INTRODUCTION

A nurse duty is to provide enhancement

to the health of the people. Being a student
it’s a great opportunity having a part of this
advocacy. We had given all the chance to
render service to people not only by taking
care them when they are sick but also to
provide them knowledge in order to empower
them and become self reliant.
 
This study has been made to enhance
our ability in giving care to our patient.
Individual patient has different needs
because they have different illness and
The objectives of this study
are to:

* To understand the causes of thyroid

enlargement and the clinical evaluation
of this condition.
* To understand the cell of origin,
pathophysiology, risk factors and
management of thyroid carcinoma
* To be able to make a plan for the proper
management of the certain disease.
 
 DEFINITION OF MEDICAL
TERMS
Borborygmus a lso k n o w n a s sto m a ch g ro w lin g , o r
-

ru m b lin g , is th e ru m b lin g so u n d p ro d u ce d b y th e
m o v e m e n t o f g a s th ro u g h th e in te stin e s o f
a n im a ls , in clu d in g h u m a n s
B ru it
  so u n d s - B lo w in g a n d sw ish in g so u n d in th e
abdom en

Thyroidectomy - is the surgical removal of all or

part of the thyroid gland . This gland is in the
neck . It produces hormones that regulate
metabolism .

Thyroid lobectomy or partial thyroidectomy—

removal of only a part of the thyroid ( the right
or left lobe and / or center
Total or near - total thyroidectomy — all of the
thyroid is removed
 DEFINITION OF MEDICAL
TERMS
Sheehan syndrome, also known as postpartum
hypopituitarism or postpartum pituitary necrosis- is
hypopituitarism (decreased functioning of the pituitary gland),
 
caused by necrosis due to blood loss and hypovolemic shock
during and after childbirth

Thyrotoxicosis- excessive thyroid hormone in the body.

 REVIEW OF THE RELATED
ANATOMY

The thyroid gland is located in the front of

the neck attached to the lower part of the
voicebox (or larynx) and to the upper part of the
windpipe (or trachea). It has two sides or lobes.
These lobes are connected by a narrow neck (or
isthmus). Each lobe is about 4 cm long and 1 to 2
cm wide. The name "thyroid" comes from the
Greek word which means "shield".
 Thyroid Hormones

The thyroid gland produces thyroid

hormones. These are peptides containing iodine.
The two most important hormones are
tetraiodothyronine (thyroxine or T4) and
triiodothyronine (T3). These hormones are
essential for life and have many effects on body
metabolism, growth, and development.
T h e th y ro id g la n d is in flu e n ce d b y h o rm o n e s
p ro d u ce d b y tw o o th e r o rg a n s :
1 . T h e p itu ita ry g la n d , lo ca te d a t th e b a se o f
th e b ra in , p ro d u ce s th y ro id stim u la tin g
h o rm o n e ( T S H )
2 . T h e h y p o th a la m u s , a sm a ll p a rt o f th e b ra in
a b o v e th e p itu ita ry , p ro d u ce s th y ro tro p in
re le a sin g h o rm o n e ( T R H ) .
 Goiter

M u ltin o d u la r g o ite r. "Goiter" is a term used

to describe any enlargement of the thyroid
gland. Several factors can lead to a goiter,
including the presence of a number of thyroid
nodules. This condition, called multinodular
goiter, can cause a tight feeling in your throat
and difficulty breathing or swallowing.

