NODULAR NON-TOXIC

GOITER

CASE PRESENTATION
gROUP 1b
Prepared by: jean c. arellano
I.INTRODUCTION

 A goiter is an enlargement of the thyroid. The thyroid is an endocrine gland that

produces hormones that help regulate your body’s metabolism. It is located on the
front of the neck, right below the “Adam’s Apple.” Goiters are seldom painful, and
tend to grow slowly.
 There are different types of goiters. A nontoxic (or sporadic) goiter is a type of
“simple” goiter that may be diffuse (enlarging the whole thyroid gland) or nodular
(enlargement caused by nodules, or lumps, on the thyroid.) The development of
nodules marks a progression of the goiter, and should be evaluated by your doctor.

NONTOXIC GOITER: DIFFUSE AND NODULAR

 Nontoxic goiter may be defined as any thyroid enlargement characterized by uniform
or selective (i.e., restricted to one or more areas) growth of thyroid tissue that is not
associated with overt hyperthyroidism or hypothyroidism and that does not result
from inflammation or neoplasia. A thyroid nodule is defined as a discrete lesion
within the thyroid gland that is due to an abnormal focal growth of thyroid cells.
 CONTINUATION
 Goiter or the enlargement of the thyroid gland is considered prevalent in the
Philippines. This disease in thyroid gland is classified as endemic, meaning
present continuously in a community, or sporadic goiter.
Based on the studies on urinary iodine levels conducted by the Department of
Health, most goiter cases are found in the mountainous provinces and other
remote areas of the country, where children and pregnant women are mostly
affected.
Some inland residents however, may have goiter because of insufficient iodine
intake in their diet aside from eating a lot of goitrogenoids, which are found in
cabbage, soybeans, peanuts, peaches, strawberries, spinach, and radishes. Other
people in remote areas are discovered to have goiter because of iron deficiency
due to poverty.
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
Our endocrine system is made up of glands that produce and secrete
hormones. One of these glands is the thyroid gland.
The thyroid gland is a butterfly-shapes organ and is composed of
two cone like lobes or wings connected together by a thin band of
connective tissues called the isthmus. This organ is the largest
endocrine gland in the body. It is situated on the anterior side of
the lower neck, in front of the trachea (windpipe), just below the
larynx (voice box).
The thyroid produces several chemical substances known as thyroid
hormones, principally thyroxine (T4) and triiodothyronine (T3) and
these circulate the body in the blood. The hormones secreted by the
thyroid gland regulate metabolism, heart rate, growth and the
body’s energy level.
Thyroxine (T4) is produced in much greater quantities than triiodothyronine (T3)
and it has a major influence on the physical and mental development and also on
the general well being. This is mainly due to the fact that it helps to control the
rate of chemical reactions in all the body cells.
The thyroid gland is also influenced by hormones produced by two other organs:
1. The pituitary gland, located at the base of the brain, which
produces thyroid stimulating horme.
2. The hypothalamus, a small part of the brain above the pituitary,
which produces thyrotropin releasing hormone (TRH).
Low levels of thyroid hormones in the blood are detected by the
hypothalamus and the pituitary. TRH is released, stimulating the pituitary
to release TSH. Increased levels of TSH, in turn, stimulate the thyroid
to produce more thyroid hormone, thereby returning the level of thyroid
hormone in the blood back to normal. The three glands and the hormones
they produce make up the "Hypothalamic - Pituitary - Thyroid axis."
 PHYSIOLOGY
Secretory Function.

