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april 27 :: vol 25 no 34 :: 2011 43NURSING STANDARD

learning zoneCONTINUING PROFESSIONAL DEVELOPMENT

Aims and intended learning outcomes

The aim of this article is to increase nurses’knowledge of the anatomy, physiology andpathophysiology of the thyroid gland.Management of the most common post-operativecomplications associated with the surgicaltreatment of thyroid disorders is discussed. Afterreading this article and completing the time outactivities you should be able to:

4 Identify the most common thyroid diseasesthat may require surgical treatment.

4Discuss the complexity of surgical proceduresinvolving the thyroid gland.

4Describe the most common post-operativecomplications associated with surgicaltreatment of patients with thyroid disorders.

4 Identify early signs and symptoms of commoncomplications following thyroid surgery.

4Describe the role of the nurse in the post-operative care of the patient following a thyroidectomy.

Introduction

Thyroid hormones are responsible for manyimportant metabolic functions in humanphysiology. They increase the basal metabolicrate, affect protein synthesis, help to regulate longbone growth and promote neuronal maturation(Table 1). Patients with altered thyroidfunctioning may require surgical intervention.Thyroidectomy or those procedures involving theremoval of a part of the thyroid gland, althoughrelatively straightforward, may be associatedwith serious complications. This article reviewsthe anatomy and physiology of the thyroid gland,as well as describing the surgical procedures andcommon complications.

Anatomy and physiology

The thyroid gland is one of the largest endocrineglands in the body, weighing approximately 20g

NS590 Furtado L (2011) Thyroidectomy: post-operative care and common complications. Nursing Standard. 25, 34, 43-52. Date of acceptance: February 28 2011.

Thyroidectomy: post-operative careand common complications

SummaryAny surgical procedure involves risks. Thyroid surgery can causepotentially fatal complications during the early post-operative phase.It is essential that nurses have the knowledge and skills to detectearly signs and symptoms of potential complications and takeappropriate action. Early detection and rapid response are key to maintaining patient safety and minimising harm.

AuthorLuís Furtado, registered nurse, General Surgery Department,Hospital do Divino Espírito Santo de Ponta Delgada EPE, São MiguelIsland (Azores), Portugal. Email: [email protected]

KeywordsPost-operative care, surgical complications, thyroidectomy

These keywords are based on subject headings from the BritishNursing Index. All articles are subject to external double-blind peerreview and checked for plagiarism using automated software. Forauthor and research article guidelines visit the Nursing Standardhome page at www.nursing-standard.co.uk. For related articlesvisit our online archive and search using the keywords.

Time out 1Using an anatomy and physiology textbook, review your knowledge of the thyroid gland. Make a list of its main functions and mechanisms of physiological regulation.

Page 54Thyroidectomy multiplechoice questionnaire

Page 55Read Winifred Sargerson’spractice profile on plaster casting

Page 56Guidelines on how towrite a practice profile

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44 april 27 :: vol 25 no 34 :: 2011 NURSING STANDARD

(Toni et al 2003). Venous drainage is establishedby three main pathways: the superior, middle and inferior thyroid veins (Guyton and Hall2006). The thyroid gland is innervated by thesympathetic and parasympathetic divisions of the autonomic nervous system (Sherman andColborn 2003). The external laryngeal nerve is adivision of the superior laryngeal nerve, a branchof the vagus nerve, supplying the cricothyroidmuscle (Page et al 2003). Since this muscle isinvolved in the movements of the vocalapparatus, damage to the nerve will impairphonation (Skandalakis 2004). Anotherimportant nervous structure is the recurrent orinferior laryngeal nerve, also a branch of thevagus; this nervous structure enters the pharynxbelow the inferior constrictor muscle to innervatethe intrinsic muscles of the larynx, playing amajor role in controlling the movements of thevocal cords (Sherman and Colborn 2003).

