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INTRODUCTION:

The thyroid gland is a butterfly-shaped organ and is composed of two cone-like lobes or wings, lobus

dexter(right lobe) and lobus sinister(left lobe), connected via the isthmus. The organ is situated on the anterior

side of the neck, lying against and around the larynx and trachea, reaching posteriorly the oesophagus and

carotid sheath. It starts cranially at the oblique line on the thyroid cartilage (just below the laryngeal

prominence, or 'Adam's Apple'), and extends inferiorly to approximately the fifth or sixth tracheal ring. It is

difficult to demarcate the gland's upper and lower border with vertebral levels because it moves position in

relation to these during swallowing. Hormones produced by the thyroid gland have an enormous impact on

your health, affecting all aspects of your metabolism. It produces two main hormones, thyroxine (T-4) and

triiodothyronine (T-3). They maintain the rate at which your body uses fats and carbohydrates, help control your

body temperature, influence your heart rate, and help regulate the production of protein. Your thyroid gland

also produces calcitonin, a hormone that regulates the amount of calcium in your blood.

When your thyroid doesn't produce enough hormones, the balance of chemical reactions in your body

can be upset. There can be a number of causes, including autoimmune disease, treatment for hyperthyroidism,

radiation therapy, thyroid surgery and certain medications.

Hypothyroidism is the underproduction of the thyroid hormones T3 and T4. Hypothyroid disorders may occur as a

result of congenital thyroid abnormalities, autoimmune disorders such as Hashimoto's thyroiditis, iodine

deficiency, especially in poorer countries, or the removal of the thyroid following surgery to treat severe

hyperthyroidism. Typical symptoms are abnormal weight gain, tiredness, baldness, cold intolerance, and


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bradycardia. Hypothyroidism is treated with hormone replacement therapy, such as levothyroxine, which is

typically required for the rest of the patient's life. Thyroid hormone treatment is given under the care of aphysician and may take a few weeks to become effective.[16]

Negative feedback mechanisms result in growth of the thyroid gland when thyroid hormones are being

produced in sufficiently low quantities as a means of increasing the thyroid output; however, where the

hypothyroidism is caused by iodine insufficiency, the thyroid is unable to produce T3 and T4 and as a result, the

thyroid may continue to grow to form a non-toxic goiter. It is termed non-toxic as it does not produce toxic

quantities of thyroid hormones, despite its size.

Hypothyroidism upsets the normal balance of chemical reactions in your body. It seldom causes

symptoms in the early stages, but, over time, untreated hypothyroidism can cause a number of health

problems, such as obesity, joint pain, infertility and heart disease.

The National Health and Nutrition Examination Survey (NHANES 1999-2002) of 4,392 individuals reflecting

the US population reported hypothyroidism (defined as TSH levels >4.5 mIU/L) in 3.7% of the

population.2 Hypothyroidism is more common in women with small body size at birth and low body mass index

during childhood. Iodine deficiency as a cause of hypothyroidism is more common internationally. The

prevalence is reported as 2-5% depending on the study, increasing to 15% by age 75 years.


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NHANES 1999-2002 reported that the prevalence of hypothyroidism (including subclinical) was higher in

whites (5.1%) and Mexican Americans than in African Americans (1.7%). African Americans tend to have lowerTSH values. Generally, thyroid disease is much more common in females than in males, with reports of

prevalence 2-8 times higher in females. The frequency of hypothyroidism, goiters, and thyroid nodules increases

with age. Hypothyroidism is most prevalent in elderly populations, with 2% to as much as 20% of older age

groups having some form of hypothyroidism. The Framingham study found hypothyroidism (TSH >10 mIU/L) in

5.9% of women and 2.4% of men older than 60 years.4

In NHANES 1999-2002, the odds of having hypothyroidismwere 5 times greater in persons aged 80 years and older than in individuals aged 12-49 years.2

Hyperthyroidism is a overactive thyroid, is the overproduction of the thyroid hormones T3 and T4, and is most

commonly caused by the development of Graves' disease an autoimmune disease in which antibodies are

produced which stimulate the thyroid to secrete excessive quantities of thyroid hormones. The disease can

result in the formation of a toxic goiter as a result of thyroid growth in response to a lack of negative feedback

mechanisms. It presents with symptoms such as a thyroid goiter, protruding eyes (exopthalmos), palpitations,

excess sweating, diarrhea, weight loss, muscle weakness and unusual sensitivity to heat.

Increased production of thyroid hormone in Graves' disease leads to a stimulation or quickening of the

body's metabolism. This results in symptoms of Hyperthyroidism that include

nervousness, anxiety, irritability, weight loss, bulging eyes, and hypertension. Hyperthyroidism may also lead to

serious, potentially life-threatening complications


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Hyperthyroidism is more common in women than in men. People over the age of fifty who

have hypertension or atherosclerosis are at risk for developing Hyperthyroidism.

Hyperthyroidism can also be caused by the growth of a thyroid nodule on the thyroid gland. A thyroid

nodule is a noncancerous cyst that produces additional thyroid hormone, resulting in hyperthyroidism (high

levels of thyroid hormone). It affects about 5 per 10,000 people (NWHIC).

A number of conditions, including Graves' disease, toxic adenoma, Plummer's disease (toxic multinodular

goiter) and thyroiditis, can cause Disorders of thyroid function, whether hyperthyroidism or hypothyroidism are

medical conditions that can have a significant impact on public health and can even shorten the lifespan of

individuals of any age. Thyroid disorders, goitrous and non goitrous forms, occur with great frequency in the

adult population ranging from 0.5 to 5% in overt disease and 3 to10% in the subclinical forms depending on the

population, age and sex examined. Lack of dietary iodine is an important underlying cause of thyroid disorders,

excess iodine, genetic background, and other geographical and dietary factors can trigger thyroid disorders.

Children, pregnant women and lactating mothers are most at risk to iodine deficiency as this may result in

permanent damage to the developing brain. In the general adult population which is the backbone of the

labor force of a country, deficient and excessive iodine can cause subtle thyroid abnormalities with

considerable consequences. Small aberrations in thyroid function have been associated with overweight and

blood pressure problems.

In modern technology, thyroidectomy is being improved. Nowadays, we have a latest kind of method. It

is being done by a robot. According to the article, this method is useful, simple, safer, and easier. Surgeons gain


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access through a two-to-three-inch armpit incision, and then work their way through skin and fat and finally in

between two big neck muscles. "It's a long way down a big tunnel to get to that thyroid through the armpit thatwould not be possible without telescopes and long instruments. One of the advantages of this method is that

scarring will be avoided. After the surgery, there will no scarring in the site of the incision. And it was being

proven that patients undergoing this method have a faster recovery period than of those used the traditional

method. (http://www.sciencedaily.com/releases/2010/07/100706112607.htm)

Being a nurse in the society requires characteristics to be a productive member of the society. Three

characteristics that entail a nurse include: knowledge, skills and attitude. A nurse needs the knowledge to

function well and to render care from those suffering from diseases. Through this information contains in this

case report may help him/her to give the appropriate care for these patients. Also, this information may set as

a guide to the nurse as he/she goes along with his/her profession.


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Chapter II

ANATOMY AND PHYSIOLOGY


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y ANATOMY OF THE THYROID GLAND

A large, highly vascular endocrine gland situated in the base of the neck. The thyroid consists of two lobes, one on

each side of the trachea, just below the larynx or voice box. The two lobes are connected by a narrow band of tissue

called the isthmus. Internally, the gland consists of follicles, which produce thyroxine and triiodothyronine hormones. Both

these hormones contain iodine.

The thyroid controls how quickly the body burns energy, makes proteins, and how sensitive the body should be to

other hormones. The thyroid participates in these processes by producing thyroid hormones, principally thyroxine (T4) and

triiodothyronine (T3). These hormones regulate the rate of metabolism and affect the growth and rate of function of many

other systems in the body. Iodine is an essential component of both T3 and T4. The thyroid also produces the hormone

calcitonin, which plays a role in calcium homeostasis. Thyroid hormones also help maintain normal blood pressure, heart

rate, digestion, muscle tone, and reproductive functions.

The thyroid tissue is made up of two types of cells: follicular cells and parafollicular cells. Most of the thyroid tissue

consists of the follicular cells, which secrete iodine-containing hormones called thyroxine (T4) and triiodothyronine (T3).

The parafollicular cells secrete the hormone calcitonin. The thyroid needs iodine to produce the hormones.

About 95 percent of the active thyroid hormone is thyroxine, and most of the remaining 5 percent is

triiodothyronine. Both of these require iodine for their synthesis. Thyroid hormone secretion is regulated by a negative

feedback mechanism that involves the amount of circulating hormone, the hypothalamus, and the anterior pituitary gland

(adenohypophysis).