The thyroid can become very large so that

it can easily be seen as a mass in the
neck . This picture depicts the outline of a
normal size thyroid in black and the
greatly enlarged goiter in pink .
 Factors which may cause the
thyroid to become enlarged:
* A diet deficient in iodine can cause a
goiter but this is rarely the cause because of
the readily available iodine in our diets.
* Hashimoto's disease, an autoimmune
disorder that causes chronic inflammation —
and underactivity (hypothyroidism) — of your
thyroid gland
* A genetic defect of receptors that release
th y ro id - stim u la tin g h o rm o n e ( T S H )
* Radiation treatments to your head or neck in
childhood
S ym p to m s
•presence of anterior neck mass.
•for particularly large masses, compression of the
local structures may result in difficulty in
breathing
•weight loss despite increased appetite
•heat intolerance
DIAGNOSIS
•the diagnosis of a goiter is usually made at the
time of a physical examination when an enlargement
of the thyroid is found.
•Tests that may be done include:
•Free thyroxine (T4)
•Thyroid scan and uptake
•Thyroid stimulating hormone (TSH)
•Ultrasound of thyroid
If nodules are found on ultrasound, a biopsy should be done
to check for thyroid cancer
Risk Factors for Thyroid Disease
Some of the key risk factors for thyroid disease
include...
*Female: Women are at greater risk than men.
*Age - being 50 and above poses the highest risk of
thyroid disease, though it can strike at any age.
*A personal or family history of thyroid and/or
autoimmune disease increases risk.
*Surgical removal of all or part of the thyroid, or
radioactive iodine treatment to the thyroid -- both
which typically result in an underactive thyroid.
*Being pregnant or within the first year after
childbirth
Current or former smoker
*Iodine or herbal supplements containing
iodine, in pill or liquid form
*Living in an iodine-deficient area
*Overconsumption of raw goitrogenic foods,
i.e., Brussel sprouts, turnips, cauliflower, soy
products and others
* Overconsumption of soy foods
Treatments include:

*Antithyroid drugs (propylthiouracil,

methimazole)
*Radioactive iodine
*Surgery
PATHOPHYSIOLOGY
ILLUSTRATION
 ASSESSMENT
 
 
Room: 606 D
Patient Name: Carlito Tolentino
Age: 46 year old
Birthday: March 8 1963
Address: West Capitol, Pasig City
Civil Status: Married
Religion: Roman Catholic
 
Health History:
 
M r C a rlito h a s b e e n h o sp ita lize d sin cr
N o v e m b e r 2 2 , 2 0 0 9 fo r th e re a so n th a t h e h a s a
th y ro id m a ss o n th e rig h t lo w e r n e ck . H e h a s
b e e n d ia g n o se d la st six m o s th a t th e re is a
m a ss o n h is le ft n e ck .
 
W h e n h e w a s still in e le m e n ta ry , h e a cq u ire d
m e a sle s a n d ch ick e n p o x . L a st 1 9 9 9 h e h a d
u n d e rg o n e a n a p p e n d e cto m y a t M e d ica l C ity .
H e h a d n e v e r e n co u n te re d a n a ccid e n t. H e h a s
n o a lle rg y o n fo o d s b u t h e a s a n a lle rg y w h e n
h e to o k a m e d icin e fo r h is p ro sta te .
 
H is fa m ily h a s a h isto ry o f ca n ce r,
h y p e rte n sio n a sth m a , a n d a lso a th y ro id
p ro b le m .
Psychosocial:
 
H e liv e s w ith h e r w ife a n d 2 ch ild re n b e ca u se h is
2 o th e r ch ild re n h a s th e ir o w n fa m ily . H e g ra d u a te d
a t P a sig C a th o lic S ch o o l a n d n o w w o rk in g a s a
g o v e rn m e n t e m p lo y e e . H e is a R o m a n C a th o lic a n d
h e b e lie v e s th a t G o d w ill h e lp th e m in e v e ry tria l
th a t w ill co m e in to th e ir liv e s .

H e is w e ll g ro o m e d a n d ca n re m e m b e r e v e n
sm a ll d e ta ils o f h is p a st a ctiv itie s . H e is a le rt a n d
o rie n te d . H e p rim a rily sp e a k s Ta g a lo g . T h e y u su a lly
re ly o n d o cto rs in te rm s o f th e ir h e a lth ca re .
 H e u su a lly sle e p 6 h o u rs a d a y. H e w a lks a llth e w a y to
h is o ffice fo r a lm o st 2 0 m in u te s in th e m o rn in g a n d
a fte rn o o n . T h a t se rve s a s h is exe rcise .

