it is sensitive to the effects of various radioactive isotopes of iodine
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produced by nuclear fission. In the event of large accidental releases of such
material into the environment, the uptake of radioactive iodine isotopes by the thyroid
can, in theory, be blocked by saturating the uptake mechanism with a large surplus
of non-radioactive iodine, taken in the form of potassium iodide tablets. While
biological researchers making compounds labelled with iodine isotopes do this, in
the wider world such preventive measures are usually not stockpiled before an
accident, nor are they distributed adequately afterward. One consequence of the
Chernobyl disaster was an increase in thyroid cancers in children in the years
following the accident.

The use of iodized salt is an efficient way to add iodine to the diet. It has
eliminated endemic cretinism in most developed countries, and some governments
have made the iodination of flour mandatory. Potassium iodide and Sodium iodide
are the most active forms of supplemental iodine.




















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Chapter III
CLINICAL INTERVENTION

Description of Prescribed Surgical Treatment Performed


Thyroidectomy is a surgical procedure in which all or part of the thyroid gland
is removed. Located in the forward (anterior) part of the neck just under the skin and
in front of the Adam's apple. The thyroid is one of the body's endocrine glands, it
secretes its products inside the body, into the blood or lymph. The thyroid produces
several hormones that have two primary functions: they increase the synthesis of
proteins in most of the body's tissues, and they raise the level of the body's oxygen
consumption.

Types of Thyroidectom:
1. Total Thyroidectomy (Complete Removal of the Thyroid) - This is the
most common type of thyroid surgery and preferred by most surgeons for cases of
hyperthyroidism, often used for thyroid cancer, and in particular, aggressive cancers,
such as medullary or anaplastic thyroid cancer. It is used for goiter and Graves.

2. Subtotal/Partial Thyroidectomy (Removal Half of the Thyroid Gland) - For
this operation, cancer must be small and non-aggressive -- follicular or papillary --
and contained to one side of the gland. When a subtotal or partial thyroidectomy is
performed, typically, surgeons perform a bilateral subtotal thyroidectomy which
leaves from 1 to 5 grams on each side/lobe of the thyroid.

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3. Thyroid Lobectomy (Removal of Only About a Quarter of the Gland) -
This is less commonly used for thyroid cancer, as the cancerous cells must be small
and non-aggressive.

Preparation and Positioning of the Patient
The patient may lie either in the half sitting position with slightly reclined head,
(Fig 1.1a) or be lying with the head hanging (Fig. 1.1b). The advantage of the lying
position is that the venous pressure is positive preventing an air embolus. The
pressure in the cervical veins in the sitting position is on average 2.4cm and, in the
lying position with the head hanging, 8.1 cm. however, it must not be overlooked that
a pressure in the venous system is dangerous even under positive pressure if the
vein is opened (Keminger and Maager 1969).

Fig. 1.1a

Fig. 1.1b

Skin preparation
Using iodine solution with soap and sterile water, begin at the anterior neck
extending upward to just below the infra-auricular border and lower lip, and down-
ward to 2.5 to 5 cm (1 to 2 inches) above the nipples; continue down to the table at
the neck, around the shoulders, and at the sides.
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Preparation of Surgical Instruments
Draping
Simple and effective draping of the head can be achieved with Kaspars goiter
towel (Fig.1.2a). The tapes are tied behind the patients neck (Fig. 1.2a). Before 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

Fig. 1.2b

Fig. 1.2c


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Operative Procedure
The Skin Incision
It should lay two fingers breadth above the suprasternal notch. The
incision should be carried out in one straight stroke through skin 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.

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

Fig. 1.3b Kochers Collar Incision

Operative Technique
The fascia is divided on both sides of veins, held up with the forceps, clamped
(Fig 1.4) and then divided between two clamps (Fig 1.5). The fascia bridges lying
between the veins are divided from left to right. Veins should also be dealt with along
the medial edge of both the sternocleidomastoid muscles. The upper fascia and
platysmal flap is elevated as far as the laryngeal eminence (Fig 1.6) and the superior
fascial flap is elevated using a pair of forceps. The superior stumps of the vein are
ligated and the superior stumps transfixed (Fig 1.7).

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Fig. 1.4

Fig 1.5

Fig. 1.6
The deep strap muscles are divided in the mid line with scissors or scalpel up
to the cricoid (Fig 1.7).

As rule the muscles should not be divided. Division of the sternohyoid and
sternothryroid muscles may lead to rapid tiring of the voice and reduction of its
range. However it should be remembered that more damage may caused by blunt
forceful retraction than by deliberate division.
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Fig 1.7


Fig 1.8

Division of the Isthmus
The division of the isthmus, beginning at its superior or inferior edge, thus
allowing the trachea to be located. It is elevated from the trachea by spreading
movements with artery forceps. (Fig 1.9), bringing the delicate connective tissue
sheath of the trachea into view.

Fig 1.9

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A voluminous, adenomatous, and parenchymatous isthmus is divided
between clamps with scissors from below upwards. A small artery usually runs along
the superior edge from one pole to the other, and this should also be clamped and
divided (Fig.1.10)


Fig. 1.10

Fig. 1.11a

Fig 1.11b
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Figures 1.11a and 1.11b, Babcock are applied to inferior and superior (not
shown) aspects of the thyroid lobe to facilitate medial retraction on the gland. This
exposes the area when the parathyroid glands and recurrent laryngeal nerve are
located.