The parathyroid glands lie on either side of the thyroid (Kuriloff and Sanborn 2004).Parathyroid hormone, along with vitamin D,regulates calcium and phosphorus concentrationsin the body (Udelsman and Donovan 2004). The thyroid gland produces two relatedhormones: thyroxine (T4) and triiodothyronine(T3). These hormones have a critical role in cell differentiation during development, and

(Seeley et al 2007), and is larger in females. It iscomposed of two lobes connected by a narrowband of thyroid tissue called the isthmus (Kirsten2000) (Figure 1). The lobes are lateral to theupper portion of the trachea and inferior to thelarynx. The isthmus extends across the anterioraspect of the trachea – the thyroid gland extendsfrom the level of the fifth cervical vertebra to thefirst thoracic vertebra (Shaheen 2003). It issurrounded by the perithyroid sheath and isattached to the cricoid cartilage by the ligament ofBerry (De Felice and Di Lauro 2004). The thyroidgland contains numerous follicles, which aresmall spheres, with walls composed of a singlelayer of cuboidal epithelial cells. The centre, orlumen, of each thyroid follicle is filled with aprotein called thyroglobulin to which thyroidhormones are bound. The follicles store largeamounts of thyroid hormones (Genuth 2004).

The thyroid gland has a rich blood supply(Skandalakis 2004). The arterial supply isbilateral from the external carotid arteries,flowing through the superior thyroid artery, and the subclavian system, through the inferiorthyroid branch of the thyrocervical trunk

learning zone surgical nursing

Target tissue Effect Mechanism

Heart Chronotropic (affecting the rate of Increase the number and affinity of the heart beat). beta-adrenergic receptors.

Inotropic (affecting the force or Enhance responses to circulating catecholaminesenergy of muscular contractions). and affect the proportions of cardiac proteins.

Adipose tissue Catabolic. Stimulate lipolysis.

Muscle Catabolic. Increase protein breakdown.

Bone Developmental and metabolic. Promote normal growth and skeletal development, accelerate bone turnover.

Nervous system Developmental. Promote normal brain development.

Gut Metabolic. Increase the rate of carbohydrate absorption.

Lipoprotein Metabolic. Stimulate formation of low-density lipoproteinreceptors (increased thyroid hormone levels stimulate fat mobilisation, leading to increased concentrations of fatty acids in plasma. They also enhance oxidation of fatty acids in many tissues. Plasma concentrations of cholesterol and triglycerides are inversely correlated with thyroid hormone levels).

Other Calorigenic. Stimulate oxygen consumption by metabolically active tissues (exceptions include adult brain, testes, uterus, lymph nodes, spleen and anterior pituitary). Increase metabolic rate.

(Jameson and Weetman 2008)

TABLE 1

Physiological effects and mechanisms of thyroid hormones



help maintain thermogenic and metabolichomeostasis in adults (Larsen et al 2008).

T4 is produced only in the thyroid gland,whereas about 80% of T3 is derived from theconversion of T4 to T3 in the peripheral tissues,including adipose tissue, endothelial or epithelialtissue, and muscular and nervous tissue. Theremaining 20% of T3 comes from the thyroidgland (Genuth 2004). Thyroid hormone synthesisdepends on an adequate intake of dietary iodine(John and Sieber 2008).

Thyroid-stimulating hormone (TSH), producedin the anterior lobe of the pituitary gland, must bepresent to maintain thyroid hormone synthesisand secretion. TSH causes an increase in synthesisof thyroid hormones, which are then stored in thethyroid follicles and attached to thyroglobulin(Dillmann 2004). Thyrotropin-releasing hormone(TRH), produced in the hypothalamus, workswith TSH to increase T3 and T4 secretion in thethyroid gland. When TRH increases, TSHsecretion also increases (Kondo et al 2006). The thyroid hormones have a negative feedbackeffect on the hypothalamus and anterior pituitarygland: as T3 and T4 increase in the circulatorysystem, they inhibit TRH and TSH secretion (John and Sieber 2008).

