ANGELES UNIVERSITY FOUNDATION

Angeles City

College of Nursing

CASE REPORT:

COLLOID NODULAR

GOITER

(THYROIDECTOMY)

Submitted By:

Bungay, Maria Paula

Fabunan , Roman III

Napalit, Bea Nikkisia D.

Group 10/ BSN III-3

Submitted To:

Ma. Teresa Cabanayan, R.N., M.N.

August 16, 2013

I. Introduction

Colloid nodular goiter is the enlargement of an otherwise normal thyroid

gland. Colloid nodular goiters are also known as endemic goiters. They are

usually caused by not getting enough iodine in the diet. Colloid nodular

goiters tend to occur in certain areas with iodine-poor soil. These areas are

usually away from the sea coast. An area is defined as endemic for goiter if

more than 10% of children ages 6 - 12 have goiters. Certain things in the

environment may also cause thyroid enlargement. Small- to moderate-sized

goiters are relatively common in the United States. The Great Lakes,

Midwest, and Intermountain regions were once known as the "goiter belt."

The routine use of iodized table salt now helps prevent this deficiency.

(http://health.nytimes.com/health/guides/disease/colloid-nodular-goiter)

Thyroid nodules are very common, with an estimated prevalence of

approximately 4% by palpation (5% in women and 1% in men living in iodine-

sufficient regions). A thyroid nodule larger than 1 cm in diameter is usually

palpable. However, the detection of a nodule by palpation also depends on its

location within the thyroid, on the structure of the patient’s neck and on the

experience of the examiner. In the Framingham Study, clinically apparent

thyroid nodules were present in 6.4% of the women and 1.6% of the men who

participated, with an estimated annual incidence, by palpation, of 0.001. The

lifetime risk of developing a thyroid nodule is reported to be 15%.

Nevertheless, only 5% of the clinically apparent thyroid nodules are

malignant. Thyroid carcinoma annual incidence is 1-2 per 100,000 population,

which accounts for 90% of the malignancies of the entire endocrine system,

1% of total human malignancies and 0.5% of total deaths from malignancies.

Although thyroid malignant tumors are not usually aggressive, thyroid

malignancies are responsible for more deaths than all other malignancies of

the endocrine system. (http://emedicine.medscape.com/article/127491-

overview)

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The overall prevalence in the Philippines of iodine deficiency among

patients with thyroid nodules is high at 63.4%. Despite of government efforts

to eliminate iodine deficiency in our country, this remains as a significant

health problem among adult Filipinos with thyroid nodules. It may be a risk

factor for nodular thyroid disease and these results show that it may also play

a crucial role in promoting the development of thyroid carcinoma, although

more patients are needed to accurately evaluate the association between

iodine exposure and risk of thyroid carcinoma. (R. Dejesus, et al., 2008)

There are new trends regarding the treatment, Thyroidectomy. 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.

(http://www.medicalnewstoday.com/articles/67471.php) Another is that the

scar less thyroid surgery was discovered as 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

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recovery time and less discomfort on the part of the patients.

(http://www.sciencedaily.com/releases/2009/11/091124174735.htm)

It is important for the student nurses to study about such disease and

surgery since they will be future nurses. They can use their knowledge when

they will encounter the disease condition or surgery as they go along with

their career. This case report will help them understand and improve their

skills, and they can give the best care possible to their patients having

colloidal nodular goiter or some related diseases. New trends and

technologies about the surgery can be discovered and be shared to other

healthcare team especially to the surgeons and whole operating team.

II. Anatomy and Physiology

Thyroid Gland

The thyroid gland is an endocrine gland located inferior to the larynx. It is

butterfly shaped and brownish-red in color, which lies on the trachea, in the

anterior neck. It establishes a structural form consisting of two lobes connected in

the middle by an isthmus, one on each side of the trachea, just inferior to the

larynx.

Internally, the thyroid gland consists of numerous follicles, which are small

spheres filled with a sticky, gelatinous material called cuboidal epithelial cells.

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Each thyroid follicle is filled with proteins, called thyroglobulin, which are

synthesized and secreted by the cells of the thyroid follicles. As part of the

thyroglobulin molecules, large amounts of thyroid hormones are stored in the

thyroid follicles. In between the delicate network of loose connective tissue

between the follicles contains scattered parafollicular cells.

Thyroid Hormones

The thyroid hormones are triiodothyronine known as T3 and

tetraiodothyronine known as T4. Another name for the T4 is thyroxin. T3

constitutes 90% of thyroid gland secretions and T4 10%. Although calcitonin is

secreted by the Para follicular cells of the thyroid gland, T3 and T4 are

considered to be thyroid hormones because they are more clinically important

and because they are secreted from the thyroid follicles.

T3 and T4 Synthesis

Thyroid stimulating hormone (TSH) from the anterior pituitary stimulates

thyroid hormone synthesis and secretions. TSH causes increase in the synthesis

if T3 and T4, which are then stored inside the thyroid follicles as part of the

thyroglobulin. TSH also causes T3 and T4 to be released from the thyroglobulin

and enter the circulatory system. An adequate amount of iodine is the diet is

required for thyroid hormone synthesis because iodine is a component of T3 and

T4.

Transport in the Blood

Thyroid hormones are transported in combination with plasma proteins in

the circulatory system. Approximately 70%-75% of circulating thyroid hormones

are bound to thyroxin-binding globulin (TBG), which is synthesized by the liver,

and 20%-30% are bound to other plasma proteins, including albumen. Thyroid

hormones, bound to these plasma proteins, form a large reservoir of circulating

thyroid hormones. Thyroid hormones are converted to other compounds and

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excreted in the urine.