Fig. 1.12
Figure 1.12, downward traction on the superior Babcock clamp exposes the
superior pole vessels, including the branches of the superior thyroid artery. The
external laryngeal nerve courses along the cricothyroid muscle just medial to the
superior pole vessels. To avoid injury to this nerve, which controls tension of the
vocal cords, the superior pole vessels are divided individually as close as possible to
the point where they enter the thyroid.


Fig 1.13
Figure 1.13, as the thyroid is retracted medially; gentle dissection with a Hoyt
clamp is used to expose the parathyroid glands, inferior thyroid artery, and recurrent
laryngeal nerve. The recurrent nerve usually passes behind the inferior thyroid artery
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but occasionally lies anterior to it. They nerve can then be traced upward, and its
position in relation to the thyroid can be determined. Parathyroid glands that lie on
the thyroid surface can be mobilized with their vascular supply and thus preserved.


Fig 1.14
Figures 1.14, to perform total lobectomy, the branches of the inferior thyroid
artery are divided at the surface of the thyroid gland. The inferior thyroid veins can
now be ligated and divided. Superiorly, the connective tissue (ligament of Berry),
which binds the thyroid to the tracheal rings, is carefully divided. Division of ligament
allows the thyroid to be mobilized medially.


Fig. 1.15
Figure 1.15, the dissection of the thyroid from the trachea can be performed
with the cautery by division of the loose connective tissue between these structures.
Dissection is extended under the Isthmus, and the specimen is divided, so that the
isthmus is included with the resected lobe.

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Fig 1.16
Figure 1.16, subtotal lobectomy necessitates identification of the parathyroid
glands inferior thyroid artery, and recurrent laryngeal nerve, as previously described.
The line of resection is selected to preserve the parathyroid glands and their blood
supply and to protect the recurrent laryngeal nerve. It should be based on the inferior
thyroid artery or its major branches.


Fig 1.17a

Fig 1.17b
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Figures 1.17 A and B, clamps are placed along the line of resection, and the
thyroids gland is divided. The divided tissue is ligated or suture-ligated with 3-0 silk.
The dissection is extended to the trachea. (Sabiston, D.C., Jr. [Ed]: Atlas of General
Surgery Philadelphia, WE.B. Sauders, 1995.)


Fig 1.18
At the end of the resection the remnant of capsule and parenchyma is closed
by individual horizontal suture (Fig 1.18) to achieve good homeostasis. This
procedure is facilitated by traction to the opposite side on the capsule sutures which
have been left long, and by lateral displacement of the common carotid artery with a
hook.

Before closing the neck it is advisable to increase positive pressure
respiration for a brief period to increase the pressure in the superior vena cava and
thus show any venous bleeding points or potential points of entry for air emboli which
have been overlooked. Then a pyramidal lobe if present is removed and aberrant
adenomas in the region of the upper and lower pole are looked for. The cavity is
drained for 24 hours by penrose drain (Fig. 1.19)

Fig 1.19
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Fig 1.20a
Wound closure is limited to suture of the strap muscles (Fig 1.19) and the
placing of skin clips (Fig 1.20a and b) which are removed 3 days later.


Fig. 1.20b

Fig 1.21
1.2 Indication of Prescribed Surgical Treatment
Thyroidectomy is usually performed for the following reasons:
1. As therapy for some individuals with thyrotoxicosis; those with Graves
disease; and others with a hot nodule or toxic nodular goiter.
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2. To establish a definitive diagnosis of a mass within the thyroid gland,
especially when cytologic analysis after fine needle aspiration (FNA) is either
non-diagnostic or equivocal.
3. To treat benign and malignant thyroid tumors.
4. To alleviate pressure symptoms or respiratory difficulties associated with a
benign or malignant process.
5. To remove an unsightly goiter (Figure 9).
6. To remove large substernal goiters, especially when they cause respiratory
difficulties.
7. Young patients and are free from any condition that makes them poor
operative risks (DM, heart disease, renal disease)
Specific:
o A small thyroid nodule or cyst
o A thyroid gland that is so overactive it is dangerous (thyrotoxicosis)
o Benign (noncancerous) tumors of the thyroid
o Cancer of the thyroid
o Thyroid swelling (nontoxic goiter) that makes it hard for you to breathe or
swallow

Thyroid surgery (Thyroidectomy) is a common operation, but one which needs
to be taken seriously because of the potential complications which may occur.
Commonly, this surgery is done because of suspected cancer. Patient risk factors,
appearance on ultrasound examination or needle biopsy results may cause your
surgeon to recommend surgical removal of the thyroid.

If there is a vocal cord paralysis or rapid growth of a solid mass also indicates
a cancer. Unfortunately, one of the forms of thyroid cancer, follicular carcinoma, can
appear benign on needle biopsy and may also be read as benign on frozen section
during surgery.

If the thyroid becomes so large that it compresses the trachea or
esophagus surgical removal is indicated. A thyroid cyst that recurs after a single or
repeated needle drainage is also an indication for removal. Rarely, a thyroiditis will
cause scaring in the neck which also compresses the airway. The thyroid must also
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be removed in this case. However, cases of thyroiditis have an increased
complication rate due to bleeding and scarring.