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The thyroid is controlled by the hypothalamus and pituitary. The gland gets its name from the Greek word for

"shield", after the shape of the related thyroid cartilage. Hyperthyroidism (overactive thyroid) and hypothyroidism

(underactive thyroid) are the most common problems of the thyroid gland.

The thyroid gland is butterfly-shaped organ and is composed of two cone-like lobes or wings: lobus dexter (right

lobe) and lobus sinister (left lobe), connected with the isthmus. The organ is situated on the anterior side of the neck, lying

against and around the larynx and trachea, reaching posteriorly the oesophagus and carotid sheath. It starts cranially at

the oblique line on the thyroid cartilage (just below the laryngeal prominence or Adam's apple) and extends inferiorly to

the fourth to sixth tracheal ring. It is difficult to demarcate the gland's upper and lower border with vertebral levels as it

moves position in relation to these during swallowing.

The normal thyroid gland is easily palpable. Palpation is carried out from behind using the digits to feel for the

cricoid cartilage and for the 1st tracheal ring directly below it. The isthmus of the thyroid overlies the 2nd through the

fourth tracheal rings, to which the pretracheal fascia (a fibrous sheath that contains the thyroid and allows it to glide

smoothly over the nearby contents) firmly attaches through suspensory ligaments (extensions of the fascia). This

attachment allows the thyroid to move with the larynx during swallowing, an important fact in palpating the thyroid as it is

appropriate to ask the patient to sip a glass of water while palpating the gland, as to allow the inferior portion to be better

felt when it elevates with the larynx.


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The thyroid isthmus is variable in presence and size, and can encompass a cranially extending pyramid lobe (lobus

pyramidalis or processus pyramidalis), remnant of the thyroglossal duct. The thyroid is one of the larger endocrine glands,

weighing 2-3 grams in neonates and 18-60 grams in adults, and is increased in pregnancy.

The thyroid is supplied with arterial blood from the superior thyroid artery, a branch of the external carotid artery,

and the inferior thyroid artery, a branch of the thyrocervical trunk, and sometimes by the thyroid ima artery, branching

directly from the aortic arch. The venous blood is drained via superior thyroid veins, draining in the internal jugular vein,

and via inferior thyroid veins, draining via the plexus thyroideus impar in the left brachiocephalic vein. Lymphatic drainage

passes frequently the lateral deep cervical lymph nodes and the pre- and parathracheal lymph nodes. The gland is

supplied by sympathetic nerve input from the superior cervical ganglion and the cervicothoracic ganglion of the

sympathetic trunk, and by parasympathetic nerve input from the superior laryngeal nerve and the recurrent laryngeal

nerve.

y PHYSIOLOGY OF THE THYROID GLAND

The primary function of the thyroid is production of the hormones thyroxine (T4), triiodothyronine (T3), and

calcitonin. Up to 80% of the T4 is converted to T3 by peripheral organs such as the liver, kidney and spleen. T3 is about

ten times more active than T4.

y T3 and T4 Production and Action

Thyroxine (T4) is synthesised by the follicular cells from free tyrosine and on the tyrosine residues of the protein

called thyroglobulin (TG). Iodine is captured with the "iodine trap" by the hydrogen peroxide generated by the enzyme

thyroid peroxidase (TPO) and linked to the 3' and 5' sites of the benzene ring of the tyrosine residues on TG, and on free


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tyrosine. Upon stimulation by the thyroid-stimulating hormone (TSH), the follicular cells reabsorb TG and proteolytically

cleave the iodinated tyrosines from TG, forming T4 and T3 (in T3, one iodine is absent compared to T4), and releasing

them into the blood. Deiodinase enzymes convert T4 to T3. Thyroid hormone that is secreted from the gland is about 90%

T4 and about 10% T3.

Cells of the brain are a major target for the thyroid hormones T3 and T4. Thyroid hormones play a particularly

crucial role in brain maturation during fetal development. A transport protein (OATP1C1) has been identified that seems to

be important for T4 transport across the blood brain barrier. A second transport protein (MCT8) is important for T3

transport across brain cell membranes.

In the blood, T4 and T3 are partially bound to thyroxine-binding globulin, transthyretin and albumin. Only a very

small fraction of the circulating hormone is free (unbound) - T4 0.03% and T3 0.3%. Only the free fraction has hormonal

activity. As with the steroid hormones and retinoic acid, thyroid hormones cross the cell membrane and bind to

intracellular receptors (1, 2, 1 and 2), which act alone, in pairs or together with the retinoid X-receptor as transcription

factors to modulate DNA transcription.


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y T3 and T4 Regulation

The production of thyroxine and triiodothyronine is regulated by thyroid-stimulating hormone (TSH), released by the

anterior pituitary (that is in turn released as a result of TRH release by the hypothalamus). The thyroid and thyrotropesform a negative feedback loop: TSH production is suppressed when the T4 levels are high, and vice versa. 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 (in which an accelerated metabolism would generate more heat).

TSH production is blunted by somatostatin (SRIH), rising levels of glucocorticoids and sex hormones (estrogen and

testosterone), and excessively high blood iodide concentration.

y Calcitonin

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


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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, but not the parathyroids.

y Significance of Iodine

In areas of the world where iodine (essential for the production of thyroxine, which contains four iodine atoms) is

lacking in the diet, the thyroid gland can be considerably enlarged, resulting in the swollen necks of endemic goitre.

Thyroxine is critical to the regulation of metabolism and growth throughout the animal kingdom. Among

amphibians, for example, administering a thyroid-blocking agent such as propylthiouracil (PTU) can prevent tadpoles from

metamorphosing into frogs; conversely, administering thyroxine will trigger metamorphosis.

In humans, children born with thyroid hormone deficiency will have physical growth and development problems,

and brain development can also be severely impaired, in the condition referred to as cretinism. Newborn children in many

developed countries are now routinely tested for thyroid hormone deficiency as part of newborn screening by analysis of a

drop of blood. Children with thyroid hormone deficiency are treated by supplementation with synthetic thyroxine, which

enables them to grow and develop normally.

Because of the thyroid's selective uptake and concentration of what is a fairly rare element, it is sensitive to the

effects of various radioactive isotopes of iodine produced by nuclear fission. In the event of large accidental releases of

such material into the environment, the uptake of radioactive iodine isotopes by the thyroid can, in theory, be blocked by

saturating the uptake mechanism with a large surplus of non-radioactive iodine, taken in the form of potassium iodide

tablets. While biological researchers making compounds labelled with iodine isotopes do this, in the wider world such


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preventive measures are usually not stockpiled before an accident, nor are they distributed adequately afterward. One

consequence of the Chernobyl disaster was an increase in thyroid cancers in children in the years following the accident.

The use of iodized salt is an efficient way to add iodine to the diet. It has eliminated endemic cretinism in most

developed countries, and some governments have made the iodination of flour mandatory. Potassium iodide and Sodium

iodide are the most active forms of supplemental iodine.


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Chapter III

The Patient and his Illness

PATHOPHYSIOLOGY (Book- Centered)

a. Schematic diagram

HYPERTHYROIDISM

Modifiable Factors

y

Diety Toxic nodular

goiters/ adenomas

y thyroiditis

y Amiodarone

y Autoimmune

Non- modifiable Factors

y

Gender (female)y Age

Over functionin of the th roid land

Loss of the normal regulatory controls of TH secretion


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Excessive amount of thyroid hormone

sympathetic nervous system

Cardiac system

Number of beta adrenergic receptors

heart contraction

Body

Metabolism

HyperactivityCardiac output and

stroke volume

Fatigue

Resting hand

tremors

Depression

Negative nitrogen

balance

Metabolismof CHO Fat,

and CHON

Lipid

depletion

Weight Weakness


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GI motility Loose bowel

movement

Diarrhea

Absorption of glucose in the

intestine

glyconeolysis Release of

insulin in

bloodstream

Blood

glucose

Hyperglycemia

Reproductive system or sexual

desire

fertility

Male - gynecomastia

Female

oligomenorrhea

or amenorrhea


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Dilate superficial

capillaries

Cardiac output

appetite

Warm and

moist skin

Unable to

tolerate

heat

PALPITATION TACHYCARDIA

Retraction of

upper eyelid

Sclera exposure Exophthalmos

Mood cyclic Mild euphoria Extreme hyperactivity Delirium


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b. Synthesis of the disease

Hyperthyroidism is the term for overactive tissue within the thyroid gland causing an overproduction of

thyroid hormones (thyroxine or "T4" and/or triiodothyronine or "T3"). Hyperthyroidism is thus a cause of

thyrotoxicosis, the clinical condition of increased thyroid hormones in the blood. It is important to note that

hyperthyroidism and thyrotoxicosis are not synonymous. For instance, thyrotoxicosis could instead be caused by

ingestion of exogenous thyroid hormone or inflammation of the thyroid gland, causing it to release its stores of

thyroid hormones. Thyroid hormone is important at a cellular level, affecting nearly every type of tissue in thebody.