Effects of Thyroid Hormones

Thyroid hormones interact with their target tissues in a fashion similar to

that of the steroid hormones. They readily diffuse through plasma membranes

into the cytoplasm of cells. Within cells, they bind to receptor molecules in the

nuclei. Thyroid hormones combined with their receptor molecules interact with

DNA in the nuclei to influence genes and initiate new protein synthesis. The

newly synthesized proteins within the targets cells mediate the cells’ response to

thyroid hormones. It takes up to a week after the administration of thyroid

hormones for a maximal response to develop, and new protein synthesis

occupies much of that time.

Thyroid hormones affect nearly every tissue in the body, but not all tissues

respond identically. Metabolism is primarily affected in some tissues, and growth

and maturation are influenced in others. The normal rate of metabolism depends

on an adequate supply of thyroid hormone, which increases the rate at which

glucose, fat, and protein are metabolized. The metabolic rate can increase 60%-

100% when blood thyroid hormones are elevated. Maintaining normal body

temperature depends on an adequate amount of thyroid hormones.

Normal growth and maturation of organs also depend on thyroid

hormones. Specifically, bone, hair, teeth, connective tissue, and nervous tissue

require thyroid hormones for normal growth and development. Both normal

growth and maturation of brain require thyroid hormones.

Regulation of Thyroid Hormone Secretion

Thyroid hormone secretion is regulated by hormones produced in the

hypothalamus and anterior pituitary. Thyrotropin-releasing hormone (TRH) is

produced in the hypothalamus. Chronic exposure to cold increases TRH

secretion, whereas stress, starvation, injury, and infections, decreases TRH

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secretion. TRH stimulates TSH secretion from the anterior pituitary. Small

fluctuations in blood levels of TSH occur on daily basis, with a small nocturnal

increase. TSH stimulates the secretion of thyroid hormones from the thyroid

gland. TSH also increases the synthesis of thyroid hormones, as well as causing

an increase in thyroid gland cell size and number. Decreased blood levels of

TSH lead to decreased secretion of thyroid hormones and thyroid gland atrophy.

Thyroid hormones have a negative feedback effect on the hypothalamus and

anterior pituitary gland. As thyroid hormone levels increase in the circulatory

system, they inhibit TRH and TSH secretion. Also, if the thyroid gland is removed

or if the secretion of thyroid hormones declines, TSH levels in the blood increase

dramatically.

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Non- Modifiable Factors:Age (40 years old)Gender (Female)

Family History of Goiter

Modifiable Factors:Lack of Iodine in diet

Living in an area where there is endemic iodine deficiency

Pregnancy

Decreased Iodine intake

Decreased Iodine in glandular cells

Pituitary gland will release TSH as a compensatory mechanism

Increased TSH production

Increased cellularity and hyperplasia of the Thyroid gland

Increased size of Thyroid land(Colloid Nodular Goiter)

Inadequate secretion of Thyroid hormones (T3 andT4) Lab results: T3: <75 ng/dL; T4: <10 mcg/dL<

Compression of vasculature

Obstruction of venous return

Compression of the esophagus

Difficulty in swallowing

Dysphagia

Compression of trachea

Narrowed Airway

Difficulty in breathing

III. The Patient and His Illness

PATHOPHYSIOLOGY (BOOK-CENTERED)

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Severe enlargement

Narrowed thoracic inlet when hands are raised

Compression of blood vessels to the head

Decreased blood flow

Dizziness

Pemberton’s sign

Venous engorgement

Distended neck veins

Synthesis of the Disease

Enlargement of the thyroid, or goiter, is the most common manifestation of

thyroid disease. Colloid nodular goiter impaired synthesis of thyroid

hormone, most often caused by dietary iodine deficiency. Impairment of thyroid

hormone synthesis leads to a compensatory rise in the serum TSH, which in turn

causes hypertrophy and hyperplasia of thyroid follicular cells and, ultimately,

gross enlargement of the thyroid gland. The compensatory increase in functional

mass of the gland is enough to overcome the hormone deficiency, ensuring

a euthyroid metabolic state in the vast majority of affected persons. If the

underlying disorder is sufficiently severe (e.g., a congenital biosynthetic defect),

the compensatory responses may be inadequate to overcome the impairment in

hormone synthesis, resulting in goitrous hypothyroidism. The degree of thyroid

enlargement is proportional to the level and duration of thyroid hormone

deficiency. (https://www.inkling.com/read/robbins-basic-pathology-kumar-abbas-

aster-9th/chapter-19/diffuse-and-multinodular-goiter)

Thyroid hormones are extremely important and have diverse actions. They act on

virtually every cell in the body to alter gene transcription: under- or over-

production of these hormones has potent effects. Disorders associated with

altered thyroid hormone secretion are common and affect about 5% women and

0.5% men. Like the catecholamines epinephrine and norepinephrine, thyroid

hormones are synthesized from the amino acid tyrosine. The synthesis of thyroid

hormones requires the iodination of tyrosine molecules and the combination of

two iodinated tyrosine residues. Whilst tyrosine is relatively easily iodinated,

iodine is rare, ranking 61st in the list of most common elements and forming just

0.000006% of the Earth's mantle. The thyroid gland has evolved not only to trap

this element avidly from dietary sources but also to maintain a large store of the

iodinated tyrosines to maintain the secretion of thyroid hormones during periods

of relative iodine deficiency. (http://www.ncbi.nlm.nih.gov/books/NBK28/)

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1. Definition of the Disease

Colloid nodular goiter is the enlargement of an otherwise

normal thyroid gland. Colloid nodular goiters are also known as

endemic goiters. They are usually caused by not getting enough iodine in the

diet. Colloid nodular goiters tend to occur in certain areas with iodine-poor

soil. These areas are usually away from the sea coast. An area is defined as

endemic for goiter if more than 10% of children ages 6 - 12 have goiters.