2 Risk and Benefits of Undergoing Treatment
Risk Benifits
1. Hypoparathyroidism or recurrent
lesion, have not been investigated
systematically.

2. Recurrent laryngeal nerve injuries.


3. Cervical hematomas.

1. As therapy for some individuals
with thyrotoxicosis; those with Graves
disease; and others with a hot nodule or
toxic nodular goiter.

2. To establish a definitive diagnosis
of a mass within the thyroid gland,
especially when cytologic analysis after
fine needle aspiration (FNA) is either
non-diagnostic or equivocal.

3. To treat benign and malignant
thyroid tumors.

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

5. To remove an unsightly goiter.

3 Risks and Benefits of Not Undergoing Treatment
Risk Benefits
1. A small thyroid nodule or cyst.

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

1. The patient may have decreased
risk of developing any
postoperational complications.
Page | 26


3. Benign (noncancerous) tumors of
the thyroid

4. Cancer of the thyroid

5. Thyroid swelling (nontoxic goiter)
that makes it hard for you to breathe or
swallow



1.3 Required Instruments, Devices, Supplies, Equipment and Facilities
Retractors:
1.) DOUBLE-ENDED RICHARDSON RETRACTOR used to retract deep
incisions


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


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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


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.



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


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.


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Grasping Instruments:
11.) BABCOCK CLAMP used to grasp delicate tissue


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.
.

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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.


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


19.) #3 KNIFE HANDLES -


Page | 31

20.) BLADES NO. 10 the flat part of a tool or weapon that (usually) has a
cutting edge.


21.) TENOTOMY The surgical division of a tendon for relief of a deformity
caused by congenital or acquired shortening of a muscle, as in clubfoot or
strabismus


22.) CURVED IRIS

Suturing Instruments:
23. ) NEEDLE HOLDER used to hold needles when suturing. They may also be
placed on the sewing category.








Page | 32

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.


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.


Page | 33

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.









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

Page | 34

1.4 Perioperative Tasks and Responsibilities of The Nurse
DUTIES OF SCRUB NURSE
Ensures that the circulating nurse has checked the equipment.
Ensures that the theater has been cleaned before the trolley is set.
Prepares the instruments and equipment needed in the operation.
Uses sterile technique for scrubbing, gowning and gloving.
Receives sterile equipment via circulating nurse using sterile technique.
Performs initial sponges, instruments and needle count, checks with
circulating nurse.

When Surgeon Arrives After Scrubbing:
Perform assisted gowning and gloving to the surgeon and assistant
surgeon as soon as they enter the operation suite.
Assemble the drapes according to use. Start with towel, towel clips, draw
sheet and then lap sheet. Then, assist in draping the patient aseptically
according to routine procedure.
Place blade on the knife handle using needle holder, assemble suction tip
and suction tube.
Bring mayo stand and back table near the draped patient after draping is
completed.
Secure suction tube and cautery cord with towel clips or allis.
Prepares sutures and needles according to use.

During an Operation
Maintain sterility throughout the procedure.
Awareness of the patients safety.
Adhere to the policy regarding sponge/ instruments count/ surgical
needles.
Arrange the instrument on the mayo table and on the back table.

Before the Incision Begins
Provide 2 sponges on the operative site prior to incision.
Page | 35

Passes the 1st knife for the skin to the surgeon with blade facing
downward and a hemostat to the assistant surgeon.
Hand the retractor to the assistant surgeon.
Watch the field/ procedure and anticipate the surgeons needs.
Pass the instrument in a decisive and positive manner.
Watch out for hand signals to ask for instruments and keep instrument as
clean as possible by wiping instrument with moist sponge.
Always remove charred tissue from the cautery tip.
Notify circulating nurse if you need additional instruments as clear as
possible.
Keep 2 sponges on the field.
Save and care for tissue specimen according to the hospital policy.
Remove excess instrument from the sterile field.
Adhere and maintain sterile technique and watch for any breaks.

End of Operation
Undertake count of sponges and instruments with circulating nurse.
Informs the surgeon of count result.
Clears away instrument and equipment.
After operation: helps to apply dressing.
Removes and siposes of drapes.
De-gown.
Prepares the patient for recovery room.
Completes documentation.
Hand patient over to recover room.

Scrub Duties
Perform surgical hand scrub.
Gown and glove using closed glove technique.
Regown and glove when breaks in technique occur.
Assist the 1st scrub in setting up case (back table, mayo stand and O.R.
basins).The tasks include:
o Arrange instruments and supplies (back table, mayo stand and O.R.).
Page | 36

o Count needles, instruments and sponges.
o Check instruments for proper functions.
o Prepare irrigating solution.
o Draw medications properly.
o Gown and glove surgeon and assistant.
o Assist with draping.
o Prepare electric cautery, suction and light handles for proper use.
o Prepare necessary sutures.
o Pass instruments to surgeon and assistant.
o Retract, sponge, and suction during case as necessary.
o Proper identification and handling of specimen.
o Prepare instruments for decontamination at completion of case.
o Dispose of sharps properly.
o Discard soiled drapes and trash properly.
o Transport soiled drapes and trash properly.
o Anticipate the surgeon and assistant needs.
o Anticipate the operative procedure needs.

