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Client with Multinodular

Non-Toxic Goiter,
Bilateral
GROUP 3Y1-2D

Case Presentation Objectives:


On the completion of this case presentation, the listeners will be able
to:

Understand the pathophysiology and etiology of Non-Toxic Goiter

Understand the assessment parameters

Describe the diagnostic tests used and results

Recognize the contributing risk factors associated in the


development of the disease

Identify the different signs and symptoms that maybe manifested

Learn the appropriate nursing interventions, treatment plan, and


prognosis

Understand the role of drug therapy in managing the patient

Learn about management and rehabilitation factors that optimize


health

Introduction

A goiter is an enlargement of the thyroid. The thyroid is a gland. It


produces hormones that help regulate your bodys metabolism. It is
located on the front of the neck, right below the Adams apple.
Goiters are seldom painful. They tend to grow slowly.

There are different types of goiters. With nontoxic, there is often


normal thyroid function with a nontoxic goiter.

It is a type of simple goiter that may be:

Diffuseenlarging the whole thyroid gland

Nodularenlargement caused by nodules, or lumps, on the thyroid

The development of nodules marks a progression of the goiter.


Causes:

Heredity (family history of goiters)

Taking a lot of substances (goitrogens) that inhibit


production of thyroid hormonecommon goitrogens
include foods such as cabbage, turnips, brussel sprouts

Iodine deficiency

Risk Factors
The following factors increase your chance of developing nontoxic goiter:

Sex: female (nontoxic goiter is more common in women than men)

Age: over 40 years

A diet low in iodine

Symptoms
Nontoxic goiters usually do not have noticeable symptoms, unless they become very large.
If you experience any of these, do not assume it is due to this condition. These may be
caused by other, less serious health conditions.

Swelling on the neck

Breathing difficulties, coughing, or wheezing with large goiter

Difficulty swallowing with large goiter

Feeling of pressure on the neck

Hoarseness

Health History
General Data

Patients Name: Jennifer Lawrence

Age: 61

Sex: Female

Address: Sto. Nino, South Cotabato

Chief Complaint: Anterior neck mass

A. History of Present Illness:

30 years prior to admission when the patient noted a 1.5 x 1.5


cm mass on the neck that moves with deglutition with no other
associated signs and symptoms such as fever, weight loss,
palpitations, and heat/cold intolerance. Patient sought consult
at a health center and was seen by a general practitioner. She
was given 2 thyroxine 10 mg and had not returned for a follow
up checkup.

During the interim, patient noted gradual enlargement of the


mass with no other associated signs and symptoms until 3
years PTA when patient noted dysphagia to liquids and with
episodes of difficulty of breathing. Still no consult and no
medications taken.
Patient sought consult at Qwag Station Hospital and was
subsequently evaluated fand was referred here at AFPMC for
surgery.

B. Past Medical History: none


C.Family History: Goiter (mother)
D. Personal and Social History: Non-alcoholic drinker, Non
smoker
E. Physical Assessment:
Age: 61
Date assessed: June 17, 2014

Vital Signs
Temperature: 36.8 C
Pulse rate: 90
Respiratory rate: 21
Blood pressure: 120/80

PHYSICAL EXAMINATION

GENERAL APPEARANCE AND MENTAL STATUS:


conscious, coherent and ambulatory

*HEAD AND NECK (GENERAL):

*LUNGS: dyspnea, wheezing

(+) anterior neck mass, left, that moves with


deglutition, non-tender, 4x2.5 cm

ABDOMEN: flabby, normoactive bowel sounds,


nontender

Engorgement of neck vein,

HERNIA: none

Hoarseness of voice

GENITALIA: no deformities

EYES: no discharge and pink conjunctiva

BACK: no deformities

EARS: no lesions or discoloration and normal


voice tones audible

EXTREMITIES: pulses full and equal

NEUROLOGICAL: no sensory deficit

*NOSE: nasal flaring

SKIN: good skin turgor

MOUTH: buccal mucosa and gums are pink

LYMPHATIC: no palpable lymph nodes

TEETH: incomplete

CHEST: no deformities

ANATOMY AND PHYSIOLOGY

Normal Adult Thyroid


weighs 20-25g
Located at the front of the neck
"butterfly" shape, with two lateral lobes that are
connected by a narrow section called the isthmus