Thyroid hormones enter the systemiccirculation bound to plasma proteins (John andSieber 2008). Only small amounts of T4 and T3circulate in their biologically active free form.This helps to maintain adequate levels in the body by exerting negative feedback on thehypothalamus and pituitary gland (Larsen et al 2008). Even small changes in biologically

active free hormone concentrations result inimmediate changes in TSH secretion, making this hormone a reliable indicator of thyroidfunction (Dillmann 2004).

Laboratory assessment

There are a variety of diagnostic tests that can bepreformed to assess thyroid function. However,no single test can be relied on exclusively. Thehigh sensitivity and specificity of TSH assays hasimproved laboratory assessment and evaluationof thyroid function. This is because TSH levelschange dynamically, responding to alterations in T3 and T4. Therefore, thyroid function testingshould assess whether TSH levels are suppressed,normal or elevated. In general, a normal TSHexcludes a primary abnormality (that whichoccurs in the organ itself) of thyroid function(Amato et al 2006).

If an abnormal TSH level is found,measurement of circulating thyroid hormonelevels to confirm diagnosis of hyperthyroidism(suppressed TSH) or hypothyroidism (elevatedTSH) must be performed (Jameson and Weetman2008). T3 and T4 are highly protein-bound, and a variety of factors, for example illness,medications or genetics, can influence proteinbinding. It is useful, therefore, to measure the free hormone levels, which correspond to thebiologically available hormone pool (Davies and Larsen 2008). Reference values for normalthyroid function are shown in Table 2.

Total thyroid hormone levels are high when thyroxine-binding globulin is increased as a result of oestrogens (pregnancy, oralcontraceptives, hormone therapy, tamoxifen)and decreased when thyroxine-binding globulinis reduced (androgens, nephrotic syndrome).Genetic disorders and acute illness can also cause abnormalities in thyroid hormone bindingproteins, as well as a vast number of drugs, forexample phenytoin, carbamazepine, salicylates and non-steroidal anti-inflammatory drugs (Lal and Clark 2010).

FIGURE 1

Anatomy of the thyroid gland

Larynx

Carotid artery

Isthmus

Right lobe

Trachea

Left lobe

Time out 2A patient is admitted to the emergency department at your hospital with tachycardia, tremor and palpitations, in addition to continued weight loss over the past six months. An initial physical examinationreveals asymmetry in the right anterior cervicalregion and blood tests highlight increasedserum levels of free T3 and T4 hormones. Makea list of the associated signs and symptoms andcompare your answers with the following text.

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as scaly thickening and induration. The lesionsare slightly pigmented and often have an ‘orangepeel’ texture, and papules or nodules may develop (Anderson and Miller 2003). Laboratoryfindings in Graves’ disease include elevatedserum T3 and T4, as well as depressed serumTSH levels (Cheng et al 2010).

Common disorders of the thyroid

The pathophysiology of the thyroid gland hasbeen studied intensively (Weitzel 2008). Thyroiddysfunction may occur for a number of reasonsand may result in thyroidectomy.Hyperthyroidism Thyrotoxicosis is ahypermetabolic state caused by abnormally highcirculating levels of free T3 and T4. It is generallycaused by hyperfunction of the thyroid gland and is commonly referred to as hyperthyroidism(Hanks and Salomone 2008). The clinicalmanifestations of hyperthyroidism areinconsistent and include changes related to a hypermetabolic state induced by excessiveamounts of thyroid hormones, as well as thoserelated to sympathicotonia, a conditioncharacterised by hyperstimulation of thesympathetic nervous system (Davies and Larsen 2008) (Table 3).

