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Non-Toxic Goiter,
Bilateral
GROUP 3Y1-2D
Introduction
Causes:
Iodine deficiency
Risk Factors
The following factors increase your chance of developing nontoxic goiter:
Symptoms
Nontoxic goiters usually do not have noticeable symptoms, unless they become very large.
If you experience any of these, do not assume it is due to this condition. These may be
caused by other, less serious health conditions.
Hoarseness
Health History
General Data
Age: 61
Sex: Female
Vital Signs
Temperature: 36.8 C
Pulse rate: 90
Respiratory rate: 21
Blood pressure: 120/80
PHYSICAL EXAMINATION
HERNIA: none
Hoarseness of voice
GENITALIA: no deformities
BACK: no deformities
TEETH: incomplete
CHEST: no deformities
Hormones produced:
Thyroxine (T4)
Tri-iodothyronine (T3)
Function:
Weighs 20-25 g
Predisposing Factors
*Sex: Female
*Age: >40 years
*Family Hx of Goiter
Etiology: May be
caused by one or
several factors
stated
Presence of uniform
follicular epithelial
hyperplasia
Development of areas
of involution and
fibrosis interspersed
with areas of focal
hyperplasia
Precipitating Factors
Hx of radiation therapy to
head and neck
Regular intake of goitrogens
(cabbage, turnips, etc)
Excessive amounts of Iodine
Iodine Defiency
Development of nodules
Development of functional
autonomy
Drug Study
Generic
/Brand Name
midazolam
Dormicum,
Pfizer
Midazolam
omeprazole
Acifre,
Omepron
Drug
Class
Indication
Preprocedur
Antial sedation.
anxiety
Aids in
agents,
induction of
sedative/h anesthesia
ypnotics
and as part
of balanced
2mg IV
anesthesia
(PPI)
Proton
Pump
Inhibitor
For
treating
acidinduced
inflammatio
n and ulcers
of the
Action
Adverse
Effect
Bradycardia,
tachycardia,
Depresses the
CV collapse,
limbic system and hypertension,
reticular
hypotension,
formation by
palpitations,
increasing or
edema
facilitating the
inhibitory
neurotransmitter
activity of GABA
Suppresses
Angina,
gastric secretion tachycardia,
by inhibiting
bradycardia,
hydrogen/potassi palpitation,
um ATPase
abdominal
enzyme system in pain
the gastric
Nursing
Consideration
Assess level of
sedation and
level of
consciousness
throughout and
for 2-6 hr
following
administration.
Assess GI system:
bowel sounds,
abdomen for pain
and swelling,
appetite loss
Drug Study
Generic
/Brand
Name
ketorolac
Toradol,
Toradol IM
cefoxitin
Drug
Class
Indication
Antibiotic
Action
Reduces the
production of
prostaglandins.Blo
cks the enzymes
that cells use to
make
prostaglandins. As
a result, pain as
well as
inflammation and
its signs and
symptomsredness, swelling,
fever, and pain.
Respiratory tract Inhibits bacterial
infection, bone, wall synthesis,
joint and skin
thus promoting
Adverse
Effect
Nursing
Consideration
Blurred vision,
confusion,
dryness of the
mouth flushing
Assess patients
condition before
therapy and
regularly thereafter
to monitor drugs
effectiveness.
Phlebitis and
inflammation
at the site of
Assess patients
previous sensitivity
reaction to
Generic
/Brand
Name
tramadol
Ultram,
Zydol
Drug
Class
Narcotic
(opiate)
100 mg
slow IV
initially
then
tramadol
200 mg
in 234 cc
PNSS x
10ggts/mi
n
Indication
Management
of moderate to
moderately
severe pain
Action
Centrally acting
opiate receptor
agonist that
inhibts the
uptake of
norepinephrine
and serotonin
May produce
opioid-like
effects, but
causes less
respiratory
depression than
morphine
Adverse
Effect
Nursing
Consideration
CNS:
drowsiness,
dizziness,
vertigo
Nursing Process
Objectives:
To alleviate anxiety
To relieve pain
Assessment
Diagnosis
Planning
Interventions
Rationale
Evaluation
PRE-OP
Subjective Data:
Kinakabahan po ako
sa
gagawing operasyon,
as verbalized by
the patient.