DUTIES OF CIRCULATING NURSE
Before an Operation
Checks all equipment for proper functioning such as cautery machine,
suction machine, OR light and OR table.
Make sure theater is clean.
Arrange furniture according to use.
Place a clean sheet, arm board (arm strap) and a pillow on the OR table.
Provide a clean kick bucket and pail.
Collect necessary stock and equipment.
Turn on aircon unit.
Help scrub nurse with setting up the theater.
Assist with counts and records.

During the Induction of Anesthesia
Turn on OR light.
Page | 37

Assist the anesthesiologist in positioning the patient.
Assist the patient in assuming the position for anesthesia.
Anticipate the anesthesiologists needs.
If spinal anesthesia is contemplated:
o Place the patient in quasi fetal position and provide pillow.
o Perform lumbar preparation aseptically.
o Anticipate anesthesiologists needs.

After the Patient is Anesthetized
Reposition the patient per anesthesiologists instruction.
Attached anesthesia screen and place the patients arm on the arm
boards.
Apply restraints on the patient.
Expose the area for skin preparation.
Catheterize the patient as indicated by the anaesthesiologist.
Perform skin preparation.

During Operation
Remain in theater throughout operation.
Focus the OR light every now and then.
Connect diatherapy, suction, etc.
Position kick buckets on the operating side.
Replenishes and records sponge/ sutures.
Ensure the theater doors remain closed and patients dignity is upheld.
Watch out for any break in aseptic technique.

End of Operation
Assist with final sponge and instruments count.
Signs the theater register.
Ensures specimen are properly labeled and signed.

After an Operation
Hands dressing to the scrub nurse.
Page | 38

Helps remove and dispose of drapes.
Helps to prepare the patient for the recovery room.
Assist the scrub nurse, taking the instrumentations to the service
(washroom).
Ensures that the theater is ready for the next case.

Circulating Duties
Clean operating room and discard suction prior to case.
Gather all supplies, instruments and equipment necessary for case.
Arrange O.R. furniture properly.
Open and flip sterile supplies for the surgical procedure.
Assist with IV therapy.
Assist the anaesthesiologist.
Assist with the skin preparation.
Tie gowns of the scrub nurse and surgeon.
Provide scrub personnel with sitting stools and foot stools as necessary.
Turn and help adjust lights as necessary.
Supply the scrub nurse with necessary supplies.
Receive and label specimen properly.
Log and deliver specimen to pathology properly.
Help apply wound dressing.

1.5 Expected Outcome of Surgical Treatment Performed
After a thyroidectomy, the patient may experience neck pain and a hoarse or
weak voice. This doesn't necessarily mean there's permanent damage to the nerve
that controls the vocal cords. These symptoms are often temporary and may be due
to irritation from the breathing tube (endotracheal tube) that's inserted into the
windpipe (trachea) during surgery, or as a result of nerve irritation but not
permanent damage caused by the surgery.

The long-term effects of thyroidectomy depend on how much of the thyroid is
removed. If only part of the thyroid is removed, the remaining portion typically takes
Page | 39

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

If the entire thyroid is removed, the body can't make thyroid hormone and may
develop signs and symptoms of underactive thyroid (hypothyroidism). As a result,
the patient need to take a pill every day that contains the thyroid hormone thyroxine
(levothyroxine). This hormone replacement is identical to the hormone normally
made by the thyroid gland and performs all of the same functions. The Doctor will
determine the amount of thyroid hormone replacement the patient need based on
blood tests.

The patient may experience some short-term, less serious side effects after
surgery. These can include:
Pain when swallowing, or in the neck area pain can come from the
Tracheal tube after surgery or from the surgery itself. This should subside
within a few days; an over-the-counter non-steroidal pain reliever, like
ibuprofen, can relieve discomfort.
Neck tension and tenderness there will be a tendency to hold the head
stiffly in one position after surgery, and this can cause neck and muscle
tension. It's good to do gentle stretching and range of motion exercises to
prevent muscle stiffness in the neck area. Simply turning the head to the
right, then rolling the chin across the chest until the head is facing left can
help loosen tight muscles.
Voice problems the voice may be hoarse, whispery, or tired. Some
people find that periods of hoarseness can last as long as two to three
months.
Irritated windpipe if the patient had a Tracheal tube during general
anesthesia, it can irritate the windpipe and may make the patient feel as if
he have something stuck in his throat. This feeling usually goes away
within five days.

Thyroidectomy is generally a safe surgical procedure. However, some people
have major or minor complications. Possible complications include:
Page | 40

Hemorrhage (bleeding) beneath the neck wound if this occurs, the wound
bulges and the neck swells, possibly compressing structures inside the neck and
interfering with breathing. This is an emergency.

Thyroid storm. If a thyroidectomy is done to treat a very overactive gland
(thyrotoxicosis), there may be a surge of thyroid hormones into the blood. This is a
very rare complication because medications are given before surgery to prevent this
problem.

Injury to the recurrent laryngeal nerve because this nerve supplies the
vocal cords, injury can lead to vocal cord paralysis and can produce a husky voice.
In rare cases, if both vocal cords are paralyzed, the opening of the throat may be
obstructed, causing breathing problems.