Treatment of hyperthyroidism may includenon-invasive techniques such radioactive iodineto slow hormonal production, or anti-thyroiddrugs to prevent thyroid hormone synthesis.When this approach fails or is ineffective, partialor total removal of the thyroid gland will beconsidered (Lal and Clark 2010).Graves’ disease This disease is characterised by a triad of manifestations, includingthyrotoxicosis, infiltrative ophthalmopathy and infiltrative dermopathy. Graves’ disease is common in people aged 20-40 years, withwomen seven times more likely to have thedisease than men. Its aetiology is thought to beautoimmune. The clinical manifestations ofGraves’ disease include those that are common to all forms of thyrotoxicosis, as well as thoseassociated uniquely with the specificity of thisdisorder (Smith 2010). The severity ofthyrotoxicosis varies between patients.

Diffuse enlargement of the thyroid gland ispresent in all cases of Graves’ disease. Thisenlargement is usually smooth and symmetrical,but asymmetry may be present too. The increasedblood flow through the hyperactive gland oftenproduces an audible bruit. The ophthalmopathyresults in abnormal protrusion of the eyeball(exophthalmos) (Figure 2). The extra-ocularmusculature is usually weak and it is possible thatthe exophthalmos will persist or progress furtherdespite effective treatment, resulting sometimes in corneal injury. Pretibial myxoedema and, moreappropriately, thyroid infiltrative dermopathyare terms used to describe localised lesions of theskin resulting from the deposition of hyaluronicacid, secondary to thyroid disease, which present


TABLE 2

Reference values for normal thyroid function

Test Normal values

Serum thyroxine (T4) 4.5-12.0μg/dL

Free thyroxine (FT4) 0.7-1.9ng/dL

Serum triiodothyronine (T3) 80-180ng/dL

Free triiodothyronine (FT3) 230-619pg/dL

Triiodothyronine resin uptake (T3RU) 26-42%

Thyroid-stimulating hormone (TSM) 0.5-6.0μU/mL


TABLE 3

Signs and symptoms of hyperthyroidism

Signs Symptoms

Tachycardia Palpitations

Tremors Nervousness

Weight loss Alterations in appetite

Muscle weakness Fatigue

Thyroid hypertrophy Frequent bowel movements

Diplopia (double vision) Sleep disturbance (insomnia)

Exophthalmos Exertional intolerance (protrusion of the eyeball) and dyspnoea

Dependent lower-extremityoedema


FIGURE 2

Characteristic appearance of exophthalmos

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ISCA

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Diffuse and multinodular goitre The enlargementof the thyroid gland, also known as goitre, is oneof the most common manifestations of thyroiddisease (Braverman 2001). Diffuse andmultinodular goitres reflect impaired synthesis of thyroid hormones and are most often caused by dietary iodine deficiency (Braverman 2001).Impairment of thyroid hormone synthesis leads to a compensatory rise in serum TSH levels, withconsequent hypertrophy and hyperplasia of the thyroid follicular cells, causing grossenlargement of the thyroid gland (Zbucki et al2007). The compensatory increase in functionalmass of the gland can overcome the hormonedeficiency, achieving a euthyroid metabolic state. If the compensatory strategies appear to be inadequate, goitrous hypothyroidismdevelops (Pelizzo et al 2010).

The dominant clinical features of goitre arecaused by the effects of the enlarged gland(Wright-Pascoe 2010). Besides altered bodyimage, goitres may also cause airway obstructionand compression of large vessels in the neck andupper thorax (Telusca et al 2010).

Neoplasms of the thyroid Thyroid neoplasmsinclude a significantly high variety ofmorphological patterns (Wu and Liu 2010). A follicular adenoma is a benign encapsulatedmass of follicles (Baloch and LiVolsi 2002).Generally these are solitary. If there are multiplenodules in a lobe or a thyroid gland, it is probablymore appropriate to make a diagnosis ofmultinodular goitre with adenomatous change(Pal et al 2008). One important characteristic ofnon-neoplastic disease is that it does not seem to bea precursor of malignant disease (Mai et al 2001).

