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

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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
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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 doctor’s 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

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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.
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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

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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 (α1, α2, β1 and β2), 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

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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.

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 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.

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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

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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

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 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.
 Preparation of Surgical Instruments
 Draping
Simple and effective draping of the head can be achieved with Kaspar’s goiter
towel (Fig.1.2a). The tapes are tied behind the patient’s neck (Fig. 1.2a). Before the
head and the lateral parts of the neck are covered with the goiter towel, the patient’s
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 Kocher’s Collar Incision

 Operative Technique

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 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).
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)

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 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
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 1. As therapy for some individuals with
not been investigated systematically. thyrotoxicosis; those with Graves’ 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

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 3. Cervical hematomas. (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. 1. The patient may have decreased risk of
developing any postoperational
complications.
2. A thyroid gland that is so
overactive it is dangerous
(thyrotoxicosis).

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

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

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

4.) GELPI – has single point tips; ratchet to hold tissue apart

 Clamping Instruments:
5.) MOSQUITO – used to clamp blood vessels

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 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

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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.”

Page | 30
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 -

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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.

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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

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 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 patient’s 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.

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  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 surgeon’s 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:

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 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.
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.

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 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 anesthesiologist’s needs.
 If spinal anesthesia is contemplated:
o Place the patient in quasi fetal position and provide pillow.
o Perform lumbar preparation aseptically.
o Anticipate anesthesiologist’s needs.

 After the Patient is Anesthetized

 Reposition the patient per anesthesiologist’s instruction.
 Attached anesthesia screen and place the patient’s 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 patient’s 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.

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  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
windpipe (trachea) during surgery, or as a result of nerve irritation — but not
permanent damage — caused by the surgery.

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 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
he have something stuck in his throat. This feeling usually goes away
within five days.

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 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 surgeon’s 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.
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  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 Chvostek’s 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,

Page | 43
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.
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 Grave’s 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.

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1.7 Nursing Management of Physiologic, Physical, and Psychosocial Outcomes

Problem #1: Acute Pain

Expected
Scientific
Assessment Diagnosis Planning Intervention Rationale outcome/
Explanation
Evaluation
S > Patient Acute pain Patient Short term: > Establish rapport > To gain the trust Short term:
may report experiences After 5 hours of and cooperation of The patient
pain on the pain due to the nursing the client shall have
operative site operative interventions, demonstrated
procedure the patient will > Monitor vital >To provide baseline use of
done. As the be able to signs data. relaxation skills
O > Patient anesthetic demonstrate and diversional
may manifest: agent wear off, use of activities as
- facial sensation relaxation skills > Perform a > To assess etiology/ indicated for
grimaces returns and and diversional comprehensive precipitating individual
- restlessness pain of the activities as assessment of contributory factors situation.
- irritability incision, and indicated for pain to include
- reduced other individual location, Long term:
interaction manipulations situation. characteristics, The patient
with people done on the onset/duration, shall have
- change in body comes Long term: frequency, quality, reported

Page | 45
respiration, into awareness. After 4 days of severity (1 to 10), feeling of well-
blood The injured nursing and precipitating or being and
pressure, and tissue releases interventions, aggravating factors comfort.
pulse pain the patient will > This can influence
substances report feeling of > Note location of the amount of pain
such as well-being and surgical experienced
prostaglandins, comfort. procedures
histamine and
kinin. These > To ensure comfort
substances > Observe body despite impaired
transmit pain language for communication
impulse to the evidence of pain
spinal cord. > To assist client for
From the spinal > Provide quiet alleviation of pain
cord, the pain environment
message is
sent to the brain > To prevent fatigue
where it is > Encourage
processed and adequate rest
is perceived as periods
pain. The > Promotes rest,
message is > Encourage use redirects attention

Page | 46
 transmitted of relaxation
back to the site techniques such as
of injury then soft music, focused
through the breathing
spinal cord. In > Helpful in
the spinal cord > Take time to alleviating anxiety
and in the brain, listen and maintain and refocusing
many chemicals frequent contact attention, which may
such as with patient relieve pain
endorphins,
serotonin and >To provide
adrenaline are >Administer pharmacologic
involved in analgesic treatment of pain.,
modulation and medications as
transmission of ordered.
pain. > To promote timely
> 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
 Scientific Desired
Assessment Diagnosis Objectives Interventions Rationale
Explanation Outcomes
S > the patient Ineffective If hemorrhage Short Term: > Establish rapport > To gain the trust Short Term:
may verbalize airway (bleeding) After 1 hour of and cooperation of The patient will
dyspnea clearance beneath the nursing the client be able to
related to neck wound interventions, maintain
O > the bleeding and/ occurs, the the patient will > Monitor vital > To provide airway
patient may or laryngeal wound bulges be able to signs, level of baseline data and patency.
manifest: edema and the neck maintain consciousness, note deviations
- presence of swells, possibly airway orientation from normal Long Term:
surgical compressing patency. The patient will
wound on the structures > Auscultate breath >To ascertain be able to
low collar area inside the neck Long Term: sounds and assess status and note maintain vital
of neck and interfering After 3 days air movement progress signs,
- adventitious with breathing. of nursing respirations,
breath sounds This is an interventions, > Check dressing > To identify signs and breath
( wheezes, emergency. the patient will site for profuse of bleeding sounds within
crackles) Laryngeal be able to bleeding (side of normal limits.
- changes in edema may maintain vital neck and back of
respiratory also occur due signs, head) every 15
rate and to surgical respirations, minutes for 1 hour
rhythm manipulation. and breath immediately after