Thyroid hormone functions as a controller of the pace of all of the processes in the body. This pace is called

metabolism. If there is too much thyroid hormone, every function of the body tends to speed up. It is therefore

not surprising that some of the symptoms of hyperthyroidism are nervousness, irritability, increased perspiration,

heart racing, hand tremors, anxiety, difficulty sleeping, thinning of the skin, fine brittle hair, and muscular

weaknessespecially in the upper arms and thighs. More frequent bowel movements may occur, but diarrhea

is uncommon. Weight loss, sometimes significant, despite a good appetite may occur, vomiting, and, for

women, menstrual flow may lighten and menstrual periods may occur less often. Thyroid hormone is critical to


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normal function of cells. In excess, it both overstimulates metabolism and exacerbates the effect of the

sympathetic nervous system, causing "speeding up" of various body systems and symptoms resembling an

overdose of epinephrine (adrenaline). These include fast heart beat and symptoms of palpitations, nervous

system tremor such as of the hands and anxiety symptoms, digestive system hypermotility (diarrhea),

considerable weight loss and unusually low lipid panel (cholesterol) levels as indicated by a blood test.

Hyperthyroidism usually begins slowly. At first, the symptoms may be mistaken for simple nervousness due to

stress. If one has been trying to lose weight by dieting, one may be pleased with weight loss success until the

hyperthyroidism, which has quickened the weight loss, causes other problems.

Etiology

Modifiable factor

1. Diet

This risk factor has something to do with the intake of iodine where in due to low level of Iodine it may

lead to thyroid causing adenoma resulting to hyperthyroidism.

2. Toxic nodular goiters/ adenomas

This risk factor is the most common etiology in Switzerland, 53%, thought to be atypical due to a low level

of dietary iodine in this country that may lead to overstimulation of the thyroid gland causing increased release

of thyroid hormone.

3. Thyroiditis

When it comes to this risk factor it has something to do with the inflammation of the thyroid gland

resulting to excessive secretion of thyroid hormone.


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4. Amiodarone

An anti-arrhythmic drug is structurally similar to thyroxine and may cause either under- or over activity of

the thyroid.

5. Autoimmune disorder

The immune system incorrectly treats self-antigens as foreign antigens; thereby due to this mechanism it

may lead to over stimulation of the thyroid gland causing excessive secretion of thyroid hormone.

Non-modifiable factors

1. Gender (female)

2. Age

Signs andsymptoms

1. Fatigue and depression

-due to increased stimulation in the sympathetic nervous system and increase blood flow in the brain

leading to hyperactivity in turn leads to extreme fatigue and depression, again followed by episodes of over

activity.

2. Palpitation and tachycardia

-due to increased sympathetic nervous system activity excessive amount of TH stimulate the cardiac

system and increase number of beta- adrenergic receptors.

3. Exopthalmos


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-because the eyes are surrounded by unyielding bone, fluid accumulation in the fat pads and muscles

behind the eyeballs causes protruding eyes and a fixed stare in the client. Also it is due to increased adrenergic

activity results in the retraction of the upper eyelids which presents with increased sclera exposure or

exophthalmos.

4. Delirium

-the clients emotions are adversely affected by the turbulent activity within the body. Moods maybe

cyclic, ranging from mild euphoria to extreme hyperactivity to delirium.

5. Increased appetite

-There is elevation in metabolic rate manifesting in elevation in metabolism of protein, fat and

carbohydrate. The accelerated protein and fat metabolism lead to weight loss and muscular weakness. The

body attempts to remedy the weight loss and so the patient's appetite is increased in the process.

6. Lipid depletion and nutritional deficiency- Due increased metabolism, leading to a negative nitrogen balance causing lipid depletion and state of

nutritional deficiency

7. Warm, moist skin and diaphoresis

-Patient is unable to tolerate hot weather as a result of the increase in the body metabolism. The

superficial capillaries dilate leading to increased peripheral blood flow and also an increase in cardiac output

as the body tries to eliminate excess heat from the system. This accounts for warm and moist skin and also for

the perspiration.

8. Thin and soft hair

-brought about by increase thyroid hormone leading to increased in the metabolism


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9. Decreased fertility

-Noticeable changes occur in the reproductive systems. There is either increase sexual desire orlow sex

drives in both sexes. In the hyperthyroid males gynaecomastia is sometimes present, whereas there is

oligomenorrhoea or amenorrhoea in the females. However, there may be decrease in fertility in severe

hyperthyroidism.

10. Decreased glucose

-The increase in metabolism also brings about an increase in the absorption of glucose from the

intestines. This excessive absorption of glucose triggers off glyconeolysis which in combination with the glucose

absorption leads to hyperglycaemia. Excessive glucose in the blood leads to the release of insulin into the

blood stream which brings about a rapid fall in blood glucose level. This glyconeolysis and insulin release lead

to rapid rise and fall in blood glucose level as well.


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Pathophysiology: Book-based

HYPORTHYROIDISM

Non-modifiable: Modifiable:

Genetic

Age

Gender

Autoimmune

disease

Congenitaldisease

Treatment for

hyperthyroidism

Radiation therapy

Thyroid surgery

Medications

Pituitary disorder

iodine deficiency

Pre nanc

Decrease Thyroid

StimulatingHormone

frompituitarygland


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Decrease Thyroid

Hormone

Decreaseenergy,

constanttiredness

Decrease Metabolism andheat formation

Raised

bloodcho

lesterol

Intolerance

tocold

Weightgain

Dizziness,

Fatigue,

slu

ggishness

Muscle

weakness

cram s

Anemia Dryscalyskin,

brittlenails

andhairloss

Compensation:

Enlarged

thyroidgland

Hoarsenessof voice

Headach

e,nape

pain,increase

blood

pressure

Constipation

Swollen

abdomen

Menstrual

irregularities


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Inabilityto

concentrate

Impaired

coordination


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Synthesis of the disease: hypothyroidism

Hypothyroidism is a common endocrine disorder resulting from deficiency of thyroid hormone. It usually is a

primary process in which the thyroid gland produces insufficient amounts of thyroid hormone. It can also be

secondarythat is, lack of thyroid hormone secretion due to inadequate secretion of either thyrotropin (ie,

thyroid-stimulating hormone [TSH]) from the pituitary gland or thyrotropin-releasing hormone (TRH) from the

hypothalamus (secondary or tertiary hypothyroidism). The patient's presentation may vary from asymptomatic

to, rarely, coma with multisystem organ failure (myxedema coma). The most common cause in the Unites

States is autoimmune thyroid disease (Hashimoto thyroiditis).

Cretinism refers to congenital hypothyroidism, which affects 1 per 4000 newborns.

Subclinical hypothyroidism, also referred to as mild hypothyroidism, is defined as normal serum free T4 levels with

slightly high serum TSH concentration.

Pathophysiology

Localized disease of the thyroid gland that results in decreased thyroid hormone production is the most

common cause of hypothyroidism. Under normal circumstances, the thyroid releases 100-125 nmol of thyroxine

(T4) daily and only small amounts of triiodothyronine (T3). The half-life of T4 is approximately 7-10 days. T4, a

prohormone, is converted to T3, the active form of thyroid hormone, in the peripheral tissues by 5-deiodination.

Early in the disease process, compensatory mechanisms maintain T3 levels. Decreased production of T4 causes


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an increase in the secretion of TSH by the pituitary gland. TSH stimulates hypertrophy and hyperplasia of the

thyroid gland and thyroid T4-5'-deiodinase activity. This, in turn, causes the thyroid to release more T3.

Because all metabolically active cells require thyroid hormone, deficiency of the hormone has a wide range of

effects. Systemic effects are due to either derangements in metabolic processes or direct effects by

myxedematous infiltration (ie, accumulation of glucosaminoglycans in the tissues).

The myxedematous changes in the heart result in decreased contractility, cardiac enlargement, pericardial

effusion, decreased pulse, and decreased cardiac output. In the GI tract, achlorhydria and decreased

intestinal transit with gastric stasis can occur. Delayed puberty, anovulation, menstrual irregularities, and

infertility are common. Decreased thyroid hormone effect can cause increased levels of total cholesterol and

low-density lipoprotein (LDL) cholesterol and a possible change in high-density lipoprotein (HDL) cholesterol dueto a change in metabolic clearance. In addition, hypothyroidism may result in an increase in insulin resistance.

