Thyroidectomy is the removal of either part of or the

whole thyroid gland itself. The group has chosen the

said case for its complexity and the learning that each
member can acquire. Its rarity makes it not only an
interesting matter but also provides an opportunity to
have new knowledge regarding the case. The group has
included in this presentation the anatomy and
physiology of the aforementioned part of the human
body as well as the information regarding the
procedure done. Another part included are the
nursing care plans, medication study, laboratory result
interpretation and the pathophysiology.
Carcinoma of the thyroid is a malignant neoplasm of
the gland
Incidence increase with age. The average age at time of
diagnosis is 45 years.
Associated with being exposed to radiation (head and
neck part.)
Papillary and well differentiated adenocarcinoma (most
common)
Growth is slow and spread is confined to lymph nodes that
surround thyroid area; cure rate is excellent after removal of
involved areas.
Follicular
Occurs predominantly in middle-aged and older person;
progression of disease is rapid; high mortality rate
Parafollicular-meduallary thyroid carcinoma (MTC)
Rare, inheritable type of malignancy that can be detected
early.
Undifferentiated anaplastic carcinoma
Most aggressive and lethal solid tumor found in human; least
common of all thyroid cancer; often fatal within months of
diagnosis.
Upon palpation of the thyroid there may be a firm,
irregular, fixed, painless mass or nodules
Usually asymptomatic
Thyroid scan will detect a cold nodule with little
uptake
Fine needle aspiration biopsy
Surgical exploration
Surgical removal is extensive, as required
Thyroid replacement
For unresectable cancer,patient is referred for
treatment with
131
I,chemotherapy or radiation therapy.
Functions:
1. Water Balance
2. Uterine contraction and Milk release
3. Growth, metabolism and tissue maturation
4. Ion regulation
5. Heart rate and blood pressure regulation
6. Blood glucose control
7. Immune system regulation
8. Reproductive function control
Anterior Pituitary Gland
Posterior Pituitary Gland
Thyroid Gland
Parathyroid glands
Adrenal Medulla
Adrenal Cortex
Pancreas
Reproductive organs:
Ovaries & Testes
Thymus gland
Pineal body
A gland made up of two lobes connected by a narrow
band called the isthmus.
The lobes are located on either side of the trachea just
inferior to the larynx.
One of the most largest endocrine gland.
Appears more red than surrounding tissues because it
is highly vascular.
Main Function: TO SECRETE THYROID
HORMONES (T3 & T4) these binds to intracellular
receptors in cells and regulate the rate of metabolism
in the body
Gland Hormone Target Tissue Response
Thyroid Gland Thyroid hormones
(Thyroxine and
Triiodothyronine)
Most cells of the
body
Increases
metabolic rates,
essential fro
normal process of
growth and
maturation
Calcitonin Primarily bones Decreases the rate
of bone
breakdown;
prevents large
increase in blood
calcium levels
following a meal.
Predisposing Factors:
Age: 50 y/o
Family history of cancer
Goiter
Abnormal chromosomal
Pattern present at birth
Genes mutate
Over time
Cells become
undifferentiated
Immune system
Fails to recognize
The malignant cells
Tumor continuously
grow
Thyroid gland
Functioning is impaired
And it grows in size
Causing obstruction
Of airway
Resulting to:
DOB, Impaired voice
Production and dysphagia
Results Normal Findings Interpretation
Hemoglobin 92 g/l 110-165 g/l decrease
Hematocrit 0.28 cv/l 0.35-0.50 cv/l decrease
WBC 5.6 5.0-10 normal
Segmenters 68.5% 43-76% normal
Lymphocytes 26.4 % 17-48% normal
Monocytes 5.1% 4-10% normal
January 7, 2013
January 9, 2013
Results Normal Findings Interpretation
FBS 109.8 mg/dl 70-110 mg/dl normal
Sodium 139 mEq/l 135-148 mEq/L normal
Potassium 3.1 mEq/l 3.5-5.3 mEq/l decrease
Blood Chemistry


Interpretation:
Mild Left ventricular Cardiomegaly
Otherwise, essential normal chest findings

Radiologic
Findings
January 7, 2013
is an operation that involves
the surgical removal of all or part of
the thyroid gland.
Less extreme variants of
thyroidectomy include:
Hemithyroidectomy" (or "unilateral
lobectomy") -- removing only half of
the thyroid
Isthmectomy" -- removing the band
of tissue (or isthmus) connecting the
two lobes of the thyroid