Malignant neoplasms may also occur in thethyroid gland (Baloch and LiVolsi 2002).Papillary carcinoma is the most commonmalignant tumour of the thyroid gland incountries that have diets which are either iodine-sufficient or iodine-excessive (Nosé 2010).Iodine-rich food include fish, cheddar cheese,eggs and seaweed. This form of carcinomabehaves in an indolent manner (develops at a slowrate or in a way that may be easily confused with abenign thyroid disorder) and has good prognosis

following treatment (Khanafshar and Lloyd2011). There are other forms of malignancy in the thyroid gland, such as follicular carcinoma,anaplastic tumours, sarcoma, squamous cellcarcinoma and medullary and micromedullarycarcinomas. These forms of malignancy occur lessfrequently, compared with papillary carcinomas,and have a less favourable prognosis, dependingon the spread of the malignant lesion and its stageof development (LiVolsi and Baloch 2004).

Thyroidectomy

Surgical intervention generally involves one of sixdifferent procedures (Lang 2010):

4Partial thyroid lobectomy – removal of theupper or lower portion of one lobe.

4Thyroid lobectomy – removal of one entire lobe.

4Thyroid lobectomy with isthmusectomy –removal of one lobe and the isthmus.

4Subtotal thyroidectomy – removal of one lobe,the isthmus and most of the other lobe.

4Total thyroidectomy – removal of the entire gland.

4Radical total thyroidectomy – removal of theentire gland and cervical lymphatic nodes.

As with any other surgical procedure, there arepotential complications. These include damage to the recurrent laryngeal nerve and secondaryhypoparathyroidism (Pasieka 2005). However,the procedure is generally well tolerated and can be performed with minimal disfigurement(Bliss et al 2000).

Potential complications and post-operativenursing care

The initial post-operative phase begins when thepatient arrives in the post-anaesthetic recoveryroom. Nursing care should be directed atassessing and maintaining cardiopulmonary andneurological status, comfort level and metabolicstate (Roberts and Fenech 2010). The secondpost-operative phase begins when the patient

Time out 3List the various dietary sources of iodine as well as differences in the availability of this source in different countries. Consider a situation in which you are going on a humanitarian mission to the Democratic Republic of Congo. Design a diet regimen that best suits the specificneeds of this population.

Time out 4Make a list of the most common post-operative complications you have seen in practice. Think about what specific complications a patient might present with after thyroid surgery. List the post-operative observationsyou would carry out and provide the rationalefor each.



reported to the surgical team. The patient’stemperature should be monitored closely, as should his or her white blood cell count(Osmólski et al 2006). Antibiotic prophylaxis is recommended only in immunocompromisedindividuals or those with valvular cardiacdisorders (Rosato et al 2004).Nerve injury Injury to the recurrent laryngealnerve is one of the most serious complications of thyroid gland surgery. It may be caused bydifferent mechanisms, including incision,clamping, stretching of the nerve, nerveskeletonisation (a process in which a small fibre of the nerve is divided from the main structure),local compression of the nerve as a result ofoedema or haematoma, or even thermal injurycaused by electrocoagulation (Hillermann et al2003, Randolph et al 2004, Goncalves Filho and Kowalski 2005). In most cases, this type of injury is not observed during the surgicalprocedure, therefore nurses need to monitor thepatient’s voice quality, swallowing reflex andrespiratory status post-operatively (Beldi et al2004). There may be transient vocal cord paresis lasting no more than six weeks but if this continues for six to 12 months with noimprovement the damage is deemed to bepermanent (Hermann et al 2004).

