Thyroidectomy

Thyroidectomy is the removal of either part of or the whole thyroid gland itself. The group has chosen the said case for its complexity and the learning that each member can acquire. It’s rarity makes it not only an interesting matter but also provides an opportunity to have new knowledge regarding the case. The group has included in this presentation the anatomy and physiology of the aforementioned part of the human body as well as the information regarding the procedure done. Another part included are the nursing care plans, medication study, laboratory result interpretation and the pathophysiology.

Introduction

Cancer of the Thyroid

Carcinoma of the thyroid is a malignant neoplasm of the gland

Definition

Incidence increase with age. The average age at time of diagnosis is 45 years.

Associated with being exposed to radiation (head and neck part.)

Etiology

Papillary and well differentiated adenocarcinoma (most common)Growth is slow and spread is confined to lymph nodes

that surround thyroid area; cure rate is excellent after removal of involved areas.

FollicularOccurs predominantly in middle-aged and older person;

progression of disease is rapid; high mortality rateParafollicular-meduallary thyroid carcinoma (MTC)

Rare, inheritable type of malignancy that can be detected early.

Undifferentiated anaplastic carcinomaMost aggressive and lethal solid tumor found in human;

least common of all thyroid cancer; often fatal within months of diagnosis.

Types

Upon palpation of the thyroid there may be a firm, irregular, fixed, painless mass or nodules

Usually asymptomatic

Clinical Manifestation

Thyroid scan will detect a “cold” nodule with little uptake

Fine needle aspiration biopsySurgical exploration

Diagnostic evaluation

Surgical removal is extensive, as requiredThyroid replacementFor unresectable cancer,patient is referred

for treatment with 131I,chemotherapy or radiation therapy.

Management

Anatomy and Physiology

Functions:1. Water Balance2. Uterine contraction and Milk release3. Growth, metabolism and tissue maturation4. Ion regulation5. Heart rate and blood pressure regulation6. Blood glucose control7. Immune system regulation8. Reproductive function control

Endocrine System

Anterior Pituitary GlandPosterior Pituitary GlandThyroid GlandParathyroid glandsAdrenal MedullaAdrenal CortexPancreasReproductive organs:

Ovaries & TestesThymus glandPineal body

Major Glands

A gland made up of two lobes connected by a narrow band called the isthmus.

The lobes are located on either side of the trachea just inferior to the larynx.

One of the most largest endocrine gland.Appears more red than surrounding tissues

because it is highly vascular. Main Function: TO SECRETE THYROID

HORMONES (T3 & T4) – these binds to intracellular receptors in cells and regulate the rate of metabolism in the body

Thyroid Gland

Thyroid Gland

Gland Hormone Target Tissue ResponseThyroid Gland Thyroid

hormones (Thyroxine and Triiodothyronine)

Most cells of the body

Increases metabolic rates, essential fro normal process of growth and maturation

Calcitonin Primarily bones Decreases the rate of bone breakdown; prevents large increase in blood calcium levels following a meal.

Thyroid hormones

Pathophysiology

Predisposing Factors:Age: 50 y/oFamily history of cancerGoiter

Abnormal chromosomalPattern present at birth

Genes mutateOver time

Cells becomeundifferentiated

Immune systemFails to recognizeThe malignant cells

Tumor continuouslygrow

Thyroid glandFunctioning is impairedAnd it grows in size

Causing obstructionOf airway

Resulting to:DOB, Impaired voiceProduction and dysphagia

Laboratory Studies

Results Normal Findings

Interpretation

Hemoglobin 92 g/l 110-165 g/l decreaseHematocrit 0.28 cv/l 0.35-0.50 cv/l decreaseWBC 5.6 5.0-10 normalSegmenters 68.5% 43-76% normalLymphocytes 26.4 % 17-48% normalMonocytes 5.1% 4-10% normal

January 7, 2013

January 9, 2013

Results Normal Findings

Interpretation

FBS 109.8 mg/dl 70-110 mg/dl normalSodium 139 mEq/l 135-148 mEq/L normalPotassium 3.1 mEq/l 3.5-5.3 mEq/l decrease

Blood Chemistry

Interpretation:Mild Left ventricular CardiomegalyOtherwise, essential normal chest findings

Radiologic FindingsJanuary 7, 2013

Treatment

Thyroidectomy

is an operation that involves the surgical removal of all or part of the thyroid gland.