Certain things in the environment may also cause thyroid enlargement. Small-

to moderate-sized goiters are relatively common in the United States. The

Great Lakes, Midwest, and Intermountain regions were once known as the

"goiter belt." The routine use of iodized table salt now helps prevent this

deficiency. (http://www.drugs.com/enc/colloid-nodular-goiter.html)

A risk factor for colloid nodular goiters include being over age 40, due to

the lack of nutritional iodine in early adult life. Another risk factor is having a

female gender since single and multiple thyroid nodules were found in 0.8%

of men and 5.3% of women, with an increased frequency in women over 45

years of age.(http://www.thyroidmanager.org/chapter/ multinodular-goiter/)

Family history of goiter is not really a major risk factor but it increases the risk

of having the disease. Living in an area where there is endemic iodine

deficiency and not getting enough iodine in your diet are also considered as

one of the risk factors for colloid nodular goiter since Iodine is vital to thyroid

hormone formation. (http://www.geocities. com/medipedia/001178.htm)

There are signs and symptoms of colloid nodular goiter which are

breathing difficulties, Dizziness when the arms are raised above the head

because of large goiter, enlarged neck veins, swallowing difficulties, thyroid

swelling because of the nodules, and pemberton’s sign.

(http://www.drugs.com/enc/ colloid-nodular-goiter.html)

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2. Non Modifiable/Modifiable Factors

Non Modifiable Factors:

40 years old- due to lack of nutritional iodine in early adult life

Female- Single and multiple thyroid nodules were found in 0.8% of men

and 5.3% of women, with an increased frequency in women over 45 years

of age.

Family History of Goiter- it increases the risk for acquiring the disease

Modifiable Factors:

Lacks of Iodine in diet- Endemic goiters occur within groups of people

living in geographical areas with iodine-depleted soil, usually regions away

from the sea coast. People in these communities might not get enough

iodine in their diet. The modern use of iodized table salt in the U.S.

prevents this deficiency. However, inadequate iodine is still common in

central Asia and central Africa.

Living in an area where there is endemic iodine deficiency- Iodine is vital

to the formation of thyroid hormone

Pregnancy- may increase the need for iodine and require thyroid

hypertrophy to increase iodine uptake that might otherwise satisfy minimal

needs. An elevated renal clearance   of iodine   occurs during normal

pregnancy. It has been suggested that in some patients with endemic

goiter there are similar increases in renal iodine losses.

3. Signs and Symptoms

Difficulty of breathing- due to the narrowed airway caused by enlargement

of thyroid gland which compresses the trachea

Dysphagia- Due to compression of esophagus made by the enlargement

of thyroid glands which causes difficulty of swallowing

Dizziness- decreased blood flow

Enlarged neck veins- due to compression of vasculature that leads to

venous engorgement

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Pemberton’s sign- manifestations of latent increased pressure in the

thoracic inlet by altering arm position to further narrow the aperture.

IV. Clinical Intervention

1.1 Description of prescribed surgical treatment performed.

The prescribed surgical treatment performed is known as Thyroidectomy.

Thyroidectomy is the removal of the thyroid gland; which can be total or partial. In

contrast, total thyroidectomy is performed to remove the entire gland. As for

subtotal or partial thyroidectomy it removes only part of the thyroid gland.

A thyroidectomy begins with general anesthesia administered by an

anesthesiologist. General anesthesia is a type of medically induced coma and

loss of protective reflexes resulting from the administration of one or more

general anesthetic agents. A variety of medications may be administered, to

ensure sleep, amnesia, analgesia, relaxation of skeletal muscles, and loss of

control of reflexes of the autonomic nervous system. However, some surgeons

are now using local anesthesia, plus a sedative, which associates with a shorter

hospital stay, shorter actual surgery time, and less vomiting and nausea during

post-operative.

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The anesthesiologist is the one who is in charge with the administration of

the drugs into the patient's veins and then places an airway tube in the windpipe

to ventilate the patient during the operation. After the patient has been

anesthetized, the surgeon makes an incision 3-inch to 4-inch cut in the middle of

the neck, right on top of the thyroid gland. Then the surgeon will remove all or

part of the gland.

The initial incision is

made over the marked line as described in the preparation section. A number 15

blade is used to incise through the epidermis and dermis. Using a Shaw scalpel

or monopolar cautery, dissection is carried through the subcutaneous fat to the

platysma. Once the level of the platysma has been identified along the length of

the incision, the platysma is incised. Using the double-pronged skin hooks and

the Shaw scalpel or monopolar cautery, subplatysmal flaps are elevated

superiorly and inferiorly. After elevating the subplatysmal flaps, the Mahorner or

alternative self-retaining retractor may be inserted. Precaution should be taken to

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not lacerate or damage the skin edges with the retractor.

The strap muscles (sternohyoid and sternothyroid) should then be

identified. In the midline between the strap muscles, the cervical linea Alba can

be identified. Once identified, bluntly dissect through this fascia. The Harmonic

scalpel or monopolar cautery can then be used to dissect through this fascia

superiorly and inferiorly along the length of the sternohyoid muscle. In cases of

large goiter or neoplasm, the strap muscles may be divided to aid exposure.