Frequency

United States

The National Health and Nutrition Examination Survey (NHANES 1999-2002) of 4,392 individuals reflecting the US

population reported hypothyroidism (defined as TSH levels >4.5 mIU/L) in 3.7% of the population.Hypothyroidism

is more common in women with small body size at birth and low body mass index during childhood.


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International

Iodine deficiency as a cause of hypothyroidism is more common internationally. The prevalence is reported as2-5% depending on the study, increasing to 15% by age 75 years.

Mortality/Morbidity

In developed countries, death caused by hypothyroidism is uncommon.

History

Hypothyroidism commonly manifests as a slowing in physical and mental activity but may be asymptomatic.

Symptoms and signs of this disease are often subtle and neither sensitive nor specific. Classic signs and

symptoms, such as cold intolerance, puffiness, decreased sweating, and coarse skin, previously reported in 90-97% of patients, may actually occur in only 50-64% of younger patients. Many of the more common symptoms

are nonspecific and difficult to attribute to a specific cause. Individuals can also present with obstructive sleep

apnea (secondary to macroglossia) or carpal tunnel syndrome. Women can present with galactorrhea and

menstrual disturbances. Consequently, the diagnosis of hypothyroidism is based on clinical suspicion and

confirmed by laboratory testing.

Myxedema coma is a severe form of hypothyroidism that results in an altered mental status, hypothermia,

bradycardia, hypercarbia, and hyponatremia. Cardiomegaly, pericardial effusion, cardiogenic shock, and

ascites may be present. Myxedema coma most commonly occurs in individuals with undiagnosed or untreated


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hypothyroidism who are subjected to an external stress, such as low temperature, infection, or medical

intervention (eg, surgery or hypnotic.

High Riskgroup

Race

NHANES 1999-2002 reported that the prevalence of hypothyroidism (including subclinical) was higher in whites

(5.1%) and Mexican Americans than in African Americans (1.7%). African Americans tend to have lower TSH

values.

Sex

Community studies use slightly different criteria for determining hypothyroidism; therefore, female-to-male ratios

vary. Generally, thyroid disease is much more common in females than in males, with reports of prevalence 2-8

times higher in females.

Age

The frequency of hypothyroidism, goiters, and thyroid nodules increases with age. Hypothyroidism is most

prevalent in elderly populations, with 2% to as much as 20% of older age groups having some form of


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hypothyroidism. The Framingham study found hypothyroidism (TSH >10 mIU/L) in 5.9% of women and 2.4% of

men older than 60 years. In NHANES 1999-2002, the odds of having hypothyroidism were 5 times greater in

persons aged 80 years and older than in individuals aged 12-49 years.

Causes/predisposing factors

Primary hypothyroidism

Autoimmune: The most frequent cause of acquired hypothyroidism is autoimmune thyroiditis (Hashimoto

thyroiditis). The body recognizes the thyroid antigens as foreign, and a chronic immune reaction ensues,

resulting in lymphocytic infiltration of the gland and progressive destruction of functional thyroid tissue. Up

to 95% of affected individuals have circulating antibodies to thyroid tissue. Antimicrosomal or antithyroid

peroxidase (anti-TPO) antibodies are found more commonly than antithyroglobulin antibodies (95% vs

60%). These antibodies may not be present early in the disease process and usually disappear over time.6

Postpartum thyroiditis: Up to 10% of postpartum women may develop lymphocytic thyroiditis in the 2-10

months after delivery. The frequency may be as high as 25% in women with type 1 diabetes mellitus. The

condition is usually transient (2-4 mo) and can require a short course of treatment with levothyroxine (LT4),

but postpartum patients with lymphocytic thyroiditis are at increased risk of permanent hypothyroidism.

The hypothyroid state can be preceded by a short thyrotoxic state. High titers of anti-TPO antibodies

during pregnancy have been reported to be 97% sensitive and 91% specific for postpartum autoimmune

thyroid disease.


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Subacute granulomatous thyroiditis: Inflammatory conditions or viral syndromes may be associated with

transient hyperthyroidism followed by transient hypothyroidism (de Quervain or painful thyroiditis,

subacute thyroiditis). These are often associated with fever, malaise, and a painful and tender gland.

Drugs: Medications such as amiodarone, interferon alpha, thalidomide, lithium, and stavudine have also

been associated with primary hypothyroidism.

Iatrogenic

o Use of radioactive iodine for treatment of Graves disease generally results in permanent

hypothyroidism within 1 year after therapy. The frequency is much lower in patients with toxic

nodular goiters and those with autonomously functioning thyroid nodules. Patients treated with

radioiodine should be monitored for clinical and biochemical evidence of hypothyroidism.

o Thyroidectomy

o External neck irradiation (for head and neck neoplasms, breast cancer, or Hodgkin disease) may

result in hypothyroidism; patients who have received these treatments require monitoring of thyroid

function.

Rare: Rare causes include inborn errors of thyroid hormone synthesis.

Iodine deficiency or excess: Worldwide, iodine deficiency is the most common cause of hypothyroidism.

Excess iodine, as in radiocontrast dyes, amiodarone, health tonics, and seaweed, inhibits iodideorganification and thyroid hormone synthesis. Most healthy individuals have a physiologic escape from

this effect; however those with abnormal thyroid glands may not. These include patients with

autoimmune thyroiditis, surgically treated Graves hyperthyroidism (subtotal thyroidectomy) and prior

radioiodine therapy.


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Worldwide, iodine deficiency remains the foremost cause of hypothyroidism. In the United States and

other areas of adequate iodine intake, autoimmune thyroid disease is most common. The prevalence of

antibodies is higher in women, and increases with age.

Central hypothyroidism

Central hypothyroidism (secondary or tertiary) results when the hypothalamic-pituitary axis is damaged. Various

causes should be considered.

Pituitary adenoma

Tumors impinging on the hypothalamus

History of brain irradiation

Drugs (eg, dopamine, lithium)

Sheehan syndrome

Genetic disorders

The following are symptoms of hypothyroidism:

Fatigue, loss of energy, lethargy decrease heat production and metabolism of the body resulting from

decrease thyroid hormone.


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Weight gain decrease use of nutrients supplied by foods or breakdown of nutrients used for activities.

Decreased appetite there is a feeling of fullness

Cold intolerance decrease heat production.

Dry skin and hair loss decrease supply of nutrients in the skin and in the hair.

Sleepiness -decrease/slowed metabolism.

Muscle pain, joint pain, weakness in the extremities decreased heat, metabolism and supply of

adequate nutrients in the body.

Emotional lability, mental impairment

Forgetfulness, impaired memory, inability to concentrate- thyroid hormone acts as a medium for faster

activities and mental alertness, when these hormones are inadequate, forgetfulness, impaired memory

and inability to concentrate may occur.

Constipation there is gastric stasis because of slowed meatabolism.

Menstrual disturbances, impaired fertility thyroid hormone is essential in the regulation of other hormones

of the body including menstruation.

Decreased perspiration decrease heat production

Fullness in the throat, hoarseness- as a compensation of the thyroid gland, it may be possible that it will

atrophy and enlarge as a result, it may affect the vocal cords.o Additional signs specific to different causes of hypothyroidism, such as diffuse or nodular goiter or

pituitary tumor, can occur.


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Metabolic abnormalities associated with hypothyroidism include anemia, dilutional hyponatremia,

hyperlipidemia, and reversible increase in creatinine.

source: http://emedicine.medscape.com/article/122393-overview


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Chapter IV

CLINICAL INTERVENTION (HYPERTHYROIDISM)

y Description of Prescribed Surgical Treatment Performed

Thyroidectomy is a surgical procedure in which all or part of the thyroid gland is removed. Located in the forward

(anterior) part of the neck just under the skin and in front of the Adam's apple. The thyroid is one of the body's endocrine

glands, it secretes its products inside the body, into the blood or lymph. The thyroid produces several hormones that have

two primary functions: they increase the synthesis of proteins in most of the body's tissues, and they raise the level of the

body's oxygen consumption.

y Types of Thyroidectomy:


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1. Total Thyroidectomy (Complete Removal of the Thyroid) - This is the most common type of thyroid surgery

and preferred by most surgeons for cases of hyperthyroidism, often used for thyroid cancer, and in particular, aggressive

cancers, such as medullary or anaplastic thyroid cancer. It is used for goiter and Graves.

2. Subtotal/Partial Thyroidectomy (Removal Half of the Thyroid Gland) - For this operation, cancer must be small

and non-aggressive -- follicular or papillary -- and contained to one side of the gland. When a subtotal or partial

thyroidectomy is performed, typically, surgeons perform a bilateral subtotal thyroidectomy which leaves from 1 to 5 grams

on each side/lobe of the thyroid.

