nodular non toxic goiter

NODULAR NON-TOXIC NODULAR NON-TOXIC GOITERGOITER

CASE PRESENTATIONgROUP 1bPrepared by: jean c. arellano

I.INTRODUCTIONI.INTRODUCTION

A goiter is an enlargement of the thyroid. The thyroid is an endocrine gland that produces hormones that help regulate your body’s metabolism. It is located on the front of the neck, right below the “Adam’s Apple.” Goiters are seldom painful, and tend to grow slowly.

There are different types of goiters. A nontoxic (or sporadic) goiter is a type of “simple” goiter that may be diffuse (enlarging the whole thyroid gland) or nodular (enlargement caused by nodules, or lumps, on the thyroid.) The development of nodules marks a progression of the goiter, and should be evaluated by your doctor.

NONTOXIC GOITER: DIFFUSE AND NODULAR Nontoxic goiter may be defined as any thyroid enlargement characterized by

uniform or selective (i.e., restricted to one or more areas) growth of thyroid tissue that is not associated with overt hyperthyroidism or hypothyroidism and that does not result from inflammation or neoplasia. A thyroid nodule is defined as a discrete lesion within the thyroid gland that is due to an abnormal focal growth of thyroid cells.

CONTINUATIONCONTINUATION

Goiter or the enlargement of the thyroid gland is considered prevalent in the Philippines. This disease in thyroid gland is classified as endemic, meaning present continuously in a community, or sporadic goiter.Based on the studies on urinary iodine levels conducted by the Department of Health, most goiter cases are found in the mountainous provinces and other remote areas of the country, where children and pregnant women are mostly affected.Some inland residents however, may have goiter because of insufficient iodine intake in their diet aside from eating a lot of goitrogenoids, which are found in cabbage, soybeans, peanuts, peaches, strawberries, spinach, and radishes. Other people in remote areas are discovered to have goiter because of iron deficiency due to poverty.

ANATOMY AND PHYSIOLOGYANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGYANATOMY AND PHYSIOLOGY

Our endocrine system is made up of glands that produce and secrete

hormones. One of these glands is the thyroid gland.

The thyroid gland is a butterfly-shapes organ and is composed of two cone like lobes or wings connected together by a thin band of connective tissues called the isthmus. This organ is the largest endocrine gland in the body. It is situated on the anterior side of the lower neck, in front of the trachea (windpipe), just below the larynx (voice box).

The thyroid produces several chemical substances known as thyroid

hormones, principally thyroxine (T4) and triiodothyronine (T3) and these circulate the body in the blood. The hormones secreted by the thyroid gland regulate metabolism, heart rate, growth and the body’s energy level.

Thyroxine (T4) is produced in much greater quantities than triiodothyronine (T3) and it has a major influence on the physical and mental development and also on the general well being. This is mainly due to the fact that it helps to control the rate of chemical reactions in all the body cells.

The thyroid gland is also influenced by hormones produced by two other organs:

1. The pituitary gland, located at the base of the brain, which

produces thyroid stimulating horme.

2. The hypothalamus, a small part of the brain above the pituitary,

which produces thyrotropin releasing hormone (TRH).

Low levels of thyroid hormones in the blood are detected by the

hypothalamus and the pituitary. TRH is released, stimulating the pituitary

to release TSH. Increased levels of TSH, in turn, stimulate the thyroid

to produce more thyroid hormone, thereby returning the level of thyroid

hormone in the blood back to normal. The three glands and the hormones

they produce make up the "Hypothalamic - Pituitary - Thyroid axis."

Regulation of the thyroid gland's secretory function

Secretory Function.

The primary function of the thyroid gland is to secrete two hormones, thyroxine (T4) and triiodothyronine (T3) (Johnson, 1995). Figure 2 illustrates the secretory function of the thyroid and associated organs. These thyroid hormones serve several purposes that include (a) regulating carbohydrate and lipid metabolism, (b) stimulating oxygen consumption by cells, and (c) controlling growth and development

PHYSIOLOGY

The production and secretion of thyroid hormones by the thyroid gland are controlled by the thyroid stimulating hormone (TSH) produced by the pituitary gland. TSH is, in turn, regulated by the thyroid-releasing hormone (TRH) secreted from the hypothalamus. Iodine is necessary to synthesize thyroid hormones. Ingested iodine is absorbed into the circulatory system and stored in the thyroid before being converted into thyroid hormones.