Hormones produced:

Thyroxine (T4)

Tri-iodothyronine (T3)

Function:

Produces hormones which regulate


the bodys metabolic rate

Heart and digestive function, muscle


control, brain development

Its correct functioning depends on


having a good supply of iodine from
the diet

Release of thyroid hormones from the


thyroid gland is controlled by
thyrotrophin-releasing hormone from the
hypothalamus and by the thyroid
stimulating hormone produced by the
pituitary gland.

Weighs 20-25 g

The thyroid gland can become overactive


(hyperthyroidism) or underactive (hypothyroidism).
Thyrotoxicosis is the term given when there is too
much thyroid hormone in the bloodstream.

Pathophysiology: Nodular Non Toxic Goiter

Predisposing Factors
*Sex: Female
*Age: >40 years
*Family Hx of Goiter

Etiology: May be
caused by one or
several factors
stated

Presence of uniform
follicular epithelial
hyperplasia

Development of areas
of involution and
fibrosis interspersed
with areas of focal
hyperplasia

Precipitating Factors
Hx of radiation therapy to
head and neck
Regular intake of goitrogens
(cabbage, turnips, etc)
Excessive amounts of Iodine
Iodine Defiency

Development of areas of involution


and fibrosis interspersed with areas
of focal hyperplasia

Thyroid architecture loses


uniformity

Development of nodules

*Thyroid gland slowly


increases in size

Development of functional
autonomy

May lead to thyrotoxicosis

Reduced TSH Level

Drug Study
Generic
/Brand Name
midazolam
Dormicum,
Pfizer
Midazolam

omeprazole
Acifre,
Omepron

Drug
Class

Indication

Preprocedur
Antial sedation.
anxiety
Aids in
agents,
induction of
sedative/h anesthesia
ypnotics
and as part
of balanced
2mg IV
anesthesia

(PPI)
Proton
Pump
Inhibitor

For
treating
acidinduced
inflammatio
n and ulcers
of the

Action

Adverse
Effect

Bradycardia,
tachycardia,
Depresses the
CV collapse,
limbic system and hypertension,
reticular
hypotension,
formation by
palpitations,
increasing or
edema
facilitating the
inhibitory
neurotransmitter
activity of GABA
Suppresses
Angina,
gastric secretion tachycardia,
by inhibiting
bradycardia,
hydrogen/potassi palpitation,
um ATPase
abdominal
enzyme system in pain
the gastric

Nursing
Consideration
Assess level of
sedation and
level of
consciousness
throughout and
for 2-6 hr
following
administration.
Assess GI system:
bowel sounds,
abdomen for pain
and swelling,
appetite loss

Drug Study
Generic
/Brand
Name
ketorolac
Toradol,
Toradol IM

cefoxitin

Drug
Class

Indication

Used for shortterm


NSAID
managementn
(up to 5 days)
30 mg IV moderately
as rescue severe acute
dose
pain that
otherwise would
require
narcotics. It
most often used
after surgery.

Antibiotic

Action

Reduces the
production of
prostaglandins.Blo
cks the enzymes
that cells use to
make
prostaglandins. As
a result, pain as
well as
inflammation and
its signs and
symptomsredness, swelling,
fever, and pain.
Respiratory tract Inhibits bacterial
infection, bone, wall synthesis,
joint and skin
thus promoting

Adverse
Effect

Nursing
Consideration

Blurred vision,
confusion,
dryness of the
mouth flushing

Assess patients
condition before
therapy and
regularly thereafter
to monitor drugs
effectiveness.