Division of the strap muscles should be performed high (cephalad), as the

innervation of the strap muscles occurs more inferiorly. Just deep to this

dissection places the thyroid gland, and overlying fascia should be easily

identified.

If cancer has been identified, the surgeon removes all or part of the gland.

However, if other diseases or nodules are present, the surgeon may remove only

part of the gland. The total amount of glandular tissue removed depends on the

condition being treated. The surgeon may place a drain, which is a soft plastic

tube that allows tissue fluids to flow out of an area, before closing the incision.

The incision is closed with either sutures (stitches) or metal clips. Then a

dressing is placed over it. Once the thyroid gland is identified, attention should be

turned to a single lobe. Specifically, with the use of Richardson retractors and

blunt dissection, capsular dissection should be carried to the lateral aspect of the

thyroid lobe, where it meets the carotid sheath fascia. Once the lateral border of

the dissection has been performed, the carotid artery identified, blunt dissection

may be carried out superiorly.

After identifying and stimulating the recurrent laryngeal nerve, the thyroid

gland can be removed. Berry’s ligament defines the posterolateral attachment of

the thyroid gland. Blunt dissection can be used to further expose this fascial

attachment. Then a harmonic scalpel can be used to transect the ligament.

Often, a minimal amount of thyroid tissue is left adjacent to the entrance of the

recurrent laryngeal nerve into the larynx, to reduce the risk of injuring the nerve.

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If the patient is undergoing a total thyroidectomy, attention should first be

turned to the opposite thyroid lobe and recurrent laryngeal nerve. Once the entire

specimen has been dissected and is only attached posteriorly to the pretracheal

fascia, it can be removed. Then removed specimen should be inspected.

PATIENT POSITIONING

The patient should be placed in a supine position with the apex of the

patient’s head at the top of the operating bed.

A shoulder roll or gel pad should be placed at the level of the acromion

process of the scapula to help extend the neck.

Care should be taken to avoid hyperextension of the neck, and the head

should be supported to provide maximal exposure of the surgical field

without hyperextension.

Patient’s arms should be gently tucked by either side.

After intubation, the bed can either be rotated 180º from the

anesthesiologists or sufficiently moved away from their machines to

provide a maximal work area.

PROCEDURE

General anesthesia is used.

Performed under

general anesthesia with endotracheal intubation.

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The following key anatomic locations should be found by superficial

palpation and marked with a marking pen: Thyroid cartilage, Cricoid

Cartilage, Superior edge of clavicles and Sternal notch.

Traditionally, a collar incision is used. The incision should be created in a

curvilinear fashion within a skin crease approximately 2 cm or 2 finger-breadths

above the superior edge of the clavicle and sternal notch. Although smaller

incisions lengths have been described, in the authors' experience, an incision

length of between 6 cm and 8 cm is used to allow for adequate exposure without

causing stretch injury to the surrounding skin.

1.2 Indication of prescribed general treatment.

Indications

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Thyroid cancer

If medications were not effective during drug therapy

If there is pressure made in the larynx

If there are complications of dyspnea or difficulty of breathing

If goiter constricts airways

If multiple nodules are present and large

If there is difficulty swallowing

Graves’ Disease

Hyperthyroidism

Thyroid Toxic Nodule

Risk

Thyroidectomy is generally safe. But as of any surgery, thyroidectomy carries a

risk of complications.

Potential complications include:

Bleeding

Airway obstruction caused by bleeding

Permanent or weak voice due to nerve damage

Surgical scar

Anesthetic complications

Infections

Permanent hypothyroidism and hypocalcemia

Difficulty projecting the voice

Benefits

Scars heal quickly and nearly invisible

1 week recovery

1.3 Required instruments, devices, supplies, equipment, and facilities.

Basic surgical instruments required:

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1. #3 knife handle- used to hold a variety of different surgical blades while

giving the user more maneuverability and comfort.

2. #15 blade- has a small curved cutting edge and is the most popular blade

shape ideal for making short and precise incisions.

3. Adson tissue forceps with and without teeth- standard thumb-

operated, wishbone type forceps for grasping tissue, with a rat-tooth tip

with a single point on one side fitting in between two teeth on the other.

4. DeBakey forceps- Forceps widely used in general abdominal and

vascular surgery. Designed to grasp delicate tissues without trauma.

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5. Halsted mosquito forceps - is used to clamp blood vessels or tag sutures.

6. Reinhoff swan neck clamp (or Burlisher clamp) - is used to clamp deep

blood vessels.   Burlishers have two closed finger rings.  Burlishers with an

open finger ring are called tonsil hemostats.  Other names: Schmidt tonsil

forcep, Adson forcep.

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7.Allis tissue forceps- forceps with inward-curving toothed blades and a

ratcheted handle. Designed for grasping fascia and tendons.

8.Richardson retractor (Small)- is a surgical instrument by which a surgeon

can either actively separate the edges of a surgical incision or wound, or can

hold back underlying organs and tissues, so that body parts under the incision

may be accessed.

9.Peanut/ Kittner

sponges - help to not

only apply pressure to

stop bleeding, but

to prevent tissue trauma

from suction tips

and other instruments.

11. Double- pronged skin hooks-

is used to grasp, hold, and position

delicate soft tissues during the suturing phase of a surgical procedure.

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12.Mahorner retractor – To retract, secure and apply traction to soft tissue and

bone. To provide visualization and maintain wound exposure.

13.Bipolar electro cautery forceps- an electro cautery in which both active

and return electrodes are incorporated into a single handheld instrument,

so that the current passes between the tips of the two electrodes and

affects only a small amount of tissue.