Hemithyroidectomy - entire isthmus is removed along with 1 lobe.
Done in benign diseases of only 1 lobe.
Subtotal thyroidectomy - done in toxic thyroid; primary or secondary
and also for toxic MNG (Multi-nodular goiter)
Partial thyroidectomy - removal of gland in front of trachea after
mobilization. It is done in nontoxic MNG. role is controversial.
Near total thyroidectomy - Both lobes are removed except for a small
amount of thyroid tissue (on one or both sides) in the vicinity of the
recurrent laryngeal nerve entry point and the superior parathyroid
gland; done in papillary thyroid carcinoma
Total thyroidectomy- Entire gland is removed. Done in case of
follicular carcinoma of thyroid, medullary cancer of thyroid.
Hartley Dunhill operation- removal of 1 entire lateral lobe with
isthmus and partial/subtotal removal of opposite lateral lobe. It is done
in nontoxic MNG.

Thyroid cancer
Toxic thyroid nodule (produces too much thyroid
hormone)
Multi-nodular goiter (enlarged thyroid gland with
many nodules), causing compression of nearby
structures.
Graves' disease an autoimmune disease that affects
the thyroid causing it to enlarge and become
hyperactive. (There is exophthalmos/bulging eyes)
Thyroid nodule, if fine needle aspirate (FNA) results
are unclear

Horizontal anterior neck incision (if possible, within a skin
crease)
Create upper and lower flaps between the platysma and
strap muscles
Divide vertically between the strap muscles and anterior
jugular veins
Separate the strap muscles from the thyroid gland
Divide the middle thyroid vein
Mobilize the superior pole of the thyroid lobe. Divide the
superior thyroid artery and vein close to the thyroid gland
(avoid injury to the external branch of the superior
laryngeal nerve and the superior parathyroid gland)
Identify the recurrent laryngeal nerve whenever
possible using the nerve monitoring device
Identify the inferior parathyroid artery
Divide the inferior thyroid artery and vein
Separate the thyroid lobe and isthmus from the
trachea
Repeat this process for the other thyroid lobe. Remove
the thyroid gland
Reapproximate the strap muscles
Reapproximate the platysma muscle
Close the skin with a subcuticular stitch

Hypothyroidism/Thyroid insufficiency in up to 50% of
patients after ten years
Laryngeal nerve injury in about 1% of patients, in particular
the recurrent laryngeal nerve: Unilateral damage results in
a hoarse voice. Bilateral damage presents as laryngeal
obstruction after surgery and can be a surgical emergency:
an emergency tracheostomy may be needed. Recurrent
Laryngeal nerve injury may occur during the ligature of the
inferior thyroid artery.
Hypoparathyroidism temporary (transient) in many
patients, but permanent in about 1-4% of patients
Anesthetic complications

Infection
Stitch granuloma
Chyle leak
Hemorrhage/Hematoma
(This may compress the airway,
becoming life-threatening.)
Surgical scar/keloid
Removal or devascularization of
the parathyroids.
Thyroid storm in operations
performed for hyperthyroidism

Patients Name: Patient A.
Address: Bautista San Pablo City
Age: 50yrs old
Gender: Female
Civil status: widowed
Date of Admission: January 7, 2013
Time: 10:53am
Admitting Diagnosis: Papillary Carcinoma,
S/P thyroidectomy

Final Diagnosis: Papillary Carcinoma, thyroid gland
S/P L lobectomy, isthmusectomy
Chief Complaint: No voice, dysphagia, shortness of
breath
History of Present Illness: A few weeks prior to
admission the patient experienced dysphonia. The
patient was admitted last Oct. 3 due to colloid
adenomatous goiter and underwent an operation: Left
lobectomy and isthmusectomy. Was readmitted last
January 7, 2013 due to dysphagia and shortness of
breath and was diagnosed with Papillary Carcinoma
and underwent completion thyroidectomy.
Past Medical History: Colloid Goiter
Previous Hospitalization: when she underwent
appendectomy; October 3, 2012 underwent left
lobectomy and isthmusectomy
Initial Vital Signs (Upon Admission):
BP: 140/80
RR: 20
PR: 86
Temp: 37.4
Pre-operative V/S:
BP: 150/90
RR:24
PR: 80
Temp: 36.6
Post-operative V/S:
BP: 152/86
PR: 85
RR: 22
Temp: 37