Page | 48
- difficulty Bilateral sounds within surgery
vocalizing recurrent nerve normal limits.
- restlessness injury with acute > Keep dressing > To prevent
- cyanosis paralysis of size minimized impaired view of
both vocal incision site
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 of 45 degrees
the airway
because of the > Monitor for signs > To identify early
adduction of the of respiratory signs of respiratory
true vocal distress or distress caused by
cords. 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 the
diaphragm and
enhancing
drainage of /
ventilation to
different lung
segments

> If indicated, keep > To clear airway

suction equipment at when secretions
bedside; gently are blocking airway
suction oropharynx
only when
necessary
> To maintain
> Keep environment patent airway
allergen free
> To use if patient

Page | 50
> Have experiences severe
tracheostomy tray respiratory distress
and oxygen
immediately
available at bedside
> To mobilize
> Encourage use of secretions
warm versus cold
liquids as
appropriate
> To prevent
> Provide fatigue
opportunities for rest
> Hoarseness and
> Encourage voice sore throat
rest, but do assess secondary to
speech and edema or damage
swallowing to laryngeal nerve
periodically may last several
days. Increased
difficulty may
indicate impending

Page | 51
 obstruction

> To assess
> Evaluate changes changes
in sleep pattern
> To identify
> Observe for signs/ infectious process/
symptoms of promote timely
infection 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

Scientific Expected
Assessment Diagnosis Planning Intervention Rationale
Explanation outcome/

Page | 52
 Evaluation
S>ø Altered The decreased Short term: > Establish > To gain trust and Short term:
Tissue in hemoglobin After 3 hours of rapport. to have a good The patient
O > The patient Perfusion r/t concentration nursing relationship to the shall have
may manifest: excessive in the blood of interventions, patient and to the demonstrated
- Generalized blood loss client may lead the patient will SO. measures to
weakness secondary to tissue be able to improve
- Paleness and to surgery perfusion demonstrate > To have a baseline circulation.
pallor ineffective. The measures to > Monitor and data.
- Altered BP level of the improve record vital signs Long term:
- Dizziness hemoglobin of circulation. > To prevent further The patient
- Vomiting the patient may > Instruct patient to complications. shall able to
- Headache give the Long term: have complete bed demonstrate
- Body malaise outcome of After 3 days of rest. increased
-Hypoventilation decrease in nursing > Compliance to and perfusion as
- Cold skin oxygen interventions, > Stress out the of the patient to the individually
resulting in the patient will importance of regimen will result in appropriate.
failure to be able to compliance to the effective treatment
nourish the demonstrate therapeutic and faster healing
tissues at the increased regimen to hasten process.
capillary level. perfusion as healing process.
This may exist individually > To prevent

Page | 53
without appropriate > Encourage aspiration.
decreased relaxation
cardiac output: technique such as
however, there deep breathing
may be a exercise.
relationship > For patient
between > Provide comfortability.
cardiac output environment
and tissue conducive for
perfusion. resting.
> To know what the
> Encourage patient is trying to
expression and voice out and what
verbalization of the patient feelings.
feelings.
> To maintain
>Administer IV electrolyte balance.
fluids as ordered.
> To identify what
>Evaluate nursing needs to be
interventions given. reinforced and
assess effectiveness

Page | 54
 of interventions
given.