3. Thyroid Lobectomy (Removal of Only About a Quarter of the Gland) - This is less commonly used for thyroid

cancer, as the cancerous cells must be small and non-aggressive.

y

Preparation and Positioning of the PatientThe patient may lie either in the half sitting position with slightly reclined head, (Fig 1.1a) or be lying with the head

hanging (Fig. 1.1b). The advantage of the lying position is that the venous pressure is positive preventing an air embolus.

The pressure in the cervical veins in the sitting position is on average 2.4cm and, in the lying position with the head

hanging, 8.1 cm. however, it must not be overlooked that a pressure in the venous system is dangerous even under

positive pressure if the vein is opened (Keminger and Maager 1969).


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Fig. 1.1a

Fig. 1.1b

y Skin preparation

Using iodine solution with soap and sterile water, begin at the anterior neck extending upward to just below the

infra-auricular border and lower lip, and down-ward to 2.5 to 5 cm (1 to 2 inches) above the nipples; continue down to the

table at the neck, around the shoulders, and at the sides.

y Preparation of Surgical Instruments

Draping


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Simple and effective draping of the head can be achieved with Kaspars goiter towel (Fig.1.2a). The tapes are tied

behind the patients neck (Fig. 1.2a). Before the head and the lateral parts of the neck are covered with the goiter towel,

the patients body is covered with a sterile folded linen drape. Four towel clips are used to fix the towels and ensure a

rectangular operative field (Fig 1.2b). After the skin has been incised, and the cervical fascia and the strap muscle have

been dissected the remaining free parts of the skin are covered with 2 further drapes (Fig. 1.2c). The upper drape is

folded over several times but the long one simple lay on.

Fig. 1.2a

Fig. 1.2b


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Fig. 1.2c

y Operative Procedure

The Skin Incision

It should lay two fingers breadth above the suprasternal notch. The incision should be carried out in one

straight stroke through skin and platysma. A band may be mark out the incision (Fig. 1.3a). Bleeding

intracutaneous vessels are clamped but if possible are not covered. The flap of skin and platysma is elevated

above and below.


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Fig. 1.3a - Band being used for marking out incision

Fig. 1.3b Kochers Collar Incision

y Operative Technique

The fascia is divided on both sides of veins, held up with the forceps, clamped (Fig 1.4) and then divided between

two clamps (Fig 1.5). The fascia bridges lying between the veins are divided from left to right. Veins should also be dealt

with along the medial edge of both the sternocleidomastoid muscles. The upper fascia and platysmal flap is elevated as

far as the laryngeal eminence (Fig 1.6) and the superior fascial flap is elevated using a pair of forceps. The superior

stumps of the vein are ligated and the superior stumps transfixed (Fig 1.7).


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Fig. 1.4

Fig 1.5


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Fig. 1.6

The deep strap muscles are divided in the mid line with scissors or scalpel up to the cricoid (Fig 1.7).

As rule the muscles should not be divided. Division of the sternohyoid and sternothryroid muscles may lead to rapid

tiring of the voice and reduction of its range. However it should be remembered that more damage may caused by blunt

forceful retraction than by deliberate division.

Fig 1.7


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Fig 1.8

y Division of the Isthmus

The division of the isthmus, beginning at its superior or inferior edge, thus allowing the trachea to be located. It is

elevated from the trachea by spreading movements with artery forceps. (Fig 1.9), bringing the delicate connective tissue

sheath of the trachea into view.

Fig 1.9


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A voluminous, adenomatous, and parenchymatous isthmus is divided between clamps with scissors from below

upwards. A small artery usually runs along the superior edge from one pole to the other, and this should also be clamped

and divided (Fig.1.10)

Fig. 1.10

Fig. 1.11a


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Fig 1.11b

Figures 1.11a and 1.11b, Babcock are applied to inferior and superior (not shown) aspects of the thyroid lobe to

facilitate medial retraction on the gland. This exposes the area when the parathyroid glands and recurrent laryngeal nerve

are located.


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Fig. 1.12

Figure 1.12, downward traction on the superior Babcock clamp exposes the superior pole vessels, including the

branches of the superior thyroid artery. The external laryngeal nerve courses along the cricothyroid muscle just medial to

the superior pole vessels. To avoid injury to this nerve, which controls tension of the vocal cords, the superior pole vesselsare divided individually as close as possible to the point where they enter the thyroid.


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Fig 1.13

Figure 1.13, as the thyroid is retracted medially; gentle dissection with a Hoyt clamp is used to expose the

parathyroid glands, inferior thyroid artery, and recurrent laryngeal nerve. The recurrent nerve usually passes behind the

inferior thyroid artery but occasionally lies anterior to it. They nerve can then be traced upward, and its position in relation

to the thyroid can be determined. Parathyroid glands that lie on the thyroid surface can be mobilized with their vascular

supply and thus preserved.


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Fig 1.14

Figures 1.14, to perform total lobectomy, the branches of the inferior thyroid artery are divided at the surface of the

thyroid gland. The inferior thyroid veins can now be ligated and divided. Superiorly, the connective tissue (ligament of

Berry), which binds the thyroid to the tracheal rings, is carefully divided. Division of ligament allows the thyroid to be

mobilized medially.


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Fig. 1.15

Figure 1.15, the dissection of the thyroid from the trachea can be performed with the cautery by division of the

loose connective tissue between these structures. Dissection is extended under the Isthmus, and the specimen is divided,

so that the isthmus is included with the resected lobe.

Fig 1.16Figure 1.16, subtotal lobectomy necessitates identification of the parathyroid glands inferior thyroid artery, and

recurrent laryngeal nerve, as previously described. The line of resection is selected to preserve the parathyroid glands

and their blood supply and to protect the recurrent laryngeal nerve. It should be based on the inferior thyroid artery or its

major branches.


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Fig 1.17a

Fig 1.17b

Figures 1.17 A and B, clamps are placed along the line of resection, and the thyroids gland is divided. The divided

tissue is ligated or suture-ligated with 3-0 silk. The dissection is extended to the trachea. (Sabiston, D.C., Jr. [Ed]: Atlas of

General Surgery Philadelphia, WE.B. Sauders, 1995.)


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Fig 1.18

At the end of the resection the remnant of capsule and parenchyma is closed by individual horizontal suture (Fig

1.18) to achieve good homeostasis. This procedure is facilitated by traction to the opposite side on the capsule sutures

which have been left long, and by lateral displacement of the common carotid artery with a hook.

Before closing the neck it is advisable to increase positive pressure respiration for a brief period to increase the

pressure in the superior vena cava and thus show any venous bleeding points or potential points of entry for air emboli

which have been overlooked. Then a pyramidal lobe if present is removed and aberrant adenomas in the region of the

upper and lower pole are looked for. The cavity is drained for 24 hours by penrose drain (Fig. 1.19)


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Fig 1.19

Fig 1.20a

Wound closure is limited to suture of the strap muscles (Fig 1.19) and the placing of skin clips (Fig 1.20a and b)

which are removed 3 days later.


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Fig. 1.20b

Fig 1.21

1.2 Indication of Prescribed Surgical Treatment

Thyroidectomy is usually performed for the following reasons:

1. As therapy for some individuals with thyrotoxicosis; those with Graves disease; and others with a hot nodule or

toxic nodular goiter.

2 To establish a definitive diagnosis of a mass within the thyroid gland especially when cytologic analysis after fine


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2. To establish a definitive diagnosis of a mass within the thyroid gland, especially when cytologic analysis after fine

needle aspiration (FNA) is either non-diagnostic or equivocal.

3. To treat benign and malignant thyroid tumors.

4. To alleviate pressure symptoms or respiratory difficulties associated with a benign or malignant process.

5. To remove an unsightly goiter (Figure 9).

6. To remove large substernal goiters, especially when they cause respiratory difficulties.

7. Young patients and are free from any condition that makes them poor operative risks (DM, heart disease, renal

disease)Specific:

o A small thyroid nodule or cyst

o A thyroid gland that is so overactive it is dangerous (thyrotoxicosis)

o Benign (noncancerous) tumors of the thyroid

o Cancer of the thyroid

o Thyroid swelling (nontoxic goiter) that makes it hard for you to breathe or swallow

Thyroid surgery (Thyroidectomy) is a common operation, but one which needs to be taken seriously because of the

potential complications which may occur. Commonly, this surgery is done because of suspected cancer. Patient risk

factors, appearance on ultrasound examination or needle biopsy results may cause your surgeon to recommend surgical

removal of the thyroid.