Less extreme variants of thyroidectomy include:“Hemithyroidectomy" (or

"unilateral lobectomy") -- removing only half of the thyroid

“Isthmectomy" -- removing the band of tissue (or isthmus) connecting the two lobes of the thyroid

What is Thyroidectomy?

Types of Thyroidectomy

Hemithyroidectomy - entire isthmus is removed along with 1 lobe. Done in benign diseases of only 1 lobe.

Subtotal thyroidectomy - done in toxic thyroid; primary or secondary and also for toxic MNG (Multi-nodular goiter)

Partial thyroidectomy - removal of gland in front of trachea after mobilization. It is done in nontoxic MNG. role is controversial.

Near total thyroidectomy - Both lobes are removed except for a small amount of thyroid tissue (on one or both sides) in the vicinity of the recurrent laryngeal nerve entry point and the superior parathyroid gland; done in papillary thyroid carcinoma

Total thyroidectomy- Entire gland is removed. Done in case of follicular carcinoma of thyroid, medullary cancer of thyroid.

Hartley Dunhill operation- removal of 1 entire lateral lobe with isthmus and partial/subtotal removal of opposite lateral lobe. It is done in nontoxic MNG.

Types of Thyroidectomy

Thyroid cancerToxic thyroid nodule (produces too much thyroid

hormone)Multi-nodular goiter (enlarged thyroid gland with

many nodules), causing compression of nearby structures.

Graves' disease – an autoimmune disease that affects the thyroid causing it to enlarge and become hyperactive. (There is exophthalmos/bulging eyes)

Thyroid nodule, if fine needle aspirate (FNA) results are unclear

What are the indications?

Horizontal anterior neck incision (if possible, within a skin crease)

Create upper and lower flaps between the platysma and strap muscles

Divide vertically between the strap muscles and anterior jugular veins

Separate the strap muscles from the thyroid glandDivide the middle thyroid veinMobilize the superior pole of the thyroid lobe. Divide

the superior thyroid artery and vein close to the thyroid gland (avoid injury to the external branch of the superior laryngeal nerve and the superior parathyroid gland)

Steps in the procedure

Steps in the procedure

Identify the recurrent laryngeal nerve whenever possible using the nerve monitoring device

Identify the inferior parathyroid arteryDivide the inferior thyroid artery and veinSeparate the thyroid lobe and isthmus from the

tracheaRepeat this process for the other thyroid lobe.

Remove the thyroid glandReapproximate the strap musclesReapproximate the platysma muscleClose the skin with a subcuticular stitch

Steps in the procedure

Hypothyroidism/Thyroid insufficiency in up to 50% of patients after ten years

Laryngeal nerve injury in about 1% of patients, in particular the recurrent laryngeal nerve: Unilateral damage results in a hoarse voice. Bilateral damage presents as laryngeal obstruction after surgery and can be a surgical emergency: an emergency tracheostomy may be needed. Recurrent Laryngeal nerve injury may occur during the ligature of the inferior thyroid artery.

Hypoparathyroidism temporary (transient) in many patients, but permanent in about 1-4% of patients

Anesthetic complications

Complications

InfectionStitch granulomaChyle leakHemorrhage/Hematoma (This may compress the airway,

becoming life-threatening.)Surgical scar/keloidRemoval or devascularization

of the parathyroids.Thyroid storm in operations

performed for hyperthyroidism

Complications

Biographic Data

Patient’s Name: Patient A.Address: Bautista San Pablo CityAge: 50yrs oldGender: FemaleCivil status: widowed Date of Admission: January 7, 2013Time: 10:53amAdmitting Diagnosis: Papillary Carcinoma,

S/P thyroidectomy

Final Diagnosis: Papillary Carcinoma, thyroid gland S/P L lobectomy, isthmusectomy

PATIENT’S PROFILE

Chief Complaint: No voice, dysphagia, shortness of breath

History of Present Illness: A few weeks prior to admission the patient experienced dysphonia. The patient was admitted last Oct. 3 due to colloid adenomatous goiter and underwent an operation: Left lobectomy and isthmusectomy. Was readmitted last January 7, 2013 due to dysphagia and shortness of breath and was diagnosed with Papillary Carcinoma and underwent completion thyroidectomy.