Phlebitis and
inflammation
at the site of

Assess patients
previous sensitivity
reaction to

Generic
/Brand
Name
tramadol
Ultram,
Zydol

Drug
Class

Narcotic
(opiate)
100 mg
slow IV
initially
then
tramadol
200 mg
in 234 cc
PNSS x
10ggts/mi
n

Indication
Management
of moderate to
moderately
severe pain

Action
Centrally acting
opiate receptor
agonist that
inhibts the
uptake of
norepinephrine
and serotonin
May produce
opioid-like
effects, but
causes less
respiratory
depression than
morphine

Adverse
Effect

Nursing
Consideration

CNS:
drowsiness,
dizziness,
vertigo

Assess for level of


pain relief ad
administer prn dose
as needed but not
to exceed the
GI: Nausea and recommended total
constipation
daily dose

Nursing Process

Objectives:

To alleviate anxiety

To promote effective airway clearance

To relieve pain

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation

PRE-OP

Subjective Data:
Kinakabahan po ako
sa
gagawing operasyon,
as verbalized by
the patient.

Objective Data:
Poor eye contact;
glancing about;
extraneous
movement;
restlesness

Vital signs taken


as follows:
BP 120/90
T: 37.0 C
PR: 92
RR:20

Alteration in emotional
status: Fear of the
unknown related to
impending surgery

Within 1 hour of
nursing
interventions,
the patient will
appear relaxed
and report of
anxiety is
reduced to a
manageable
level

Assess patient level of anxiety


by observing patient facial
expression and verbalization
about the surgery.

As a baseline data to
plan for future
nursing
interventions.

After 1 hour of nursing


interventions, the
patient appeared
relaxed and report of
anxiety reduced to a
manageable level

Monitor VS especially blood


pressure and pulse.

Increase in BP and
pulse may indicate
patient
anxiety.

Re-inforce doctors explanation


about the surgical procedure
To increase patient
using a simple language.
understanding

regarding surgical
procedures.
Encourage patient to verbalize
her feeling and ask questions
To gain patients
regarding surgical procedure.
cooperation.

Encourage patient to do
To divert patients
divertional therapy.
attention about the

surgery.
Provide good ventilation and

quiet environment.
To encourage rest and

relaxation which
calm the mind.

Assessment

Diagnosis

Planning

PRE-OP
Subjective Data:
Nahihirapan po akong
lumunok
at huminga, as
verbalized by the
patient.

Objective:
Irritability
Restlessness
Dyspnea

V/S taken as follows:


BP120/90
Temp 37.0 C
PR 85
RR 20

Risk for
ineffective
airway clearance
related to
tracheal swelling
due to
enlargement of
mass

Within 1 hour of
nursing
interventions,
the client will
maintain a
patent airway
and will be able
to breath easily

Interventions

Monitor client respiration


and breath sounds.

Keep head of the bed


elevated in appropriate
position.

Encourage patient to do
deep breathing
exercises.

Encourage/provide
opportunities for rest;
limit activities

Provide a well-ventilated
and quiet environment

Rationale

Evaluation

Indicative of
respiratory distress
and or accumulation
of secretion.

To take advantage of
gravity decreasing
pressure and
enhancing drainage
and ventilation

To relax the patient


and decrease her
anxiety.

Prevents and
reduces fatigue

Enhances relaxation,
conserving energy

After 1 hour
of nursing
interventions
, the patient
was able to
maintain a
patent
airway. She is
more relax
and calm

Assessment

Diagnosis

Planning

POST-OP
Subjective Data:
Masakit po ang
lalamunan ko , as
as verbalized by the
patient

Pain scale: 5/10

Objective cues:
Guarding behavior
Facial grimace

Vital signs taken


as follows:
BP 140/90
T: 36.8 C
PR: 92
RR:19

Acute pain
related to
postoperative
edema

Within 4 hours
of nursing
interventions,
the clients
report of pain is
controlled and
will display a
reduction of
pain from a
scale of 5/10 to
3/10.

Intervention

Independent:
Assess for signs of pain in both
verbal and nonverbal, note the
location and intensity and
duration.

Determine clients acceptable


level of pain and pain control
goals.

Place patient in semi-fowler


position.

Rationale

Evaluation

Useful in evaluating
pain, and determines
the effectiveness of
therapeutic
interventions.

Varies with individual


and situation.