14.Nerve Stimulator- is the use of electric current produced by a device to

stimulate the nerves for therapeutic purposes.

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15.Electro cautery instrument - The medical practice or technique

of cauterization is the burning of part of a body to remove or close off a part

of it in a process called cautery, which destroys some tissue, in an attempt

to mitigate damage, remove an undesired growth, or minimize other

potential medical harmful possibilities such as infections, when antibiotics

are not available. The practice was once widespread for treatment of

wounds. Its utility before the advent of antibiotics was effective on several

levels:

useful in stopping severe blood-loss and preventing exsanguination

to close amputations

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Equipments

a. Anesthesia Machine – to render and deliver anesthesia accurately.

b. Operating table – use in the operation where the patient lies.

Facilities

a) Operating room – a place where operations are held.

1.4 Perioperative tasks and responsibilities of the nurse

Scrub Nurse

Pre-Operative

Ensures that all equipment are checked with the circulating nurse

Prepares the instruments needed for the operation

Applies sterile technique in scrubbing

Counts the surgical equipment with the circulating nurse

Performs sterile gowning o the surgeon and the assistant surgeon

Maintains sterility throughout the surgery

Intra-Operative

Maintain patient’s safety throughout the surgery

Maintains sterility throughout the surgery

Provides the equipment that the surgeon or assistant needs

Notifies the circulating nurse if there are more needed equipment

Remove excess equipment in the sterile field

Post-Operative

Counting the sponges in the operating room with the circulating nurse

Assist the surgeon or assistant surgeon when closing the wound

Helps apply the surgical dressing to the patient

De-gowning

Washing the equipment

Prepares patient for the recovery room

Completes the documentation

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Circulating Nurse

Pre-Operative

The circulating nurse is responsible for checking the lighting and the

equipment that the surgical team will use

Ensures that all equipment are functioning correctly

Counts the equipment along with the scrub nurse to ensure its

complete

Reports the case and procedure to everyone in the operating room

Starts the opening prayer before the surgery

Intra-Operative

The circulating nurse monitors the operating room throughout the

whole operation

Counts the equipment that were used including those that were

dropped

Provides the equipment necessary in the operating room

Stays in the unsterile field until the end of the operation

Post-Operative

The circulating nurse counts all the equipment along with the scrub

nurse that was used throughout the operation

Reports that all equipment are complete

1.5 Expected outcomes of surgical treatment performed

Before a thyroidectomy is performed, the nurse should explain the possible risk and complications that the patient will manifest. Inform the patient that there is a risk that his/her voice will change after the surgery as well as possible signs of infection. Since the surgery takes place in around the neck area, it is expected that they will have difficulty swallowing.

After the surgical management, like every person after surgery they will manifest drowsiness from the effects of anesthesia and lightly sedated. It’s important to monitor the vital signs especially the respiratory rate because of

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respiratory depression from anesthesia. Soon as the effects of anesthesia wears of, the patient will feel pain as a sign that it’s wearing off. As the patient manifests pain, pain medication is given. The required dose should last for 24 hours. There will be a possible risk for the patient to acquire infection because of the incision. The wound dressing should be changed every 2 days.

Before feeding, assess signs of bowel movement including flatulence. When bowel movement is present, ask the patient that if his/her throat hurts before providing fluids. Due to the incision site made near the throat, provide small amounts of fluid. Soon as pain from the site is gone, soft diet should be provided. The patient can resume their normal diet soon as no pain is felt from the incision site.

During the recovery period, the patient may feel very self conscious and worried since the surgery may affect his/her voice. Explain to the patient that the change in voice in normal. It is expected that the voice will normalize within 2-3 days.

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1.6 Medical Management of Physiologuc Outcomes

Drugs taken for initial treatment of Hypothyroidism Drugs used for treatment

General Information of Drug Route of Admin. Dosage & Frequency of Admin.

Indication or Purpose

Generic Name: Cytomel Oral

Brand Name: Liothyronine Sodium

Classification: Synthetic Hormone

Route of Admission: Oral

Dosage: 125mcg

It replaces a hormone that is normally produced by the thyroid gland. Low thyroid levels can occur naturally or when the thyroid gland is injured by radiation/medications or removed by surgery. It is important to have adequate levels of thyroid hormone in your bloodstream to maintain normal mental and physical activity.

Nursing ResponsibilitiesBefore Treatment

1. Inform the patient that this should not be used alone or together with diet pills to treat obesity/cause weight loss in patients with normal thyroid production

2. If used in combination with diet pills (appetite suppressant drugs), serious, even life-threatening effects could occur.3. Assess for decreased renal and kidney function

During the Treatment1. Ensure the patient takes the medication with a full glass of water.2. For patients who have dyspahgia, crush the tablet and give medication dilated.3. Stay at bedside with the patient when taking the medication.

After the Treatment1. Assess for signs of allergies2. Inform the patient not to use this medication for weight loss or dietary purposes.3. Tell patient that over dosage of this medication will lead to life threatening effects.

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General Information of Drug Route of Admin. Dosage & Frequency of Admin.

Indication or Purpose

Generic Name: Levothyroxine

Brand Name: Levothoid, Levoxyl

Classification: Synthetic Hormone

Route of Admission: Oral

Dosage: 12.5 - 50 mcg once a day

Levothyroxine is used to treat an underactive thyroid (hypothyroidism). It replaces or provides more thyroid hormone, which is normally produced by the thyroid gland. Low thyroid hormone levels can occur naturally or when the thyroid gland is injured by radiation/medications or removed by surgery.

