Throidectomy

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
Page | 2

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

thyroidectomy.

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

(Retrieved

at

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 OtolaryngologyHead 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)

Page | 3

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-4e56-84854efd96144899%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

Page | 4

illness condition of their patient in order to render adequate and appropriate nursing
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.

Page | 5

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
Page | 6

secrete iodine-containing hormones called thyroxine (T4) and triiodothyronine (T3).

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.
Page | 7

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
Page | 8

compared to T4), and releasing them into the blood. Deiodinase enzymes convert T4
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 thyroidstimulating 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
Page | 9

hormone (TRH), which is produced by the hypothalamus and secreted at an

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.

Page | 10

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
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.

Page | 11

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

Page | 12

performed, typically, surgeons perform a bilateral subtotal thyroidectomy which

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

Page | 13

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 downward 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.

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

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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.

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

Fig. 1.3b Kochers Collar Incision

Operative Technique
Page | 15

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).

Fig. 1.4

Fig 1.5

Fig. 1.6

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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.

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.

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Fig 1.9
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

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Fig 1.11b
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.

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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
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.

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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 Isthmus, and the specimen is divided, so that the
isthmus is included with the resected lobe.

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.

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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.)

Fig 1.18
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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

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.

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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.
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).
Page | 24

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
o
o
o
o

A small thyroid nodule or cyst

A thyroid gland that is so overactive it is dangerous (thyrotoxicosis)
Benign (noncancerous) tumors of the thyroid
Cancer of the thyroid
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
be removed in this case.

However, cases of thyroiditis have an increased

complication rate due to bleeding and scarring.

Page | 25

2 Risk and Benefits of Undergoing Treatment

Risk
1.

Benifits

Hypoparathyroidism or recurrent
1.
lesion,

have

not

been

As therapy for some individuals

investigated with thyrotoxicosis; those with Graves

systematically.

disease; and others with a hot nodule or

toxic nodular goiter.

2.

Recurrent laryngeal nerve injuries.

2.

To establish a definitive diagnosis

of a mass within the thyroid gland,
especially when cytologic analysis after
fine needle aspiration (FNA) is either

3.

Cervical hematomas.

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

Page | 26

Risk
1. A small thyroid nodule or cyst.

Benefits
1. The patient may have decreased

2. A thyroid gland that is so overactive it is

dangerous (thyrotoxicosis).

risk

of

developing

any

postoperational complications.

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

Page | 27

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

Page | 28

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.

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

9.) CRILE a clamp for temporary stoppage of blood flow.

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10.) TOWEL CLIPS used to hold towels and drapes in place.

Page | 30

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.

Page | 31

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 | 32

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 | 33

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 | 34

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 | 35

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.
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.
Page | 36

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.).
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.
Page | 37

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.
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.
Page | 38

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.
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

Page | 39

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
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

Page | 40

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:
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
Page | 41

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.
Special monitoring required. Respiratory status should be carefully
monitored if early postoperative stridor or difficulty in clearing secretions occurs.
Patients with thyrotoxicosis who receive appropriate preoperative preparation should
undergo routine monitoring.
Patient activity and positioning. The head should be elevated 30 to 45
degrees (Semi-Fowler) when client is conscious unless client is hypotensive to
minimize edema and venous oozing. Support head and neck with pillows. Full
activity is resumed the morning after operation.
Neck Exercises. First, teach the client how to support the weight of the head
and neck when sitting up in bed. Show the client how to place the hands at the back
of the head when flexing the neck or moving. The client will probably be able to
perform this maneuver by the first postoperative day. Second, as the wound heals
(about the 2nd to 4th 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.
Page | 43

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

>

may
pain

Diagnosis

Patient Acute pain

report
on

the

operative site

>

Patient

Planning

Explanation

Short

experiences

After 5 hours of

Rationale

term: > Establish rapport

interventions,

procedure

the patient will > Monitor

the be

anesthetic

able

Evaluation
> To gain the trust Short term:
the client

operative
As

sensation

patient

shall

have

demonstrated
vital >To provide baseline use

to signs

data.

demonstrate

agent wear off, use

outcome/

and cooperation of The

pain due to the nursing

may manifest:
facial

Intervention

Patient

done.
O

Expected

Scientific

of

relaxation
skills

of

and

diversional

relaxation skills >

Perform

a > To assess etiology/ activities

grimaces

returns

- restlessness

pain

- irritability

incision,

other

individual

location,

interaction

manipulations

situation.

characteristics,

Long term:

with people

done

onset/duration,

The

frequency, quality,

shall

reduced

change

in

body

and and diversional comprehensive

of

on

the activities

as assessment

and indicated

for pain

the

comes Long term:

to

precipitating

as

of contributory factors
include

indicated

for

individual
situation.

patient
have
Page | 45

respiration,

into awareness. After 4 days of severity (1 to 10),

reported

blood

The

and precipitating or

feeling of well-

pressure, and

tissue releases interventions,

aggravating factors

being

pulse

pain

the patient will

substances

report feeling of > Note location of the amount of pain

injured nursing

such
histamine
kinin.

