CASE STUDY PRESENTATION

MENTORING PROGRAM 3/2013

Title : Care and Management of Total Thyroidectomy

Presenter : Sn. Laiwinnei binti Binjil




0BJECTIVE
1) Understand the anatomy and physiology of the th yroid gland
related to surgery.

2) Enable to understand and how ideal to handle the instrument,
scope and principle of aseptic technique.

3) Prepare the OT before arrival of the patient.

4) Prepare the right equipment for the surgery.

5) Assist the surgeon more efficiently.

6) To learn and understand the nursing care preoperatively, intra
operatively and post operatively

TOTAL THYROIDECTOMY
DEFINITION
A thyroidectomy is an operation that involves
the surgical removal of all or part of the thyroid gland.
Total thyroidectomy - Entire gland is removed. Done in
case of follicular carcinoma of thyroid, medullary
carcinoma of thyroid.
Total thyroidectomy: The gland is removed completely.
Usually done in the case of malignancy. Thyroid
replacement therapy is necessary for life.

SKIN INCISION FOR THYROIDECTOMY
The initial incision is made
over the marked line as
described in the preparation
section.
SIGN AND SYMPTOMS
Some factors that may increase the risk of complications include:

Severe hyperthyroidism
Large goiter
Obesity
Smoker
Alcoholism
Poor nutrition
Long-term illness such as diabetes

INVESTIGATIONS
Physical exam
Laboratory and imaging tests to assess thyroid function and
anatomy, such as:
Ultrasound
MRI scan
Thyroid hormone testing
Anti-thyroid medicine to suppress thyroid activity in patients
with hyperthyroidism
Thyroid scan
CT scan will assess retrosternal extension or tracheal
compression.
Nuclear medicine scan only serves to confirm the presence
of multinodular change and has little value.


TREATMENTS
Surgical treatment of a multinodular goitre include the presence of
obstructive symptoms, thyrotoxicosis, suspicious or malignant
changes on FNAC, a strong family history of thyroid cancer, the
presence of retrosternal extension, or a past history of head and neck
irradiation.

Patient with a large multinodular goitre who is otherwise
asymptomatic, thyroidectomy may also be considered for cosmetic
reasons. The only effective treatment is surgical excision. If surgery
is undertaken, total thyroidectomy is the preferred option, because it
removes all tissue likely to cause symptoms and avoids the
possibility of later recurrence, which is of the order of 30%.

Lifelong thyroxine replacement is required after total thyroidectomy.

You may be asked to stop taking some medications up to one week
before the procedure, like:
Anti-inflammatory medications, such as ibuprofen
Blood thinners
Antiplatelet medications

Do not eat or drink anything after midnight the night before the
procedure. At least 6hours nil by mouth.

PATIENTS PARTICULAR
Name : Madam X
Sex : Female
Age : 46
Address : Jalan Bunga Raya Utama, Taman Bumiko, 98000 Miri.
RN no : 2014/000840
Status : Married with one child
Family history : no history of malignancy
Medical and surgical history : No medical illness
Social history : Ex smoker 10years ago, occasional alcohol drinker


NURSING ASSESMENT
Preoperative

1. Activity / exercise
Insomnia, increased sensitivity, muscle weakness, impaired
coordination, severe fatigue, muscle atrophy, increased respiratory
frequency, tachypnea, dyspnea

2. Elimination
Urine in large amounts, diarrhea.

3. Coping / self defense
Experiencing severe anxiety and stress, both emotional and physical,
emotional instability, depression.




CONT.
4. Nutrition and metabolic
Nausea and vomiting, the temperature rises above 37.4 C.
Enlargement of the thyroid, non-pitting edema, especially in the
pretibial, diarrhea or constipation.

5. Cognitive and sensory
Talk fast and raucous, confusion, restlessness, coma, tremors of the
hands, hyperactive deep tendon reflexes, orbital pain, photophobia,
palpitations, chest pain (angina).

6. Reproductive / sexual
Decreased libido, hypomenorrhea, menorea and impotent.
Postoperative

1. Basic assessment data
The pattern of activity / rest: insomnia, severe weakness, impaired
coordination
Neuro-sensory patterns: impaired mental status and behavior, such
as confusion, disorientation, anxiety, sensitive to stimuli, hyperactive
deep tendon reflexes.

2. Priority of Nursing
Returns the status of hyperthyroidism with preoperative
Preventing complications
Eliminating pain
Provide information on procedures

CONT.

3. Purpose of repatriation
Complications can be prevented or reduced
Pain disappeared
Surgical procedure / prognosis and treatment can be understood
May need assistance in treatment techniques partially or completely,
Daily activities, maintaining the house chores.
PRE OPERATIVE CARE
At airlock
Ask the patient name and confirm with the case note and check the
wrist band.