If there is a vocal cord paralysis or rapid growth of a solid mass also indicates a cancer. Unfortunately, one of the


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If there is a vocal cord paralysis or rapid growth of a solid mass also indicates a cancer. Unfortunately, one of the

forms of thyroid cancer, follicular carcinoma, can appear benign on needle biopsy and may also be read as benign on

frozen section during surgery.

If the thyroid becomes so large that it compresses the trachea or esophagus surgical removal is indicated. A

thyroid cyst that recurs after a single or repeated needle drainage is also an indication for removal. Rarely, a thyroiditis

will cause scaring in the neck which also compresses the airway. The thyroid must also be removed in this case.

However, cases of thyroiditis have an increased complication rate due to bleeding and scarring.

2 Risk and Benefits of Undergoing Treatment

Risk Benifits

1. Hypoparathyroidism or recurrent

lesion, have not been investigated

systematically.

2. Recurrent laryngeal nerve injuries.

3. Cervical hematomas.

1. As therapy for some individuals

with thyrotoxicosis; those with Graves

disease; and others with a hot nodule or

toxic nodular goiter.

2. To establish a definitive diagnosis

of a mass within the thyroid gland,

especially when cytologic analysis after

fine needle aspiration (FNA) is either

non-diagnostic or equivocal.

3. To treat benign and malignant


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g g

thyroid tumors.

4. To alleviate pressure symptoms

or respiratory difficulties associated with

a benign or malignant process.

5. To remove an unsightly goiter.

3 Risks and Benefits of Not Undergoing Treatment

Risk Benefits

1. A small thyroid nodule or cyst.

2. A thyroid gland that is so overactive

it is dangerous (thyrotoxicosis).

3. Benign (noncancerous) tumors of

the thyroid

4. Cancer of the thyroid

1. The patient may have decreased

risk of developing any

postoperational complications.

5. Thyroid swelling (nontoxic goiter)


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y g ( g )

that makes it hard for you to breathe or

swallow

1.3 Required Instruments, Devices, Supplies, Equipment and Facilities

y

Retractors:1.) DOUBLE-ENDED RICHARDSON RETRACTOR used to retract deep incisions

2.) ARMY-NAVY RETRACTOR used to retract shallow or superficial incisions


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3.) WEITLANER ends can be blunt or sharp; has rake tips; ratchet to hold tissue apart

4.) GELPI has single point tips; ratchet to hold tissue apart

y Clamping Instruments:


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5.) MOSQUITO used to clamp blood vessels

6.) KELLY is used to clamp larger vessels and tissue. Available in short and long sizes.

7.) LAHEY thyroid forceps used to deliver the thyroid in thyroidectomy.


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8.) KOCHER a heavy, straight hemostat with interlocking teeth on the tip

9.) CRILE a clamp for temporary stoppage of blood flow.


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10.) TOWEL CLIPS used to hold towels and drapes in place.

y Grasping Instruments:


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11.) BABCOCK CLAMP used to grasp delicate tissue

12.) ADSON a small thumb forceps with two teeth on one tip and one tooth on the other.

13.) CUSHING FORCEPS

14.) PLAIN TISSUE FORCEPS used to grasp tissue.


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15.) DEBAKEY FORCEPS nontraumatic forceps used to pick up blood vessels; also known as magics.

.

16.) ALLIS a straight grasping forceps with serrated jaws, used to forcibly grasp or retract tissues or structures.

y Dissecting/ Cutting Instruments:

17.) MAYO SCISSORS used to cut heavy tissue.


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18.) METZENBAUMS "Mets" used to cut delicate tissues.

19.) #3 KNIFE HANDLES -

20.) BLADES NO. 10 the flat part of a tool or weapon that (usually) has a cutting edge.


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21.) TENOTOMY The surgical division of a tendon for relief of a deformity caused by congenital or acquired

shortening of a muscle, as in clubfoot or strabismus

22.) CURVED IRIS

y Suturing Instruments:

23. ) NEEDLE HOLDER used to hold needles when suturing. They may also be placed on the sewing category.


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y Equipments:

24.) CAUTERY UNIT This may be a separate apparatus or it may be part of an electrosurgery system. It employs a

probe with a hot metal tip or wire which is used to stop bleeding and in some cases for cutting. In its very simplest form it

may be a hand-held unit containing a large electrical cell which heats up a small wire loop at its tip on pressing a button.

Such a unit may be used to remove very small polyps and to stop bleeding. Larger units use a low voltage source from a

transformer connected to the cautery probe via a flexible lead.

y Supplies:

25.) BASIN SET


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26.) SUCTION TUBING An apparatus for removing fluid from a body cavity, consisting usually of a hollow needle

and a cannula, connected by tubing to a container in which a vacuum is created by a syringe or a suction pump.

27.) PENROSE DRAIN is a surgical device placed in a wound to drain fluid. It consists of a soft rubber tube placed

in a wound area to prevent the build up of fluid.


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28.) ELECTROSURGICAL PENCIL A novel dual mode electrosurgical pencil is provided for conventional

tissue cutting/coagulation use in a first mode of operation, and gas-enhanced coagulation by fulguration in a

second mode of operation.

29.) STERI STRIPS


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30.) ADENOID SUCTION

1.4 Perioperative Tasks and Responsibilities of The Nurse

DUTIES OF SCRUB NURSE

y Ensures that the circulating nurse has checked the equipment.

y Ensures that the theater has been cleaned before the trolley is set.

y Prepares the instruments and equipment needed in the operation.

y Uses sterile technique for scrubbing, gowning and gloving.

y Receives sterile equipment via circulating nurse using sterile technique.

y Performs initial sponges, instruments and needle count, checks with circulating nurse.

When Surgeon Arrives After Scrubbing:

y Perform assisted gowning and gloving to the surgeon and assistant surgeon as soon as they enter the

operation suite.

y Assemble the drapes according to use. Start with towel, towel clips, draw sheet and then lap sheet. Then, assist

in draping the patient aseptically according to routine procedure.


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p g p p y g p

y

Place blade on the knife handle using needle holder, assemble suction tip and suction tube.y Bring mayo stand and back table near the draped patient after draping is completed.

y Secure suction tube and cautery cord with towel clips or allis.

y Prepares sutures and needles according to use.

During an Operationy Maintain sterility throughout the procedure.

y Awareness of the patients safety.

y Adhere to the policy regarding sponge/ instruments count/ surgical needles.

y Arrange the instrument on the mayo table and on the back table.

Before the Incision Begins

y Provide 2 sponges on the operative site prior to incision.

y Passes the 1st knife for the skin to the surgeon with blade facing downward and a hemostat to the assistant

surgeon.

y Hand the retractor to the assistant surgeon.

y Watch the field/ procedure and anticipate the surgeons needs.

y Pass the instrument in a decisive and positive manner.

y Watch out for hand signals to ask for instruments and keep instrument as clean as possible by wiping

instrument with moist sponge.

y Always remove charred tissue from the cautery tip.

y Notify circulating nurse if you need additional instruments as clear as possible.


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y g y p

y

Keep 2 sponges on the field.y Save and care for tissue specimen according to the hospital policy.

y Remove excess instrument from the sterile field.

y Adhere and maintain sterile technique and watch for any breaks.

End of Operationy Undertake count of sponges and instruments with circulating nurse.

y Informs the surgeon of count result.

y Clears away instrument and equipment.

y After operation: helps to apply dressing.

y

Removes and siposes of drapes.y De-gown.

y Prepares the patient for recovery room.

y Completes documentation.

y Hand patient over to recover room.

Scrub Duties

y Perform surgical hand scrub.

y Gown and glove using closed glove technique.

y Regown and glove when breaks in technique occur.

y Assist the 1st scrub in setting up case (back table, mayo stand and O.R. basins).The tasks include:

o Arrange instruments and supplies (back table, mayo stand and O.R.).


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o

Count needles, instruments and sponges.o Check instruments for proper functions.

o Prepare irrigating solution.

o Draw medications properly.

o Gown and glove surgeon and assistant.

o Assist with draping.

o Prepare electric cautery, suction and light handles for proper use.

o Prepare necessary sutures.

o Pass instruments to surgeon and assistant.

o Retract, sponge, and suction during case as necessary.

o Proper identification and handling of specimen.

o Prepare instruments for decontamination at completion of case.

o Dispose of sharps properly.

o Discard soiled drapes and trash properly.

o Transport soiled drapes and trash properly.

o Anticipate the surgeon and assistant needs.

o Anticipate the operative procedure needs.

DUTIES OF CIRCULATING NURSE

Before an Operation

y Checks all equipment for proper functioning such as cautery machine, suction machine, OR light and OR table.

y Make sure theater is clean.