Nursing ResponsibilitiesBefore Treatment

1. Take with full glass of water to prevent chocking, gagging, dysphagia or getting tablets stuck to throat.2. Infants with congenital or acquired hypothyroidism, institute therapy with full doses as soon as the diagnosis is made.3. Infants and children who cannot swallow tablets, the correct dosage maybe crushed and suspended in a small formula or water

and given by a dropper or spoon. The tablet may also be sprinkled over cooked cereal and apple sauce.

During the Treatment1.  Do not change brands of T4 products, due to possible bioequivalence problems.2.  Do not add IV doses to other IV fluids3. Arrange for regular, periodic blood tests of thyroid function

After Treatment1. This drug replaces an important hormone and will need to be taken for life. Do not discontinue without consulting the physician.

Serious problems can occur.2. Report headache, chest pain, palpitations, fever, weight loss, sleeplessness, nervousness, irritability, unusual sweating,

intolerance to heat, diarrhea.3. Wear a medical ID tag to alert emergency medical personnel that you are using this drug.

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Drugs used during ThyroidectomyDrugs given

General Information of Drug Route of Admin. Dosage & Frequency of Admin.

Indication or Purpose

Generic Name: Halothane

Classification: Inhalation Anesthetic Route of Admission: Inhalation

Dosage: variable

Volatilized Halothane, USP acts as an inhalation anesthetic. Induction and recovery are rapid and depth of anesthesia can be rapidly altered. Halothane anesthesia progressively depresses respiration. There may be tachypnea with reduced tidal volume and alveolar ventilation. Halothane vapor is not an irritant to the respiratory tract, and no increase in salivary or bronchial secretions ordinarily occurs. Pharyngeal and laryngeal reflexes are rapidly obtunded. It causes bronchodilation. Hypoxia, acidosis, or apnea may develop during deep anesthesia.

Nursing ResponsibilitiesBefore Treatment

1. Only the anesthesiologist can provide this medication to the patient.

2. Explain the procedure to the patient if there are signs of anxiety present.

3. Advise the patient not to eat anything for 8 hours before the operation.

4. Keep food away from the site of the patient.

During the Procedure 1. Provide safety measures to prevent further injury.

2. Monitor respiratory rate. 3. Provide safety to the patient while sedated.

After the Surgical Procedure 1. Alert anesthesiologist if there is absence of patient’s breathing. 2. Monitor patient’s respiratory rate after surgery.

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Medications given after surgery

General Information of Drug Route of Admin. Dosage & Frequency of Admin.

Indication or Purpose

Generic Name: Morphine SulfateBrand Name: Duramorph, EpimorphClassification: Narcotic Agonist

Route of Admission: IV

Dosage: 10–30 mg

Morphine Sulfate is an opioid agonist indicated for the relief of moderate to

severe acute and chronic pain where use of an opioid analgesic is

appropriate

Nursing Responsibilities

Before Treatment:

1. Morphine and other opiates/opiods are common antigens in an allergic reaction. Check chart and ideally with patient for allergies

before administration.

2. Morphine is a CNS and Respiratory depressant. Extreme caution needs to be exercised in administration to compromised

patients.

3. Morphine should not be taken with other narcotics agents.

During Treatment:

1. Provide the dose needed for 24 hours. This may cause drug dependence.

2. Ensure it is given to the right patient when giving the medication

After Treatment:

1. Provide other techniques in relief pain.

2. Report physician if there is an occurrence of severe nausea, vomiting, constipation, shortness of breath or difficulty breathing,

rash.

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1.7 Nursing management of physiologic and psychosocial outcomes.

Problem # 1: (Pre-Operative) Impaired Breathing Pattern related to Narrowing of airway

Assssment Nursing Diagnosis

Scientific Explanation

Objectives Nursing Interventions Rationale Expected Outcome

S – Ø

O - The patient may manifest:

>Dyspnea

>Change in respiratory rate

>Difficulty vocalizing

>Orthopnea

>Cyanosis

Impaired breathing pattern related to narrowed airway.

Impaired breathing pattern is characterized by enlargement of the thyroid gland which compresses the trachea that leads to narrowed airway which causes difficulty of breathing.

Short Term: After 4-5 hours of, the nursing interventions patient will be able to demonstrate behaviors to improve breathing pattern.

Long Term:After 1-3 days of nursing interventions, the patient will be able to demonstrate improved oxygen exchange.

1. Therapeutic communication.

2. Monitor vital signs frequently.

3. Monitor respirations and breath sounds, noting rate and sounds.

4. Evaluate patient’s cough/gag reflex and swallowing ability.

5. Position head appropriate for age and condition.

6. Elevate head of bed and change position every 2 hours and prn.

7. Assist with the use of respiratory devices and treatments.

8. Position the patient appropriately.

9. Encourage deep breathing and coughing exercise.

1. To gain trust and cooperation of the pt.

2. VS could indicate possible bleeding.

3. To indicate respiratory distress.

4. To determine ability to protect own airway.

5. To open or maintain open airway in at-rest or compromised individual.

6. To decrease pressure on the diaphragm and enhance drainage of ventilation to different lung segments.

7. To maintain airways, improve respiratory function and gas exchange.

8. To prevent vomiting with aspiration into lungs.

9. To maximize effort.

Short Term:After 4-5 hours of nursing interventions, the patient shall have demonstrated behaviors to improved breathing pattern.

Long Term:After 1-3 days of nursing interventions, the patient shall have demonstrated improved oxygen exchange.