Day 1
(Intraoperative)
Day 2
(Postoperative)
Skin Inspection: dry and scaly, tan-colored skin
Palpation: saggy
Nails Inspection: short cut nails
Palpation: no deformities, no clubbing noted
Hair Inspection: well distributed, dry, black hair
Head Inspection: normocephalic
Palpation: no bulging or mass palpated
Eyes Inspection: pupils are equally round and reactive to light
accumulation, no discharges, white sclera, pale
conjunctiva
Ears Inspection: no discharges noted, has difficulty hearing
(during interview patient asks the student nurses to
repeat questions numerous times)
Palpation: no tenderness
Nose Inspection: patent; no discharges noted; symmetrical
Mouth and Pharynx With ET tube Inspection: no dentures, dry lips and mucosa
Neck with surgical incision
on midway between
cricoid insternal notch
Inspection: visible neck mass
Thorax and Lungs Inspection: normal chest expansion, 1:2 anteroposterior
diameter
Auscultation: no crackles heard
Cardiovascular BP: 150/90 Auscultation: no murmurs sound heard
Breast and Axillae Inspection: nipples are symmetrical, no discharges
and lesions noted
Palpation: no unusual mass or lump prominent
Abdomen Inspection: with scar from operation
(appendectomy) on right lower quadrant,
Auscultation: bourborygmi sound heard <3 seconds
Palpation: no rebound tenderness
Genitals Inspection: no abnormal discharges noted
Anus and Rectum Inspection: No hemorrhoids noted, patent
Extremities unable to move all of
the extremities , with
safety straps on upper
extremities
Able to move extremities
Level of Consciousness patient under general
anaesthesia,
unconscious and
incoherent
Conscious and coherent
Intraoperative
ASSESSMEN
T
DIAGNOS
IS
PLANNING IMPLEMENTATI
ON
RATIONALE EVALUATIO
N
Objective:
>with surgical
incision on
midway
between
cricoid
insternal
notch
>with body
temp: 36.6 C

Risk for
infection
related to
invasive
procedure
After series of
nursing
interventions,
infection will
be prevented
as manifested
by: >normal
body temp
>no foul
odour or
discharge
>no swelling
>good wound
healing
>Maintain
sterility of the
field:
-Assist patient in
wearing of OR
gown and head
cap
-Prepare
instruments
aseptically
-Proper use of
personal
protective
equipment
-Surgical hand
washing and
scrubbing
-Wear sterile
gloves
-Do skin prep
-Assist with
honesty and
conscience



To maintain
sterility of
the field












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

ASSESSMEN
T
DIAGNOSIS PLANNING IMPLEMENTATI
ON
RATIONALE EVALUATIO
N
>Drape skin with
sterile cloth




>Dress wound
aseptically


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

ASSESSMEN
T
DIAGNOSI
S
PLANNING IMPLEMENTATI
ON
RATIONALE EVALUATIO
N
Objective:
>patient
under general
anaesthesia
>unconscious
and
incoherent
>unable to
move all of
the
extremities
Risk for
perioperativ
e
positioning
injury r/t
anesthetic
effect
After series
of nursing
intervention
s patient will
be free from
injury as
manifested
by:
>absence of
muscular or
skeletal pain
>skin
remain
intact
>no signs of
pressure
sores
>Transfer patient
to Or table
properly:
-lock cart/bed in
place
-support clients
body and limb
-use adequate # or
personnel during
transfer
>Never leave
patient
>Place safety strap
to secure patient
>apply and
reposition
padding of
pressure
points/bony
prominences

>to prevent
shear and
friction
injuries





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

After series of
nursing
interventions,
goal met,
patient was
free from
injury as
manifested
by:
>absence of
muscular or
skeletal pain
>skin remain
intact
>no signs of
pressure sores
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATIO
N
RATIONALE EVALUATION
>Check
peripheral
pulses and skin
color
periodically
>Protect body
from contact
with metal
parts of the
operating table
>Place and
check cautery
pad are
properly in
place and with
lubricant; check
other metals in
the body
>Reposition
slowly and in
transfer in bed
(to PACU)