Injury to a portion of the superior laryngeal nerve If this occurs, patients
who sing may not be able to hit high notes, and the voice may lose some projection.

Hypoparathyroidism. If the parathyroid glands are mistakenly removed or
unintentionally damaged during a thyroidectomy, the patient may suffer from
hypoparathyroidism, a condition in which the levels of parathyroid hormone (a
hormone that helps regulate body calcium) are abnormally low.

Hypothyroidism: Transient hypothyroidism is seen in 2% to 4% of all
patients after thyroidectomy and in 20% to 22% of those who undergo total or
repeated thyroidectomy. Permanent hypothyroidism occurs in under 0.6% of
patients.

Wound infection.

1.6 Medical Management of Physiologic Outcomes
Usual Postoperative Course. Outpatient procedures are appropriate for
solitary benign nodules and have been performed for thyrotoxicosis and thyroid
cancer in some centers; otherwise, the hospital stay is 1 to 2 days.

Page | 41

Special monitoring required. Respiratory status should be carefully
monitored if early postoperative stridor or difficulty in clearing secretions occurs.
Patients with thyrotoxicosis who receive appropriate preoperative preparation should
undergo routine monitoring.

Patient activity and positioning. The head should be elevated 30 to 45
degrees (Semi-Fowler) when client is conscious unless client is hypotensive to
minimize edema and venous oozing. Support head and neck with pillows. Full
activity is resumed the morning after operation.

Neck Exercises. First, teach the client how to support the weight of the head
and neck when sitting up in bed. Show the client how to place the hands at the back
of the head when flexing the neck or moving. The client will probably be able to
perform this maneuver by the first postoperative day. Second, as the wound heals
(about the 2
nd
to 4
th
postoperative day); demonstrate range-of-motion exercises to
prevent contractures. With the surgeons permission, teach the client to flex the head
forward and laterally, to hyperextend the neck, and to turn the head from side to
side. Have the client perform these exercises several times every day.

Medications. Give meperidine (Demerol) or morphine sulfate every 1-2 hours
as needed for pain in throat area. Give continuous mist inhalation until chest is clear.
If a total thyroidectomy has been performed, explain self-administration of thyroid
replacement medications (T4) used to treat hypothyroidism: Levothyroxine sodium
(Synthroid, Levothroid, Levoxine). Teach client the medication regimen and the need
for lifelong replacement therapy.

Alimentation: Full liquids are permitted on the day of operation and a soft
diet can be started on afternoon of day 2.

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




Page | 42

Postoperative Complications
In the Hospital
Hemorrhage: Although it is extremely rare (less than 0.5%), a hematoma in
the area of resection may cause airway obstruction early in the postoperative period.
Removal of the skin and strap muscle sutures and evacuation of the hematoma in
the recovery room is preferable to tracheostomy. Patients are then returned to the
operating room for irrigation of the operative site, control of hemorrhage, and
repeated closure of the wound.

Hypothyroidism: Transient hypothyroidism is seen in 2% to 4% of all
patients after thyroidectomy and in 20% to 22% of those who undergo total or
repeated thyroidectomy. Permanent hypothyroidism occurs in under 0.6% of
patients. Symptomatic hypocalcemia (less than 7.5mg/dl) is characterized by
anxiety, perioral or finger tingling, and a positive Chvosteks sign, and usually
develops 16 to 24 hours after surgery. Intravenous calcium is given to relieve acute
symptoms in the hospital and oral calcium therapy is prescribed at the time of
discharge.

Recurrent laryngeal nerve injury: Paralysis of one vocal cord causes
hoarseness and difficulty in clearing secretions. This almost always is related to
traction on the recurrent nerve and may also resolve over a period of days to
months. Permanent recurrent nerve palsy occurs in as many as 4.5% of all
thyroidectomies, usually resulting from intended sacrifice of a nerve involved with
carcinoma.

Thyroid storm: Thyroid storm should not occur after surgery for
thyrotoxicosis in adequately prepared patients, but it may be seen in patients with
untreated thyrotoxicosis who are undergoing other operations. Symptoms of tremor,
agitation, tachycardia, and hyperthermia are treated with intravenous fluids,
propranolol, potassium iodide, and steroids.

After Discharge
Recurrent benign nodule or goiter: Recurrence of a benign nodule or goiter
can be prevented by the lifelong administration of thyroid hormone.
Page | 43

Recurrent thyroid cancer: To decrease the incidence of recurrent cancer in
the neck, lungs, or bone, thyroid hormone replacement is delayed until radioactive
iodine is administered.

Late or recurrent hyperthyroidism: Annual thyroid function tests are
indicated in patients who are receiving thyroid hormone after operation for goiter or
cancer and in those who are originally euthyroid after operation for Graves disease.

Permanent hypothyroidism: Vitamin D is added to calcium replacement
to enhance absorption. In serial parathyroid hormone levels begin to raise, first the
vitamin D and then the calcium supplement should be tapered.