Safe Environment:
 
N o kn o w n a lle rg ie s o n fo o d . H e h a s a n a lle rg y o n
m e d icin e fo r p ro sta te . S kin is d ry a n d in ta ct. M u co u s
m e m b ra n e is p in kish . Te m p e ra tu re is 3 6 . 2 C
 

 
 
 
Nutrition:
 
Soft diet is instructed. Good skin turgor. IV is Eurosol-R
in Water located at the right hand. Height 172 cm, weight
72 kg.

 
 
 Physical Assessment:
Skull:
Round
No tenderness noted upon palpation
 
Scalp:
No scars noted
No lice and dandruff
 
Hair:
Black with some white hair
Uneven distribution of hair
 
Face:
The shape is round Symmetrical
No involuntary movements of the facial
muscle
Eyes:
The cornea is clear and transparent
The cornea looks smooth
Symmetrical
Vision is 20/20
No discharged noted on both eyes
 
Nose:
It is located at the mid line
No noted nasal discharge
No flaring
Nasal septum is in the midline and not
perforated
 
Ears:
Earlobes are parallel and symmetrical
Ears:
No lesion noted on inspection
No noted discharged at the ear canal
Skin same in color as in the complexion
 
 Mouth:
Lips are pinkish
Oral mucous are moist
Use of dentures
Gums are pinkish in color
No swelling
Tongue is pink in color
 
Neck:
The neck is straight
Presence of mass on the right lower part
Symmetrical
Chest:
No lesion is noted
Skin color is uniform
Normal breath sound
 
Abdomen:
Scar on right lower section
No lesion noted
Skin color is uniform
No venous engorgement
Absence of bruit sounds
Borborygmus
 
 
Extremities:
Symmetrical
No lesion or mass is noted
Skin color is uniform
  INTERPRETATION OF THE
LABARATORY TEST
  

T H Y R O ID T E S T

Test Result Normal

TSH 2.20 uIu/ml 0.47-4.64
FT3 2.82 pg/ml 1.45-3.38
FT4 1.11ng/ml 0.71-1.85

Interpretation :
Based on the lab result they are all normal this means that his thyroid is working
normally.

HEMATOLOGY
Test Result Normal
Hemoglobin 154 g/dl 135-170
Hematocrit 0.45 0.40-0.54
RBC 4.96 4.60-6.20
WBC 5.90 4.50-10.00
Interpretation :
All his results are normal, this means that there is no imbalance in his cells.
 NCP
Assessment Nursing Diagnosis Scientific explanation Planning Intervention Rationale Evaluation

Subjective: Pain related to The skin has been After an hour of Independent:
Medyo masakit as surgical interruption traumatized during intervention the >Assess >Useful in evaluating >reported that the
verbalized by the of the skin as the operation, which patient will: verbal/nonver pain, choice of pain is relived and
patient. manifested by contains nociceptors. >Will report that the Bal reports of pain intervention rated the pain scale
Objective: guarding behavior. Nociceptors are pain is relieve by noting location >Prevents stress on 3/10
>Guarding behavior receptors that are rating the pain scale ,intensity, and the suture line and >No more guarding
>Facial grimace. preferentially from 7/10 to 3/10. duration reduces muscle behavior.
>Pain scale 7/10 sensitive to noxious > Will demonstrate >Maintain head/neck tension. It will limit >Facial grimace is
>Post operative stimulus. They are use of relaxation in neutral position stretching and absent
(thyroidectomy) free nerve endings in skills and diversional and support during prevent muscle strain
the skin that respond activities. position changes. in the operative area.
to intense damaging >Will follow Instruct patient to >Helps refocus
stimuli. The joints, prescribe use hands to support attention and assist
skeletal muscle, fascia pharmacologigal neck during patient to manage
tendons have also regimen. movement and avoid discomfort kore
nociceptors that have hyperextension of the effectively.
the potential to neck. >Reduces pain and
transmit stimuli that >Encourage patient discomfort
produce pain. to use relaxation >Reduces edema and
techniques. decreases perception
Collaborative: of pain
>Administer
analgesic as
prescribe by the
physician
>Provide ice collar as
indicated.
 INTERVENTION
Name Action Classification Indication Contra Indication Route Dose Adverse Side Effect Nursing Consideration
Effect