Past Medical History: Colloid GoiterPrevious Hospitalization: when she underwent

appendectomy; October 3, 2012 underwent left lobectomy and isthmusectomy

Initial Vital Signs (Upon Admission):BP: 140/80RR: 20PR: 86Temp: 37.4

Pre-operative V/S:BP: 150/90RR:24PR: 80Temp: 36.6

Post-operative V/S:BP: 152/86PR: 85RR: 22Temp: 37

Physical Assessment

Day 1(Intraoperative)

Day 2(Postoperative)

Skin Inspection: dry and scaly, tan-colored skinPalpation: saggy

Nails Inspection: short cut nailsPalpation: no deformities, no clubbing noted

Hair Inspection: well distributed, dry, black hair

Head Inspection: normocephalicPalpation: no bulging or mass palpated

Eyes Inspection: pupils are equally round and reactive to light accumulation, no discharges, white sclera, pale conjunctiva

Ears Inspection: no discharges noted, has difficulty hearing (during interview patient asks the student nurses to repeat questions numerous times)Palpation: no tenderness

Nose Inspection: patent; no discharges noted; symmetrical

Mouth and Pharynx With ET tube Inspection: no dentures, dry lips and mucosa

Neck with surgical incision on midway between cricoid insternal notch

Inspection: visible neck mass

Thorax and Lungs Inspection: normal chest expansion, 1:2 anteroposterior diameterAuscultation: no crackles heard

Cardiovascular BP: 150/90 Auscultation: no murmurs sound heard

Breast and Axillae Inspection: nipples are symmetrical, no discharges and lesions notedPalpation: no unusual mass or lump prominent

Abdomen Inspection: with scar from operation (appendectomy) on right lower quadrant,Auscultation: bourborygmi sound heard <3 secondsPalpation: no rebound tenderness

Genitals Inspection: no abnormal discharges noted

Anus and Rectum Inspection: No hemorrhoids noted, patent

Extremities unable to move all of the extremities , with safety straps on upper extremities

Able to move extremities

Level of Consciousness patient under general anaesthesia,unconscious and incoherent

Conscious and coherent

Intraoperative

Nursing Care Plan

ASSESSMENT

DIAGNOSIS

PLANNING IMPLEMENTATION

RATIONALE

EVALUATION

Objective: >with surgical incision on midway between cricoid insternal notch>with body temp: 36.6 C

Risk for infection related to invasive procedure

After series of nursing interventions, infection will be prevented as manifested by: >normal body temp>no foul odour or discharge >no swelling>good wound healing

>Maintain sterility of the field:-Assist patient in wearing of OR gown and head cap-Prepare instruments aseptically-Proper use of personal protective equipment -Surgical hand washing and scrubbing-Wear sterile gloves-Do skin prep-Assist with honesty and conscience

To maintain sterility of the field

After series of nursing interventions, goal partially met, no signs of infection noted as manifested by:>normal body temp: 37 C>no foul odour or discharge noted>No swelling

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

>Drape skin with sterile cloth

>Dress wound aseptically

>To maintain sterility, to avoid exposure of unaffected operation site and privacy >to protect incision site from microorganism

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

Objective: >patient under general anaesthesia>unconscious and incoherent>unable to move all of the extremities

Risk for perioperative positioning injury r/t anesthetic effect

After series of nursing interventions patient will be free from injury as manifested by:>absence of muscular or skeletal pain>skin remain intact>no signs of pressure sores

>Transfer patient to Or table properly:-lock cart/bed in place-support client’s body and limb-use adequate # or personnel during transfer >Never leave patient>Place safety strap to secure patient>apply and reposition padding of pressure points/bony prominences

>to prevent shear and friction injuries

>to provide safety>To prevent unintended movement>to maintain position of safety, especially when repositioning or table attachment

After series of nursing interventions, goal met, patient was free from injury as manifested by:>absence of muscular or skeletal pain>skin remain intact>no signs of pressure sores