 The primary function of the thyroid

Regulation of the thyroid gland's
secretory function
gland is to secrete two hormones,
thyroxine (T4) and triiodothyronine
(T3) (Johnson, 1995). Figure 2
illustrates the secretory function of
the thyroid and associated organs.
These thyroid hormones serve
several purposes that include (a)
regulating carbohydrate and lipid
metabolism, (b) stimulating
oxygen consumption by cells, and
(c) controlling growth and
development
 The production and secretion of thyroid hormones by the thyroid gland are
controlled by the thyroid stimulating hormone (TSH) produced by the pituitary
gland. TSH is, in turn, regulated by the thyroid-releasing hormone (TRH) secreted
from the hypothalamus. Iodine is necessary to synthesize thyroid hormones.
Ingested iodine is absorbed into the circulatory system and stored in the thyroid
before being converted into thyroid hormones.
 Parathyroid Glands. 
The parathyroid glands are small pieces of reddish-brown tissue that lie on both
sides of the thyroid gland. While most individuals possess four parathyroid glands,
two superior and two inferior, total numbers of parathyroid glands vary among
individuals. These glands are responsible for producing parathyroid hormone,
which, along with vitamin D, regulate calcium and phosphorus concentrations in the
body. Compromise of the vascular system to the parathyroids during thyroid surgery
may result in ischemia and subsequent transient hypocalcemia. Since the inadvertent
removal of the parathyroid glands may result in severe tetany and death, care must
be taken by the surgeon to identify and preserve the parathyroid glands during
surgery.
 . The thyroid and thyrotropes form a negative feedback loop: TSH production
is suppressed when the T4 levels are high. The TSH production itself is
modulated by thyrotropin-releasing hormone (TRH), which is produced by
the hypothalamus and secreted at an increased rate in situations such as cold
exposure (to stimulate thermogenesis). TSH production is blunted
by somatostatin (SRIH), rising levels of glucocorticoids and sex
hormones (estrogen and testosterone), and excessively high blood iodide
concentration.
 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 (thyroidectomy), but not the parathyroids.
 PATHOPHYSIOLOGY
Symptoms
Etiology: Risk Factors:
Nontoxic goiters
Exact causes are not Common in Female
usually do not
known Age: over 40 years
have noticeable
Not getting enough
symptoms.
Complications
In general, goiters iodine in the diet.
may be caused by The main
too much or too •Breathing difficulties
NEGATIVE FEEDBACK
symptom is a
little thyroid swollen thyroid  (may rarely occur with
MECHANISM
hormones. gland. very large goiters)
Hypothalamus •Cough
•Hoarseness
Possible Cause: •Swallowing difficulties
•Heredity (family TRH (thyroid
history of goiters) Pituitary Gland releasing
Regular use of hormone)
medications such as  Obstruction
:: lithium TSH (thyroid
Thyroid Glalnd stimulating hormone of airway
Regular intake of
substances
(goitrogens) that T3
inhibit production of (triiodothyronine)
Body T4 (thyroxine)
thyroid hormone.
EXPLANATION
Nodular non toxic goiter exact cause is unknown but in general, goiters may
be caused by too much or too little thyroid hormones. The possible cause
are heredity, regular use of medications such as lithium, regular intake of
substances goitrogens that inhibit production of thryroid hormone. For the
risk factor or predisposing factor it is common for client age 40 years and
above, common in female. also for not getting enough iodine in diet.
Usually the symptom is not noticeable but the main symptom is swollen
thyroid gland that will will lead to complications like breathing difficulties,
cough, hoarseness of voice and swallowing difficulties that will result to
obstruction of airway. For the negative feedback mechanism first the
hypothalamus a small part of the brain above the pituitary, will produces
thyrotropin releasing hormone (TRH) and then the TRH will stimulate
the pituitary gland to release TSH. Increased levels of TSH, in turn,
stimulate the thyroid gland to produce more thyroid hormone which is the
T3 and T4, thereby returning the level of thyroid hormone in the blood
back to normal.
IV.LABORATORY AND
DIAGNOSTIC TEST
 Examination of the neck—to assess any thyroid enlargement
 Ultrasound —a test that uses sound waves to identify nodules of the neck
and thyroid
 Blood tests—to assess levels of thyroid hormones (eg, thyroid stimulating
hormone). Thyroid autoantibodies tests may also be done.
 Thyroid scan (scintigraphy)—a picture of your thyroid gland taken after
you have been given a shot or drink of a radioisotope. The scan will show
how your thyroid is functioning and used to exclude thyroid cancer .
 Fine needle aspiration biopsy —a small needle will be inserted into a
nodule in the thyroid to obtain a tissue sample. The sample will be examined
to determine if it is benign or malignant (cancer). In 50%-60% of all
biopsies taken, the results are noncancerous.
 Barium swallow —a test to determine if the enlarged goiter is compressing
the esophagus, thus causing swallowing difficulty
 X-ray of neck and chest for large goiters—to see if the trachea is
compressed
 V.MEDICAL MANAGEMENT
 To gain the patients confidence and reduce anxiety.
 Quiet and relaxing form of environment.
V.SURGICAL MANAGEMENT
 Thyroidectomy
VI.NURSING CARE MANAGEMENT

