Download - Colloid Nodular Goiter
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.
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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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