Make sure all the documents such as, consent for operation,
medication chart, chest x-ray, ultrasound and blood investigations
are available.

Make sure all consents was signed by patient and checked according
to standard checklist.

Patient wheel into the operation theatre.


RECEPTION BAY









Induction Room
Operation Room

IN THE THEATRE

Make sure the humidity (50%
60%) and temperature of the
theatre is suitable (18- 22C )
to prevent the growth of
microorganism.
IN THE THEATRE
Double check all the consents,
site of operation, procedure
and patient identity with
identity tag to make sure that
everything is correct.

IN THE THEATRE
Confirm with anesthetist team
if patient has any allergy,
airway risk, risk of blood loss
and adequate intravenous
access.

HARMONIC MACHINE
Make sure the harmonic
machine can be functioning
during an operation.
IN THE THEATRE
Check for the functioning of
the diathermy, GA machine,
pulse oxymeter, and suction
machine to ensure that the
operation will run smoothly.

Prepare and check the
set required for the
procedure and make sure
it is complete.
Basic Set

INSTRUMENT
Used poviden iodine 10% -
remove as many bacteria as
possible from the operative site
and surrounding area before
operating to prevent growth of
the microorganism.

POSITION PATIENT FOR THYROIDECTOMY
patient should be placed in
supine position with the apex
of the patient head at the top of
the operating bed.
A shoulder roll or gel pad
should be placed at the level of
the acromion process of the
scapula to help extend the
neck.

INTRA OPERATIVE
CARE
INTRA OPERATIVE
Used povioden iodine 10% -remove as many bacteria as possible
from the operative site and surrounding area before operating to
prevent growth of the microorganism.
Only sterile items are use to prevent infection.
Swab and instrument count are done before, during and after the
procedure to ensure that it tally.
Be alert to ensure smooth running during the procedure.
Redivac drain size 10 is ready in case surgeon need it to monitor
bleeding and bile secretion.
Make sure specimen is correct

SCRUBING GOWNING
GLOVING
Diathermy plate applied at the
correct site ( muscle area, no
hairy area, avoid body
prominence and implant
insitu.) to prevent diathermy
burn

Swab and instrument
count are done before,
during and after the
procedure to ensure
that it tally.
Be alert to ensure
smooth running during
the procedure.

Swab and
instrument count
form
SPECIMEN THROID GLAND FOR HPE
POST OP CARE

AT RECOVERY BAY

After surgery patients are required to remain in a recovery area until
the immediate effects of anesthesia subside and vital signs is stable.

Face mask oxygen 5L/minutes to maintains oxygen concentration
and to prevent hypoxia because patient was under general
anaesthesia


CONT.
Monitored :
Vital signs to ensure that there are no reactions to anesthesia or
internal injuries present. There may be some nausea and vomiting.

Check intravenous access and make sure it is patent.

Check dressing drain site for bleeding.

Keep patient warm

CONT.
Before discharge to the ward anesthetist have to sign the discharge
form to ensure patient is fit for discharge.

Make sure patients document is available such as post operative
note order, x-ray film, case note, medication chart.

Specimen enter in the specimen book

Hand-over to ward staff regarding patient condition and post
operative order.


Nursing
care
plan
Pre
operative
care
Intra
operative
care
Post
operative
care
NURSING CARE
PRE OP
Nursing
diagnosis
Objective Nursing
interventions
Evaluation
1. Anxiety /
fear related to
operation
procedures

Patient will
verbalise
reduced
anxiety
1. Provide
emotional support
by talking to
patient
2. Inform patient
regarding the
outcomes of the
operation
procedure
3. Explain to
patient the pre
operative
preparation and
post operative care

Patient verbalise that
she is ready for
operation

NURSING CARE INTRA
OP
Nursing
diagnosis
Objective Nursing
interventions
Evaluation
2. Potential
swabs and
instruments
irregularities.
Swabs and
instruments
counts
maintain
correct.
1. Do initial,
second and final
swabs and
Instruments
count.
2.Take note on all
newly added
sharps, swabs,
instruments and
loose items.
3. Keep track and
tag on any swabs
or instrument
inserted into
patients cavity intra
operatively


Swab and
instrument
count done by
circulating
nurse and
scrub nurse.
Count tally.
Surgeon
informed .form
signed by scrub
and circulating
nurse.