A.PRE-OPERATIVE PHASE
- Gain the patient’s confidence and reduce anxiety.
- Efforts are necessary to protect the patient from such tension and
stress to avoid precipitating thyroid storm.
- Quiet and relaxing forms of recreation.
- Instructs the patient about the importance of eating a diet high in
carbohydrates and proteins.
- Supplementary vitamins, particularly thiamine and ascorbic acid,
may be prescribed.
- The patient is reminded to avoid tea, coffee, cola and other
stimulants.
B.INTRA-OPERATIVE PHASE
 Preventing breakage of continuity of aseptic technique.
 Correct counting of sponges and used instrument
inside the operating room.
 Secure patient safety.
 Proper positioning.
 Monitoring VS.
C.POST-OPERATIVE PHASE
- Periodically assess the surgical dressings and reinforce them if necessary.
- When the patient is in a recumbent position, the nurse observes the sides
and the back of the neck as well as the anterior dressing for bleeding.
- Monitor the pulse and blood pressure for any indication of internal
bleeding.
- Intensity of pain is assessed, and analgesic agents are administered as
prescribed for pain.
- Inform the patient that oxygen will assist breathing.
- When moving and turning the patient, carefully supports the patient’s
head and avoid tension on the sutures.
Post-op continuation
- Place patient in comfortable position (semifowler’s) with the head elevated
and supported by pillows.
- Administer IV fluids.
- Water may be given by mouth as soon as nausea subsides.
- Cold fluids and ice may be taken better than other fluids.
- Advise the patient to talk as little as possible to reduce edema to the vocal
cords.
- An overbed table is provided for access to frequently used items so the
patient avoids turning on his or her head.
- The patient is usually permitted to out of bed as soon as possible.
- Encouraged to eat foods that are easily swallowed.
- A high-calorie diet may be prescribed to promote weight gain.
VII.COMMON NURSING
DIAGNOSIS
Risk for ineffective airway clearance related to
tracheal obstruction; swelling, bleeding,
laryngeal spasm
Impaired verbal communication related to vocal
cord injury/laryngeal nerve damage ;tissue
edema; pain/discomfort.
 Acute pain related to Surgical
interruption/manipulation of tissues/muscles,
post-operative edema.
NURSING CARE PLAN
Post-operative phase
ASSESSMENT NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Independent

Objective Risk for After 8 hours 1.Monitor RR, 1.Respirations After 8 hours of
cue: ineffective of nursing depth, and work may remain continuous
-swelling airway intervention of breathing. somewhat rapid, nursing
clearance the patient will but development intervention the
related to be able to have of respiratory patient maintain
tracheal an effective distress is patent airway
obstruction airway indicative of with aspiration
secondary to clearance. tracheal prevented.
swelling. compression
from edema or
hemorrhage.
2.Auscultate 2.Ronchi may
breath sounds, indicate airway
noting presence obstruction/accu
of ronchi. mulation of
copious thick
secretions.
3.Assess for 3.Indicators of
dyspnea, stridor, tracheal
crowding, and obstruction/lary
cyanosis. ngeal spasm,
requiring
prompt
evaluation and
intervention.
ASSESSMENT NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
4.Caution 4.Reduces
patient to avoid likelihood of
bending neck; tension on
support head surgical wound.
with pillows.

5.Assist with 5.Maintains

repositioning, clear airway and
deep breathing ventilation.
exercises, and/or Although routine
coughing as coughing is not
indicated. encouraged and
may be painful,
it may be needed
to clear
secretions.