Objective Data:
Poor eye contact;
glancing about;
extraneous
movement;
restlesness
Alteration in emotional
status: Fear of the
unknown related to
impending surgery
Within 1 hour of
nursing
interventions,
the patient will
appear relaxed
and report of
anxiety is
reduced to a
manageable
level
As a baseline data to
plan for future
nursing
interventions.
Increase in BP and
pulse may indicate
patient
anxiety.
regarding surgical
procedures.
Encourage patient to verbalize
her feeling and ask questions
To gain patients
regarding surgical procedure.
cooperation.
Encourage patient to do
To divert patients
divertional therapy.
attention about the
surgery.
Provide good ventilation and
quiet environment.
To encourage rest and
relaxation which
calm the mind.
Assessment
Diagnosis
Planning
PRE-OP
Subjective Data:
Nahihirapan po akong
lumunok
at huminga, as
verbalized by the
patient.
Objective:
Irritability
Restlessness
Dyspnea
Risk for
ineffective
airway clearance
related to
tracheal swelling
due to
enlargement of
mass
Within 1 hour of
nursing
interventions,
the client will
maintain a
patent airway
and will be able
to breath easily
Interventions
Encourage patient to do
deep breathing
exercises.
Encourage/provide
opportunities for rest;
limit activities
Provide a well-ventilated
and quiet environment
Rationale
Evaluation
Indicative of
respiratory distress
and or accumulation
of secretion.
To take advantage of
gravity decreasing
pressure and
enhancing drainage
and ventilation
Prevents and
reduces fatigue
Enhances relaxation,
conserving energy
After 1 hour
of nursing
interventions
, the patient
was able to
maintain a
patent
airway. She is
more relax
and calm
Assessment
Diagnosis
Planning
POST-OP
Subjective Data:
Masakit po ang
lalamunan ko , as
as verbalized by the
patient
Objective cues:
Guarding behavior
Facial grimace
Acute pain
related to
postoperative
edema
Within 4 hours
of nursing
interventions,
the clients
report of pain is
controlled and
will display a
reduction of
pain from a
scale of 5/10 to
3/10.
Intervention
Independent:
Assess for signs of pain in both
verbal and nonverbal, note the
location and intensity and
duration.
Rationale
Evaluation
Useful in evaluating
pain, and determines
the effectiveness of
therapeutic
interventions.
After 4 hours
of nursing
interventions
, the clients
report of pain
is controlled
with a pain
scale of 2/10.
reduce tension.
Instruct in and encourage use
of relaxation techniques, such
as focused breathing
To maintain
acceptable level of
Dependent: Give analgesics as pain.