>To monitor
circulation


>which could
produce
injury and
pain


>for proper
conductor of
cautery and to
prevent from
injury

>to prevent
severe drop of
BP,
dizziness/uns
afe transfer

Health Perception
The patient is aware of her condition and was a bit emotional
when she told the student nurses what was her final
diagnosis. She reported about her previous illnesses such as
goiter and had told the student nurses that she sought
medical assistance once the signs and symptoms of her illness
arise.
Nutrition and Metabolic
The patient eats 3 meals a day. She said she often prefers meat
over vegetables but often eats fruits if available. But 2 months
prior to her operation she experienced difficulty of
swallowing and experienced decrease in appetite (able to
finish cup of rice of prepared food) due to dysphagia.
Elimination Pattern
The patient verbalized that she usually defecates 1-2 times a
day and urinate at least 4-6 times a day. But the day after the
surgery she hadnt defecate even once. (cc hourly)

Activity and Exercise
The patients occupation is pangangalakal ng bote. But if she
has a free time she sells AVON products. Because of her job,
she often walks under the sun and that serves as her exercise.
But prior to hospitalization while suffering from her
condition the patient had experienced easy fatigability.
Sleep and Rest
She sleeps at least 6-8 hours a day with no interruption. From
8 pm-4 am.
Cognitive and Perceptual
During the interview the day after the surgery despite her
difficulty speaking the patient was well oriented and
answered the questions coherently. She also used hand
gestures to send her message more clearly. When asked to rate
her pain perception she gave the value of 6 out of 10.
Self Perception/ Self Concept
The patient appears to be headstrong despite her condition.
She verbalized her fear but not for herself instead for her kids
who are dependent to her.

Role/Relationship
The patients husband died (due to heart attack) 2 years ago
and she was left alone supporting her 4 children. She also
took care of her 2 handicapped lumpo children.
Sexual and Reproductive
The patient is already a widow.
Coping /Stress Tolerance
The patient said that when dealing with her problems she
often deals with them alone because the communication
between her and her children isnt very open. And when asked
about how she deals with the pain she felt all she does is rest
and wait for the pain to lessen.
Values/Belief
The patient is a known Catholic. When it comes to dealing
with medical problems she doesnt use herbal medicines nor
go to faith healer instead she goes straight to a doctor.

Postoperative
ASSESSMEN
T
DIAGNOSIS PLANNING IMPLEMENTATI
ON
RATIONAL
E
EVALUATI
ON
SUBJECTIVE:
Nahihirapan
akong
lumunok, as
verbalized by
the patient.
OBJECTIVE:
>decreased
swallowing
ability
>with incision
on neck area
>with
drainage on
incision site
>v/S: RR-22,
BP- 152/86

Risk for
aspiration
r/t neck
surgery
After series
of nursing
intervention
s patient will
prevent
aspiration as
within 8
hours of
duty, as
evidenced
by:
>be able to
finish
prepared
foods
>RR within
normal
range
>be able to
communicat
e well
verbally
>Nurse-patient
interaction
>Monitor v/s

>Observe for neck
edema





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

>To build
trust and
rapport
>To have
baseline
data

>Client on
neck surgery
is at
particular
risk of
airway
obstruction
& inability to
handle
secretions
>To prevent
risk of
aspiration
>The rested
client may
have less
difficulty
swallowing
After series of
nursing
interventions,
goal partially
met, as
evidenced by:
>the client was
able to finish
her prepared
food. RR of 22
>minimally
uses gestures
while
communicatin
g
ASSESSMEN
T
DIAGNOSIS PLANNING IMPLEMENTATI
ON
RATIONALE EVALUATIO
N
>unable to
finish
prepared food
>more on
gestures when
answering the
questions
>Instruct to feed
slowly, using
small bites, to
chew slowly and
thoroughly
>Provide soft
foods that stick
together/ form a
bolus
>Offer cold
liquids rather
than warm
liquids.






>Crush oral meds
and mix with fruit
juices
>To prevent
risk for
aspiration


>To aid
swallowing
effort
>Colds may
soothe the
trachea while
warm may
trigger
bleeding that
nay
contribute
bleeding that
may cause
obstruction
of airway
>to reduce
swallowing
effort and to
eliminate
taste of
pulverized
meds
ASSESSMEN
T
DIAGNOSIS PLANNING IMPLEMENTATI
ON
RATIONALE EVALUATIO
N
>Minimize use of
hypnotics and
sedatives
whenever possible
>Instruct to
reduce/limit
activities after
eating
>May impair
coughing and
swallowing

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