6.Suction mouth 6.Edema/pain

and trachea as may impair
indicated, noting patients ability
color and to clear own
charactersitics of airway.
sputum.
ASSESSMENT NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
7.Check 7.If bleeding
dressing occurs,
frequently, anterior
especially dressing may
posterior appear dry
portion. because blood
pools
dependently.
8.Investigate 8.May
reports of indicate
difficulty edema/seques
swallowing, tered bleeding
drooling of in tissues
oral surrounding
secretions. operative site.
9.Keep 9.Compromis
tracheostomy ed airway
tray at may create a
bedside. life-
threatening
situation
requiring
emergency
procedure.
ASSESSMENT NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Collaborative

10.Provide 10.Reduces
steam discomfort of
inhalation; sore throat and
humidify tissue edema
room air. and promotes
expectoration
of secretions.

11.Assist 11.May be
with/prepare necessary to
for maintain
procedures, airway if
e.g., obstructed by
tracheostomy edema of
glottis or
hemorrhage.

12.Return to 12.May require

surgery. ligation of
bleeding
vessels.
ASSESSMENT NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Objective cue: Independent

-guarding Acute pain After 8 hours 1.Assess 1.Useful in After 8 hours of

behavior. related to of nursing verbal/nonverbal evaluating pain, continuous
reports of pain, choice of nursing
-restlessness postoperative intervention
noting location, interventions, intervention the
-narrowed edema. the patient pain intensity (0 – 10 effectiveness of patient will report
focus will be scale) and therapy. pain is relieved.
relieved. duration.
Subjective
cue:
Report of pain
2.Place in semi- 2.Prevents
fowlers position hyperextension of
and support the neck and
head/neck with protects integrity
sandbags or small of the suture line.
pillows.

3.Maintain 3.Prevents stress

head/neck in on the suture line
neutral position and reduces
and support muscle tension.
during position
changes. Instruct
patient to use
hands to support
neck during movt,
and to avoid
hyperextension of
neck.
ASSESSMENT NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
4.Keep call 4. Limits
bell and stretching,
frequently muscle strain
needed items in operative
within easy area.
reach.  

5. Give cool 5.Although

liquids or soft both may be
foods , such as soothing to
ice cream or sore throat, soft
popsicles. foods may be
tolerated better
than liquids if
patient
experiences
difficulty
swallowing.
6. Encourage 6. Helps
patient to use refocus
relaxation attention and
techniques, assits patient to
e.g., guided manage
imagery, soft pain/discomfor
music, t more
progressive effectively.
relaxation.
ASSESSMENT NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Collaborative

7. Administer 7.Reduces .
analgesics pain and
and/or discomfort;
analgesic enhances rest.
throat
sprays/lozenge
s as necessary.

8. Provide ice 8.Reduces

collar if tissue edema
indicated. and decreases
perception of
pain.
IX.DISCHARGE INSTRUCTIONS
Explain to the patient and family the need for
rest, relaxation, and nutrition.
MEDICATIONS
thyroid hormone level checked to make sure that
they are on the correct dose of thyroid
replacement medication. This is done 2-3 weeks
after surgery.
analgesic agents are administered as prescribed
for pain.
EXERCISE/ACTIVITY
The patient is permitted to resume his or her
former activities and responsibilities completely
once recovered from surgery.
 TREATMENT
Radioactive Iodine 
 Radioactive iodine treatment is used to reduce the size of large
goiter. It is used in the elderly when surgical treatment is not an
option.
Thyroidectomy
 A surgery to remove a portion or all of the thyroid gland. It is
the treatment of choice if the goiter is so large to cause difficulty
in breathing or swallowing.
HEALTH TEACHING
Demonstrating to the patient how to support the
neck with the hands after surgery to prevent
stress on the incision.
The patient and the family need to be
knowledgeable about the signs and symptoms of
the complications that may occur and those that
should be reported.
OPD FOLLOW UP
Instructthe patients about the importance of
follow-up visits to the physician or the clinic for
monitoring of thyroid status.
DIET
Soft diet, easily swallowed food.
High calorie diet to promote weight gain.
SEXUALITY/SPIRITUALLY
Sexual activity resumed after 2 to 3 months after
surgery.
References:
Wikipedia
Slideshare
 Brunner and Suddarths Textbook of
Medical Surgical Nursing 12th edition by
lippincott.
Anatomy and Physiology by Mosby.
http://www.emedicine.com