prescribed and evaluate
effectiveness
Laboratory Findings
HEMATOLOGY
AUGUST 22, 2014
COMPLETE BLOOD COUNT
RESULT
REFERENCE
VALUES
UNIT
INTERPRETATION
Hemoglobin
Hematocrit
RBC Count
DIFFERENTIAL COUNT:
140.0
0.39
5.73
120 - 160
4.0 10.0
gms/L
X10g/L
WNL
Segmenters
Lymphocytes
Eosinophils
0.50
0.36
0.06
0.35 0.65
0.25 0.35
0.02 0.04
0.07
0.01
83.3
29.6
36
11.90
303
0.03 0.06
0.00 0.01
0.03 0.05
80 100
26 32
32 - 36
10.0 15.0
130.0 400.0
0 30
fL
g/dL
X10g/L
Monocytes
Basophils
Stabs
ATYPICAL CELSS:
MCV
MCH
MCHC
RDW
Platelet Count
ESR
Prothrombin
Time
INR
21.1
10.6 13.6
Seconds
1.00
Activity
104.00
74 94
AFTT
25.3
29.9 32.3
Seconds
28
2-7
Minutes
WNL
2-4
Minutes
Reticulocyte
Count
Blood Type
1 MIN 30
SECS
HEMATOLOGY
RESULT
AUGUST 03, 2014
COMPLETE BLOOD
COUNT
Hemoglobin
132.0
REFERENCE
VALUES
UNIT
INTERPRETATION
120 - 160
gms/L
WNL
Hematocrit
RBC Count
DIFFERENTIAL
COUNT:
Segmenters
Lymphocytes
Eosinophils
0.37
4.43
0.37 0.43
4.0 10.0
X10g/L
WNL
WNL
0.40
0.45
0.07
0.35 0.65
0.25 0.35
0.02 0.04
Monocytes
Basophils
Stabs
0.07
0.01
0.03 0.06
0.00 0.01
0.03 0.05
ATYPICAL CELSS:
MCV
MCH
83.6
29.8
80 100
26 32
fL
MCHC
RDW
Platelet Count
36
11.80
257
32 - 36
10.0 15.0
130.0 400.0
g/dL
X10g/L
ESR
0 30
TEST
AUGUST 22, 2014
RESULT
CREA Jaffle
Corrp.
Urea/Bun liquid
63
3.65
(( ) AVL
Sodium
141
Potassium
3.9
136 145
mmol/L
3.5 5.1 mmol/L
Chloride
105
97 111 mmol/L
FUNCTIONAL STUDIES:
NORMAL VALUES
25 June 2014
UNIT
FLAG
REFERENCE RANGE
umol/L
44 80
mmol/L
278 764
( ) Easylyte
FT3 RIA
3.55 pmol/L
FT4 RIA
17.00 pmol/L
TSH IRMA
0.84 IU/L
( 0.3 5 IU/L )
IMPRESSION:
DIFFUSE
COMPLEX
ENLARGED
ENLARGED
ISTHMUS
CT Scan Report
Multiple plain and contrast enhanced axial CT images of the neck were obtained with no untoward reaction.
A well defined heterogeneous soft tissue mass with calcifications and with central hypodensities within is noted
occupying the entire left thyroid lobe with intrathoracic extension. The mass displaces the trachea and
esophagus to the right with no evident fat plane between the two structures and the mass. Adjacent common
carotid artery and internal jugular vein are intact. It measures approximately 9.91 x 6.49 x 6.21 cm (CC x W x
AP).
The right thyroid lobe is enlarged measuring 5.12x2.56x2.16 cm. A fairly-defined heterogeneously enhancing
complex lesions with calcifications is noted within its mid to inferior aspect measuring 2.39x1.74x1.36cm (CC x
W x AP). Likewise, a subcentimeter hypodense lesion is seen in the superior aspect of the right thyroid lobe.
The isthmus is enlarged but with normal parenchymal attenuation.
The oral floor muscle is bilateral symmetrical and normally developed. The spaces of oral floor and neck are
clear and well defined.Cervical vessels that can be evaluated with CT have normal appearance. Unenlarged
lymph nodes are seen in both submandibular (level l) and both posterior triangle of the neck (level V).
IMPRESSION:
THYROMEGALY
THYROID
TISSUE
CORRELATION IS SUGGESTED
THYROID
UNENLARGED
When cancerous cells are found in and around the thyroid gland, all or part of the thyroid is typically surgically
removed.
When the thyroid enlargement - or goiter - has become so large that it is cosmetically necessary to remove it, or
the size is making swallowing or breathing more difficult
When thyroid nodules enlarge and make swallowing or breathing more difficult
When radioactive iodine (RAI) treatment for Graves Disease or hyperthyroidism has been performed several
times and is still not effective
When a woman is pregnant, and her hyperthyroidism cannot be controlled by other means
In most cases, surgery of the thyroid is not highly complicated, and usually takes no more than two hours. It is
frequently performed on an outpatient or overnight basis. There are few complications that result, but when
they do, they typically fall into one of two categories: damage to the voice box and / or vocal cords, or damage
to the parathyroid glands. If there is damage to the parathyroid glands, this will affect the levels of calcium in
the blood, however, this is very rare.