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION

RATIONALE EVALUATION

>Check peripheral pulses and skin color periodically >Protect body from contact with metal parts of the operating table>Place and check cautery pad are properly in place and with lubricant; check other metals in the body>Reposition slowly and in transfer in bed (to PACU)

>To monitor circulation

>which could produce injury and pain

>for proper conductor of cautery and to prevent from injury

>to prevent severe drop of BP, dizziness/unsafe transfer

Gordon’s Functional Health Pattern

Health PerceptionThe patient is aware of her condition and was a bit

emotional when she told the student nurses what was her final diagnosis. She reported about her previous illnesses such as goiter and had told the student nurses that she sought medical assistance once the signs and symptoms of her illness arise.

Nutrition and MetabolicThe patient eats 3 meals a day. She said she often prefers

meat over vegetables but often eats fruits if available. But 2 months prior to her operation she experienced difficulty of swallowing and experienced decrease in appetite (able to finish ½ cup of rice of prepared food) due to dysphagia.

Elimination PatternThe patient verbalized that she usually defecates 1-2 times

a day and urinate at least 4-6 times a day. But the day after the surgery she hadn’t defecate even once. (cc hourly)

Activity and ExerciseThe patient’s occupation is “pangangalakal ng bote”. But if

she has a free time she sells AVON products. Because of her job, she often walks under the sun and that serves as her exercise. But prior to hospitalization while suffering from her condition the patient had experienced easy fatigability.

Sleep and RestShe sleeps at least 6-8 hours a day with no interruption.

From 8 pm-4 am.Cognitive and Perceptual

During the interview the day after the surgery despite her difficulty speaking the patient was well oriented and answered the questions coherently. She also used hand gestures to send her message more clearly. When asked to rate her pain perception she gave the value of 6 out of 10.

Self Perception/ Self ConceptThe patient appears to be headstrong despite her condition.

She verbalized her fear but not for herself instead for her kids who are dependent to her.

Role/RelationshipThe patient’s husband died (due to heart attack) 2 years

ago and she was left alone supporting her 4 children. She also took care of her 2 handicapped “lumpo” children.

Sexual and ReproductiveThe patient is already a widow.

Coping /Stress ToleranceThe patient said that when dealing with her problems she

often deals with them alone because the communication between her and her children isn’t very open. And when asked about how she deals with the pain she felt all she does is rest and wait for the pain to lessen.

Values/BeliefThe patient is a known Catholic. When it comes to

dealing with medical problems she doesn’t use herbal medicines nor go to faith healer instead she goes straight to a doctor.

Postoperative

Nursing Care Plan

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

SUBJECTIVE:“Nahihirapan akong lumunok”, as verbalized by the patient.OBJECTIVE:>decreased swallowing ability>with incision on neck area>with drainage on incision site>v/S: RR-22, BP- 152/86

Risk for aspiration r/t neck surgery

After series of nursing interventions patient will prevent aspiration as within 8 hours of duty, as evidenced by:>be able to finish prepared foods>RR within normal range>be able to communicate well verbally

>Nurse-patient interaction >Monitor v/s

>Observe for neck edema

>Elevate client to best comfortable position for eating and drinking>Teach to provide rest period prior to feeding time

>To build trust and rapport>To have baseline data

>Client on neck surgery is at particular risk of airway obstruction & inability to handle secretions >To prevent risk of aspiration>The rested client may have less difficulty swallowing

After series of nursing interventions, goal partially met, as evidenced by:>the client was able to finish her prepared food. RR of 22>minimally uses gestures while communicating

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

>unable to finish prepared food>more on gestures when answering the questions

>Instruct to feed slowly, using small bites, to chew slowly and thoroughly>Provide soft foods that stick together/ form a bolus>Offer cold liquids rather than warm liquids.

>Crush oral meds and mix with fruit juices

>To prevent risk for aspiration

>To aid swallowing effort>Colds may soothe the trachea while warm may trigger bleeding that nay contribute bleeding that may cause obstruction of airway>to reduce swallowing effort and to eliminate taste of pulverized meds

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

>Minimize use of hypnotics and sedatives whenever possible>Instruct to reduce/limit activities after eating

>May impair coughing and swallowing

>May increase intra-abdominal pressure, which may slow digestion and increase risk of regurgitation.