After 4 hours
of nursing
interventions
, the clients
report of pain
is controlled
with a pain
scale of 2/10.

To protect the integrity


of the suture line.

To distract attention and

reduce tension.
Instruct in and encourage use
of relaxation techniques, such
as focused breathing
To maintain

acceptable level of
Dependent: Give analgesics as pain.
prescribed and evaluate

effectiveness

Laboratory Findings
HEMATOLOGY
AUGUST 22, 2014
COMPLETE BLOOD COUNT

RESULT

REFERENCE
VALUES

UNIT

INTERPRETATION

Hemoglobin
Hematocrit
RBC Count
DIFFERENTIAL COUNT:

140.0
0.39
5.73

120 - 160

4.0 10.0

gms/L

X10g/L

WNL

Segmenters
Lymphocytes
Eosinophils

0.50
0.36
0.06

0.35 0.65
0.25 0.35
0.02 0.04

0.07
0.01

83.3
29.6
36
11.90
303

0.03 0.06
0.00 0.01
0.03 0.05

80 100
26 32
32 - 36
10.0 15.0
130.0 400.0
0 30

fL

g/dL

X10g/L

Monocytes
Basophils
Stabs
ATYPICAL CELSS:
MCV
MCH
MCHC
RDW
Platelet Count
ESR

Prothrombin
Time
INR

21.1

10.6 13.6

Seconds

1.00

Activity

104.00

74 94

AFTT

25.3

29.9 32.3

Seconds

28

2-7

Minutes

WNL

2-4

Minutes

Reticulocyte
Count
Blood Type

Clotting Time 6 MIN


Bleeding
Time

1 MIN 30
SECS

HEMATOLOGY
RESULT
AUGUST 03, 2014
COMPLETE BLOOD

COUNT
Hemoglobin
132.0

REFERENCE
VALUES

UNIT

INTERPRETATION

120 - 160

gms/L

WNL

Hematocrit
RBC Count
DIFFERENTIAL
COUNT:
Segmenters
Lymphocytes
Eosinophils

0.37
4.43

0.37 0.43
4.0 10.0

X10g/L

WNL
WNL

0.40
0.45
0.07

0.35 0.65
0.25 0.35
0.02 0.04

Monocytes
Basophils
Stabs

0.07
0.01

0.03 0.06
0.00 0.01
0.03 0.05

ATYPICAL CELSS:
MCV
MCH

83.6
29.8

80 100
26 32

fL

MCHC
RDW
Platelet Count

36
11.80
257

32 - 36
10.0 15.0
130.0 400.0

g/dL

X10g/L

ESR

0 30

TEST
AUGUST 22, 2014

RESULT

CREA Jaffle
Corrp.
Urea/Bun liquid

63
3.65

(( ) AVL

Sodium

141

Potassium

3.9

136 145

mmol/L
3.5 5.1 mmol/L

Chloride

105

97 111 mmol/L

FUNCTIONAL STUDIES:
NORMAL VALUES
25 June 2014

UNIT

FLAG

REFERENCE RANGE

umol/L

44 80

mmol/L

278 764

( ) Easylyte

135 140 mmol/L

3.5 5.3 mmol/L


98 107 mmol/L

FT3 RIA

3.55 pmol/L

( 2.2 6.8 pmol/L )

FT4 RIA

17.00 pmol/L

( 10.3 25.74 pmol/L )

TSH IRMA

0.84 IU/L

( 0.3 5 IU/L )

Thyroid Ultrasound Report


JULY 10, 2014
The right thyroid lobe is normal in size but with coarse parenchymal echopattern. It measures 5.3 x 2.59
x 1.61 cm. a predominantly solid complex solid lesion with distinct border measuring 1.41 x 1.49 x 0.6
cm isnoted on its superior aspect in which color Doppler study shows positive flow. Likewise, another
predominantly solid complex lesion with indistinct border and with calcifications within measuring 2.29 x
2.37 x 1.47 cm is noted in its mid to anterior aspect. Color Doppler study shows positive flow.
A lobulated solid mass with calcifications within is noted occupying almost the entire left thyroid lobe
slightly displacing the rest of the thyroid and the trachea towards the right, with note of a possible
intathoracic extension. It measures 7.64 x 4.96 x 4.16 cm. color Doppler study shows positive flow.
The isthmus is enlarged with coarse parenchymal echopattern. It measures 0.71 cm. no focal mass
lesion seen.
Unenlarged cervical lymph nodes are noted in the left.