Parathyroid Glands.

The parathyroid glands are small pieces of reddish-brown tissue that lie on both sides of the thyroid gland. While most individuals possess four parathyroid glands, two superior and two inferior, total numbers of parathyroid glands vary among individuals. These glands are responsible for producing parathyroid hormone, which, along with vitamin D, regulate calcium and phosphorus concentrations in the body. Compromise of the vascular system to the parathyroids during thyroid surgery may result in ischemia and subsequent transient hypocalcemia. Since the inadvertent removal of the parathyroid glands may result in severe tetany and death, care must be taken by the surgeon to identify and preserve the parathyroid glands during surgery.

. The thyroid and thyrotropes form a negative feedback loop: TSH production is suppressed when the T4 levels are high. The TSH production itself is modulated by thyrotropin-releasing hormone (TRH), which is produced by the hypothalamus and secreted at an increased rate in situations such as cold exposure (to stimulate thermogenesis). TSH production is blunted by somatostatin (SRIH), rising levels of glucocorticoids and sex hormones (estrogen and testosterone), and excessively high blood iodide concentration.

An additional hormone produced by the thyroid contributes to the regulation of blood calcium levels. Parafollicular cells produce calcitonin in response to hypercalcemia. Calcitonin stimulates movement of calcium into bone, in opposition to the effects of parathyroid hormone (PTH). However, calcitonin seems far less essential than PTH, as calcium metabolism remains clinically normal after removal of the thyroid (thyroidectomy), but not the parathyroids.

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Etiology:Exact causes

are not knownIn general,

goiters may be caused by too much or too little thyroid hormones.

Possible Cause:•Heredity (family history of goiters)Regular use of medications such as :: lithium

Regular intake of substances

(goitrogens) that inhibit production of

thyroid hormone.

Risk Factors:Common in FemaleAge: over 40 yearsNot getting enough iodine in the diet.

SymptomsNontoxic goiters usually do not have noticeable symptoms.

The main symptom is a

swollen thyroid gland.

•Breathing difficulties (may rarely occur with very large goiters)•Cough•Hoarseness•Swallowing difficulties

Hypothalamus

Pituitary Gland

TRH (thyroid releasing hormone)

TSH (thyroid stimulating hormone

Body

T3 (triiodothyronine)

T4 (thyroxine)

Thyroid Glalnd

Complications

NEGATIVE FEEDBACK MECHANISM

Obstruction of

airway

EXPLANATIONEXPLANATION

Nodular non toxic goiter exact cause is unknown but in general, goiters may be caused by too much or too little thyroid hormones. The possible cause are heredity, regular use of medications such as lithium, regular intake of substances goitrogens that inhibit production of thryroid hormone. For the risk factor or predisposing factor it is common for client age 40 years and above, common in female. also for not getting enough iodine in diet. Usually the symptom is not noticeable but the main symptom is swollen thyroid gland that will will lead to complications like breathing difficulties, cough, hoarseness of voice and swallowing difficulties that will result to obstruction of airway. For the negative feedback mechanism first the hypothalamus a small part of the brain above the pituitary, will produces thyrotropin releasing hormone (TRH) and then the TRH will stimulate the pituitary gland to release TSH. Increased levels of TSH, in turn, stimulate the thyroid gland to produce more thyroid hormone which is the T3 and T4, thereby returning the level of thyroid hormone in the blood back to normal.

IV.LABORATORY AND IV.LABORATORY AND DIAGNOSTIC TESTDIAGNOSTIC TEST

Examination of the neck—to assess any thyroid enlargement Ultrasound —a test that uses sound waves to identify nodules of the neck

and thyroid Blood tests—to assess levels of thyroid hormones (eg, thyroid stimulating

hormone). Thyroid autoantibodies tests may also be done. Thyroid scan (scintigraphy)—a picture of your thyroid gland taken after

you have been given a shot or drink of a radioisotope. The scan will show how your thyroid is functioning and used to exclude thyroid cancer .