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Problem #2: (Post-Operative) Acute Pain related to Surgical IncisionAssessment Nursing Diagnosis Scientific

ExplanationObjectives Nursing Interventions Rationale Expected

Outcome

S - ØPatient may verbalize with a pain scale of 8/10

O - patient may manifest:

>Facial Grimaces

>Restlessness

>Irritability

>Sleep Disturbances

>Moaning, cryingChange in blood pressure, heart rate and respiratory rate

Acute Pain related to surgical incision

Unpleasant sensory arising from actual or potential tissue damage that stimulate the of peripheral nervous system which causes the activation of central nervous system at the spinal cord level transmits the signal to the brain to cause pain.

Short Term:After 4-5 hours of, the nursing interventions, the patient will demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation.

Long Term:After 3-4 days of nursing interventions, the patient will report relieve and controlled pain.

1. Therapeutic communication.

2. Monitor vital signs.3. Assess verbal/non-

verbal reports of pain, noting location, intensity (0-10 scale), and duration.

4. Accept the description of pain. Experienced and convey acceptance of client’s response to pain.

5. Determine client’s acceptable level of pain and pain control goals.

6. Provide comfort measures (heat or cold packs, quiet environment and calm activities).

7. Monitor skin color and temperature and vital signs.

1. To gain trust of the patient.

2. For baseline data.

3. Useful in evaluating pain, choice of interventions, effectiveness of therapy.

4. Pain is a subjective experience and cannot be felt by others.

5. Varies with individual and situation.

6. To promote non- pharmacological pain management.

7. They are usually altered in acute pain.

Short Term:After4-5 hours of nursing interventions, the patient shall have demonstrated use of relaxation skills and diversional activities, as indicated, for individual situation.

Long Term:After 3-4 days of nursing interventions, the patient shall have reported relieve and controlled pain.

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Problem # 3: (Pre-operative) Imbalanced Nutrition: Less Than Body Requirements related to hypermetabolic state and impaired utilization and storage of nutrients.

Assessment Nursing Diagnosis

Scientific Explanation

Objectives Nursing Interventions Rationale Expected Outcome

S- Ø

O - the patient may manifest:

> Loss of weight

>Restlessness

>Weakness of muscles required for mastication

Imbalanced Nutrition: Less Than Body Requirements related to impaired or lack of consumption of the nutrients needed by the body

The body needs adequate nutrients to support the normal bodily function.

The risk factors of colloid nodular goiter will lead to decreased iodine in the glandular cells which Imbalances the nutrition. With decreased Iodine in the body, there will be decrease secretion of thyroid hormones which affects the growth and metabolism.

Short term:

After 6hrs of NI, the pt will manifest a increase in appetite by demonstrating proper eating habits

Long term:

After 2 days of NI, the pt will maintain weight and body mass or begin to gain weight by consuming adequate nutrients.

1. Weigh daily

2. Monitor nutritional

intake

3. Provide oral hygiene

before meals

4. Assess for difficulty

swallowing

5. Administer

antiemetic’s as

ordered

6. Give fluids by mouth

as tolerated as

ordered

7. Provide small,

frequent meals.

8. Monitor electrolytes,

hemoglobin and

hematocrit.

1. To monitor weight gain

or loss

2. To determine intake of

nutrients.

3. To Improve taste of

food.

4. To determine difficulty of

swallowing.

5. To relieve nausea and

vomiting

6. To promote adequate

hydration

7. To prevent feeling of

fullness and ensures

adequate nutritional

intake.

8. To Inadvertent removal

or devascularization of

the parathyroid glands

can cause postoperative

hypoparathyroidism.

Short term:

Patient shall have manifested an increase in appetite by demonstrating proper eating habits

Long term:

Patient shall have maintained weight and body mass or begin to gain weight by consuming adequate nutrients.

Problem # 4: (Post-Operative) Risk for Impaired Verbal Communication related to Surgical Wound

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Assessment Nursing Diagnosis

Scientific Explanation Objectives Nursing Interventions Rationale Expected Outcome

S: Ø

O: Patient may Manifest:

>Speak or verbalized with difficulty.

>Difficulty of forming words or sentences.

>Hoarseness.

>Slurring.

>Stuttering.

i.

Risk for Impaired Verbal Communication related to surgical wound

Unpleasant sensory arising from actual or potential tissue damage that stimulate the of peripheral nervous system which causes the activation of central nervous system at the spinal cord level transmits the signal to the brain to cause pain. If there is pain, the patient may experience difficulty when speaking, which can prevent the patient from communicating orally.

Short Term:After 4 hours of nursing interventions, the patient will be able to establish methods of communication in which necessities can be expressed.

Long Term:After 2-3 days of nursing interventions, patient will be able to participate in therapeutic communication and demonstrate congruent verbal or non-verbal communication.

1. Assess speech periodically; encourage voice rest.

2.  Keep communication simple; ask yes/no questions.

3.  Provide alternative methods of communication as appropriate, e.g., slate board, letter/picture board. Place IV line to minimize interference with written communication.

4.  Anticipate needs as possible. Visit patient frequently.

5.  Post notice of patient’s voice limitations at central station and answer call bell promptly.

6.  Maintain quiet environment.

1. Hoarseness and sore throat may occur secondary to tissue edema or surgical damage to recurrent laryngeal nerve and may last several days. Permanent nerve damage can occur (rare) that causes paralysis of vocal cords and/or compression of the trachea.

2. To reduce demand for response; promotes voice rest.

3.  To facilitate expression of needs.

4.  To reduce anxiety and patients need to communicate.

5. To prevent patient from straining voice to make needs known/summon assistance.

6.  To enhance ability to hear whispered communication and reduces necessity for patient to raise/strain voice to be heard.