Subtotal Thyroidectomy:
Thyroid Lobectomy:
Thyroidectomy
Thyroid surgical procedures begin with the insertion of an endotracheal tube, followed by the
administration of general anesthesia. Once the anesthesia takes effect, the procedure begins with an
incision 2 inches to 4 inches long that stretches horizontally over the thyroid. Based on the tests
performed before the procedure and the appearance of the thyroid, the final determination of how much
of the thyroid should be removed is made in this case the whole thyroid glands will be removed.
At this point, the whole thyroid glands are removed using a scalpel. Special care is taken not to harm or
disturb the parathyroid glands and the vocal cords, both of which rest in the neck near the thyroid.
A biopsy may also be done to examine the tissues of the thyroid, the parathyroid and, in rare cases, nearby
lymph nodes. This is done to make sure that the portion of the thyroid that is left, if any, is not diseased.
In some cases, the tissue is examined by a pathologist immediately, so that a second surgery to remove a
diseased portion of the thyroid is not necessary.
Once the thyroid has been removed and any necessary samples have been taken, the area is examined for
bleeding. Once the surgeon is confident that there is no bleeding present, the incision is closed. It may be
closed with staples or sutures, and in some cases, a surgical drain may be placed to remove fluid from the
area in the days after surgery.
Once a sterile bandage is applied to the incision, the surgery is completed. Anesthesia is discontinued and
medication is given to wake the patient. The patient is then taken to the recovery room to be closely
monitored while the remaining anesthetic wears off.
Health Teachings
Teaching and Emotional Support
It is still recommended to perform deep breathing, coughing and leg exercises while you are resting in bed.
Consults
Your surgical team will visit you before you are discharged and discuss your operation.
Mobility
You may walk as much as you like. Short frequent walks are a great way to start and assistance is available if
required. Please let the nursing staff know if you plan to leave the ward.
Hygiene
You may shower yourself. Assistance is available if required, please ask the nursing staff.
Nutrition
You may eat and drink as you like, unless otherwise ordered by your doctor.
Continence state
You may walk to the toilet as required.
Observations
Your observations such as temperature, pulse and wound and drain/s will be monitored
regularly until you are discharged.
Medications
You will recommence your normal medications as ordered by your doctor, plus any
required for pain relief. Please let the nursing staff know when you have pain.
The drip (IV) will continue until you are taking adequate amounts of fluids and until
any IV medications (if applicable) are ceased. It will then be removed.
Treatments
The drain/s (if applicable) in your wound will be removed as ordered by your doctor.
This is usually the morning after your operation.
Your doctor will advise when the staples/sutures will be removed. Often this is before
you go home. If so, some steri-strips (bandaids) will be applied. Please leave these on
until they peel or fall off (these can get wet when you shower).
What to expect
Some pain/discomfort at your wound site may be experienced. This is generally aggravated by
movement, coughing and sneezing. Gently support the wound area when you need to cough. This
discomfort will eventually settle. You can take analgesia as discussed with your doctor or nurse.
You may notice redness, slight swelling and bruising around the wound, this is quite normal.
You may notice that you have a poor appetite for some time.
What to do
Maintain adequate fluid intake (68 glasses per day).
You may take simple analgesia, eg. Panadol/Panadeinehowever, do not take any more than eight
tablets within a 24 hour period.
Return if
You have any difficulty swallowing or breathing.
You notice increased swelling from/around the wound and/or a discharge from the
wound, inflammation, throbbing around the wound or it feels hot to touch.
You experience a tingling feeling in your mouth or fingers and/or numbness in your
fingers.
You experience a marked increase in pain that is not relieved with simple
analgesia, eg. Panadol/Panadeineno more than eight tablets within a 24 hour
period.