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y

Arrange furniture according to use.y Place a clean sheet, arm board (arm strap) and a pillow on the OR table.

y Provide a clean kick bucket and pail.

y Collect necessary stock and equipment.

y Turn on aircon unit.

y

Help scrub nurse with setting up the theater.y Assist with counts and records.

During the Induction of Anesthesia

y Turn on OR light.

y

Assist the anesthesiologist in positioning the patient.y Assist the patient in assuming the position for anesthesia.

y Anticipate the anesthesiologists needs.

y If spinal anesthesia is contemplated:

o Place the patient in quasi fetal position and provide pillow.

o Perform lumbar preparation aseptically.

o Anticipate anesthesiologists needs.

After the Patient is Anesthetized

y Reposition the patient per anesthesiologists instruction.

y Attached anesthesia screen and place the patients arm on the arm boards.

y Apply restraints on the patient.


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y

Expose the area for skin preparation.y Catheterize the patient as indicated by the anaesthesiologist.

y Perform skin preparation.

During Operation

y

Remain in theater throughout operation.y Focus the OR light every now and then.

y Connect diatherapy, suction, etc.

y Position kick buckets on the operating side.

y Replenishes and records sponge/ sutures.

y

Ensure the theater doors remain closed and patients dignity is upheld.y Watch out for any break in aseptic technique.

End of Operation

y Assist with final sponge and instruments count.

y Signs the theater register.

y Ensures specimen are properly labeled and signed.

After an Operation

y Hands dressing to the scrub nurse.

y Helps remove and dispose of drapes.

y Helps to prepare the patient for the recovery room.


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y

Assist the scrub nurse, taking the instrumentations to the service (washroom).y Ensures that the theater is ready for the next case.

Circulating Duties

y Clean operating room and discard suction prior to case.

y

Gather all supplies, instruments and equipment necessary for case.y Arrange O.R. furniture properly.

y Open and flip sterile supplies for the surgical procedure.

y Assist with IV therapy.

y Assist the anaesthesiologist.

y

Assist with the skin preparation.y Tie gowns of the scrub nurse and surgeon.

y Provide scrub personnel with sitting stools and foot stools as necessary.

y Turn and help adjust lights as necessary.

y Supply the scrub nurse with necessary supplies.

y

Receive and label specimen properly.y Log and deliver specimen to pathology properly.

y Help apply wound dressing.

1.5 Expected Outcome of Surgical Treatment Performed

After a thyroidectomy, the patient may experience neck pain and a hoarse or weak voice. This doesn't necessarily

mean there's permanent damage to the nerve that controls the vocal cords. These symptoms are often temporary and


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may be due to irritation from the breathing tube (endotracheal tube) that's inserted into the windpipe (trachea) during

surgery, or as a result of nerve irritation but not permanent damage caused by the surgery.

The long-term effects of thyroidectomy depend on how much of the thyroid is removed. If only part of the thyroid is

removed, the remaining portion typically takes over the function of the entire thyroid gland, and the patient doesn't need

thyroid hormone therapy.

If the entire thyroid is removed, the body can't make thyroid hormone and may develop signs and symptoms of

underactive thyroid (hypothyroidism). As a result, the patient need to take a pill every day that contains the thyroid

hormone thyroxine (levothyroxine). This hormone replacement is identical to the hormone normally made by the thyroid

gland and performs all of the same functions. The Doctor will determine the amount of thyroid hormone replacement the

patient need based on blood tests.

The patient may experience some short-term, less serious side effects after surgery. These can include:

Pain when swallowing, or in the neck area pain can come from the Tracheal tube after surgery or from the

surgery itself. This should subside within a few days; an over-the-counter non-steroidal pain reliever, like

ibuprofen, can relieve discomfort.

Neck tension and tenderness there will be a tendency to hold the head stiffly in one position after surgery,

and this can cause neck and muscle tension. It's good to do gentle stretching and range of motion exercises to

prevent muscle stiffness in the neck area. Simply turning the head to the right, then rolling the chin across the

chest until the head is facing left can help loosen tight muscles.

V i bl th i b h hi ti d S l fi d th t i d f h


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Voice problems the voice may be hoarse, whispery, or tired. Some people find that periods of hoarseness

can last as long as two to three months.

Irritated windpipe if the patient had a Tracheal tube during general anesthesia, it can irritate the windpipe

and may make the patient feel as if he have something stuck in his throat. This feeling usually goes away within

five days.

Thyroidectomy is generally a safe surgical procedure. However, some people have major or minor complications.

Possible complications include:

Hemorrhage (bleeding) beneath the neck wound if this occurs, the wound bulges and the neck swells, possibly

compressing structures inside the neck and interfering with breathing. This is an emergency.

Thyroid storm. If a thyroidectomy is done to treat a very overactive gland (thyrotoxicosis), there may be a surge of

thyroid hormones into the blood. This is a very rare complication because medications are given before surgery to prevent

this problem.

Injury to the recurrent laryngeal nerve because this nerve supplies the vocal cords, injury can lead to vocal cord

paralysis and can produce a husky voice. In rare cases, if both vocal cords are paralyzed, the opening of the throat may

be obstructed, causing breathing problems.

Injury to a portion of the superior laryngeal nerve If this occurs, patients who sing may not be able to hit high

notes, and the voice may lose some projection.


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Hypoparathyroidism. If the parathyroid glands are mistakenly removed or unintentionally damaged during a

thyroidectomy, the patient may suffer from hypoparathyroidism, a condition in which the levels of parathyroid hormone (a

hormone that helps regulate body calcium) are abnormally low.

Hypothyroidism: Transient hypothyroidism is seen in 2% to 4% of all patients after thyroidectomy and in 20% to

22% of those who undergo total or repeated thyroidectomy. Permanent hypothyroidism occurs in under 0.6% of patients.

Wound infection.

1.6 Medical Management of Physiologic Outcomes

Usual Postoperative Course. Outpatient procedures are appropriate for solitary benign nodules and have been

performed for thyrotoxicosis and thyroid cancer in some centers; otherwise, the hospital stay is 1 to 2 days.

Special monitoring required. Respiratory status should be carefully monitored if early postoperative stridor or

difficulty in clearing secretions occurs. Patients with thyrotoxicosis who receive appropriate preoperative preparation

should undergo routine monitoring.

Patient activity and positioning. The head should be elevated 30 to 45 degrees (Semi-Fowler) when client is

conscious unless client is hypotensive to minimize edema and venous oozing. Support head and neck with pillows. Full

activity is resumed the morning after operation


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activity is resumed the morning after operation.

Neck Exercises. First, teach the client how to support the weight of the head and neck when sitting up in bed.

Show the client how to place the hands at the back of the head when flexing the neck or moving. The client will probably

be able to perform this maneuver by the first postoperative day. Second, as the wound heals (about the 2nd to 4th

postoperative day); demonstrate range-of-motion exercises to prevent contractures. With the surgeons permission, teach

the client to flex the head forward and laterally, to hyperextend the neck, and to turn the head from side to side. Have the

client perform these exercises several times every day.

Medications. Give meperidine (Demerol) or morphine sulfate every 1-2 hours as needed for pain in throat area.

Give continuous mist inhalation until chest is clear. If a total thyroidectomy has been performed, explain self-

administration of thyroid replacement medications (T4) used to treat hypothyroidism: Levothyroxine sodium (Synthroid,

Levothroid, Levoxine). Teach client the medication regimen and the need for lifelong replacement therapy.

Alimentation: Full liquids are permitted on the day of operation and a soft diet can be started on afternoon of day

2.

Drains: Closed suction drains are removed on the first postoperative day.

y Postoperative Complications


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y Postoperative Complications

In the Hospital

Hemorrhage: Although it is extremely rare (less than 0.5%), a hematoma in the area of resection may cause

airway obstruction early in the postoperative period. Removal of the skin and strap muscle sutures and evacuation of the

hematoma in the recovery room is preferable to tracheostomy. Patients are then returned to the operating room for

irrigation of the operative site, control of hemorrhage, and repeated closure of the wound.

Hypothyroidism: Transient hypothyroidism is seen in 2% to 4% of all patients after thyroidectomy and in 20% to

22% of those who undergo total or repeated thyroidectomy. Permanent hypothyroidism occurs in under 0.6% of patients.

Symptomatic hypocalcemia (less than 7.5mg/dl) is characterized by anxiety, perioral or finger tingling, and a positive

Chvosteks sign, and usually develops 16 to 24 hours after surgery. Intravenous calcium is given to relieve acute

symptoms in the hospital and oral calcium therapy is prescribed at the time of discharge.