Short Term:After 4 hours of nursing interventions, the patient shall have established methods of communication in which necessities can be expressed.

Long Term:After 2-3 days of nursing interventions, he patient shall have participated in therapeutic communication and demonstrated congruent verbal and non-verbal communication.

Problem # 5: (Post-Operative) Risk for Infection related to surgical woundAssessment Nursing

DiagnosisScientific

ExplanationObjectives Nursing Interventions Rationale Expected

Outcome

S – Ø Risk for Infection Contamination of Short Term: 1. Therapeutic 1. To gain trust and Short Term:

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O - The patient may manifest:

>Pallor

>Weakness

>With dry and intact dressing on the excised area

>Swelling over the incision area

related to surgical wound

a wound surface with microorganism thus these colonization has a complete new cells for oxygen and nutrition and because their by-products can interfere with a healthy surface condition that leads to infection

After 3-4 hours of, the nursing interventions, the patient will verbalize understanding of individual causative factors might contribute infection.

Long Term:After 4 days of nursing interventions, the patient will achieve timely wound healing.

communication.2. Monitor and record

vital signs.3. Stress proper hand

washing technique.4. Instruct on proper

wound care.5. Encourage to eat

vitamin C rich foods.6. Emphasized

necessity of taking antibiotics as directed.

7. Closely observe and instruct to report signs and symptoms of infection such as fever, sore throat, swelling, pain and drainage.

8. Inspect the wound for swelling, unusual drainage, odor redness, or separation of the suture lines.

cooperation of the patient.

2. To obtain baseline data.

3. Poor nutritional status may cause inability to muster a cellular immune response to pathogens and are therefore more susceptible to infection.

4. To maintain optimal nutritional status.

5. To promote wound healing.

6. To boost the immune system.

7. To prevent and detect as early as possible the presence of any progressing infection.

8. Wound infection is accompanied by signs of inflammation and a delay in healing.

After 3-4 hours of nursing interventions, the patient shall have verbalized understanding of individual causative factors might contribute infection.

Long Term:After 4 days of nursing interventions, the patient shall have achieved timely wound healing.

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IV. Conclusion

One type of goiter is Colloid nodular goiter. It is the enlargement of an

otherwise normal thyroid gland. They are also known as endemic goiters.

The risk factors for this disease are age of 40 years old, female gender,

family history of goiter due to their natural causes to an at-risk patient.

Since iodine is vital in the formation of thyroid hormones, lack of it can

also be considered as a risk factor. Some symptoms may also be

experienced.

The recommended surgery for colloid nodular goiter is Thyroidectomy

where in the thyroid gland is removed ablatively because if the disease is

left untreated, the disease may develop to more serious complications

such as thyroid cancer. Each of the operating team has their

responsibilities before, during and after the surgery. Certain anesthesia

and other drugs are administered even hours before the procedure.

This study is recommended for student nurses to use as a reference if

ever they will encounter this on their duty. This can also be used to widen

their knowledge or to hone their skills. This can help the future student

nurses if ever they will become interested as to what or how the case of

Colloid Nodular Goiter really works. We also recommend this study to the

other health care team to also hone their skills or use as a reference if

ever they will encounter the same case as the researchers. For the

community, I recommend this especially to people who are at risk and also

for those who already had this disease. This can help those who are at

risk to avoid, prevent, and not acquire at all. And for those who already

had the disease, this can help them to maintain their health or be aware of

what will happen if their problem aggravated.

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The case report has given us the opportunity to learn about the

colloid nodular goiter. Doing this study enhanced our knowledge and

helped us know the complications of the disease that leads to severe

diseases. The knowledge we gained would be useful especially in our

duty, because we would be able to provide the best care possible to our

patient. As we continue with our career, we would more likely encounter

patients having this disease condition or surgery. Even us ourselves can

protect our health from the disease and we may also know the benefits

and disadvantages of having such surgery like thyroidectomy. Our

willingness to learn molds us towards being competent nurses. We

learned how to appreciate the importance of cooperation which enabled

us to finish our case report. We are thankful for the trust and guidance that

our clinical instructor gave us all throughout the process of this study.

35

V. References/ Bibliography

BOOKS:

Seeley’s Principles of Anatomy and Physiology 2009

J. Black, J. Hawks.2009.Medical-Surgical Nursing 8th edition: clinical management for positive outcomes. Coronary Heart Disease. Pp.1410-1415

L. Williams, Wilkins. 2009. Professional Guide to Diseases 9th Edition. Coronary Artery Disease. Pp. 42-46

M. Doenges, et.al. 2008. Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales.

L. Williams, Wilkins. 2013. Nursing 2013 Drug Handbook.

WEBSITES:

http://www.ohlonecenter.org/research-papers/the-thyroid-gland-anatomy-

physiology/

http://emedicine.medscape.com/article/1891109-overview#a15

http://www.rnpedia.com/home/notes/pharmacology-drug-study-notes/

morphine-sulfate

http://www.drugs.com/levothyroxine.html

http://health.nytimes.com/health/guides/disease/colloid-nodular-goiter

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

http://emedicine.medscape.com/article/127491-overview

http://www.medicalnewstoday.com/articles/67471.php

http://www.sciencedaily.com/releases/2009/11/091124174735.htm

http://www.drugs.com/enc/colloid-nodular-goiter.html

http://www.geocities. com/medipedia/001178.htm

https://www.inkling.com/read/robbins-basic-pathology-kumar-abbas-aster-

9th/chapter-19/diffuse-and-multinodular-goiter

http://www.ncbi.nlm.nih.gov/books/NBK28/

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