IMPRESSION:
DIFFUSE

THYROID PARENCHYMAL DISEASE

COMPLEX

LESIONS, RIGHT THYROID LOBE, AS DESCRIBED

ENLARGED

LEFT THYROID LOBE WITH MASS, AS DESCRIBED. SUGGEST TISSUE CORRELATION

ENLARGED

ISTHMUS

CT Scan Report
Multiple plain and contrast enhanced axial CT images of the neck were obtained with no untoward reaction.
A well defined heterogeneous soft tissue mass with calcifications and with central hypodensities within is noted
occupying the entire left thyroid lobe with intrathoracic extension. The mass displaces the trachea and
esophagus to the right with no evident fat plane between the two structures and the mass. Adjacent common
carotid artery and internal jugular vein are intact. It measures approximately 9.91 x 6.49 x 6.21 cm (CC x W x
AP).
The right thyroid lobe is enlarged measuring 5.12x2.56x2.16 cm. A fairly-defined heterogeneously enhancing
complex lesions with calcifications is noted within its mid to inferior aspect measuring 2.39x1.74x1.36cm (CC x
W x AP). Likewise, a subcentimeter hypodense lesion is seen in the superior aspect of the right thyroid lobe.
The isthmus is enlarged but with normal parenchymal attenuation.
The oral floor muscle is bilateral symmetrical and normally developed. The spaces of oral floor and neck are
clear and well defined.Cervical vessels that can be evaluated with CT have normal appearance. Unenlarged
lymph nodes are seen in both submandibular (level l) and both posterior triangle of the neck (level V).
IMPRESSION:

THYROMEGALY

THYROID

TISSUE

MASS INVOLVING THE LEFT THYROID LOBE WITH INTRATHOTACIC EXTENSION.

CORRELATION IS SUGGESTED

THYROID

NODULES, RIGHT THYROID LOBE

UNENLARGED

LEVEL l AND V LYMPH NODES, BILATERAL

FINAL DIAGNOSIS: MULTI-NODULAR NON TOXIC GOITER, BILATERAL


OPERATION: TOTAL THYROIDECTOMY UNDER G.A. / AUGUST 25, 2014

THYROIDECTOMY: SURGERY TO REMOVE THE THYROID GLAND

Thyroid surgery is performed in a number of circumstances:

When cancerous cells are found in and around the thyroid gland, all or part of the thyroid is typically surgically
removed.

When the thyroid enlargement - or goiter - has become so large that it is cosmetically necessary to remove it, or
the size is making swallowing or breathing more difficult

When thyroid nodules enlarge and make swallowing or breathing more difficult

When radioactive iodine (RAI) treatment for Graves Disease or hyperthyroidism has been performed several
times and is still not effective

When a woman is pregnant, and her hyperthyroidism cannot be controlled by other means

In most cases, surgery of the thyroid is not highly complicated, and usually takes no more than two hours. It is
frequently performed on an outpatient or overnight basis. There are few complications that result, but when
they do, they typically fall into one of two categories: damage to the voice box and / or vocal cords, or damage
to the parathyroid glands. If there is damage to the parathyroid glands, this will affect the levels of calcium in
the blood, however, this is very rare.

Types of Thyroid Surgery:


Total Thyroidectomy:

Most common type of surgery

Complete removal of the thyroid

Frequently preferred by doctors over other options and is


used for cancers such as medullary and/or anaplastic that are
larger and more aggressive.