Fine needle aspiration biopsy —a small needle will be inserted into a nodule in the thyroid to obtain a tissue sample. The sample will be examined to determine if it is benign or malignant (cancer). In 50%-60% of all biopsies taken, the results are noncancerous.

Barium swallow —a test to determine if the enlarged goiter is compressing the esophagus, thus causing swallowing difficulty

X-ray of neck and chest for large goiters—to see if the trachea is compressed

V.MEDICAL MANAGEMENTV.MEDICAL MANAGEMENT To gain the patients confidence and reduce anxiety.Quiet and relaxing form of environment.

V.SURGICAL MANAGEMENTV.SURGICAL MANAGEMENT

Thyroidectomy

VI.NURSING CARE MANAGEMENTVI.NURSING CARE MANAGEMENT

A.PRE-OPERATIVE PHASE

- Gain the patient’s confidence and reduce anxiety.

- Efforts are necessary to protect the patient from such tension and stress to avoid precipitating thyroid storm.

- Quiet and relaxing forms of recreation.

- Instructs the patient about the importance of eating a diet high in carbohydrates and proteins.

- Supplementary vitamins, particularly thiamine and ascorbic acid, may be prescribed.

- The patient is reminded to avoid tea, coffee, cola and other stimulants.

B.INTRA-OPERATIVE PHASEB.INTRA-OPERATIVE PHASE

Preventing breakage of continuity of aseptic technique. Correct counting of sponges and used instrument

inside the operating room.Secure patient safety.Proper positioning.Monitoring VS.

C.POST-OPERATIVE PHASE

- Periodically assess the surgical dressings and reinforce them if necessary.

- When the patient is in a recumbent position, the nurse observes the sides and the back of the neck as well as the anterior dressing for bleeding.

- Monitor the pulse and blood pressure for any indication of internal bleeding.

- Intensity of pain is assessed, and analgesic agents are administered as prescribed for pain.

- Inform the patient that oxygen will assist breathing.

- When moving and turning the patient, carefully supports the patient’s head and avoid tension on the sutures.

Post-op continuation- Place patient in comfortable position (semifowler’s) with the head elevated and supported by pillows.- Administer IV fluids.- Water may be given by mouth as soon as nausea subsides.- Cold fluids and ice may be taken better than other fluids.- Advise the patient to talk as little as possible to reduce edema to the vocal cords.- An overbed table is provided for access to frequently used items so the patient avoids turning on his or her head.- The patient is usually permitted to out of bed as soon as possible.- Encouraged to eat foods that are easily swallowed.- A high-calorie diet may be prescribed to promote weight gain.

VII.COMMON NURSING VII.COMMON NURSING DIAGNOSISDIAGNOSISRisk for ineffective airway clearance

related to tracheal obstruction; swelling, bleeding, laryngeal spasm

Impaired verbal communication related to vocal cord injury/laryngeal nerve damage ;tissue edema; pain/discomfort.

Acute pain related to Surgical interruption/manipulation of tissues/muscles, post-operative edema.

NURSING CARE PLANNURSING CARE PLANPost-operative phase

ASSESSMENT NURSING

DIAGNOSISINFERENCE GOAL INTERVENTION RATIONALE EVALUATION

Independent

Objective cue:-swelling

Risk for ineffective airway clearance related to tracheal obstruction secondary to swelling.

After 8 hours of nursing intervention the patient will be able to have an effective airway clearance.

1.Monitor RR, depth, and work of breathing.

1.Respirations may remain somewhat rapid, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage.

After 8 hours of continuous nursing intervention the patient maintain patent airway with aspiration prevented.

2.Auscultate breath sounds, noting presence of ronchi.

2.Ronchi may indicate airway obstruction/accumulation of copious thick secretions.

3.Assess for dyspnea, stridor, crowding, and cyanosis.

3.Indicators of tracheal obstruction/laryngeal spasm, requiring prompt evaluation and intervention.

ASSESSMENT NURSING DIAGNOSIS

INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

4.Caution patient to avoid bending neck; support head with pillows.

4.Reduces likelihood of tension on surgical wound.

5.Assist with repositioning, deep breathing exercises, and/or coughing as indicated.

5.Maintains clear airway and ventilation. Although routine coughing is not encouraged and may be painful, it may be needed to clear secretions.