Nursing
diagnosis
Objective Nursing interventions Evaluation
3. High risk for
electrical burns
related to the
use of the
electrosurgical
unit

Patient will
not sustain
electrical
burns

1. Check diathermy machine
for proper functioning order
before use
2. Assess size and patients
skin condition before
applying diathermy plate.
3. Select appropriate size of
adhesive electro surgical
pad.
4.Do not place pad in areas
of scarred tissue, bony
prominence or hairy areas.
5. Protect patient from
contact with metal surfaces






No redness
over
pt`s.skin at
diathermy
plate area
NURSING CARE POST OP
Nursing
diagnosis
Objective Nursing interventions Evaluation
1. Pain
related to
surgery
-operation
site
Patient
verbalise
experiencin
g less pain

1. Assess verbal/nonverbal
reports of pain, noting
location, intensity (010
scale), and duration.

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


3. Maintain head/neck in
neutral position and support
during position changes.
Instruct patient to use hands to
support neck during movement
and to avoid hyperextension of
neck.
Useful in evaluating
pain, choice of
interventions,
effectiveness of
therapy.
Prevents
hyperextension of
the neck and protects
integrity of the
suture line.
Prevents stress on
the suture line and
reduces muscle
tension
Nursing
diagnosis
Objective Nursing interventions Evaluation


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

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

6. Administer analgesics and/or
analgesic throat sprays/lozenges
as necessary.
Provide ice collar if indicated.

Although both
may be soothing to
sore throat, soft
foods may be
tolerated better than
liquids if patient
experiences
difficulty
swallowing.
Helps refocus
attention and assists
patient to manage
pain/discomfort
more effectively.
Reduces pain
and discomfort;
enhances rest.



Nursing
diagnosis
Objective Nursing interventions Evaluation
2.
Communication,
impaired verbal
May be related
to
Vocal cord
injury/laryngeal
nerve damage
Tissue edema;
pain/discomfort



Establish
method of
communicati
on in which
needs can be
understood.


1. Assess speech
periodically; encourage
voice rest.
2. Keep communication
simple; ask yes/no
questions.
3. Provide alternative
methods of communication
as appropriate, e.g., slate
board, letter/picture board.
Place IV line to minimize
interference with written
communication.


Hoarseness and
sore throat may
occur secondary to
tissue edema or
surgical damage to
recurrent laryngeal
nerve and may last
several days.
Permanent nerve
damage can occur
(rare) that causes
paralysis of vocal
cords and/or
compression of the
trachea.
Reduces demand
for response;
promotes voice rest.
Facilitates
expression of needs.

Nursing
diagnosis
Objective Nursing interventions Evaluation
4. Anticipate needs as
possible. Visit patient
frequently.

5. Post notice of patients
voice limitations at central
station and answer call bell
promptly.


6. Maintain quiet
environment.


Reduces anxiety
and patients
need to
communicate.
Prevents
patient from
straining voice to
make needs
known/summon
assistance.
Enhances
ability to hear
whispered
communication
and reduces
necessity for
patient to
raise/strain voice
to be heard.


HEALTH EDUCATION
Post op day 2. advice patient and give health education about the
medication and folloe up with doctor.
Take your medication as directed as doctor instruction.

Use a pillbox labeled with the days of the week. This will help you
remember whether youve taken your medication each day.

Take your medication with a liquid. But avoid taking it with soy
milk. Soy milk can affect how well your body absorbs the
medication. The pill needs to reach your stomach and not dissolve in
your throat.

Try to take your medication with the same types and amounts
of food and liquid each day. This helps control the amount of thyroid
hormone in your system.

After taking your medication:
Wait 4 hours before eating or drinking anything that contains
soy.
Wait 4 hours before taking certain medications. These include:
Iron supplements
Calcium supplements
Antacids that contain either calcium or aluminum hydroxide
Medications that lower your cholesterol

Do not stop taking your medication even if you become pregnant.

Never stop taking medications on your own.

Keeping Your Doctors Appointments

See your doctor for regular visits. These are needed to monitor
your health.

Have routine blood tests done. These check the level of
thyroid hormone in your body. This helps your doctor know
whether to adjust the dosage of your medication if needed.

Tell your doctor about any signs of further thyroid problems.


Signs that you may have too much thyroid hormone in your body
include:
Restlessness
Rapid weight loss
Sweating
Signs that you may have too little thyroid hormone in your body
include:
Fatigue or sluggishness
Puffy hands, face, or feet
Hoarseness
Muscle pain
Slow pulse (less than 60 beats per minute)
To see doctor when :
Call your doctor right away if you have any of the following:
Fever above 37.2c
Swelling or bleeding at the incision site
Choking
Short of breathing
A sore throat that last longer than 7 days
Tingling or cramps in your hands, feet, or lips