Page | 44

1.7 Nursing Management of Physiologic, Physical, and Psychosocial Outcomes

Problem #1: Acute Pain
Assessment Diagnosis
Scientific
Explanation
Planning Intervention Rationale
Expected
outcome/
Evaluation
S > Patient
may report
pain on the
operative site


O > Patient
may manifest:
- facial
grimaces
- restlessness
- irritability
- reduced
interaction with
people
Acute pain

Patient
experiences
pain due to the
operative
procedure done.
As the
anesthetic agent
wear off,
sensation
returns and pain
of the incision,
and other
manipulations
done on the
body comes into
Short term:
After 5 hours of
nursing
interventions,
the patient will
be able to
demonstrate
use of
relaxation skills
and diversional
activities as
indicated for
individual
situation.

> Establish rapport



> Monitor vital
signs


> Perform a
comprehensive
assessment of pain
to include location,
characteristics,
onset/duration,
frequency, quality,
> To gain the trust
and cooperation of
the client

>To provide baseline
data.


> To assess etiology/
precipitating
contributory factors




Short term:
The patient
shall have
demonstrated
use of
relaxation skills
and diversional
activities as
indicated for
individual
situation.

Long term:
The patient
shall have
Page | 45

- change in
respiration,
blood
pressure, and
pulse

awareness. The
injured tissue
releases pain
substances
such as
prostaglandins,
histamine and
kinin. These
substances
transmit pain
impulse to the
spinal cord.
From the spinal
cord, the pain
message is sent
to the brain
where it is
processed and
is perceived as
pain. The
message is
Long term:
After 4 days of
nursing
interventions,
the patient will
report feeling of
well-being and
comfort.
severity (1 to 10),
and precipitating or
aggravating factors

> Note location of
surgical
procedures


> Observe body
language for
evidence of pain

> Provide quiet
environment


> Encourage
adequate rest
periods





> This can influence
the amount of pain
experienced


> To ensure comfort
despite impaired
communication

> To assist client for
alleviation of pain


> To prevent fatigue



reported
feeling of well-
being and
comfort.
Page | 46

transmitted back
to the site of
injury then
through the
spinal cord. In
the spinal cord
and in the brain,
many chemicals
such as
endorphins,
serotonin and
adrenaline are
involved in
modulation and
transmission of
pain.

> Encourage use of
relaxation
techniques such as
soft music, focused
breathing

> Take time to
listen and maintain
frequent contact
with patient


>Administer
analgesic
medications as
ordered.

> Monitor
effectiveness of
pain medications
> Promotes rest,
redirects attention




> Helpful in
alleviating anxiety
and refocusing
attention, which may
relieve pain

>To provide
pharmacologic
treatment of pain.,


> To promote timely
intervention/revision
of plan of care


Page | 47

Problem # 2: 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

O > the patient
may manifest:
- presence of
surgical
wound on the
low collar area
of neck
- adventitious
breath sounds
( wheezes,
crackles)
- changes in
respiratory
rate and
Ineffective
airway
clearance
related to
bleeding and/
or laryngeal
edema

If hemorrhage
(bleeding)
beneath the
neck wound
occurs, the
wound bulges
and the neck
swells, possibly
compressing
structures inside
the neck and
interfering with
breathing. This
is an
emergency.
Laryngeal
edema may also
occur due to
Short Term:
After 1 hour of
nursing
interventions,
the patient will
be able to
maintain
airway
patency.

Long Term:
After 3 days of
nursing
interventions,
the patient will
be able to
maintain vital
signs,
> Establish rapport



> Monitor vital signs,
level of
consciousness,
orientation

> Auscultate breath
sounds and assess
air movement

> Check dressing
site for profuse
bleeding (side of
neck and back of
head) every 15
> To gain the trust
and cooperation of
the client

> To provide
baseline data and
note deviations
from normal

>To ascertain
status and note
progress

> To identify signs
of bleeding



Short Term:
The patient will
be able to
maintain
airway
patency.

Long Term:
The patient will
be able to
maintain vital
signs,
respirations,
and breath
sounds within
normal limits.

Page | 48

rhythm
- difficulty
vocalizing
- restlessness
- cyanosis


surgical
manipulation.
Bilateral
recurrent nerve
injury with acute
paralysis of both
vocal cords may
occur during
surgery which
may cause
obstruction of
the airway
because of the
adduction of the
true vocal cords.

respirations,
and breath
sounds within
normal limits.

minutes for 1 hour
immediately after
surgery

> Keep dressing size
minimized


> Position patient on
back with head of
bed elevated 30 to
45 degrees

> Monitor for signs of
respiratory distress
or obstructed airway
q 1 : stridor,
wheezing, coarse
airway crackles,
dyspnea, cyanosis,
labored respirations




> To prevent
impaired view of
incision site

> To promote ease
in breathing



> To identify early
signs of respiratory
distress caused by
tracheal edema




Page | 49


> Teach and assist
patient to turn,
cough, and deep
breathe q2h and prn









> If indicated, keep
suction equipment at
bedside; gently
suction oropharynx
only when necessary

> Keep environment

> To prevent
pulmonary
complications and
to take advantage
of gravity
decreasing
pressure on the
diaphragm and
enhancing drainage
of / ventilation to
different lung
segments

> To clear airway
when secretions
are blocking airway



> To maintain
Page | 50

allergen free

> Have
tracheostomy tray
and oxygen
immediately
available at bedside

> Encourage use of
warm versus cold
liquids as
appropriate

> Provide
opportunities for rest

> Encourage voice
rest, but do assess
speech and
swallowing
periodically
patent airway