Recurrent laryngeal nerve injury: Paralysis of one vocal cord causes hoarseness and difficulty in clearing

secretions. This almost always is related to traction on the recurrent nerve and may also resolve over a period of days to

months. Permanent recurrent nerve palsy occurs in as many as 4.5% of all thyroidectomies, usually resulting from

intended sacrifice of a nerve involved with carcinoma.

Thyroid storm: Thyroid storm should not occur after surgery for thyrotoxicosis in adequately prepared patients,

but it may be seen in patients with untreated thyrotoxicosis who are undergoing other operations. Symptoms of tremor,

agitation tachycardia and hyperthermia are treated with intravenous fluids propranolol potassium iodide and steroids


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agitation, tachycardia, and hyperthermia are treated with intravenous fluids, propranolol, potassium iodide, and steroids.

After Discharge

Recurrent benign nodule or goiter: Recurrence of a benign nodule or goiter can be prevented by the lifelong

administration of thyroid hormone.

Recurrent thyroid cancer: To decrease the incidence of recurrent cancer in the neck, lungs, or bone, thyroid

hormone replacement is delayed until radioactive iodine is administered.

Late or recurrent hyperthyroidism: Annual thyroid function tests are indicated in patients who are receiving

thyroid hormone after operation for goiter or cancer and in those who are originally euthyroid after operation for Graves

disease.

Permanent hypothyroidism: Vitamin D is added to calcium replacement to enhance absorption. In serial

parathyroid hormone levels begin to raise, first the vitamin D and then the calcium supplement should be tapered.

Clinical Interventions (Hypothyroidism)

Pharmacological Management


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Desired Outcome:

To correct TH deficiency

Reverse the manifestations

Prevent further cardiac and arterial damage

Thyroid Replacement Therapy

Levothyroxinesodium Drug of choice converted in the body to both T3 and T4

The majority of people with hypothyroidism are treated with one of the synthetic forms of the T4 thyroid

hormone (Levoxyl, Synthroid). This is a more stable form of thyroid hormone and requires once a day

dosing, whereas preparations containing T3 (the most active thyroid hormone) are much shorter-acting

and need to be taken multiple times a day. Synthetic T4 is readily and steadily converted to T3 naturally

in the bloodstream in the great majority of people, and this conversion is appropriately regulated by the

body's tissues. A brand name preparation of L-thyroxine is recommended over generic preparations, and

individuals should use the same brand of levothyroxine throughout treatment

Cytomel

Thyrolar

Thycar


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Nursing Management

Problem #1: Acute Pain

Assessment DiagnosisScientific

Explanation

Planning Intervention Rationale

Expected

outcome/

Evaluation

S > Patient

may report

pain on the

operative site

O > Patient

may manifest:

- facial

grimaces

- restlessness

- irritability

- reduced

Acute pain Patient

experiences

pain due to the

operative

procedure

done. As the

anesthetic

agent wear off,

sensation

returns and

pain of the

incision, and

other

Short term:

After 5 hours

of nursing

interventions,

the patient will

be able to

demonstrate

use of

relaxation

skills and

diversional

activities as

indicated for

> Establish

rapport

> Monitor vital

signs

> Perform a

comprehensive

assessment of

pain to include

> To gain the trust

and cooperation of

the client

>To provide

baseline data.

> To assess

etiology/

precipitating

contributory factors

Short term:

The patient

shall have

demonstrated

use of

relaxation

skills and

diversional

activities as

indicated for

individual

situation.

interaction

with people

- change in

manipulations

done on the

body comes

individual

situation.

location,

characteristics,

onset/duration,

Long term:

The patient

shall have


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g

respiration,

blood

pressure, and

pulse

y

into

awareness.

The injured

tissue releases

pain

substances

such as

prostaglandins,

histamine and

kinin. These

substances

transmit pain

impulse to the

spinal cord.

From the

spinal cord, the

pain message

is sent to the

brain where it

Long term:

After 4 days of

nursing

interventions,

the patient will

report feeling

of well-being

and comfort.

frequency,

quality, severity

(1 to 10), and

precipitating or

aggravating

factors

> Note location of

surgical

procedures

> Observe body

language for

evidence of pain

> Provide quiet

environment

> This can

influence the

amount of pain

experienced

> To ensure

comfort despite

impaired

communication

> To assist client

for alleviation of

pain

reported

feeling of

well-being

and comfort.

is processed

and is

perceived as

> Encourage

adequate rest

> To prevent

fatigue


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pain. The

message is

transmitted

back to the site

of injury then

through the

spinal cord. In

the spinal cord

and in the

brain, many

chemicals

such as

endorphins,

serotonin and

adrenaline are

involved in

modulation

and

transmission of

periods

> Encourage use

of relaxation

techniques such

as soft music,

focused breathing

> Take time to

listen and

maintain frequent

contact with

patient

>Administer

analgesic

medications as

ordered.

> Promotes rest,

redirects attention

> Helpful in

alleviating anxiety

and refocusing

attention, which

may relieve pain

>To provide

pharmacologic

treatment of pain.,

pain.

> Monitor

effectiveness of

> To promote timely

intervention/revision


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pain medications of plan of care

Problem # 2: Ineffective Airway Clearance Related to Bleeding and/ or Laryngeal Edema

Assessment DiagnosisScientific

ExplanationObjectives Interventions Rationale

Desired

Outcomes

S > the

patient may

verbalize

dyspnea

O > the

patient may

manifest:

- presence of

surgical

wound on the

low collar

area of neck

- adventitious

breath

Ineffective

airway

clearance

related to

bleeding and/

or laryngeal

edema

If hemorrhage

(bleeding)

beneath the

neck wound

occurs, the

wound bulges

and the neck

swells,

possibly

compressing

structures

inside the neck

and interfering

with breathing.

This is an

Short Term:

After 1 hour

of nursing

interventions,

the patient

will be able

to maintain

airway

patency.

Long Term:

After 3 days

of nursing

interventions,

the patient

> Establish rapport

> Monitor vital

signs, level of

consciousness,

orientation

> Auscultate breath

sounds and assess

air movement

> Check dressing

site for profuse

> To gain the trust

and cooperation

of the client

> To provide

baseline data and

note deviations

from normal

>To ascertain

status and note

progress

> To identify signs

of bleeding

Short Term:

The patient

will be able to

maintain

airway

patency.

Long Term:

The patient

will be able to

maintain vital

signs,

respirations,

and breath

sounds within

sounds (

wheezes,

crackles)

emergency.

Laryngeal

edema may

will be able

to maintain

vital signs,

bleeding (side of

neck and back of

head) every 15

normal limits.


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- changes in

respiratory

rate and

rhythm

- difficulty

vocalizing

-

restlessness

- cyanosis

also occur due

to surgical

manipulation.

Bilateral

recurrent

nerve injury

with acute

paralysis of

both vocal

cords may

occur during

surgery which

may cause

obstruction of

the airway

because of the

adduction of

the true vocal

cords.

respirations,

and breath

sounds

within normal

limits.

minutes for 1 hour

immediately after

surgery

> Keep dressing

size minimized

> Position patient

on back with head

of bed elevated 30

to 45 degrees

> Monitor for signs

of respiratory

distress or

obstructed airway q

1 : stridor,

wheezing, coarse

> To prevent

impaired view of

incision site

> To promote

ease in breathing

> To identify early

signs of

respiratory

distress caused

by tracheal

edema

airway crackles,

dyspnea, cyanosis,

labored


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respirations

> Teach and assist

patient to turn,

cough, and deep

breathe q2h and

prn

> If indicated, keep

suction equipment

at bedside; gently

> To prevent

pulmonary

complications and

to take advantage

of gravity

decreasing

pressure on the

diaphragm and

enhancing

drainage of /

ventilation to

different lung

segments

> To clear airway

when secretions

are blocking

suction oropharynx

only when

necessary

airway


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> Keep

environment

allergen free

> Have

tracheostomy tray

and oxygen

immediately

available at

bedside

> Encourage use of

warm versus cold

liquids as

appropriate

> Provide

opportunities for

> To maintain

patent airway

> To use if patient

experiences

severe respiratory

distress

> To mobilize

secretions

> To prevent

fatigue

rest

> Encourage voice

> Hoarseness and

sore throat

secondary to


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rest, but do assess

speech and

swallowing

periodically

> Evaluate

changes in sleep

pattern

> Observe for

signs/ symptoms ofinfection

edema or damage

to laryngeal nerve

may last several

days. Increased

difficulty may

indicate

impending

obstruction

> To assess

changes

> To identify

infectious

process/ promote

timely intervention

> To promote

timely intervention

> Note physician if

dressing requires

reinforcement more

th ti

/ revision in plan

of care

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