6.Suction mouth and trachea as indicated, noting color and charactersitics of sputum.

6.Edema/pain may impair patients ability to clear own airway.



7.Check dressing frequently, especially posterior portion.

7.If bleeding occurs, anterior dressing may appear dry because blood pools dependently.

8.Investigate reports of difficulty swallowing, drooling of oral secretions.

8.May indicate edema/sequestered bleeding in tissues surrounding operative site.

9.Keep tracheostomy tray at bedside.

9.Compromised airway may create a life-threatening situation requiring emergency procedure.



Collaborative

10.Provide steam inhalation; humidify room air.

10.Reduces discomfort of sore throat and tissue edema and promotes expectoration of secretions.

11.Assist with/prepare for procedures, e.g., tracheostomy

11.May be necessary to maintain airway if obstructed by edema of glottis or hemorrhage.

12.Return to surgery.

12.May require ligation of bleeding vessels.



Objective cue: Independent

-guarding behavior.-restlessness-narrowed focus

Subjective cue:Report of pain

Acute pain related to postoperative edema.

After 8 hours of nursing intervention the patient pain will be relieved.

1.Assess verbal/nonverbal reports of pain, noting location, intensity (0 – 10 scale) and duration.

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

After 8 hours of continuous nursing intervention the patient will report pain is relieved.

2.Place in semi-fowlers position and support head/neck with sandbags or small pillows.

2.Prevents hyperextension of the neck and protects integrity of the suture line.

3.Maintain head/neck in neutral position and support during position changes. Instruct patient to use hands to support neck during movt, and to avoid hyperextension of neck.

3.Prevents stress on the suture line and reduces muscle tension.



4.Keep call bell and frequently needed items within easy reach.

4. Limits stretching, muscle strain in operative area.

5. Give cool liquids or soft foods , such as ice cream or popsicles.

5.Although both may be soothing to sore throat, soft foods may be tolerated better than liquids if patient experiences difficulty swallowing.

6. Encourage patient to use relaxation techniques, e.g., guided imagery, soft music, progressive relaxation.

6. Helps refocus attention and assits patient to manage pain/discomfort more effectively.



Collaborative

7. Administer analgesics and/or analgesic throat sprays/lozenges as necessary.

7.Reduces pain and discomfort; enhances rest.

.

8. Provide ice collar if indicated.

8.Reduces tissue edema and decreases perception of

pain.

IX.DISCHARGE INSTRUCTIONSIX.DISCHARGE INSTRUCTIONS

Explain to the patient and family the need for rest, relaxation, and nutrition.

MEDICATIONSMEDICATIONSthyroid hormone level checked to make sure that

they are on the correct dose of thyroid replacement medication. This is done 2-3 weeks after surgery.

analgesic agents are administered as prescribed for pain.

EXERCISE/ACTIVITYEXERCISE/ACTIVITY

The patient is permitted to resume his or her former activities and responsibilities completely once recovered from surgery.

TREATMENTTREATMENT

Radioactive Iodine Radioactive iodine treatment is used to reduce the size of large

goiter. It is used in the elderly when surgical treatment is not an option.

ThyroidectomyA surgery to remove a portion or all of the thyroid gland. It is

the treatment of choice if the goiter is so large to cause difficulty in breathing or swallowing.

HEALTH TEACHINGHEALTH TEACHINGDemonstrating to the patient how to support the

neck with the hands after surgery to prevent stress on the incision.

The patient and the family need to be knowledgeable about the signs and symptoms of the complications that may occur and those that should be reported.

OPD FOLLOW UPOPD FOLLOW UP

Instruct the patients about the importance of follow-up visits to the physician or the clinic for monitoring of thyroid status.

DIETDIET Soft diet, easily swallowed food.High calorie diet to promote weight gain.

SEXUALITY/SPIRITUALLYSEXUALITY/SPIRITUALLY

Sexual activity resumed after 2 to 3 months after surgery.

References:References:

WikipediaSlideshare Brunner and Suddarths Textbook

of Medical Surgical Nursing 12th edition by lippincott.

Anatomy and Physiology by Mosby.

http://www.emedicine.com

nodular non toxic goiter

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