> To use if patient
experiences severe
respiratory distress



> To mobilize
secretions



> To prevent
fatigue

> Hoarseness and
sore throat
secondary to
edema or damage
to laryngeal nerve
Page | 51







> Evaluate changes
in sleep pattern

> Observe for signs/
symptoms of
infection


> Note physician if
dressing requires
reinforcement more
than one time
may last several
days. Increased
difficulty may
indicate impending
obstruction

> To assess
changes

> To identify
infectious process/
promote timely
intervention

> To promote
timely intervention /
revision in plan of
care




Page | 52

Problem #3: Altered Tissue Perfusion r/t Excessive Blood Loss Secondary to Surgery
Assessment Diagnosis
Scientific
Explanation
Planning Intervention Rationale
Expected
outcome/
Evaluation
S >

O > The patient
may manifest:
- Generalized
weakness
- Paleness and
pallor
- Altered BP
- Dizziness
- Vomiting
- Headache
- Body malaise
-Hypoventilation
- Cold skin

Altered
Tissue
Perfusion r/t
excessive
blood loss
secondary
to surgery
The decreased
in hemoglobin
concentration in
the blood of
client may lead
to tissue
perfusion
ineffective. The
level of the
hemoglobin of
the patient may
give the
outcome of
decrease in
oxygen
resulting in
failure to
Short term:
After 3 hours of
nursing
interventions,
the patient will
be able to
demonstrate
measures to
improve
circulation.

Long term:
After 3 days of
nursing
interventions,
the patient will
be able to
> Establish rapport.





> Monitor and
record vital signs

> Instruct patient to
have complete bed
rest.

> Stress out the
importance of
compliance to the
therapeutic
> To gain trust and to
have a good
relationship to the
patient and to the
SO.

> To have a baseline
data.

> To prevent further
complications.


> Compliance to and
of the patient to the
regimen will result in
effective treatment
Short term:
The patient
shall have
demonstrated
measures to
improve
circulation.

Long term:
The patient
shall able to
demonstrate
increased
perfusion as
individually
appropriate.
Page | 53

nourish the
tissues at the
capillary level.
This may exist
without
decreased
cardiac output:
however, there
may be a
relationship
between
cardiac output
and tissue
perfusion.


demonstrate
increased
perfusion as
individually
appropriate
regimen to hasten
healing process.

> Encourage
relaxation
technique such as
deep breathing
exercise.

> Provide
environment
conducive for
resting.

> Encourage
expression and
verbalization of
feelings.

>Administer IV
fluids as ordered.
and faster healing
process.

> To prevent
aspiration.




> For patient
comfortability.



> To know what the
patient is trying to
voice out and what
the patient feelings.

> To maintain
electrolyte balance.
Page | 54
















>Evaluate nursing
interventions given.

> To identify what
needs to be
reinforced and
assess effectiveness
of interventions
given.
Page | 55

Problem # 4: Impaired Verbal Communication Related to Damage and/or Manipulation of Laryngeal Nerves Secondary to
Surgery
Assessment Diagnosis
Scientific
Explanation
Objectives Interventions Rationale
Desired
Outcomes
S > the
patient may
verbalize
dyspnea

O > the
patient may
manifest:
- presence of
surgical
wound on the
low collar
area of neck
- impaired
articulation
- inability to
speak
Impaired
verbal
communication
related to
damage and/or
manipulation
of laryngeal
nerves
secondary to
surgery



Injury that
results from
severing,
clamping,
compressing, or
stretching either
the recurrent
laryngeal nerve
or superior
laryngeal nerve
during thyroid
surgery may
result in severe
untoward
sequelae for the
patient. The
recurrent
Short Term:
After 4 hours of
nursing
interventions,
the patient will
be able to use
alternative
communication
methods in
which needs
can be
expressed.

Long Term:
After 6 days of
nursing
interventions,
> Establish
rapport


> Monitor vital
signs



> Monitor voice
quality q2h


> Monitor for
edema at surgical
incision and
glottis
> To gain the trust
and cooperation of
the client

> To provide
baseline data and
note deviations
from normal

> To evaluate
damage to
laryngeal nerves

> To assess
contributing factors


Short Term:
The patient will
be able to use
alternative
communication
methods in
which needs
can be
expressed.

Long Term:
The patient will
be able to
communicate
verbally
without voice
change.
Page | 56

- use of
nonverbal
cues/
gestures
- difficulty
speaking or
verbalizing

laryngeal nerve
lies adjacent to
the postero-
medial aspect of
the thyroid.
Unilateral
recurrent
laryngeal nerve
injury causes
the ipsilateral
vocal cord to
remain in the
median or
paramedian
position, thus
immediate
hoarseness
occurs. The
voice may never
recover its
timbre and
the patient will
be able to
communicate
verbally without
voice change.


> Note presence
of draining tubes
that blocks
speech

>If indicated
provide
alternative means
of communication
such as use of
pad and pencil or
slate board

>Keep call bell
within reach at all
times

> reduce
environmental
stimuli

> To assess
causative factors



>To minimize
patients need to
speak





>To minimize
patients need to
speak

> To lessen anxiety
which may worsen
problem

Page | 57

focus, even
though effective
phonation can
eventually be
achieved.
Bilateral
recurrent nerve
injury with acute
paralysis of both
vocal cords
adducts the true
vocal cords.
Permanent
debilitating
hoarseness may
follow.