> This can influence comfort.

as well-being and surgical

prostaglandins,

comfort.

experienced

procedures

and
These

substances
transmit

pain

spinal

> To ensure comfort

>

impulse to the

Observe

body despite

language

for communication

cord.

> To assist client for

>

cord, the pain

environment

message

Provide

quiet alleviation of pain

is

sent to the brain

it

is

> To prevent fatigue

>

Encourage

processed and

adequate

is perceived as

periods

pain.
message

impaired

evidence of pain

From the spinal

where

and

The
is

rest
>

Promotes

rest,

> Encourage use redirects attention

Page | 46

transmitted

of

back to the site

techniques

of

as

injury then

through

the

relaxation
such

soft

music,

focused breathing

spinal cord. In

>

the spinal cord

>

and in the brain,

listen and maintain and

many chemicals

frequent

such

with patient

as

Take

time

Helpful

to alleviating

in
anxiety

refocusing

contact attention, which may

relieve pain

endorphins,
serotonin

and

adrenaline

are

involved

in

>To

provide

>Administer

pharmacologic

analgesic

treatment of pain.,

modulation and

medications

transmission of

ordered.

as
> To promote timely

pain.
>

Monitor intervention/revision

effectiveness

of of plan of care

pain medications

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

Page | 47

Assessment

Scientific

Diagnosis

Explanation
hemorrhage

S > the patient Ineffective

If

may verbalize airway

(bleeding)

dyspnea

beneath

clearance
related

>

patient

the

to neck

wound

the bleeding and/ occurs,

may or

manifest:

the

laryngeal wound

edema

and

bulges

the

neck

Objectives
Short Term:

Interventions

Outcomes
> To gain the trust Short Term:

> Establish rapport

After 1 hour of

and cooperation of The patient will

nursing

the client

the patient will >

be

able

Monitor

to signs,

vital >

level

note

orientation

from normal

patency.

wound on the

structures

low collar area

inside the neck

Long Term:

of neck

and

After 3 days air movement

- adventitious

with breathing.

of

breath sounds

This

interventions,

emergency.

the patient will site

crackles)

Laryngeal

be

- changes in

edema

respiratory

also occur due

signs,

head)

to

respirations,

minutes for 1 hour

rhythm

and

surgical

manipulation.

deviations

sounds and assess status

ascertain be
and

progress

nursing

able

Long Term:
The patient will

> Auscultate breath >To

may

provide airway

consciousness,

compressing

rate

To

maintain

surgical

wheezes,

to

of baseline data and patency.

airway

an

able

maintain

swells, possibly

is

be

interventions,

- presence of

interfering

Desired

Rationale

able

note maintain

to
vital

signs,
respirations,

>

Check

dressing > To identify signs and

for

to bleeding

profuse of bleeding
(side

of

breath

sounds within
normal limits.

maintain vital neck and back of

and

every

breath immediately

15
after
Page | 48

difficulty

Bilateral

sounds within surgery

vocalizing

recurrent nerve

normal limits.

- restlessness

injury with acute

>

- cyanosis

paralysis

size minimized

of

Keep

dressing >

To

impaired

prevent
view

of

both

vocal

cords

may

occur

during

> Position patient on > To promote ease

surgery

which

back with head of in breathing

may

cause

bed elevated 30 to

obstruction
the

of

incision site

45 degrees

airway

because of the

> Monitor for signs > To identify early

adduction of the

of

true

distress

cords.