Bilateral recurrent laryngeal nerve injury canalso occur and is a serious complication because itresults in near-midline paralysis of the vocal cordsand variable degrees of airway obstruction. It iscommonly diagnosed directly after extubation orduring the early post-operative phase (Dralle et al2004, Hermann et al 2004). Patients with this typeof nerve injury present with inspiratory stridor,dyspnoea, tachypnoea and nasal flaring (Fewins et al 2003). It may be necessary to performa definitive tracheostomy or a transverse lasercordotomy if the vocal cords fail to recuperate aftera waiting period of nine to 12 months. During thisperiod the airway is protected by performing atemporary tracheostomy. Aspiration may occur,

is transferred to the surgical care unit. Nursesshould be aware of the most commoncomplications that can occur in these patients,including bleeding, wound infection, nerve injury, lymphatic structure injury, secondaryhypoparathyroidism and thyroid storm, asdescribed below, and ensure that the appropriateactions are taken. Early detection and rapidresponse are key to ensure safe nursing practiceand positive patient outcomes (LeMone andBurke 2000) (Table 4).Haemorrhage Symptomatic haemorrhagerequiring surgical intervention occurs inapproximately 0.1% to 1.5% of patientsundergoing thyroid surgery (Burkey et al 2001). It occurs mainly because of the abundant blood supply to the organ and as a result of theextensive dissection that occurs during removal of the thyroid gland. In the majority of patients,symptomatic haemorrhage occurs between six and 12 hours after the initial procedure(Rosato et al 2004).

Post-operative nursing evaluation includes thefrequent observation of the anterior and posteriordressings, since it is here where blood tends toaccumulate (Kumrow and Dahlen 2002). Thisassessment is important and monitoring should include a comparison of any changes with the initial assessment after arrival from thepost-anaesthetic recovery ward. All observationsneed to be documented, as well as drainagevolumes, consistency, colour and the functionalstatus of drainage equipment (LeMone and Burke2000). The suction drain is commonly used toavoid accumulation of blood and serum (seroma)following thyroid surgery (Morrissey et al 2008).

Neck dressings should be monitored closely forchanges in fit and comfort, with inspection of thedressing’s edge to detect possible neck swelling. A change in the circumference of the neck mayindicate the formation of a haematoma (Burkeyet al 2001). Special attention must given to thepatient’s vital signs, including detection ofhypotension and tachycardia, as these mayindicate haemorrhage. Other warning signs ofpossible haematoma include respiratory distress,neck pain, cervical pressure, dysphagia andincreased blood drainage (Bononi et al 2010).Wound infection Thyroidectomy wounds (Figure 3) should be observed for signs ofinfection. Infection is often caused by theStaphylococcus or Streptococcus species.However, post-operative thyroidectomy woundinfections are relatively rare, occurring in only0.3-0.8% of cases (Rosato et al 2004). Thepresence of an odorous discharge should be

learning zone surgical nursing FIGURE 3

Thyroidectomy wound

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but is more likely with superior laryngeal nerveinjury. In this kind of iatrogenic lesion, there ispartial or total loss of the protective airwayreflexes, depending on the severity of the nerveinjury, leading to potential choking, difficultyswallowing and problems with singing or yelling(Friedman et al 2002).Injury of the lymphatic structures Lymph nodedissection, as part of thyroid surgery, may resultin injury to the thoracic and lymphatic ducts.

Chyle leak, which is an iatrogenic rupture oflymphatic ducts, is characteristic of this type ofinjury (Reeve and Thompson 2000). Diagnosisis often delayed because early drainage resemblesblood rather than chyle. However, in a few days following surgery, nurses can detect acontinuous drainage of a milky or opaque fluid (chyle) – mainly constituted of fat, free acids, sphingomyelin, cholesterol andphospholipids – from the operative site.

Nursing diagnosis Risk factors Nursing interventions

Risk of ineffective Tracheal obstruction. Monitor respiratory rate and depth and work of breathing.airway clearance Swelling. Auscultation of breath sounds, noting presence of rhonchi. Bleeding. Assess for dyspnoea, stridor and cyanosis. Laryngeal spasm. Note quality of voice. Support the patient’s head with pillows. Assist with repositioning, deep breathing exercises and/or coughing as indicated. Suction mouth and trachea as indicated. Regularly check dressing conditions and the area under the patient’s neck and shoulders for drainage. Assess neck dressing for signs of tightness. Assess neck for signs of swelling, which is frequently related to haematoma formation.