Brand NSAID Analgesic >Management of >Contraindicated Oral 200mg I >Headache >Stomach >Give the medication with
Name: acte pain with allergies to cap Q12 >dizziness upset food or after meals if GI
Celebrex >Acute and long sulfnamides, >Nausea upset occurs
Generic term treatment celocoxid, NSAIDs, >neutropenia >Report sore throat, fever,
Name: of signs and or aspirin rash, swelling in ankles, and
Celecoxib symptoms of >pregnancy third change in vision.
rheumatoid trimester
arthritis and >lactation
ostheoarthritis.
 INTERVENTION
Name Action Classificatio Indication Contra Indication Route Dose Adverse Side Effect Nursing Consideration
n Effect

Generic Antifibrinolytic Antihemorr Short-term use >you are allergic Oral 500 mg 1 > Blurred >Diarrhea >Report immediately any
Name: hagic (2 to 8 days) for to any ingredient cap Q8h Vision swelling, pain, or burning at
Tranexamic reducing or in Tranexamic >Abnorma infusion site.
Acid Tablet preventing Acid lly Low > Report any changes in
excessive >you have blood Blood vision, unusual pain or
Brand bleeding clots, bleeding Pressure difficulty breathing, nausea
Name: >Reducing the within the brain, or vomiting, changes in
Cyklokapro need for blood or eye problems urinary pattern, or other
n clotting factor. (retinal disease) adverse reactions.
>you are > Breast-feeding precautions:
colorblind Consult prescriber if breast-
>you are using feeding.
factor IX complex
concentrates or
anti-inhibitor
coagulant
concentrates
 INTERVENTION
Name Action Classificati Indication Contra Indication Route Dose Adverse Side Effect Nursing Consideration
on Effect

Prophylaxis Co-amoxiclav is Hypersensitivity to Oral 625 mg >jaundice >diarrhea Co-amoxiclav should be

Brand name: antibiotic indicated for penicillin Q8h >fever >vomiting used with caution in
Co-Amoxiclav treatment of the >severe >thrush patients with allergic
Generic Name: following diarrhea diathesis, including
Clavam bacterial asthma, since such patients
(Amoxicillin- infections due to may have a higher risk of
clavulanic acid susceptible allergic reactions to co-
Co-amoxiclav organisms: amoxiclav.
augmentin) -Upper In long term use (more
respiratory tract than 10-14 days), regular
infection monitoring of renal and
Skin and soft hepatic function is
tissue infections, recommended.
Bone and joint Prolonged use of co-
infections, e.g. amoxiclav, or other
Dental infections, broadspectrum antibiotics,
e.g. dentoalveolar may lead to superinfections
abscess. due to an overgrowth of
non-susceptible organisms
and yeasts
In case of severe and
persistent diarrhoea, the
possibility of
pseudomembraneous colitis
must be considered, in
which case therapy should
be discontinued
  INTERVENTION
  
Diet :
Expect to eat a liquid and soft diet for the
first few days after surgery . If you find yourself
coughing immediately after drinking , try thicker
liquids or pudding consistency foods . If you
continue to have this problem or if you develop
chest discomfort or a fever , let your doctor know .
If a vocal cord weakness is present following
surgery , a speech pathologist will be involved in
selecting a diet that is appropriate
ave coughed up into a tissue. Take 10 deep breaths in a row every hour while awake. Remember to follow each deep breath with a coug

Exercise :
•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 .
•
•
•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.
 SURGICAL INTERVENTION
Total Thyroidectomy