vocal

respiratory signs of respiratory

or distress caused by

obstructed airway q tracheal edema

1 : stridor, wheezing,
coarse

airway

crackles,

dyspnea,

cyanosis,

labored

respirations
>

To

prevent

> Teach and assist pulmonary

Page | 49

patient

to

turn, complications and

cough,

and

deep to take advantage

breathe q2h and prn

of

gravity

decreasing
pressure

on

diaphragm

the
and

enhancing
drainage

of

ventilation

/
to

different

lung

segments
> If indicated, keep > To clear airway
suction equipment at when
bedside;
suction

secretions

gently are blocking airway

oropharynx

only

when

necessary
>

To

maintain

> Keep environment patent airway

allergen free
> To use if patient
Page | 50

>

Have experiences severe

tracheostomy
and

tray respiratory distress

oxygen

immediately
available at bedside
>

To

mobilize

> Encourage use of secretions

warm

versus

liquids

cold
as

appropriate
>
>

To

prevent

Provide fatigue

opportunities for rest

> Hoarseness and
> Encourage voice sore

throat

rest, but do assess secondary

speech

to

and edema or damage

swallowing

to laryngeal nerve

periodically

may

last

days.
difficulty

several

Increased
may

indicate impending
Page | 51

obstruction
>

To

assess

> Evaluate changes changes

in sleep pattern
> To identify
> Observe for signs/ infectious process/
symptoms

of promote

infection

timely

intervention
>

To

promote

> Note physician if timely intervention /

dressing

requires revision in plan of

reinforcement more care

than one time

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

Page | 52

Assessment
S>

Diagnosis

Expected

Scientific

Planning

Explanation

Altered

The decreased Short term:

Tissue

in

excessive

Generalized blood

weakness

Rationale

have

nursing

in the blood of interventions,

to

tissue be

able

relationship

good The
to

patient

the shall

have

patient and to the demonstrated

loss client may lead the patient will

secondary

outcome/

Evaluation
Establish > To gain trust and to Short term:

>

hemoglobin After 3 hours of rapport.

O > The patient Perfusion r/t concentration

may manifest:

Intervention

SO.

measures

to

to

improve

- Paleness and to surgery

perfusion

demonstrate

pallor

ineffective. The measures

- Altered BP

level

- Dizziness

hemoglobin

- Vomiting

the patient may

> Instruct patient to complications.

shall able to

- Headache

give

have complete bed

demonstrate

- Body malaise

outcome

of After 3 days of rest.

-Hypoventilation

decrease

in nursing

- Cold skin

oxygen

of

the improve

> To have a baseline circulation.

to >

Monitor

record vital signs

interventions,

> To prevent further The

> Compliance to and perfusion

failure

to be

the demonstrate

tissues at the increased

level. perfusion

of regimen will result in appropriate.

to compliance to the effective

therapeutic

appropriate

>
>

healing

To

prevent

Encourage aspiration.

relaxation

cardiac output:

technique such as

however, there

deep

may

exercise.

faster

as healing process.

decreased

be

and

treatment

regimen to hasten process.

This may exist individually

without

as

> Stress out the of the patient to the individually

in the patient will importance

able

patient

increased

resulting

capillary

Long term:

of circulation.
the Long term:

nourish

and data.

breathing

Page | 53

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

>

patient

Scientific

Diagnosis

Explanation
Injury
that Short Term:

the Impaired
may verbal

results

verbalize

communicatio

dyspnea

related

damage

Objectives

severing,

to clamping,

Interventions
>

Rationale

Desired

Outcomes
Establish > To gain the trust Short Term:

from After 4 hours of rapport

nursing

and cooperation of The patient will

the client

interventions,

compressing, or the patient will > Monitor

be able to use
alternative

vital >

To

provide communication
Page | 54

>

the and/or

patient

may manipulation

manifest:

of

baseline data and methods

the

note

recurrent alternative

laryngeal laryngeal nerve communication

- presence of nerves
surgical

stretching either be able to use signs

secondary

or

superior methods

to laryngeal nerve which

wound on the surgery

during

low

surgery

collar

untoward

needs > Monitor voice >

be quality q2h

can

To

damage

to Long Term:
The patient will
be

>

Monitor

for > To assess

sequelae for the After 6 days of edema at surgical contributing factors

- inability to

patient.

speak

recurrent

use

of

incision

interventions,

cues/

the

gestures

medial aspect of verbally without that

the

verbalizing

or

to

verbally
without

voice

change.

laryngeal nerve the patient will

lies adjacent to be

speaking

and

glottis

nonverbal

difficulty

able

communicate

articulation

The nursing

be

evaluate

laryngeal nerves

Long Term:

needs

expressed.

may expressed.

result in severe

impaired

from normal

in

thyroid can

area of neck

deviations which

in

able

postero- communicate
thyroid. voice change.

to > Note presence >

To

assess

of draining tubes causative factors

blocks

speech

Unilateral
recurrent

>If

indicated >To

laryngeal nerve

provide

injury

alternative means speak

the

causes
ipsilateral

patients

minimize
need

to

of communication
Page | 55

vocal

cord

to

such as use of

in

the

pad and pencil or

remain
median

or

slate board

paramedian
position,

thus

>Keep

call

bell >To

minimize

immediate

within reach at all patients

hoarseness

times

occurs.

need

to

speak

The

voice may never

>

recover

environmental

which may worsen

stimuli

problem

its

timbre

and

focus,

even

though effective

>

phonation

can

meaning

eventually

be

nonverbal

achieved.

reduce > To lessen anxiety

validate >

because

they

of may be wrong

communication

Bilateral
recurrent nerve

>

injury with acute

increasing

paralysis of both

hoarseness

vocal

physician

cords

report > to promote timely

intervention

to revision in plan of
care

adducts the true

Page | 56

vocal

cords.