Problem # 4: Impaired Verbal Communication Related to Damage and/or Manipulation of Laryngeal Nerves Secondary to
Surgery
Scientific Desired
Assessment Diagnosis Objectives Interventions Rationale
Explanation Outcomes
S > the Impaired Injury that Short Term: > Establish > To gain the trust Short Term:
patient may verbal results from After 4 hours of rapport and cooperation of The patient will

Page | 55
verbalize communication severing, nursing the client be able to use
dyspnea related to clamping, interventions, alternative
damage and/or compressing, or the patient will > Monitor vital > To provide communication
O > the manipulation stretching either be able to use signs baseline data and methods in
patient may of laryngeal the recurrent alternative note deviations which needs
manifest: nerves laryngeal nerve communication from normal can be
- presence of secondary to or superior methods in expressed.
surgical surgery laryngeal nerve which needs > Monitor voice > To evaluate
wound on the during thyroid can be quality q2h damage to Long Term:
low collar surgery may expressed. laryngeal nerves The patient will
area of neck result in severe be able to
- impaired untoward Long Term: > Monitor for > To assess communicate
articulation sequelae for the After 6 days of edema at surgical contributing factors verbally
- inability to patient. The nursing incision and without voice
speak recurrent interventions, glottis change.
- use of laryngeal nerve the patient will
nonverbal lies adjacent to be able to > Note presence > To assess
cues/ the postero- communicate of draining tubes causative factors
gestures medial aspect of verbally without that blocks
- difficulty the thyroid. voice change. speech
speaking or Unilateral
verbalizing recurrent >If indicated >To minimize

Page | 56
laryngeal nerve provide patient’s need to
injury causes alternative means speak
the ipsilateral of communication
vocal cord to such as use of
remain in the pad and pencil or
median or slate board
paramedian
position, thus >Keep call bell >To minimize
immediate within reach at all patient’s need to
hoarseness times speak
occurs. The
voice may never > reduce > To lessen anxiety
recover its environmental which may worsen
timbre and stimuli problem
focus, even
though effective > validate > because they
phonation can meaning of may be wrong
eventually be nonverbal
achieved. communication
Bilateral
recurrent nerve > report > to promote timely
injury with acute increasing intervention /

Page | 57
paralysis of both hoarseness to revision in plan of
vocal cords physician care
adducts the true
vocal cords. > anticipate >to minimize
Permanent patient’s needs as patient’s need to
debilitating indicated 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 | 58
Problem # 5: Impaired Skin and Tissue Integrity Secondary to Surgery
Scientific Desired
Assessment Diagnosis Objectives Interventions Rationale
Explanation Outcomes
S>Ø Impaired In Short Term: > Establish rapport > To gain the trust Short Term:
skin and thyroidectomy, After 2 hours and cooperation of The patient will
O > the tissue an incision will of nursing the client be able to
patient may integrity be made interventions, verbalize
manifest: secondary through the skin the patient will > Monitor vital signs > To provide understanding
- presence of to surgery in the low collar be able to baseline data of condition

Page | 59
surgical area of the neck. verbalize and causative
wound on the Next, a vertical understanding > Record size (depth, > To provide factors.
low collar cut will be made of condition width), color, comparative
area of neck through the and causative location, baseline Long Term:
- damaged strap-like factors. temperature, texture, The patient will
tissue muscles located consistency of be able to
just below the Long Term: wound/ lesion if display
skin, and these After 3 days of possible progressive
muscles will be nursing improvement
spread aside to interventions, >Inspect surrounding > To assess extent in wound
reveal the the patient will skin for erythema, of involvement healing.
thyroid gland be able to induration,
and other display maceration
deeper progressive
structures. improvement > Note odors and > To assess early
Then, all or part in wound drains emitted from progression of
of the thyroid healing. the skin/ area of wound healing or
gland will be cut injury development of
free from hemorrhage or
surrounding infection
tissues and
removed. After > To identify

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the thyroid gland > Assess adequacy contribution factors
is removed, one of blood supply and
or two stitches innervation of the
will be used to affected tissue
bring the neck > To promote timely
muscles > Inspect skin on a intervention/revision
together again. daily basis, of plan of care
Then the deeper describing lesions
layer of the and changes
incision will be observed > To assist body’s
closed with natural process of
stitches, and the > Keep the area repair

skin will be clean/dry, carefully

closed with dress wounds,

sterile paper support incision, and

tapes. The prevent infection > To protect the

incision can be wound and/or
an entry for > Useappropriate surrounding tissues

bacteria. wound coverings

> To prevent skin

breakdown due to
> Avoid use of plastic moisture

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material and remove
wet/wrinkled linens
promptly > To provide a
positive nitrogen
> Rrovide good balance to aid in
nutrition with healing and to
adequate protein and facilitate healing
calorie intake, and
vitamin/ mineral
supplements as
indicated > To prevent fatigue

> Encourage
adequate rest and
sleep > To promote
circulation and
>Encourage early reduce risks
ambulation and associated with
mobilization immobility

> To prevent
excessive tissue

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> Provide position pressure
changes
> To reduce risk of
cross-contamination
> Practice aseptic
technique in
cleansing/dressing
and medicating
lesions > To prevent spread
of infectious agent
> Instruct proper
disposal of soiled
dressing > To enhance
healing
>Refer to dietician as
appropriate

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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 people’s 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)

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