Damage to the
superior
laryngeal nerve
affects voice

> validate
meaning of
nonverbal
communication

> report
increasing
hoarseness to
physician

> anticipate
patients needs as
indicated


> because they
may be wrong



> to promote timely
intervention /
revision in plan of
care

>to minimize
patients need to
speak

Page | 58

pitch. Since the
cord is unable to
lengthen and
tense, the voice
is low in pitch
and breathy in
quality.















Page | 59

Problem # 5: Impaired Skin and Tissue Integrity Secondary to Surgery
Assessment Diagnosis
Scientific
Explanation
Objectives Interventions Rationale
Desired
Outcomes
S >

O > the
patient may
manifest:
- presence of
surgical
wound on the
low collar
area of neck
- damaged
tissue

Impaired
skin and
tissue
integrity
secondary
to surgery

In
thyroidectomy,
an incision will
be made through
the skin in the
low collar area of
the neck. Next, a
vertical cut will
be made through
the strap-like
muscles located
just below the
skin, and these
muscles will be
spread aside to
reveal the
thyroid gland
and other
Short Term:
After 2 hours
of nursing
interventions,
the patient will
be able to
verbalize
understanding
of condition
and causative
factors.

Long Term:
After 3 days of
nursing
interventions,
the patient will
be able to
> Establish rapport



> Monitor vital signs


> Record size (depth,
width), color, location,
temperature, texture,
consistency of
wound/ lesion if
possible

>Inspect surrounding
skin for erythema,
induration,
maceration
> To gain the trust
and cooperation of
the client

> To provide
baseline data

> To provide
comparative baseline





> To assess extent
of involvement


Short Term:
The patient will
be able to
verbalize
understanding
of condition
and causative
factors.

Long Term:
The patient will
be able to
display
progressive
improvement
in wound
healing.
Page | 60

deeper
structures. Then,
all or part of the
thyroid gland will
be cut free from
surrounding
tissues and
removed. After
the thyroid gland
is removed, one
or two stitches
will be used to
bring the neck
muscles
together again.
Then the deeper
layer of the
incision will be
closed with
stitches, and the
skin will be
display
progressive
improvement
in wound
healing.

> Note odors and
drains emitted from
the skin/ area of injury




> Assess adequacy
of blood supply and
innervation of the
affected tissue

> Inspect skin on a
daily basis, describing
lesions and changes
observed

> Keep the area
clean/dry, carefully
dress wounds,

> To assess early
progression of
wound healing or
development of
hemorrhage or
infection

> To identify
contribution factors



> To promote timely
intervention/revision
of plan of care


> To assist bodys
natural process of
repair
Page | 61

closed with
sterile paper
tapes. The
incision can be
an entry for
bacteria.


support incision, and
prevent infection

> Use appropriate
wound coverings


> Avoid use of plastic
material and remove
wet/wrinkled linens
promptly

> Rrovide good
nutrition with
adequate protein and
calorie intake, and
vitamin/ mineral
supplements as
indicated

> Encourage



> To protect the
wound and/or
surrounding tissues

> To prevent skin
breakdown due to
moisture


> To provide a
positive nitrogen
balance to aid in
healing and to
facilitate healing



> To prevent fatigue
Page | 62

adequate rest and
sleep

>Encourage early
ambulation and
mobilization



> Provide position
changes


> Practice aseptic
technique in
cleansing/dressing
and medicating
lesions

> Instruct proper
disposal of soiled



> To promote
circulation and
reduce risks
associated with
immobility

> To prevent
excessive tissue
pressure

> To reduce risk of
cross-contamination




> To prevent spread
of infectious agent
Page | 63

dressing

>Refer to dietician as
appropriate


> To enhance
healing


















Page | 64

Chapter IV
CONCLUSION

This case study will help significant individuals to better understand Non-toxic
goiter. How it will affect the normal process of the endocrine system to individual and
what are several changes it can bring to all peoples having this disease. Based on
the case presented, with the support of literatures and research study on
Thyroidectomy, the researchers firmly believe on the following concepts.

Chapter V
REFERENCES/BIBLIOGRAPHY

Books:
Berry, K. (2004). Operating Room Technique. Mosby, Inc.
Shields, L., Werder, H. (2002). Perioperative Nursing. Greenwich Medical
Media
Phippen, M., Wells, M. (1994). Perioperative Nursing Practice. W.B. Saunders
Company

Internet Sources:
http://www.pharmacology2000.com/Endocrine/Thyroid/physiol1.htm#Thyroid
%20Physiology/Anatomy
http://www.newworldencyclopedia.org/entry/Thyroid
http://www.sciencedaily.com/releases/2010/12/101201162111.htm
http://www.surgeryencyclopedia.com/St-Wr/Thyroidectomy.html
http://web.ebscohost.com/ehost/detail?hid=107&sid=79aa1711-581b-4e56-
8485-
4efd96144899%40sessionmgr104&vid=1&bdata=JnNpdGU9ZWhvc3QtbGl2Z
Q%3d%3d#db=a3h&AN=55216256
http://www.medicalnewstoday.com/articles/67471.php

APPENDIX
(INSERT JOURNALS HERE)