Subtotal Thyroidectomy:

For small and non-aggressivefollicular or papillary

Contained to one side of the gland

Thyroid Lobectomy:

Removal of only about a quarter of the thyroid

Thyroidectomy

Thyroid surgical procedures begin with the insertion of an endotracheal tube, followed by the
administration of general anesthesia. Once the anesthesia takes effect, the procedure begins with an
incision 2 inches to 4 inches long that stretches horizontally over the thyroid. Based on the tests
performed before the procedure and the appearance of the thyroid, the final determination of how much
of the thyroid should be removed is made in this case the whole thyroid glands will be removed.

At this point, the whole thyroid glands are removed using a scalpel. Special care is taken not to harm or
disturb the parathyroid glands and the vocal cords, both of which rest in the neck near the thyroid.

A biopsy may also be done to examine the tissues of the thyroid, the parathyroid and, in rare cases, nearby
lymph nodes. This is done to make sure that the portion of the thyroid that is left, if any, is not diseased.
In some cases, the tissue is examined by a pathologist immediately, so that a second surgery to remove a
diseased portion of the thyroid is not necessary.

Once the thyroid has been removed and any necessary samples have been taken, the area is examined for
bleeding. Once the surgeon is confident that there is no bleeding present, the incision is closed. It may be
closed with staples or sutures, and in some cases, a surgical drain may be placed to remove fluid from the
area in the days after surgery.

Once a sterile bandage is applied to the incision, the surgery is completed. Anesthesia is discontinued and
medication is given to wake the patient. The patient is then taken to the recovery room to be closely
monitored while the remaining anesthetic wears off.

Health Teachings
Teaching and Emotional Support
It is still recommended to perform deep breathing, coughing and leg exercises while you are resting in bed.
Consults
Your surgical team will visit you before you are discharged and discuss your operation.
Mobility
You may walk as much as you like. Short frequent walks are a great way to start and assistance is available if
required. Please let the nursing staff know if you plan to leave the ward.
Hygiene
You may shower yourself. Assistance is available if required, please ask the nursing staff.
Nutrition
You may eat and drink as you like, unless otherwise ordered by your doctor.
Continence state
You may walk to the toilet as required.

Observations
Your observations such as temperature, pulse and wound and drain/s will be monitored
regularly until you are discharged.
Medications
You will recommence your normal medications as ordered by your doctor, plus any
required for pain relief. Please let the nursing staff know when you have pain.

The drip (IV) will continue until you are taking adequate amounts of fluids and until
any IV medications (if applicable) are ceased. It will then be removed.

Treatments
The drain/s (if applicable) in your wound will be removed as ordered by your doctor.
This is usually the morning after your operation.

Your stockings will be placed back on after your shower.

Your doctor will advise when the staples/sutures will be removed. Often this is before
you go home. If so, some steri-strips (bandaids) will be applied. Please leave these on
until they peel or fall off (these can get wet when you shower).

Discharge advice following thyroidectomy


Please adhere to the following
Avoid lifting heavy objects.

Avoid over-exertion, eg. gardening.

Avoid constipationeat a nutritious diet and drink plenty of water.

What to expect
Some pain/discomfort at your wound site may be experienced. This is generally aggravated by
movement, coughing and sneezing. Gently support the wound area when you need to cough. This
discomfort will eventually settle. You can take analgesia as discussed with your doctor or nurse.

You may notice redness, slight swelling and bruising around the wound, this is quite normal.

The skin closures (steristrips) applied will fall off naturally.

You may notice that you have a poor appetite for some time.

Post-operative lethargy often lasts for a month or more.

What to do
Maintain adequate fluid intake (68 glasses per day).

Maintain your mobility at homecontinue gentle walking.

Progress to light activities as comfortable.

You may take simple analgesia, eg. Panadol/Panadeinehowever, do not take any more than eight
tablets within a 24 hour period.

Return if
You have any difficulty swallowing or breathing.

You notice increased swelling from/around the wound and/or a discharge from the
wound, inflammation, throbbing around the wound or it feels hot to touch.

You experience a tingling feeling in your mouth or fingers and/or numbness in your
fingers.

You feel feverish.

You experience a marked increase in pain that is not relieved with simple
analgesia, eg. Panadol/Panadeineno more than eight tablets within a 24 hour
period.

You have nausea and vomiting which does not settle.

You have any other concerns.