Impaired verbal Vocal cord injury. Assess speech periodically.communication Laryngeal nerve damage. Keep communication simple. Tissue oedema. Provide alternative methods of communication. Pain. Anticipate needs as far as possible. Discomfort. Visit the patient frequently. Maintain a quiet environment.

Risk of tetany Chemical imbalance. Monitor vital signs: remaining alert for elevated temperature, tachycardia, dysrhythmias, respiratory distress and cyanosis. Evaluate reflexes periodically. Observe for neuromuscular irritability (twitching, numbness, paraesthesias, positive Chvostek’s and Trousseau’s signs, seizure activity). Keep side rails raised/padded, the bed in low position, and an artificial airway at bedside. Avoid use of restraints.

Acute pain Surgical manipulation. Assess verbal and non-verbal reports of pain, noting location, intensity and duration. Post-operative oedema. Place in semi-Fowler’s position (head and torso at a 30-45 degree angle) and support head/neck with sand bags or small pillows. Maintain the head and neck in a neutral position and support during position changes. Instruct the patient to use hands to support the neck during movement and to avoid hyperextension of the neck. Keep the call bell and frequently needed items within easy reach of the patient. Give cool liquids or soft foods, such as ice cream or ice lollies. Encourage the patient to use relaxation techniques.

Deficient knowledge Misinterpretation. Review the surgical procedure and future expectations.regarding condition, Unfamiliarity with Discuss the need for well-balanced diet with foods high in calcium and vitamin D.prognosis, treatment, information resources. Encourage a progressive general exercise programme.self-care and Apply cold cream after sutures have been removed.discharge needs Discuss the possibility of a change in voice. Review drug therapy. Identify signs and symptoms requiring medical evaluation (fever, chills, continued and purulent wound drainage, erythema, gaps in wound edges, sudden weight loss, intolerance to heat, nausea and vomiting, diarrhoea, insomnia, weight gain, fatigue, intolerance to cold, constipation or drowsiness).

(Kumrow and Dahlen 2002, Rahman 2009, Elisha et al 2010)

TABLE 4

Post-operative care plan for patients following thyroidectomy



reaches the normal values of 9-10.5mg/dL (2.2-2.6mmol/L) (LeMone and Burke 2000).Thyroid storm Severe thyrotoxicosis or a thyroidstorm is life-threatening. Once a common post-operative complication of thyroidectomy, it is now rarely seen. This is because appropriate pre-operative medical treatment is available and allpatients undergoing elective surgery should now beeuthyroid (Rosato et al 2000). A thyroid storm ischaracterised by exaggerated signs and symptomsof hyperthyroidism (Boxes 1 and 2) and usually

This must be reported immediately to thesurgical team (Shindo and Stern 2010).Conservative management involves continuousdrainage and reduction of chyle production by total parental nutrition or by oraladministration of a low fat, high carbohydrateand high protein diet. The systemicadministration of somatostatin blocks theaction of digestive secretions (gastric, biliary,pancreatic and intestinal), reducing thoracicduct flow and thereby assisting its closure, sincemost of its circulating volume comes fromintestinal absorption (Nussenbaum et al 2000).Secondary hypoparathyroidism The incidenceof hypocalcaemia following thyroid surgeryvaries widely between 1% and more than 50%(Karamanakos et al 2010). In the majority ofsituations, post-operative hypocalcaemia istransient. Permanent hypoparathyroidism is unusual and occurs in less than 1% of allpatients undergoing total or radical totalthyroidectomy (Karamanakos et al 2010). This complication is multifactorial, but the most common causes include damage to theparathyroid glands in the form of direct injury,unrecognised and inadvertent removal of theglands or, indirectly, by devascularisation of the gland (Sasson et al 2001).