>

anticipate >to

Permanent

patients needs as patients

debilitating

indicated

minimize
need

to

speak

hoarseness
may follow.
Damage to the
superior
laryngeal nerve
affects

voice

pitch. Since the

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

Page | 57

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

Assessment
S>

Impaired
skin

>

may integrity

manifest:

Objectives

Explanation
In

Short Term:

and thyroidectomy,

the tissue

patient

Scientific

Diagnosis

Interventions
> Establish rapport

Outcomes
> To gain the trust Short Term:

After 2 hours

and cooperation of The

an incision will

of

the client

be

interventions,

made

nursing

through the skin

the patient will > Monitor vital signs

>

- presence of to surgery

in the low collar

be

baseline data

surgical

area

of

verbalize

wound on the

neck.

Next,

low

vertical cut will

the
a

able

to

understanding
of

patient

will be able to
verbalize

secondary

collar

Desired

Rationale

To

provide understanding
of

condition

and causative
> Record size (depth, >

To

provide factors.

condition width), color, location, comparative

Page | 58

area of neck

be

through

damaged

tissue

made
the

and causative temperature, texture, baseline

Long Term:

factors.

The

consistency

strap-like

wound/

of

lesion

if

will be able to

muscles located

Long Term:

just below the

After 3 days of

skin, and these

nursing

>Inspect surrounding

muscles will be

interventions,

skin

spread aside to

the patient will induration,

reveal

the

be

thyroid

gland

display

and

other

progressive

> Note odors and

deeper

improvement

drains emitted from > To assess early

structures.

in

Then, all or part

healing.

of

the

able

patient

possible

display
progressive

for

improvement

erythema, > To assess extent in

of involvement

wound

healing.

to maceration

wound the

skin/

area

of progression

of

wound

or

injury

thyroid

healing

development

of

gland will be cut

hemorrhage

or

free

infection

from

surrounding
tissues
removed.

and
After

> Assess adequacy >

To

identify

of blood supply and contribution factors

the thyroid gland

innervation

of

is removed, one

affected tissue

the

Page | 59

or two stitches
will be used to

> Inspect skin on a > To promote timely

bring the neck

daily

muscles

describing

together

again.

Then the deeper

layer

of

basis, intervention/revision
lesions of plan of care

and

changes

observed

the

> To assist bodys

incision will be

>

closed

clean/dry,

carefully repair

stitches, and the

dress

wounds,

skin

support incision, and

with
will

be

closed

with

sterile

paper

tapes.

The

incision can be
an

entry

Keep

the

area natural process of

prevent infection
>
>

Use

To

protect

appropriate wound

wound coverings

the

and/or

surrounding tissues

for

bacteria.

> To prevent skin

> Avoid use of plastic breakdown due to
material and remove moisture
wet/wrinkled

linens

promptly
>

To

provide

a
Page | 60

>

Rrovide

good positive

nutrition

with balance to aid in

adequate protein and healing

calorie

nitrogen

intake,

vitamin/

and

to

and facilitate healing

mineral

supplements

as

indicated
> To prevent fatigue
>

Encourage

adequate

rest

and

sleep
>
>Encourage
ambulation
mobilization

To

early circulation
and reduce
associated

promote
and
risks
with

immobility
>
>

Provide

changes

To

position excessive

prevent
tissue

pressure
> To reduce risk of
Page | 61

>

Practice

aseptic cross-contamination

technique

in

cleansing/dressing
and

medicating

lesions
> To prevent spread
>

Instruct

disposal

of

proper of infectious agent

soiled

dressing
>

To

enhance

>Refer to dietician as healing

appropriate

Page | 62

Page | 63

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-4e5684854efd96144899%40sessionmgr104&vid=1&bdata=JnNpdGU9ZWhvc3QtbGl2Z

Q%3d%3d#db=a3h&AN=55216256
http://www.medicalnewstoday.com/articles/67471.php
APPENDIX
(INSERT JOURNALS HERE)

Page | 64