Definition
Thyroidectomy is the surgical removal of all
or part of the thyroid gland . This gland is in
the neck . It produces hormones that regulate
metabolism .
 SURGICAL INTERVENTION
Total Thyroidectomy

Possible Complications
C o m p lica tio n s a re ra re b u t n o p ro ce d u re is
co m p le te ly fre e o f risk . If y o u a re p la n n in g to h a v e
a th y ro id e cto m y , y o u r d o cto r w ill re v ie w a list o f
p o ssib le co m p lica tio n s w h ich m a y in clu d e :
•
•Damage to the parathyroid gland , which
controls calcium metabolism ( could lead to
nerve and heart problems )
•Voice changes due to damage to nerves
leading to the voice box ( rare )
•Scarring
•Bleeding
•Infection
 SURGICAL INTERVENTION
Total Thyroidectomy

Some factors that may increase the

risk of complications include :
•
•Severity of hyperthyroidism
•Size of goiter
•Obesity
•Smoking
•Alcoholism
•Poor nutrition
•Long - term illness
 NURSING INTERVENTION

–   A sse ss fo r h e m a to m a fo rm a tio n

–   A sse ss la ry n g e a l strid o r d u rin g re sp ira tio n s
–   S e m i- F o w le r ’ s p o sitio n / p illo w - lu b rica te n e ck
in cisio n
–   M o n ito r V S in clu d in g p a in co n tro l
–   M o n ito r sig n s o f te ta n y se co n d a ry to
h y p o p a ra th y ro id ism ( tin g lin g in to e s , fin g e rs , o r
a ro u n d m o u th ; m u scu la r tw itch in g ; a p p re h e n sio n )
 EVALUATION

T h e p a tie n t h a s b e e n o p e ra te d fo r 2 d a y s n o w .
H e h a s still a d isch a rg e o n th e in cisio n site b u t it is
m in im a l o n ly . In te rm s o f re sp ira tio n h e h a s n o
d ifficu lty in b re a th in g b u t in te rm s o f sw a llo w in g
h e ca n ’ t sw a llo w b ig p a rticle s o f fo o d .

He is now ambulatory and maintain a semi semi

fowlers position . Level of calcium is monitored if
there is an indication of hypocalcemia .
Discharge Planning
Medicine
1.Advice to continue the medication as ordered by the
physician.
2.Inform the patient’s guardian on the right dose and
the right time in taking the medications.
3.Explain in layman’s term the action of the drugs
the patient taking.

Exercise:
1.Instruct the patient to deep breathing exercise
regulary for lung expansion
Treatment:
* Assessment of post operative status
will be done by the surgeon.
* Assessment of the serum calcium
level will be done by the endocrinologist.

H e a lth Te a ch in g :
•
•Keep the incision clean and dry.
•Do not get the incision wet until your doctor
allows. If it does get wet, dry it immediately.
•Perform neck exercises as instructed by your
doctor.
•Take all medications as prescribed by your
doctor.
•Be sure to follow your doctor's instructions.
Out patient department follow up/ check-up:
Remind the patient or the immediate family
member for follow up check up as their physician
instructed them

DIET :
There should be an increase in the calcium diet to
prevent osteoporosis since the body can no longer
produce calcitonin. Low calcium level in the blood would
stimulate the parathyroid gland to produce parathormone,
thereby stimulating osteoclasts to break down bone,
release calcium in the blood and increase GI calcium
absorption.
 RECCOMENDATION
vBalance diet and increase fluid
intake
vHave yourself an activities that
helps you to relax .
vGive your time enough time rest and
sleep .
vAvoid rising immediately after
sitting

.
•
 
BIBLIOGRAPHY
 
Amy M Karch. 2008 Lippincott’s Nursing Drug
Guide.

Doenges, Marilyn; Moorhouse, Mary Frances;

Murr, Allice. Nurses pocket Drug Guide

Merriam Webster Medical Dictionary

Texbook of Medical-Surgical Nursing