Symptoms of hypoparathyroidism usuallyoccur 24-72 hours post-operatively (Reeve andThompson 2000). Patients will exhibit lowserum calcium levels (hypocalcaemia), and mayexperience numbness and tingling in the hands,feet, and lips (Khan et al 2010). Nurses shouldassess these symptoms and check for positiveTrousseau’s and Chvostek’s signs, which indicatehypocalcaemia and the potential for tetany – theinvoluntary contraction of muscles. Trousseau’ssign is a carpal spasm induced by arterialocclusion of the arm with a blood pressure cuff.A positive Chvostek’s sign is elicited by tappingthe facial nerve and observing for facial nerveirritation or spasms (Prim et al 2001).

Patients exhibiting clinical signs ofhypocalcaemia may be treated with orallyadministered calcium carbonate or calcium lactatein divided doses, to a total of 2-8g per day (LeMoneand Burke 2000). Additionally, calciferol ordihydrotachysterol (a rapid-acting form of vitamin D) may be required to enhance calciumabsorption. Severe symptoms require immediateintravenous therapy with 10mL of 10% calciumgluconate over five minutes and, subsequently,continuous infusion of 0.9% sodium chloridecontaining 30-40mL of 10% calcium gluconateevery 24 hours until the total serum calcium level


BOX 1

Signs and symptoms of a thyroid storm

4Chest pain and shortness of breath.

4Tachycardia.

4Atrial fibrillation and high pulse pressure.

4Congestive heart failure.

4Agitation, restlessness and delirium.

4Psychosis.

4Coma.

4Tremor, nervousness and disorientation.

4Hyperpyrexia with flushing and sweating.

4Hyperpyrexia is out of proportion to other symptoms.

(Jameson and Weetman 2008, Elisha et al 2010)

BOX 2

Management of a thyroid storm

4 Ensure adequate oxygenation.

4 Administer glucose-containing intravenous fluids.

4 Administer beta-adrenergic blockers.

4 Administer sodium iodine.

4 Administer propylthiouracil or methimazole.

4 Administer glucocorticoids.

4 Correct electrolyte imbalances.

4 Correct acid-base imbalances.

4 Administer paracetamol.

4 Apply cooling blankets.

(Jameson and Weetman 2008, Chong et al 2010)

Time out 5In your own words, describe a thyroid storm and discuss with a colleague the nursing care requirements for a patient in this specific situation.



occurs intraoperatively or up to 18 hours post-operatively (Elisha et al 2010). Causes include surgical manipulation of the gland and/or thyroid activity that was not adequatelycontrolled pre-operatively. Symptoms includetachycardia, fever, nausea and vomiting, anxiety,restlessness, maniac behaviour and commonly,coma (Box 1). In severe cases, congestive heartfailure may occur (Bhattacharyya and Fried 2002).

Once the thyroid storm is identified, treatmentis aimed at symptomatic management. Thereduction of circulatory thyroid hormone is the main goal. Drug management includesantipyretics (aspirin must be avoided because it increases thyroid hormone levels) to reduce fever, antithyroid drugs, potassium iodine,propylthiouracil, dexamethasone and betablockers (Chong et al 2010) (Box 2).

Surgical procedures involving the partial or total removal of the thyroid gland involve a degree of risk that arises not only from thecomplexity of the intervention but also from the patient’s clinical status. It is the nurse’s role to assess the patient for potential or actualcomplications following surgery, such as

haemorrhage, haematoma, wound infection, orchanges in the normal breathing pattern (Table 4).

Conclusion

The thyroid gland plays an essential role in theregulation and maintenance of importantphysiological and metabolic functions in thehuman body. There are several disorders thatmight influence the normal functioning of thethyroid gland, including hyperthyroidism,Graves’ disease, diffuse and multinodular goitre and neoplasms. It is vital that healthcareprofessionals can identify the signs and symptoms of each disorder and begin timely interventions to prevent serious and life-threatening complications NS

Time out 6Now that you have completedthe article you might like to write a practice profile. Guidelines to help you are on page 56.

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